Electronic Health Records

What are electronic health records?

Electronic health records (EHRs) are real-time, electronic versions of patient medical history. They provide medical records and historical data to authorized users who don’t have access to the physical copies of these charts. Also known as electronic medical records (EMR), they include diagnoses, treatment plans, prescribed medications, test results, immunization records, and allergies. 

Medical professionals use EHR software to seamlessly input and access data for the best patient experience. These tools also allow patients to log into their profiles and conveniently access their own medical records. 

What information does electronic health records contain?

EHRs comprise a broad range of information about a patient’s health and medical history. While the amount of information and specific details varies depending on the system and healthcare provider practices, EHRs generally include the following.

• Patient demographics: All EHRs list patient demographic information, like the patient’s full name, date of birth, gender, physical address, phone number, email address, and emergency contacts. Providers and patients should work together to ensure this information is accurate and updated regularly.
• Vital signs: During appointments, medical staff collect vital signs such as blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. This information is recorded for the doctor or care provider to review. 

• Medical history: Healthcare professionals must thoroughly understand a patient’s medical history to offer them the best treatment and care. Medical history notes include past illnesses and conditions, surgeries, and immunization records.

• Allergies: Care providers need to be aware of their patients’ allergies for safety purposes. It’s also critical to note other allergies if a patient arrives at a visit due to an allergic reaction. 

• Medication history and information: Understanding a patient’s prescriptions, reasons for use, and dosage helps give doctors a holistic understanding of successful and unsuccessful treatment plans. Monitoring medication usage is necessary to prevent drug interactions and other adverse side effects.

• Clinical notes: Many EHRs contain historical notes and discussion points for review. They make sure patients and their providers have the same information.
• Laboratory and diagnostic results: Blood tests, urine tests, imaging reports, x-rays, CT scans, and MRIs count as examples of results.

Advantages of electronic health records

Accessing and exchanging health information electronically benefits medical providers and patients receiving care. Below are some of its key advantages.

• Better access to patient information: Healthcare workers make better-informed decisions during treatment when they have access to comprehensive, real-time electronic health records . Additionally, providers can rely on these records in order to care properly for new patients.

• Operational efficiencies and time savings: Updating, filing, and maintaining paper records is a heavy administrative task. Automated processes and EHRs reduce the administrative burden of physical paperwork. 

• Enhanced clarity and legibility: Illegible handwriting in handwritten records can lead to inaccurate patient information and create challenges for providers and patients. EHRs ensure consistency and readability across records and systems, reducing the likelihood of errors or spreading misinformation. 

• Better patient engagement and empowerment: Incorporating EHRs with patient portals into a medical practice lets patients access their information, communicate with their providers, and engage proactively in their overall care plans and treatment.. 

• Robust data security and privacy: While there are data security and privacy risks when using EHRs, electronic systems can generally provide improved security measures more than paper recordkeeping. EHRs can be restricted to specific permissions and the systems can track changes. Encryption technology helps protect sensitive data from being used without permission. 

Best practices for maintaining electronic health records

Care providers should follow these best practices to verify data accuracy, patient safety, privacy, and excellent service when using EHRs. Some essential best practices include these defined here.

• Provide comprehensive and ongoing user training: Companies should prioritize training all users, including administrative staff, healthcare providers, and support staff.. Ongoing support, accessible resources, and a dedicated knowledge team all contribute to the successful use of EHRs.

• Implement robust security practices: EHRs contain personally identifiable information (PII) and other private data, so they must be secure. Companies should utilize multi-factor authentication for logins and consider setting up role-based access controls to safeguard the system.
• Conduct regular audits: Companies need to regularly review audit trails to monitor user activity within EHR systems. Teams should develop processes for routinely conducting internal audits to see the best results. Investigate any suspicious or unauthorized activities promptly to prevent misconduct. 

Learn more about electronic case report forms (eCRF) that allow clinical investigators to digitally collect data from clinical research participants.