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Electronic health records have been around since the late 1970s, but they’ve only recently begun to boom in the health care world. In this lesson, learn about the definition, history, and benefits of EHRs.

Health Records: Paper or Electronic?

Susan’s 80-year-old father has reached the point where he can’t live alone anymore, and he’s coming to live with her. One part of the process is having her father’s medical records transferred to the doctor’s office down the street. At the office’s records department, she’s asked if her father’s previous doctor used electronic or paper medical records.The Centers for Disease Control and Prevention estimated that only 78% of doctors’ offices use electronic health records as of 2013. The remaining practices still keep medical records the old fashioned way: on paper and stored in filing cabinets.

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Susan calls her father’s doctor’s office and finds out that his records are kept in several large folders. It turns out there will be a fee to translate his paper history to an electronic health record (or EHR), which is a file contains the same information as a paper health record but stored in digital format.In addition to the doctor’s notes, the EHR provides information about the patient’s x-rays, medications, immunizations, allergies, lab results, diagnoses, and treatment plans. It’s meant to be a comprehensive overview of the patient’s history to aid physicians in making the most informed decisions possible.

The secretary explains that the EHR makes recording, searching, and transferring her father’s medical information much more efficient. When the office turned the paper record into an electronic health record, storage space and information loss were both cut drastically, and the average time to get a specific medical record was reduced significantly!

Origin of the Electronic Health Record

This has Susan wondering when the EHR was first invented and used. A quick Internet search revealed that the EHR has its roots in the 1960s, when Dr. Larry Weed came up with a related idea, the problem oriented medical record.

While doctors at the time typically recorded only their diagnosis and treatment plans, this system called for a more complete record that included x-rays, test results, and other information. The idea was that the patient could take that record to a different doctor for a second opinion without having to go through the entire diagnosis process again.This new type of record was followed up by the first EHR system, which was introduced in 1972 by the Regenstreif Institute. It was lauded as a major health care advancement at the time, but it took decades for hospital systems to embrace this technology. Even today, EHRs are widespread but not universal.

Why is this? The major reason that some small practices don’t use EHRs is that costs are often perceived as high. Implementing and maintaining a system can seem like a lot of money to a small practice. After all, providers generally must buy the services and products of an EHR vendor, pay for the server and computer equipment, and pay information technology professionals to perform upkeep on the system.

Larger practices can afford it and, in fact, end up saving money compared to the old paper and folder method. However, the barrier to implementation is so high that it often does not make financial sense for smaller practices to use this process.As the systems become more accessible, manageable, and affordable with advancements in technology, the number of completely digital providers is expected to rise. But for now, Susan is glad she chose a medical center that is part of a large university that has been using EHRs for decades.

Benefits of Transitioning

Those of us who rely on electronics daily may clearly see that EHRs are the smarter choice–they save space and time. But EHRs can also have a variety of benefits when it comes to the larger scope of health care:

  • They can lead to better care for the patient: If doctors have patients’ complete medical histories at their fingertips, they can make more informed decisions regarding diagnoses and treatment options. In turn, this can lead to improved care outcomes.

  • They can help patients become more involved in their care: EHRs can encourage patients to become more active in the health care process, which has been shown to lead to improved care outcomes. For instance, EHRs can be accessed online, allowing patients to view their medical records, check for lab results, and download prescriptions.
  • They can help coordinate care between medical staff: While some patients may only visit the doctor every six months, others have more serious issues that require seeing multiple care professionals throughout the year. EHRs allow these various medical providers to peek into real-time records of patients’ comprehensive medical records. That means physicians can make more informed care decisions, and patients spend less time re-taking exams they’ve already sat through.

  • They can increase efficiency and reduce costs: Using EHRs saves time and money. Practices reduce the time spent searching for paper files, which allows that employee to spend his or her time on more pressing tasks. Additionally, EHRs reduce the number of repeat procedures and tests. For example, if a patient had an x-ray taken two days ago at his or her general practitioner’s office, the patient would not need to take another time-consuming and expensive x-ray.

Meaningful Use and the EHR Movement

The Centers for Medicare and Medicaid Services encourages providers to use EHR systems through its Meaningful Use program. Eligible providers (those with a certain number of Medicare and Medicaid patients) must attest to the three stages of meaningful use, each of which requires meeting different objectives.

Those who don’t attest to meaningful use by the set deadlines must pay a penalty. In general, the focus of the program is to reach 100% digitization, use EHRs in meaningful ways (ways that best benefit patients and the health care system), increase interoperability (the sharing of information among providers), and reduce health care costs nationwide.

Lesson Summary

A patient’s electronic health record, or EHR, is the digitized version of a paper chart. It includes all available health care information concerning a particular patient, including lab results, height, weight, blood pressure, x-rays, and prescriptions – everything that a doctor has measured, diagnosed, or recommended. EHRs are easily searchable and transferable, but some small practices have yet to implement these systems due to the high cost of implementation and maintenance.

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