ELECTRONIC HEALTH RECORDS 2

Electronic Health Records

Electronic health records (EHR) are patient centred records that provide instant and
secure information to authorised personnel for purposes of improving quality of care provided to
patients. They are considered as digital versions of paper charts of patients. Paper charts are
medical records of a patient that contain important information such as treatment plans,
medications, tests and lab results, radiology images, progress notes, vital signs, and
demographics. Thus, like paper charts the purpose of electronic health records is to have a
centralized system with all relevant patient data which can be accessed by anyone treating the
patient. EHR, therefore, allows a healthcare professional to have a very broad view of a patient’s
health. It is expected that with such a broad view, the healthcare professional is going to provide
better quality care in a more efficient and less costly manner.
Components of EHR

Patient management component
Patient management component is required when a patient is registered and admitted in a
healthcare facility, transferred to a different facility or discharged (Ben-Assuli, 2015). Important
patient information required during registration includes contact and insurance information as
well as demographics of the patient. The first time that a patient registers in an EHR they acquire
a unique identification number. This number is called the patient medical record number (MRN)
(Ben-Assuli (2015). Each time the patient subsequently has an ‘encounter’ with the healthcare
facility another number is generated which is unique to the patient.
Clinical component

ELECTRONIC HEALTH RECORDS 3
This component has multiple sub-components within it. One of them is electronic
documentation. This sub-component includes notes of providers about a given patient such as
their physical state, history, discharge summaries, and previous consultations, and operative
notes (Ben-Assuli, 2015). In preparing these notes, providers use a variety of tools. These tools
include transcription services, speech recognition, and templates.
Another sub-component is Computerized Provider Order Entry (CPOE). This
subcomponent allows healthcare providers to enter into a computer all orders that are needed for
effective patient management (Ben-Assuli, 2015). In addition to CPOE, clinical component has
pharmacy system which is used to perform functions such as maintaining formulary of drugs,
cross-checking all orders that providers place, and filling prescriptions (Ben-Assuli, 2015).
The last sub-component is the nursing system. The system allows for collection of all
important patient information that providers need in order to better take care of the patient (Ben-
Assuli, 2015). The system also includes barcode medical charting, nursing documentation, and
medical administration record, better known by its acronym (MAR).
Billing system
During different stages of caring for patients charges are generated and claims sent to the
patient’s insurance company for payment. The billing system in EHR captures all these charges
as they are generated and tracks their payment (Ben-Assuli, 2015).
Radiology information system

ELECTRONIC HEALTH RECORDS 4
This system, together with Picture Archiving and Communications System (PACS), is
used to manage workflow of patients in a hospital. It also used to manage medical images of
patients (Ben-Assuli, 2015).
Lab component
The lab component serves two main functions. The first one is to capture all patient
results from the hospital’s lab machines. The second one is to integrate the lab machines, billing
and orders with the rest of EHR (Ben-Assuli, 2015). While the lab component is often integrated
with EHR, it can also act as a stand alone product (Ben-Assuli, 2015).
EHR Contributing factors

Making a health system such as EHR to be adopted requires widespread acceptance
among professionals in the healthcare field such as physicians, medical officers, nurses, and lab
technologists, and managers/administrators of healthcare facilities.
The increasing adoption of EHR shows that it has many benefits that make it worth
adopting. One of them is improvement in patient care. EHR allows health practitioners caring for
patients to quickly access all the relevant patient data. With such data they can care for the
patient in a more effective manner (Adler-Milstein et al., 2015). They can also better coordinate
their efforts with those of other patient care providers. Such data, therefore, allows the physician
or medical personnel to better take care of the patient through better decision-making including
the kind medications to prescribe. Having more data about a patient also reduces chances of
making medical errors (Adler-Milstein et al., 2015). The net result of all these is to improve the
quality of care that a patient receives.

ELECTRONIC HEALTH RECORDS 5
Apart from improved care patients also enjoy convenience and efficiency. With EHR in
use patients do not need to manually fill into papers various sets of information. Once their
information is collected, the healthcare facility only updates it (Kruse et al., 2016). Thus, patients
and hospital staff save time that they could have used for filling data. Additionally, they can have
their care providers give e-prescription based on the data available to them (Kruse et al., 2016).
The patient, therefore, does not need to rush to hospital any time they need prescription for a
given condition to be made.
For healthcare facilities EHR is a great cost-saving tool. For instance, storage, re-filling
and transcription costs significantly reduce when using EHR (Adler-Milstein et al., 2015). There
are also fewer billing errors which saves the healthcare facility some money. Additionally, the
use of electronic records saves the care facility resources required to maintain a manual system
with all the accompanying paperwork.

Ways of measuring EHR parts

EHR has numerous benefits to a healthcare facility but how does one measure the
effectiveness of each part? Since EHR systems are integrated with each other it is hard to
measure each part as if it is a stand alone part. The system is, therefore, measured as a whole to
assess its contribution to quality of care provided by a given facility. Some of the measures
include cost, patient experience, and process outcome (Kruse et al., 2016). A good EHR system
should be able to lead to better patient care with patients enjoying higher quality of care. It
should also improve their experience. This include convenience and saving them time. For the
hospital EHR can be measured by how much it reduces time for, among other things, the time
taken to retrieve important patient documents or health data (Kruse et al., 2016).

ELECTRONIC HEALTH RECORDS 6
Even though it has been in use for just over a decade, EHR has had a largely positive
effect on the healthcare industry. It has significantly improved the quality of care that patients
receive, increased efficiency and convenience for patients, and led to less billing errors in
hospital among many other benefits. At the heart of EHR is the realization that availing all the
important patient data that a care giver needs leads to better decision-making about a patient’s
health and improves the quality of care that the patient receives. As its benefits have become
apparent for both patients, healthcare professionals, insurance companies and administrators of
healthcare facilities, EHR’s adoption has been on the rise. This upward trend is likely to continue
for the foreseeable future.

ELECTRONIC HEALTH RECORDS 7

References

Adler-Milstein, J., DesRoches, C. M., Kralovec, P., Foster, G., Worzala, C., Charles, D., & Jha,
A. K. (2015). Electronic health record adoption in US hospitals: progress continues, but
challenges persist. Health affairs, 34(12), 2174-2180.
Ben-Assuli, O. (2015). Electronic health records, adoption, quality of care, legal and privacy
issues and their implementation in emergency departments. Health policy, 119(3), 287-
297.
Kruse, C. S., Kothman, K., Anerobi, K., & Abanaka, L. (2016). Adoption factors of the
electronic health record: a systematic review. JMIR medical informatics, 4(2), e19.