An Electronic Health Record (EHR) refers to an individual patient's medical record in digital format. Electronic health record systems 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) from many locations and/or sources. A variety of types of healthcare-related information may be stored and accessed in this way.
Types of Data stored in EHR:
An electronic medical record might include:
1.Patient demographics. 2.Medical history, examination and progress reports of health and illnesses. 3.Medicine and allergy lists, and immunization status. 4.Laboratory test results. 5.Radiology images (X-rays, CTs, MRIs, etc.) 6.Photographs, from endoscopy or laparoscopy or clinical photographs. 7.Medication information, including side-effects and interactions. 8.Evidence-based recommendations for specific medical conditions 9.A record of appointments and other reminders. 10.Billing records. 11.Eligibility 12.Advanced directives, living wills, and health powers of attorney
Advantages of EHR over paper records:
1. Medical records may be on "physical" media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure and may violate the patient's HIPAA privacy
2. Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage
3. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance
4. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for handwriting were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies
5. In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption.
Conclusion:
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Just as an FDA certification increases consumer confidence, the Healthcare Information Technology industry is making headway toward the creation of product standards. The Certification Commission for Healthcare Information Technology (CCHIT) acts as a stamp of approval on Electronic Health Records (EHRs) or Electronic Medical Records (EMRs). CCHIT certification allows organizations to identify EHR systems that have met the agreed-upon standards, as well as undergone unbiased inspections and rigorous testing.
CCHIT certification is meant to provide a certain level of protection for the buyer by making sure that an EHR system meets certain functionality and security requirements, and can reasonably integrate with other systems. With nearly 350 criteria in each area, EHRs must meet robust performance requirements to pass certification. This gives physicians and providers peace of mind that the product they are purchasing is functional and safe, and that it will provide a higher quality of care for patients. Providers who are overwhelmed by the amount and variety of EHR systems that are available can now seek products with the CCHIT seal as a prerequisite to their decision making process.
According to some skeptics, an EHR that is CCHIT compliant can also offer providers the same peace of mind that a certified EHR gives. What's the difference between the two? A certified product indicates that a vendor met all the necessary functionality, interoperability and security requirements, and paid a $28,000 administrative fee to CCHIT to undergo the certification process. A compliant product indicates that a vendor also developed its product to meet the necessary requirements, but may not have paid the administrative fee to receive the benefit of CCHIT's official endorsement.
CCHIT evaluates EHR products based on 350 criteria in the following categories:
Functionality:
Systems must meet an extensive set of functional requirements, (e.g., scheduling, encounter management, demographics, etc.)
Interoperability:
This assures that systems from different vendors can seamlessly exchange clinical, financial and administrative data.
Security:
This addresses how effectively the product protects the information stored in it. For example, backup, authentication, access control, etc.
While certification does demonstrate a degree of financial esteem and indicates a vendor's financial viability, a compliant system may be all some providers are seeking. Whether an EHR system is CCHIT certified or compliant, it still is prudent to apply due diligence before committing any resources.
Industry experts offer the following tips for health center teams that are considering purchasing an EHR in 2007:
Do your research. Review trade publications, ask questions at industry conferences that feature vendor exhibits.
Think about hiring a consultant. While this can sometimes be costly, a third person brings an objective perspective to your search. Depending upon his/her expertise, he/she may ask questions that you and your team have not considered.
Consult with your Information Technology (IT) staff to think through any operational considerations. For instance, how much storage space for patient records can you accommodate? How often will back-ups be required? Are you equipped to handle these issues?
Ask for references. Don't take a vendor's word for it. Talk to customers that are actually using the product.
Nuesoft Xpress released its EMR in April 2006, and is currently developing it to meet CCHIT certification criteria.
Both Penn & Jennifer Mcduffee are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.
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