Key capabilities and core functions of electronic health records

Electronic Health Records

Since the introduction of electronic health records, the U.S. government, information systems developers and associations of healthcare providers have worked toward establishing a uniform, integrated system of electronic health records. This collaboration is designed to significantly enhance patient safety and treatment, as well as effectively assist in the management of public health issues such as disease. While some health practitioners report difficulties in dealing with electronic health records, it appears that continued efforts and refinements are gradually solving problems of computerization and are improving healthcare.

Characteristics and Components of Efficient EHR

In 2003, the Institute of Medicine released a report called Key capabilities of an electronic health record system. In this consensus report, the Institute stated that an electronic health records system should consist of:

"a longitudinal collection of electronic health information for and about persons;

2. [immediate] electronic access to person- and population-level information by authorized users;

3. Provision of knowledge and decision-support systems [that enhance the quality, safety, and efficiency of patient care] and support for efficient processes for health care delivery" (Institute of Medicine, 2003, p. 4).

Flowing from these basic ideas, the Institute identified 8 "core care delivery functions" (Institute of Medicine, 2003, p. 7), later adopted within the 2004 National Research Council's Patient safety: Achieving a new standard for care (National Research Council, 2004). Addressing many health-related issues, including electronic health records, the Council addressed the issues of: continuity of a patient's care among multiple providers; effective communication between the patient and his/her healthcare providers, and among multiple providers; coordination of care due to multiple healthcare professionals' comprehensive and easy access to the patient's history and current treatment(s); accountability among healthcare professionals for accurate data collection, entry of data into the electronic systems and compliance with reporting requirements; basic categories of vital information that should be included in the electronic records system.

The 8 core functions are:

1. Health Information and Data: In order to make well-grounded treatment decisions, the healthcare professional must have prompt access to important patient information, such as the diagnoses, any pertinent allergies, lab results and prescribed medications;

2. Result Management: In order to optimize the efficiency of patient care and enhance the patient's safety, all healthcare professionals can promptly receive and review all test results;

3. Order Management: In order to make orders more legible and avoid repetition, thus making orders speedier, prescriptions, tests and various healthcare treatments are entered into a computerized system;

4. Decision Support: To comply with "best clinical practices" for screenings, prevention and drug interactions, electronic records can automatically issue notices, cues and warnings;

5. Electronic Communication and Connectivity: In order to enhance care continuity, increase the speed and accuracy of diagnoses and avoid negative impacts on patient care, the electronic system increases the effectiveness, security and accessibility of medical records, information shared between healthcare professionals and data obtained directly from patients;

6. Patient Support: Patients with chronic illnesses requiring self-monitoring and self-testing can easily review their records, education about their illnesses, and other tools that help them deal as effectively as possible with their diseases;

7. Administrative Processes: Hospitals and clinics can enhance their scheduling, efficiency and the timeliness of their services through computerized administrative systems;

8. Reporting: Healthcare professionals can comply more efficiently with the reporting requirements of the federal government, applicable state government and private associations, which also assist in federal, state and private examination and oversight regarding public safety and disease issues.

Case Study Showing Advantages and Drawbacks of Electronic Health Records

The source of this empirical information is a nurse practitioner in Psychiatry who: practiced Registered Nursing in hospitals in the States of New York and Rhode Island for 26 years; obtained her further degrees/certifications/licenses to work as a nurse practitioner and prescribe psychotropic medications; has worked as a nurse practitioner for hospitals and clinics in the State of Rhode Island for the past 12 years; uses both paper and electronic health records in her practice. In "Katherine's" experience, electronic medical records have all the good and bad characteristics of computers; in addition, regulations/practices lag behind the technology and ultimately create more work. Electronic medical records are good in that: she can more easily track trends for each patient, which is very important when monitoring and adjusting prescriptions; a stable patient's prescriptions can be refilled with a single computer click; she can access other professionals' notes and lab work, which saves her time and saves her patients' money by avoiding duplication. The current drawbacks of electronic medical records are: at this point, the computer software systems are so poorly programmed and there is so little money available for updated software that she must click screen after screen for each patient, which takes considerably more time; when power goes down, which it recently did due to a Winter storm, they have no access to some of their patients' most vital information and had to reschedule all appointments; patients must give written permission to integrate all their records and only 10% of her patients have done so, which means that she must usually work with a mix of computer systems and written records; she can hand-write a scrip in seconds but is now required to use a slower computer system, then back it up with phone calls to pharmacists and handwritten or typed, signed records. Having worked with electronic records for approximately six years, Katherine believes that there will come a day when electronic medical records are as easy and widespread as laptop computers; however, there are significant "bugs," delays and outdated regulations that currently create more time-consuming administrative work and treatment difficulties.

Conclusion

Governmental bodies, Information Technology professionals and healthcare professionals are working together to toward the ideal of a streamlined industry-wide system of electronic records. Though there are still barriers and issues that make the use of electronic records more difficult at times, these multi-disciplinary professionals continue to refine and adapt these systems. Presenting problems inherent in new computer systems, pockets of resistance and regulations/requirements that lag behind technology, healthcare professionals nevertheless envision the day when electronic health records become a seamless and highly effective tool for excellent patient care and lower healthcare costs.