This chapter provides an overview of electronic health records (EHRs). It defines key terms like electronic medical record and EHR. Federal regulations and incentive programs aim to expedite EHR implementation by 2015. EHRs are expected to improve outcomes, efficiency and population health through benefits like streamlined communication and immediate access to patient information across providers. Standardized computer protocols like HL7 are important for EHR interoperability.

2. Chapter 1
Overview
of
Electronic Health Records

3. Chapter Topics
 Distinctions between electronic medical records and electronic health
records
 Role of interoperability and computer protocols in facilitating
communication between electronic health record systems
 Federal regulations influencing the implementation of electronic health
records
 Benefits of electronic health record use
 Barriers to electronic health record implementation
 Current and future workforce considerations

4. Objectives
• Define the terms electronic medical record (EMR) and electronic
health record (EHR) and understand their distinctions.
• Explain the concept of interoperability and its importance in the
EHR environment.
• Define the terms syntactic interoperability level and semantic
interoperability level.
• Define computer protocol and discuss the most common
communication protocol, HL7.
• Describe the Health Information Technology for Economic and
Clinical Health Act and the federal incentive programs for
implementing EHRs.
• Understand the concept of meaningful use and identify its three
main components.
• List and discuss the benefits and barriers to implementing EHRs.
• List and discuss the evolving roles of the health information
manager in the EHR environment.

5. Electronic Health Records
• Historically patient records were paper-based
• U.S. is entering a new era in which electronic health record (EHR) use is expected from
providers
• Incentive programs are in place to influence and expedite EHR implementation
• Beginning January 1, 2015, provider reimbursement will be reduced if EHRs are not
used
• Rationale for EHR implementation includes:
• Operational/administrative efficiency benefits
• Improved patient outcomes
• Enhanced population health

6. Electronic Health Records
• This image depicts the broad range of data collection, reporting, and sharing
capabilities within EHRs

7. Electronic Medical Record
v. Electronic Health Record
• EMR and EHR are incorrectly used synonymously
• EMR
• Electronic version of patient record for use within one facility
• Is considered the legal record of care for that facility
• EHR
• Contains patient information gathered from multiple EMRs
• Is a longitudinal collection of patient information from multiple sources
• Is considered interactive
• Allows for interoperability with various health information systems

8. Checkpoint: Your Turn
A longitudinal collection of patient information from multiple sources is
depicted in which of the following:
• Electronic medical record
• Electronic health record
True or false: Eventually, providers will see reducations to reimbursement if
they opt to not use EHRs
• True
• False

9. Interoperability
• Interoperability is the ability of one computer system to communicate with another
• Six recognized levels of interoperability exist
Level of Interoperability Description
Level 0 Standalone system; no interoperability
Level 1 Infrastructure allowing for exchange of bits and
bytes of data
Level 2* Syntactic interoperability introduces common
data format for information exchange, but
meaning of the data is not interpreted
Level 3* Semantic interoperability occurs, allowing the
meaning of data to be shared and information
interpreted
Level 4 – 6 The higher the level, the greater amount of data
manipulation and conceptualization occurs
*Most focus on interoperability in EHRs is in relation to levels 2 and 3

10. Interoperability
• Research at the Virginia
Modeling, Analysis and
Simulation Center defined the
hierarchy of interoperability
and led to the development of
Levels of Conceptual
Interoperability Model in 2003
• The general concept of the six
levels remains the same, but
greater clarity is provided in
the Model

11. Computer Protocols
• Computer protocol is a standardized method of communicating or transmitting
data between two computer systems
• For EHRs to be useful and beneficial, all EMRs need to use standardized computer
protocols, thus allowing for interoperability and data exchange
• Computer protocols allow for various systems to talk to one another
• The goal is for universal standards related to computer protocols be used in EMRs
• Health Level 7 (or, HL7) is the most commonly used computer protocol in the
domain of EMRs and EHRs
• HL7 allows for seamless exchange of clinical and administrative data between
various systems
• HL7 is developed and maintained by an organization of the same name, comprised
of healthcare experts and information scientists

12. Computer Protocols
• This image depicts an example of HL7
• Without standard use of HL7, a complex schema of protocols would exist, making
communication and interoperability impossible

13. Computer Protocols
• The U.S. Department of Health and Human Services is also developing Consolidated
Health Informatics (CHI) standards; these are not required by law, but have been
voluntarily adopted by agencies and vendors to allow for seamless interactions
between industry, vendors, and the government
• Some of the CHI standards include the following:
• HL7
• Institute of Electrical and Electronics Engineers 1073 (IEEE 1073)
• Protocols related to medical devices
• Logical Observation Identifiers Names and Codes (LOINC)
• Protocols related to clinical laboratory data
• Digital Imaging and Communications in Medicine (DICOM)
• Protocols related to imaging results and related information

14. Computer Protocols
• The Office of the National Coordinator for Health Information Technology (ONC)
supports various health IT endeavors in the U.S.
• The ONC is also concerned with universal protocols to allow for systematic
information exchange
• One ONC effort is to establish a Nationwide Health Information Network (NwHIN)
• A NwHIN would allow for sharing of patient data from previous encounters and
admissions at the point of care, regardless where in the country the patient is seen
• The concept of this type of information sharing relies on standardized computer
protocols

15. Checkpoint: Your Turn
Which communication protocol relates to clinical laboratory data?
• LOINC
• HL7
• DICOM
• IEEE 1073
True or false: Consolidated Health Informatics standards are mandated by
law
• True
• False

16. Federal Regulations
• EHR implementation and use in the U.S. recently became a legislative focus
• The Health Information Technology for Economic and Clinical Health (HITECH) Act
was enacted in February 2009
• The HITECH Act was funded via the American Recovery and Reinvestment Act
(ARRA), which was signed into law by President Barack H. Obama
• This legislation allocated $19.2 billion dollars related to the following goals:
• Establish incentive payment programs for providers and facilities that see Medicare and
Medicaid patients; allowing eligible providers and hospitals to receive incentive
payments if they adopt certified EHR technology and depict usage in a meaningful way
• Create the Health Information Technology Extension Program, which provides support to
small and medium sized physician practices with their goals of implementing EHR
technology
• Establish national Health Information Technology Research Centers and Regional
Extension Centers; these entities work together to identify and share best practices in
the implementation of EHRs and serve as a resource to physicians and other providers

17. Federal Regulations
• Meaningful Use is a set of standards created by the Centers for Medicare and
Medicaid Services (CMS)
• The Meaningful Use standards must be met by healthcare providers participating in
the Medicare and Medicaid EHR Incentive Programs
• Meaningful Use consists of a three stage approach, consisting of these general
goals:
Meaningful Use Stage General Focus
Stage 1 Standards focus on data capture and sharing
Stage 2 Standards focus on advancing clinical processes
Stage 3 Standards focus on improved patient outcomes

18. Federal Regulations
• Stage 1 of Meaningful Use was the first
phase of the EHR incentive programs
• During 2011 – 2012 Stage 1 was first
implemented
• Three main components of Stage 1
included:
1. Use of certified EHRs in meaningful
ways, such as to e-prescribe
2. Use of certified EHRs to exchange
health information to improve quality
of care
3. Use of certified EHRs to report
various quality indicators and
measures

19. Federal Regulations
• The Medicare and Medicaid EHR Incentive
Programs allow for participation from
hospitals and eligible providers
• Eligible providers are specifically defined to
depict eligibility to participate in the Medicare
and Medicaid incentive programs
• Payments for the Medicare incentive program
include up to $44,000/provider for up to five
years
• Payments for the Medicaid incentive program
include up to $63,750/provider for up to five
years
• Medicare reimbursement will be reduced in
gradual increments beginning in 2015 for
providers not using EHR technology

20. Benefits of EHRs
• The transition toward EHRs has been a
period of adjustment for providers
• Despite the learning curve associated with
EHRs, EHRs are capable of producing a
variety of benefits related to care
processes, administrative efforts, and
patient safety
• Three examples of benefits include:
1. Improved documentation
2. Streamlined and rapid
communication
3. Immediate and improved access to
patient information

21. Benefits of EHRs
• Improved documentation can occur when EHRs
are effectively utilized; improved documentation
depends on provider commitment to quality
documentation
• In a paper-based environment, patient safety risks
existed due to illegible physician handwriting
• Illegible handwriting was found in documentation
such as progress notes, orders, prescriptions, and
patient instructions
• EHRs provide various standardized options to
capture documentation, thus eliminating
handwriting from the record
• Documentation options in the EHR may include:
• Typewritten entries (aka unstructured data )
• Dropdown menus, check boxes, arial buttons
(aka structured data)
• Scanning capability, when appropriate

22. Benefits of EHRs
• Easily decipherable clinical documentation is a necessary component of safe care
• Compare this progress note to the handwritten progress note to the on the previous slide

23. Benefits of EHRs
• EHRs can facilitate communication among
providers
• Healthcare delivery involves a variety of
providers; paper-based records do not
allow for the record to be interactive,
readily available for all users, and linked to
communication devices
• Examples of EHR communication
capabilities:
• A physician orders lab work; when the
results are finalized, the physician can
be automatically notified of available
results via messaging
• When a radiology image becomes
available, the ordering physician is
notified via messaging and may have
immediate access on their hand held
device or computer to the film image
and radiologist documentation

24. Benefits of EHRs
• EHRs allow for patient information to be readily available for providers
• In paper-based environments, access to medical records was dependent on the ability to
locate where in a facility or clinic the record was stored and if the record was or was not
already checked out or in use by another member of the healthcare team
• Value added elements of readily available EHRs include these examples:
• Providers are able to view patient records from any secure location
• When a medical report is completed, it becomes immediately available in the system in
draft or final status
• Clinical documentation necessary for coding, billing, or other processes is immediately
available

25. Consider This: Discussion

26. Barriers to EHR Implementation
• Various stakeholders have a vested interest in the use of EHRs–this includes patients,
providers, staff, payers, vendors, government, etc.
• Variables can influence personal comfort level with EHRs
• Some criticisms of this technology include:
• EHR systems are expensive, and require a long-term financial commitment
• Because the use of this technology is relatively new in the U.S., concerns related to
privacy and security of patient information exist
• Providers and health systems struggle with an inadequate applicant pool of potential
employees to support implementation and training related to EHRs
• EHRs require modification of workflow and processes, which will not feel comfortable to
all stakeholders

27. Checkpoint: Your Turn
Which of the following may be a benefit to implementing an EHR?
• Less staff turnover
• Improved documentation
• Increased time for doctors to spend with patients
Which of the following may be barriers to EHR implementation?
• Concerns related to long-term expenses
• Concerns related to privacy and security of health information
• Concerns related to workflow changes
• All of the above are potential barriers to EHR implementation

28. Moving Forward
• While initial investment in EHRs seems great, the long-term result will produce savings if
systems are leveraged to their potential
• Savings include human life (i.e., reducing medical errors) and financial (i.e., conducting
administrative processes more efficiently)
• Privacy and security risks are legitimate concerns
• Issues related to privacy and security, as well as concerns related to medical identity
theft, are a top priority for industry and government
• A continued need for qualified staff–in both provider and vendor settings–will be essential to
long-term success
• Students studying in areas related to health information management and technology
will remain in high demand

29. Consider This: Discussion

30. Evolving Roles in the EHR Environment
• According to the U.S. Bureau of Labor Statistics, a need for health information management
(HIM) professionals will increase 20% by 2018
• American Health Information Management Association (AHIMA) is the premiere organization
representing the HIM profession, with over 71,0000 members
• AHIMA offers various certification exams for HIM professionals; three are significantly
valuable to employers in the EHR environment
RHIT: Registered Health
Information Technician
(Associate’s Degree)
RHIA: Registered
Health Information
Administrator
(Bachelor’s Degree)
CHTS: Certified
Healthcare Technology
Specialist

31. Evolving Roles in the EHR
Environment
• Health Information and Management
Systems Society (HIMSS) is another
professional organization representing
health IT professionals and software
vendors
• HIMSS also offers a certification exam -
Certified Professional in Healthcare
Information and Management Systems
(CPHIMS)
• The CPHIMS is a popular credential option
for chief information officers or similar vice
president level information executives in
healthcare; approximately 37% of the
nearly 2,000 professionals with the
credential work on those capacities

32. Summary
• The road toward universal EHR adoption will be a long one, but the benefits are worth the
effort
• EHRs support reliability and efficiency in clinical, administrative, and operational processes
• Exciting career opportunities for those interested in EHRs exist and will continue to exist
• Professionals in various capacities related to EHRs make an important contribution to patient
care