Electronic Health Record

Prepared by:
Mustafa Marey Mohamed
Mohamed Ahmed Abd Elaal
Aliaa Gamal

-Under supervision:
Prof. Eman Salman Taie
Goal:
To provide participants knowledge, skills and positive attitude toward electronic
health record

Objectives:
 Define Electronic Medical Records.
 List Content of medical Records.
 Define Electronic Health Record (EHR).
 List Content of Electronic Health Record (EHR).
 Mention benefits of Electronic Health Record (EHR).
 Differentiate between EMR, EHR and PHR.
 Explain the value and importance of personal health record.
 Apply EHR within organizational budget.
 Have a positive attitude toward electronic records.
Outlines
 Definition & Content of Electronic Medical Record (EMR)
 Definition & Content of Electronic Health Record (EHR)
 Definition of Personal Health Record (PHR)
 EMR Vs. EHR Vs. PHR
 Importance of Personal Health Record (PHR)
 Types & Benefits of EHR Systems
 Advantages & Disadvantages of Electronic Health Records
 Cost of Implementing HER.
 References

Introduction:
Our world has been radically transformed by digital technology – smart phones, tablets, and
web-enabled devices have transformed our daily lives and the way we communicate.
Medicine is an information-rich enterprise. A greater and more seamless flow of information
within a digital health care infrastructure, created by electronic health records (EHRs),
encompasses and leverages digital progress and can transform the way care is delivered and
compensated.

Definition of Electronic Medical Record

An electronic record of health-related information of an individual that can be created,
gathered, managed and consulted by authorized clinicians and staff within one healthcare
organization.

Content of medical Records

The American Health Information Management Association (AHIMA) lists the following
components as being common to most patient records, regardless of facility type or medical
record system (electronic or paper based) (AHIMA, 2020).
1. Identification form.
2. Problem list.
3. Medication record.
4. History and physical findings.
5. Progress notes.
6. Consultation.
7. Physician's Advice.
8. Imaging and X-ray reports.
9. Laboratory reports.
10.Consent and authorization forms.
11.Pathology report.
12.Discharge summary.

What is an electronic health record (EHR)?

Electronic health record
An electronic record of health-related information on an individual that conforms to
nationally recognized standards and that can be created, managed, and consulted by
authorized clinicians and staff across more than one healthcare organization.

Among other types of data, an EHR typically includes:

1. Contact information
2. Information about visits to healthcare professionals
3. Allergies
4. Insurance information
5. Family history
6. Immunization status
7. Information about any conditions or diseases
8. A list of medications
9. Records of hospitalization
10.Information about any surgeries or procedures performed

Definition of Personal Health Record

Personal health record: an electronic record of health-related information on an individual that
conforms to nationally recognized standards and that can be drawn from multiple sources while
being managed, shared, and controlled by the individual.
 Differentiate between EMR, EHR and PHR.
Indicator EMR EHR PHR

Content Medical Medical information Medical information

information from from different from different
internal clinical clinicians and lab clinicians and lab
works
Accessibility Limited access by (inter-organizational Managed personally
internal system)
organization

Source of data Clinician from Clinician or analyst Clinician or analyst

single provider from multiple from multiple
providers (inter- providers
facility) (inter-facility)
Function Internal medical exchange between Personal medical
record Information organizations information

 Example for PHR:

Patient Portal
 - A patient portal is a secure website through which patients can access their PHR or EHR. Portals
often allow users to complete forms online, schedule appointments, and communicate with
providers, request refills on prescriptions, review test results, or pay bills.
Importance of the PHR.
 PHR enables individuals to get their own care based on their needs, values, and preferences.
 PHR brings together important health information across an individual's lifetime and is safe,
secure, portable, and easily accessible.
 It reduces costs by avoiding unnecessary duplicate tests and improving health care
communications.
 PHRs may be helpful to patients with chronic illnesses in enabling them to track their diseases in
connection with their providers, promote early interventions and prevent complications.

Types of EHR Systems

1. Physician-Hosted System
Physician-hosted systems very basically mean that all data is hosted on a physician’s
own servers.
This means that a physician is responsible for purchasing hardware and software, as well
as the continued maintenance and security of the data stored on their servers.

2. Remotely-Hosted System
Remotely-hosted systems shift the storage of data from the physician to a
third party.
This entity must deal with maintenance, data backup, and security. This type of
system puts the responsibility for maintaining data somewhere else besides a
single physician or medical practice.

3. Remote Systems
There are three different varieties of remote systems.
• Subsidized: A subsidized system involves a relationship with some entity that subsidizes the
cost of an EHR. Generally, a physician forms this relationship with a hospital, which then
controls the data. Keep in mind that a remote system involving a subsidizing entity can bring
up certain legal issues, including antitrust and data ownership concerns.
• Dedicated: A dedicated host system means that physicians store EHRs on a vendor’s servers.
These servers are usually in specific locations. A physician cannot control most aspects of
data storage with this system.
• Cloud: One of the most popular EHR remote systems is a cloud, or internet-based computing
system.

Benefits of EHRs
 Physician productivity
 Fewer file pulls
  Reduced transcription costs
 Access to patient information
 Improved billing and scheduling
 Ensure high-quality care.
 Improved documentation
 Create a way for communication with their patients

 Patient Satisfaction
 Access to their records
 Easier chronic disease management
 Reduced turn-around time for messages to a physician
 Improved delivery of education materials
 Safer, more reliable prescribing
 Increase patient participation in their care
 Reduced medical errors

Advantages of Electronic Health Records

 Enabling quick access to patient records.
 Securely sharing electronic information with patients and other clinicians.
 Helping providers diagnose patients, reduce medical errors, and provide safer care.
 Improving patient and provider interaction and communication.
 Helping promote legible, complete documentation and accurate, streamlined coding and
billing.
 Helping providers improve productivity and efficiency.
 Reducing costs through decreased paperwork, improved safety, reduced duplication of
testing, and improved health.

Disadvantages of Electronic Health Records

 The systems may require ongoing maintenance and updates.
 The systems may be prone to technical problems or downtime.
 The systems may not be compatible with all devices or software.
 There may be issues with data security and privacy.
 It may be difficult to fully transition to electronic records, especially if some healthcare
providers resist change.

Cost of Implementing EHR:

Implementation depends on the more expensive EHR system will be and the longer it will take to
develop. The EHR system cost includes many expenses, such as:
- Hardware
To have access to the EHR system, the organization will need desktops, laptops, tablets, and
other hardware.
- Predictive maintenance
At 100%, you will need to optimize your EHR system overtime to keep it running smoothly.
These costs are usually added to the costs of electronic medical records.
- End-user training
Budget planning should take training into account. Efficiency directly depends on this.
References
- Health Care Information Systems, Karen A. Wagner, Frances Wickham Lee, John P. Glaser
- CDC.gov. 2021. Fast Stats. Available at: https://www.cdc.gov/nchs/fastats/electronic-medical-
records.htm Accessed 29 April 2021.
-Office of the National Health Information Technology Coordinator. (2020). Federal health
information technology strategic plan. Retrieved February 2021 from
http://www.healthit.gov/sites/default/files/utility/final-federal-health-itstrategic-plan-0911.pdf