Electronic History of

Patient
- Electronic Health
Record (EHR)
 Introduction
• In the general practitioner of one of
its duties is to carry documentation
• To facilitate the work of this category
of professionals is dedicated to
"Electronic Case History."
• "Electronic History of patient " is
considered to be the only standard
used in the field of medical
informatics
Electronic Health Record(EHR)
Information system for
reference, storage on electronic
data’s, search and issuing
requests for information
(including by electronic means
of communication) of personal
medical records.
 Functions of EHR
• refers to an individual patient's medical
record in digital format
• co-ordinate the storage and retrieval of
individual records with the aid of
computers
• EHRs are usually accessed on a
computer, often over a network.
• It may be made up of electronic
medical records (EMRs)
 Electronic medical
records (EMR) & EHR
• EMRs included patient’s
demographics, medical history,
medicine and allergy lists (including
immunization status), laboratory test
results, radiology images……
• EHR systems can reduce medical errors
• EHR systems are believed to increase
physician efficiency and reduce costs
 The main components in EHR
 Personal Medical Record - any recording
made by a specific health care professional
for a particular patient.
 Electronic personal health record - any
personal medical record stored on an
electronic medium.
 Electronic medical bank - electronic
storage of patient data, and other data sets
and programs (classifiers and directories, lists
of patients and staff, and others.).
Electronic medical history
consists of 3 main sections
1st “Personal part" - general
information about the person
to seek medical help in a
medical institution:
name, age, sex, place of
residence, place of work or
study, type of insurance.
 Electronic medical history
consists
2nd “The social response" - the presence of
social data for a particular patient, information
about which can significantly affect health
care.

For example: disability, participation in

hostilities, particularly the work in
hazardous or dangerous to life
manufacturing, housing …..
Electronic medical history
consists
3. Medical condition - information
intended for healthcare
professionals, which enables the
doctor to find out about the state
of health of the patient, allowing
for treatment or prophylaxis
against a particular person.
 Electronic medical history can be used
• for Сlinics and in hospitals
• For creating a Central information resource
that allows you to work with personal data
of the patients, as well as share these data
with other medical institutions.
• for the Medical records can be
provided by insurance companies
• For Compliance with the provisions on
medical confidentiality.
 Classification
Individual:
• use medical professionals to store
templates, blanks, and fragments of
electronic copies of various
documents;
• medical documents;
• Medical documents are a copy on
paper, printed and signed by the
author
 Classification
Collective:
• It can be directly extracted from the
electronic archive by any medical
professional (having proper access rights),
and used as an official medical document;
• read electronically, medical decision-
making, printing and bonding in medical
history as an official medical document.
 advantages
1. Unity of patient information
2. Availability of information on
patients with all participants the
diagnostic and treatment
process
3. Common classifications
4. Automatic calculation of the
indicators
 advantages
5. Management of patients in
the survey
6. Ensuring the reliability, safety
and immutability of the
information provided.
 Result uses EHR
• In a convenient mode, and a visual
prompt to fill the page "Complaints",
"History of the disease", "History of Life",
"objective data"
• Planning the survey include:
laboratory testing, functional
diagnostics, ultrasound and other
additional examinations
• Appointment of specialist
consultations;
• Keeping a diary of the attending
physician;
• Scheduling repeated receptions
physician;
• Operational browsing the results of
laboratory and instrumental
studies (in graphical form), advice
of medical specialists;
• Print any of the sections of
the electronic medical
records;
• Formation of medical
reports on the basis of
medical history;
• Self-formation of any queries
on the basis of historical
data
Company for creating and
analyzing EHR
European health informatics
• European Health Action
Plan
• European Institute for Health
Records
• Electronic Health Record
systems
 Clinical Informatics in Asia
• In Asia and Australia-New
Zealand, the regional group
called
• the Asia Pacific Association for
Medical Informatics (APAMI) was
established in 1994 and now
consists of more than 15 member
regions in the Asia Pacific Region
• The Indian Association for Medical
Informatics (IAMI) was established
in 1993 . IAMI has been publishing
the Indian Journal of Medical
Informatics since 2004
 Examples
• openEHR: an open community developed
specification for a shared health record with
web-based content developed online by
experts. Strong multilingual capability.
• Virtual Medical Record: HL7's proposed model
for interfacing with clinical decision support
systems.
• SMART (Substitutable Medical Apps, reusable
technologies): an open platform specification
to provide a standard base for healthcare
applications.
• eDocLib-"Electronic patient medical history"
 Reference
• Gunter, Tracy D; Terry, Nicolas P (2005). "The Emergence
of National Electronic Health Record Architectures in the
United States and Australia: Models, Costs, and
Questions".Journal of Medical Internet
Research 7 doi:10.2196/jmir.7.1.e3.PMC 1550638. PMID 158
29475.
• "Mobile Tech Contributions to Healthcare and Patient
Experience". Top Mobile Trends. Retrieved 29 May 2014.
• Habib, J. L. (2010). "EHRs, meaningful use, and a model
EMR". Drug Benefit Trends 22 (4): 99–101.
• Kierkegaard, Patrick (2011). "Electronic health record:
Wiring Europe's healthcare".Computer Law & Security
Review 27 (5): 503–
515. doi:10.1016/j.clsr.2011.07.013.ISSN 0267-3649.
• "Electronic Health Records Overview" (PDF).