Electronic health records (EHRs)

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Contents

Last Update

  • Updated.jpg 2 April 2014

Introduction

See also Archival principles for medical librarians | Canada Health Infoway 800px-Flag of Canada.svg.png | eHealth | E-Patients | Google health projects | Medical informatics | Records management

"...Canada Health Infoway defines an electronic health record as a secure and private lifetime record of an individual's health and care history, available electronically to authorized health care providers." Canada Health Infoway

Electronic health records (EHRs), electronic medical records or electronic patient records, refers to online health records of individual patients that are made accessible on hospital and health networks. Apart from the retention, format and content differences, electronic health records are conceptually different from their print counterparts in that they are bound by strict standards of access and can be transmitted online. While print records are not as convenient as online records, or as accessible, health organizations are more capable of protecting patient confidentiality as print records are typically only accessed by health providers (although some experts dispute this assertion, and say that breaches were possible via print also). In the digital age, confidentiality is critically important as patient data resides in multiple, distributed locations and can be accessed by several patient systems (and by more than one type of user, not simply health providers). While many patients like the idea of maintaining their own EHR, or at least having access to it from their computers and handheld devices, they are also vocal in their opposition to online access unless it can be guaranteed that such access will come with strict privacy controls.

In 2013, Fernández-Alemán et al published a systematic literature review in the Journal of Biomedical Informatics about the security and privacy issues associated with EHRs.

Differences between EHRs, EMRs and PHRs

  • An electronic health record (EHR) is built to share information with other health care providers, such as laboratories and specialists. An EHR contains information from all clinicians involved in patient care and authorized clinicians can access the information they need, to provide care to that patient.
  • An electronic medical record (EMR) is a digital version of paper charts in a doctor’s office. An EMR contains notes and information collected by and for clinicians in that office.
  • A personal health record (PHR) contains the same types of information as a electronic health record—diagnoses, medications, immunizations, family medical history, and contact information for providers—but it is designed to be set up and accessed by patients themselves.

EHRs and health informatics

Health informatics is a related discipline examining national and local infrastructure, standards and other issues affecting creation of EHR systems. It is standard practice that health records are made available via large clinical systems in hospitals and health care organizations. Generally they are closely monitored for security, what might be called 'silo'd' - ie. behind firewalls or private virtual networks. However, protections are never absolute due to data management in web 2.0. EHRs have not been easily or openly web-accessible but are seen to be increasingly important for health consumers wanting to manage their own care. EHRs are now seen by Microsoft and Google to be important enough for web users to warrant significant investments of time and money. (See Google health and Microsoft Vault projects).

Computer-based patient records were discussed in an early report of the Institute of Medicine. The 1997 report made a recommendation to form an Institute to promote and develop standards for CPRs. During a ten year run, the Computer-Based Patient Record Institute (CPRI) played an important role in promoting online health records. One of the early definitions for EPRs was "The electronic health record is a computer-stored collection of health information about one person linked by a person identifier."

  • University of Notre Dame professor explores attitudes about digitization of medical records

Free & open-source health records

The newest open example of providing access to information in patient records is OpenNotes. For several years, Microsoft HealthVault and other Health 2.0 services for consumers - such as the open source Dossia - Lifelong Personally-Controlled Health Record - have sought to help patients track their own personal health information as they move through the health system. The goal with health record projects is to make personal health information accessible and transportable - which is of benefit to both consumers and physicians. In addition to Dossia, the open source Tolven Healthcare integrates the three aspects of e-health: personal health information, information held by physicians and by health organizations using informatics platforms.

Data in an electronic medical record

  • Patient demographics
  • Medical history, examination and progress reports of health and illnesses
  • Medicine and allergy lists, and immunization status
  • Laboratory test results
  • Radiology images, x-rays, computed tomography - CTs, MRIs, etc)
  • Photographs, from endoscopy or laparoscopy or clinical photographs
  • Medication information, including side-effects and interactions
  • Evidence-based recommendations for specific medical conditions
  • A record of appointments and other reminders
  • Billing records
  • Eligibility
  • Advanced directives, living wills, and health powers of attorney

Issues

Interoperability

The many systems that co-ordinate the storage and retrieval of EHRs are complex and not wholly interoperable. Typically, they are made up of medical records from many systems, locations and/or sources. A variety of healthcare-related information may be stored and accessed electronically but not all storage and retrieval issues have been resolved, particularly those records with no descriptive or metadata.

Medical errors

Some studies suggest that EHRs reduce the incidence of medical errors. In one study, however, there was no difference between print and electronic systems over fourteen different measures, there was improvement in 2 outcome measures, and worse outcome on 1 measure. (See also Electronic health record use and the quality of ambulatory care in the United States. Linder et al. Arch Intern Med. 2007.)

Increased efficiency

EHRs are said to increase physician efficiency, to reduce costs and to promote standardization of treatment and patient care. Even though EHR systems with computerized provider order entry - some health librarians will remember this as CPOE - have existed for more than 30 years, fewer than 10 percent of American hospitals currently have fully integrated systems. This statistic is even lower in the Europe, the United Kingdom and Canada.

Confidentiality & privacy

Privacy is a right for all Canadian citizens who find themselves interacting with health professionals. The right to privacy is protected by professional codes of ethics, provincial and federal legislation and the Charter of Rights and Freedoms. The federal government created the Personal Information Protection and Electronic Documents Act (PIPEDA) which established principles for the collection, use and disclosure of information that is part of commercial activities in health, such as private lab results and pharmacies. PIPEDA has been superseded by provincial legislation in many provinces in Canada, including in Ontario where there is a separate Personal Health Information Protection Act.

Overlap in terminology

Multiple terms and overlapping definitions have been used to explain electronic patient records. (see Status Report 2002: Electronic Health Records. Medical Record Institute 2002). Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some medical informatics users assigning the term EHR to a global concept and EMR to a discrete localized one. EHR and EMR are often used interchangeably. An EHR system is also often abbreviated as EHR or EMR. Health information technology is a broader term used to describe computer-based electronic aids to healthcare delivery.

Standards

  • EN 13606, a set of communication standards for EHRs
  • CONTSYS (EN 13940), supports continuity of care record standardization
  • HISA (EN 12967), a services standard for inter-system communication

The role of health librarians

Health librarians should be finding ways to link primary research, medical evidence and individual EHRs. Several American health librarians have written about the possibilities represented by EHRs, particularly in collocating relevant medical literature with health issues arising within the records themselves. Some health librarians are already working with health professionals on various hospital committees in implementing EHRs with links to electronic library collections - but health librarians are not universally involved.

Some health librarians suggest that we have some advocacy work ahead of us before we get involved in EHRs. First, we have traditionally not ventured into the private realm of patient records; we may want to work even more closely with physicians and other health professionals to demonstrate why including us in building EPR systems is important; perhaps we can link the notion of providing library services and building EPR systems to hospital accreditation issues. Where patient safety and confidentiality are concerned, perhaps health librarians can help to build EPR systems by masking individual patient identities.

Canadian context

The development and implementation of effective, interoperable EPR solutions in Canada is a priority of Canada Health Infoway. The Infoway is an independent, not-for-profit corporation initiated as the result of the Canadian federal government's announcement in September 2000 to accelerate the development and adoption of modern information technologies in health. In 2011, the Government of Canada released the report entitled "Electronic Health Records in Canada—An Overview of Federal and Provincial Audit Reports" which provides some insight into the introduction of EHR systems in Canada, and several associated issues such as privacy and security.

In 2011, Barron & Manhas wrote about the possible participation roles that health librarians could undertake within their institutions with respect to EHR implementation.

Video

References

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