This document discusses the evolution and components of electronic health records (EHRs). It provides an overview of computer hardware and software as they relate to EHRs. The document outlines the advantages and disadvantages of both manual and automated health records. It also discusses stakeholders in health information exchange, components of EHRs, and challenges in transitioning from manual to electronic records systems.

1. Chapter 5
Electronic Health Records

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Overview of computer terms
• Hardware
– Central processing unit
– Input and output devices
– Storage devices
– Networking equipment
• Software
– Operating software
– Application software

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Evolution of Electronic
Health Records
Terms used to describe automated records
• Computerized medical record
• Computer-based patient record
• Electronic medical record (EMR)
• Electronic health record (EHR)

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Evolution of Electronic
Health Records (Continued)
• IOM’s 1991 report indicated that electronic
records should support the following:
– Physician access to patient information
– New and past test results in multiple-care settings
– Computerized order entry
– Computerized decision-support systems to prevent
adverse drug interactions and improve compliance with
best practices
– Secure electronic communication among
providers/patients

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Evolution of Electronic
Health Records (Continued)
– Patient access to records, disease management tools, and
health information resources
– Computerized administration processes such as
scheduling systems
– Standards-based electronic data storage
– Reporting for patient safety and disease surveillance
efforts

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Longitudinal Patient Record
Contains records from different episodes of
care, providers, and facilities that are linked to
form a view, over time, of a patient’s health
care encounters

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Advantages of Manual Records
• Low start-up costs
• Training of staff is simple
• Requires less technically trained staff
• Paper records are available because there
is no downtime

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Disadvantages of Manual Records
• Retrieval is not easily customized
• Hand-written information can be difficult
to read
• Difficult to abstract information
• Undocumented services are not easily
discovered until discharge analysis occurs

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Advantages of Automated Records
• Improved access to patient information
• Multiple users can access patient information
simultaneously and remotely
• Elimination of paper record storage
• Improved readability of patient information
• Timely capture of data

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Advantages of Automated
Records (Continued)
• Views can be customized
• Updates occur easily
• Customized retrieval of information
• Enhanced security of patient information
• Reduction in administrative costs

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Disadvantages of
Automated Records
• Increased start-up costs
• Selection and development is time-
consuming
• Staff training is time-consuming
• Staff training can be costly
• Technical staff is needed
• User resistance can occur

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Transition to Electronic Records
• Scanning of documents
• Hybrid records
• Record transitional template

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Regional Health Information
Organization (RHIO)
Electronic network of patient medical
information gathered from multiple
health care organizations in a geographic
region

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• Hospitals
• Physicians
• Patients
• Health plans and insurers
• Public/governmental health agencies
Stakeholders in a RHIO

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American Recovery
Reinvestment Act of 2009
Areas that the act will impact include
• Incentives for adoption of EHRs
• Advancement of health information exchange
• New privacy regulations
• HIM workforce opportunities

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Components of Electronic
Health Record
• Data is defined as raw facts that are not
interpreted or processed
• Health information is defined as health data
that has been given meaning and has been
processed or organized in a manner that is
useful for decision making

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Components of Electronic
Health Records (Continued)
• Characters
• Fields
• Records
• Files
• Data
• Information

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Patient Registration Screen
(Reprinted with permission of PracticeOne.)

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publicly accessible website, in whole or in part
Administrative &
Clinical Applications
• Registration-admission-discharge-transfer system
(RADT)
• Clinical applications
– Patient monitoring systems
– Pharmacy
– Laboratory
– Radiology
– Nursing
– Medical documentation
– Patient access

20. © 2016 Cengage Learning®
. May not be scanned, copied or duplicated, or posted to a
publicly accessible website, in whole or in part
Patient Registration Insurance
Information
(Reprinted with permission of PracticeOne.)

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publicly accessible website, in whole or in part
Clinical Information
Patient History
(Reprinted with permission of PracticeOne.)

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publicly accessible website, in whole or in part
Patient Intake Screen at Exam
(Reprinted with permission of PracticeOne.)

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Transitioning to
Electronic Records
• Many challenges will have to be met
• Health information professionals must have
an understanding of automated systems
• Transitions to EHRs can take years
• Facilities need to establish and develop
implementation plans