What is in an electronic health record?
When you go to see your doctor or another healthcare profesional, you may see some changes. They may be using a tablet or a computer to store your medical information and writing ordres including:
· Demographic information
· List of conditions
· Allergy list
· Medication list
· X-rays and other imaging reports
· Laboratory and other reports
· Hospitalizations
· Immunizations
· E-prescribing
Providers have different ways of entering and using the information for better treatment outcomes for you and your family. It is easier for the providers to share your records with you during the visits and in between. You will be more empowered when you have access to your record.
EHR has many applications to support patient care and improve the patient workflow processes. EHRs make the care more patient-centered and safe. Various Applications of EHRs include the following:
1. Computerized Physician Order Entry (CPOE): Instead of writing orders which are often illegible, the provider can enter them into the EHR usually through structured data entry, and very often in sets based upon protocols. CPOE includes e-prescribing, lab orders, radiology and other diagnostic orders. Since clinical decision support (CDS) is built into most EHRs, the system checks for any conflicts such as drug interactions and allergies, and sends out alerts or reminders to the provider. Additionally, resources such as clinical practice guidelines and other resources may be available to the provider. The Veterans Affairs video demonstrated how 20% of lab tests are repeated in the paper record environment.
2. Active medication lists: Since many patients take medications, it is important to maintain an active medication list in an EHR. A patient’s medication list can be pulled up very easily from anywhere with an EHR. Since the paper chart can only be in one place, it does not have the same capability. Also, with the electronic and the bar-coded medication administration record, the medication to be administered can be check for the given patient against the list of medications that the patient is taking as well as any allergies or drug interactions. EHRs improve safety, efficiencies and costs. Dennis Quaid could have lost his children to medication error.
3. Recording demographics: This process is much easier in an EHR with structured data entry. Not only does the structure data entry save time, but the information can be used for billing and other purposes. The patient does not have to fill out multiple forms with the same information when going form one provider to another.
4. Point-of-care (POC) charting: The provider can enter patient information through points-and-clicks or via templates while interacting with the patient into an EHR. Using well-positioned computers or tablets, the doctor can make eye contact and enter and share the information with the patient. Vital signs and other SOAP notes can be entered right away.
5. Results retrieval: lab values (including out-of-range alerts), and results of others diagnostic tests-- including images--can be obtained and accessed very quickly, from multiple places to multiple authorized users when using the EHR.
6. Patient engagement and involvement: Through a secure patient portal, patients can view their clinical summaries and results, communicate with their providers, schedule appointments, get reminders and updates, and have access to educational materials. Such communications reduce unnecessary visits to the provider saving time and money. There is higher patient satisfaction when using an EHR.
7. Referrals and transfer of care: Instead of faxing or copying and mailing large amounts of paper records, the patient’s records, a far more comprehensive record can be transmitted via secure portals to other providers. There is a much better capability for coordination of care through electronic records rather than with paper records.
8. Reporting and surveillance capabilities: It is much easier to gather and transmit special data to registries and agencies for various purposes including maintaining statistics, research, disease control, newer treatment, and marketing.
9. Measuring outcomes: EHRs have the capability of data mining and measuring outcomes. In an EHR searches can be done and reports can be generated on a large number of patients to give information about a particular disease or procedure. It is much easier to measure outcomes for a large number of patients in an EHR than in a paper record.
1. Computerized Physician Order Entry (CPOE): Instead of writing orders which are often illegible, the provider can enter them into the EHR usually through structured data entry, and very often in sets based upon protocols. CPOE includes e-prescribing, lab orders, radiology and other diagnostic orders. Since clinical decision support (CDS) is built into most EHRs, the system checks for any conflicts such as drug interactions and allergies, and sends out alerts or reminders to the provider. Additionally, resources such as clinical practice guidelines and other resources may be available to the provider. The Veterans Affairs video demonstrated how 20% of lab tests are repeated in the paper record environment.
2. Active medication lists: Since many patients take medications, it is important to maintain an active medication list in an EHR. A patient’s medication list can be pulled up very easily from anywhere with an EHR. Since the paper chart can only be in one place, it does not have the same capability. Also, with the electronic and the bar-coded medication administration record, the medication to be administered can be check for the given patient against the list of medications that the patient is taking as well as any allergies or drug interactions. EHRs improve safety, efficiencies and costs. Dennis Quaid could have lost his children to medication error.
3. Recording demographics: This process is much easier in an EHR with structured data entry. Not only does the structure data entry save time, but the information can be used for billing and other purposes. The patient does not have to fill out multiple forms with the same information when going form one provider to another.
4. Point-of-care (POC) charting: The provider can enter patient information through points-and-clicks or via templates while interacting with the patient into an EHR. Using well-positioned computers or tablets, the doctor can make eye contact and enter and share the information with the patient. Vital signs and other SOAP notes can be entered right away.
5. Results retrieval: lab values (including out-of-range alerts), and results of others diagnostic tests-- including images--can be obtained and accessed very quickly, from multiple places to multiple authorized users when using the EHR.
6. Patient engagement and involvement: Through a secure patient portal, patients can view their clinical summaries and results, communicate with their providers, schedule appointments, get reminders and updates, and have access to educational materials. Such communications reduce unnecessary visits to the provider saving time and money. There is higher patient satisfaction when using an EHR.
7. Referrals and transfer of care: Instead of faxing or copying and mailing large amounts of paper records, the patient’s records, a far more comprehensive record can be transmitted via secure portals to other providers. There is a much better capability for coordination of care through electronic records rather than with paper records.
8. Reporting and surveillance capabilities: It is much easier to gather and transmit special data to registries and agencies for various purposes including maintaining statistics, research, disease control, newer treatment, and marketing.
9. Measuring outcomes: EHRs have the capability of data mining and measuring outcomes. In an EHR searches can be done and reports can be generated on a large number of patients to give information about a particular disease or procedure. It is much easier to measure outcomes for a large number of patients in an EHR than in a paper record.