Ehr

ELECTRONIC HEALTH
RECORDS
 EHR is a digital version of a patient’s medical history.
 It is a longitudinal record of patient health information.
 The term is often used interchangeably with EMR (Electronic Med
ical Record) and CPR (Computer-based Patient Record).
 It encompasses a full range of data rel evant to a patient’s care
 Demographics,
 Problems,
 Medications,
 Physician’s Observations,
 Vital Signs,
 Medical History,
 Immunizations,
 Laboratory Data,
 Radiology Reports,
 Personal Statistics,
 Progress Notes,
 Billing Data.
 Automates the data management process of com plex clinical
 Presents complete record of a patient’s
clinical encounter, related activities such as
evidence-based decision support, quality
management, and outcomes reporting.
◦ An EHR sys tem integrates data for different

purposes.
◦ It enables the administrator to utilize the data
for
◦ billing purposes,
◦ the physician to analyze patient diagnostics
information and treatment effectiveness,
◦ the nurse to report adverse conditions,
◦ the researcher to discover new knowledge.
1. Administrative System
Components
 Administrative data such as patient registration, admission, discharge, and
transfer data are key components of the EHR.
 It also includes name, demographics, employer history, chief compli ant,
patient disposition, etc., along with the patient billing information.
 Social history data such as marital status, home environment, daily routine,
dietary patterns, sleep patterns, exercise pat terns, tobacco use, alcohol use,
drug use and family history data such as personal health history, hereditary
diseases, father, mother and sibling(s) health status, age, and cause of death
can also be a part of it.
 During the registration process, a patient is generally assigned a unique
identification key comprising of a numeric or alphanumeric sequence.
 This key helps to link all the components across different platforms.
 For example, lab test data can create an electronic record; and another
record is created from radiology results.
 Both records will have the same identifier key to represent a single patient.
Records of a previous encounter are also pulled up using this key.
 It is often referred to as the medical record number or master patient index
(MPI).
 Administrative data allows the aggregation of a person’s health information
for clinical analysis and research.
2. Laboratory System
Components & Vital Signs
 Generally, laboratory systems are stand-alone systems
that are interfaced to the central EHR sys tem.
 It is a structureddata that can be expressed using standard
terminologyand stored in the formof a name-value pair.
 Lab data plays an extremely important part in the clinical
care process, providing professionals the information
needed for prevention, diagnosis, treatment, and health
management.
 Electronic lab data has several benefits including
improved presentation and reduction of error due to
manual data en try.
 A physician can easily compare the results from previous
tests. If the options are provided, he can also analyze
automatically whether data results fall within normal range
or not.
 The most common coding system used to represent
the laboratory test data is Logical Obser vation
Identifiers Names and Codes (LOINC).
 Many hospitals use their local dictionaries as well to
encode variables. A 2009–2010Vanderbilt University
Medical Center data standardization study foundthat
for simple concepts such as “weight” and
“height,”there were more than five internal rep
resentations.
 In different places there are different field names
for the same feature and the values
 Vital signs are the indicators of a patient’s general
physical condition.
 It includes pulse, respi ratory rate, blood pressure,
body temperature, body mass index (BMI), etc.
 A typical EHR system must provide the option to
accommodate these kinds of variables.
3. Radiology System
Components
In hospital radiology departments, radiology information
systems (RIS) are used for managing
medicalimageryandassociated data.
 RIS is the coredatabaseto store,manipulate,and distribute pa
tient radiological data.
 It uses Current Procedural Terminology (CPT) or International
Classification of Diseases (ICD) coding systems to identify
procedures and resources.
 Generally, an RIS consists of patient tracking, scheduling,
result reporting, and image tracking capabilities.
 RIS is usually used along with a picture archiving
communications system (PACS), which is a medical technology
for providing economical storage and convenient access to the
digital images.
 An RIS can generate an entire patient’s imagery history and
statistical reports for patients or procedures.
 Although many hospitals are using RIS, it may or may not be
integrated with the central EHR system
4. Pharmacy System
 Components
In hospitals and clinics, the pharmacy department’s responsibility
is to maintain the inventory, prescription management, billing,
and dispensing medications.
 The pharmacy component in EHR will hold the complete
medication history of a patient such as drug name, dosage, route,
quantity, frequency, start and stop date, prescribed by, allergic
reaction to medications, source of medication, etc.
 Pharmacists serve an important public health role by
administering immunizations and must have the capabilities to
document these services and share this information with other
healthcare providers and public health organizations.
 They assure safe and effective medication and support ing
patient-centered care.
 Pharmacies are highly automated in large hospitals.
 Again, it may be independent of central EHRs. The Food and Drug

Administration (FDA) requires all the drugs to be registered and
reported us
5. Clinical Documentation
 A clinical document contains the information related to the care and
services provided to the patient.
 It increases the value of EHR by allowing electronic capture of clinical
reports, patient assessments, and progress reports. A clinical
document may include [9] • Physician, nurse, and other clinician notes
• Relevant dates and times associated with the document •
Theperformers of the care described • Flow sheets (vital signs, input
and output, and problems lists) • Perioperative notes • Discharge
summaries • Transcription document management • Medical records
abstracts • Advancedirectives or living wills • Durable powers or
attorney for healthcare decisions • Consents (procedural) • Medical
record/chart tracking • Release of information (including
authorizations) • Staff credentialing/staff qualification and
appointments documentations • Chart deficiency tracking • Utilization
management • Theintended recipient of the information and the time
the document was written • Thesources of information contained
within the document

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ELECTRONIC HEALTH

◦ An EHR sys tem integrates data for different

 Again, it may be independent of central EHRs. The Food and Drug

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