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What Are Electronic Health Records?

Healthcare administrators and healthcare information systems professionals alike need a working understanding of electronic health records in today’s healthcare system. Electronic health records are digital records similar to the paper charts that document a patient’s medical history. Unlike paper charts, electronic records can contain a significant amount of patient information. Doctors and other medical professionals can maintain these records in real time, and healthcare providers with a corresponding healthcare information system can access them anywhere.

The Contents of Electronic Health Records

Electronic health records can contain a broad scope of information related to each patient. They cover the patient’s basic demographic information, medical and family history, treatment plans and responses, allergies, and immunization records. Physicians, nurses and other health practitioners can add clinical notes, prescriptions, lab results, radiology images and results from other diagnostic tools. In some healthcare information systems, patients may also add their own notes through a personal health record application linked to their electronic health records.

Better Patient Care and Diagnostics

Electronic health records provide patients with improved healthcare and allow medical practitioners to make better decisions with more information than paper records. Because a patient’s healthcare documents remain in one digital location, physicians can easily access all pertinent information before making decisions about diagnoses or treatment — without waiting for records to be transferred. Doctors also do not have to worry about parts of a paper record being lost, misfiled or neglected, which can create an incomplete picture of the patient’s medical history.

Electronic health records are also easier to read than paper records, leading to fewer mistakes and less misinterpretation of a previous provider’s notes. Handwritten notes by physicians and nurses can sometimes be illegible and difficult to interpret. Digital health records eliminate most risks of misinterpretation.

Improvements in Coordination of Care

Electronic health records do more than simply compile a patient’s medical history. Because the records are digital, healthcare information systems can analyze the information and give medical providers alerts or reminders. Physicians can quickly and efficiently avoid conflicting prescriptions or potential allergies when prescribing new treatments. The integration of this information can also improve patient care and prevent potential harm if a patient needs to see a new provider. Digital records also protect patients against unnecessary testing while improving emergency care. In addition, physicians can access updates and results in real time, often in coordination with outside laboratories and diagnostic centers, allowing them to make quicker and more informed decisions.

Save Time and Money

Medical practices, hospitals and clinics find that using electronic health records improves their offices’ efficiency and reduces waste. Practices can save a great deal of money in paper and file costs, and they can save on the labor involved in transcribing, copying, filing and pulling charts for each patient visit. Digital files also make the process of coding for billing more efficient.

Healthcare administrators and information systems managers should work diligently to understand the ins and outs of the electronic record systems their hospitals or medical practices use. A smoothly operating healthcare information system creates efficient work flow, improved quality of care, and a reduction in expenses. Everyone involved in the healthcare process, from patients to providers to administrators, benefits from the use of electronic health records.

Learn about the Southeastern Oklahoma State University online MBA in Healthcare Information Systems program.


Sources:

http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs

http://managemypractice.com/electronic-medical-recordelectronic-health-record/



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