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Electronic health records (EHRs) are digital records of a patient’s medical history, stored in databases and accessed via software or web and mobile applications. They contain a patient’s medical history, visit notes, diagnoses, treatment plans, medications, allergies, immunization records, lab test results, radiology images, and other clinical data. EHRs are an essential tool for doctors and other healthcare providers to deliver better quality care to their patients, improve safety, and enhance the efficiency of their practice.
EHRs are created and maintained by healthcare providers, such as health clinics, private practices, and hospitals. They are designed to be secure and accessible only to authorized healthcare professionals who are directly involved in a patient’s care. Complex rules, laws, and data standards developed over decades help ensure that patient data can be securely shared by multiple organizations and clinicians, enabling better coordination among everyone involved in a patient’s care.
EHRs work by gathering and storing patient data in a digital format. Data can come from a variety of sources, including healthcare providers, medical devices, and patients themselves. The data is entered into the EHR system in several ways, but most frequently is captured via direct entry into a software user interface, which can be on a computer or mobile device. Other ways of capturing data include importing scanned paper documents and other file types, direct or wireless interfaces with medical devices, and via data feeds from other medical systems, using an industry-standard format like HL7.1 The information is stored in a database designed to be secure and accessible only to authorized users.
EHR systems allow clinicians to access and share patient information much more quickly and easily than with paper patient records. This can improve coordination of care between different healthcare providers and reduce the risk of medical errors. For example, a patient with diabetes might have a primary care doctor, an endocrinologist, a nephrologist, a neurologist, a cardiologist, a nutritionist, and a pharmacist, as well as various nurses and other clinicians. Those who can review the patient’s up-to-date medical records before or during appointments are able to provide that patient with a more accurate picture of their health. Another benefit is that the patient doesn’t have to be burdened with remembering details from recent visits with other providers.
Nobody should suffer or die just because at some point medical information was missing.
Modern EHRs such as CGM APRIMA EHR and Practice Management can apply rules to the data they contain in order to automate routine tasks and help users make decisions about a patient’s care. The rules can be simple, such as health screening reminders, appointment reminders, prescription refills, and lab test orders. They can also be complex clinical decision support rules that recommend diagnostic and treatment pathways, given the patient’s specific circumstances. Application of these rules helps improve efficiency and reduce administrative and decision-making burdens for healthcare providers, allowing them to spend more time in consultation with their patients.
To ensure the security and privacy of patient data, EHR systems use multiple layers of security. This may include encryption, firewalls, access controls, and audit logs. EHR systems are also subject to strict regulatory requirements, such as the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH), which govern the collection, use, and disclosure of patient health information.
The terms "EHR" and "EMR" are often used interchangeably, but some would say there are still differences between the two.
A somewhat older term used when medical records were first being converted from paper charts, an “electronic medical record” is technically more limited in scope than an “electronic health record.” Originally, an EMR was strictly a digital record of a patient's medical information created and stored by a single clinician, practice, or provider organization and typically includes medical history, medications, allergies, immunizations, laboratory results, diagnoses, visit notes, and treatment plans. EMRs were designed to be used within a single healthcare organization, such as a hospital or clinic. Data from other sources was very limited and if a patient had access to it at all, it was usually view only.
An EHR is a digital record of a patient’s medical information that contains data contributed by multiple healthcare providers and organizations. EHRs are designed to be shared between providers and organizations, allowing for more efficient communication and better coordination of care. They typically include a more comprehensive view of a patient’s medical history, including data from patients and their connected devices in addition to the clinician-supplied data mentioned above. Today’s technology enables us to transfer data more quickly and easily between systems, driving the change in terminology from EMR to EHR.
There are several different types of EHR systems, many of which have overlapping features and capabilities.
Some common types of EHR systems include:
An ambulatory EHR is designed for use in outpatient settings including doctors’ offices and health clinics. A good ambulatory EHR system includes features such as appointment scheduling, patient registration, and medication management. Ambulatory EHRs are sometimes interfaced with practice management systems to help improve the workflow in a clinical practice. In the case of CGM APRIMA, the EHR and practice management system can be combined in one integrated platform to create a seamless experience for practices.
This type of EHR is used in hospitals and other inpatient healthcare settings. Inpatient EHRs have often evolved from older electronic medical records systems that were implemented over the last several decades. This complex process may have involved overlaying a newer software or web/mobile user interface onto the old databases that contain all the hospital’s patient data. Inpatient EHR systems typically include features unique to inpatient settings, such as bed management, electronic medication administration records, and nursing documentation.
A patient portal is not an electronic health record by itself but is typically a web or mobile application that connects to a healthcare provider’s EHR system, allowing patients to view most of their medical record. Many patient portals allow the patient to add information from other healthcare visits, such as a COVID or flu vaccination at a pharmacy, and to request changes in the case of an error in the data. Other features include secure messaging with the clinician, scheduling and viewing appointments, and managing insurance information and payments.
With an efficient patient portal such as CGM APRIMA, patients are able to pay their statements more quickly and easily, driving down costs and speeding up reimbursements for doctors and their practices. It also benefits practices as they’re not spending extra time on the phone with patients, and patients get quicker service.
A personal health record, or PHR, is a limited application that contains important basic health information that is managed by patients themselves. Like all healthcare technology, PHRs evolved over time from the paper documents patients used to receive at doctors’ offices to software applications that patients might have installed on their personal computer. Now, personal health records are at the fingertips of almost everyone in the form of health apps that come standard on their smartphones. PHRs typically allow a person to record information that can prove critical in emergency situations, like demographic data, emergency contacts, blood type, allergies and medication dosages, immunizations, prior diagnoses and surgeries, and a living will or advance directives. Many now also allow users to record health goals, nutrition and exercise, and readings from home medical devices.
Practice management software helps healthcare practices manage administrative tasks such as appointment scheduling, patient check-in, health insurance verification, claims processing, patient billing and other forms of patient communication, and running reports related to the overall operation of the practice. They are also not technically EHRs but in the case of CGM APRIMA can be offered with the EHR as a single, integrated solution. In fact, CGM APRIMA is versatile enough to interface with a user’s existing practice management system or come installed with its own, integrated solution.
Practice management EHRs may also include features such as patient portals, automated appointment reminders, and electronic billing and payment processing.
A population health EHR is usually not an EHR by itself but rather an application or module that integrates with electronic health records systems. Population health EHRs use the data in patient records to allow health professionals to gain insight into the health of entire populations, such as patients with chronic conditions or residents of a particular geographic area. They are used by large health organizations ranging from hospital systems to insurance companies to regional and national authorities like the Centers for Medicare & Medicaid Services (CMS). Population health EHR features like analytics and reporting, care coordination tools, and population health management modules help these large organizations to understand health and disease trends among populations and to develop targeted campaigns to address their needs and improve outcomes.
EHRs have several advantages over traditional paper-based records. They are more efficient, accurate, and complete than paper records. Some benefits of EHR systems are better quality of care, improved efficiency and cost savings, and endemic illness tracking.
EHR systems are designed to improve the quality of care that patients receive. They enable healthcare providers to access more complete and accurate patient information, which can help them make better treatment decisions. EHRs also enable clinicians to share information with other healthcare providers, which can improve coordination of care and reduce the risk of medical errors. For example, using evidence-based rules that have been incorporated into the system, EHRs can alert healthcare providers to potentially harmful drug interactions or allergies, reducing the risk of medication errors.
Additionally, the improved patient communication that EHRs enable can motivate patients to participate more fully in their care by collaborating with their doctors in decision making, showing up to appointments, and taking more responsibility for medication and lifestyle decisions that affect their health.
Electronic health records have the potential to make healthcare delivery more efficient and less costly because they reduce the amount of time and human resources required for administrative tasks such as charting, billing, and scheduling. Healthcare providers can easily access and share patient data, reducing the need for duplicative testing and improving care coordination. This can lead to improved patient outcomes and reduced healthcare costs.
In addition, EHRs can reduce the risk of medical errors, which can be harmful and costly to patients. By providing accurate and up-to-date patient information, EHRs help healthcare providers make more informed treatment decisions, reducing the likelihood of such errors.
EHRs also reduce costs associated with paper records, such as storage and retrieval costs. Electronic records are easier to store and access, reducing the time and resources required for record-keeping.
Electronic health record systems are an effective tool for tracking endemic illnesses. Endemic illnesses are diseases that are constantly present within a particular region or population, such as malaria in areas with tropical climates. EHR systems enable healthcare providers to identify patterns, track outbreaks, and implement preventive measures to control and reduce the spread of illnesses.
One of the key benefits of EHR systems for tracking endemic illnesses is their ability to aggregate data from multiple sources. This includes data from healthcare providers, public health agencies, and other sources. By integrating this data into a single database, EHR systems enable healthcare providers to access a complete and up-to-date picture of an endemic illness in a particular region or population. This information can be used to develop more effective prevention and treatment strategies.
As a practice evaluates potential EHR solutions, the unique benefits of a platform like CGM APRIMA EHR and Practice Management become apparent.
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EHR systems are used by a variety of healthcare professionals at organizations including hospitals, clinics, private practices, nursing homes, health insurance companies, and other related organizations. Doctors, nurses, pharmacists, and other health providers who are directly involved in patient care use EHR systems to document patient information, track medical history, and develop treatment plans.
Healthcare providers use EHR systems in a variety of ways to improve patient care and manage patient information more efficiently. Here are some of the most common ways that healthcare providers use EHR systems:
Physicians and their staff use EHR systems to document patient information including medical history, diagnoses, medications, and treatments. This information is stored in a centralized database which can be accessed by authorized healthcare professionals who are directly involved in the patient's care.
EHR systems can give healthcare providers real-time access to patient information, which informs treatment decisions and improves patient outcomes. For example, if a patient has a history of allergies or adverse reactions to certain medications, this information can be easily accessed through the EHR system, helping the provider to avoid prescribing potentially harmful medications, and the EHR can suggest alternative therapies. The application of evidence-based clinical decision support rules further helps providers make knowledgeable treatment decisions with and for their patients2, improving quality of care.
Care coordination, also known as case management, disease management, or patient navigation, is the sharing and organization of information concerning a patient’s care and is most often spearheaded by nurses and social workers. This is especially useful for older patients and those with chronic conditions who see multiple providers for complex problems and often have trouble navigating the healthcare system. EHR systems improve care coordination by allowing healthcare providers to share patient information securely and efficiently.
Since a lack of information can be frustrating for both clinicians and patients, EHR vendors, such as CompuGroup Medical, have introduced features that allow for additional, more convenient modes of communication between patients and providers. Doctors and their staff can use secure messaging in EHRs to schedule appointments, remind patients they are due for screenings or immunizations, and exchange information and images about non-emergency health concerns. Since the COVID-19 pandemic, many providers and patients also prefer to meet virtually using the telehealth technology available in applications such as CGM APRIMA.
EHR systems can generate reports and provide analytics on patient data, which can help healthcare providers identify patterns, track outcomes, and make data-driven decisions. This information can be used to develop more effective treatment plans, improve the quality of care, and participate in population health efforts.
Electronic health record systems are used by providers in various healthcare settings including:
EHRs are used extensively in primary care settings to manage patient information, track medical history, and monitor health outcomes. Primary care doctors use EHRs to document patient visits, prescribe and track medications, order laboratory tests, develop treatment plans, and communicate with patients.
Specialty care teams, such as those that provide cardiology, endocrinology, and pain management services, also use EHR systems to manage patient information and develop treatment plans. Specialty care providers generally use EHR systems that are tailored to their medical specialty. These tailored systems could be designed from the ground up for that specialty or they could be created by modifying a general use EHR with workflow customizations and templates. Robust EHRs such as CGM APRIMA will have content tailored for multiple specialties. On one hand, this kind of EHR is built in such a way that providers will only see content relevant to their area of practice, while on the other hand, having all the content within the system means that a multi-specialty group has everything it needs.
EHR systems are also used in behavioral health settings such as inpatient and outpatient mental health clinics and substance abuse treatment centers. Behavioral health providers use EHRs to document patient information, track treatment progress, and monitor medication adherence. Although EHR adoption among mental health providers has lagged behind adoption among other health providers, the sharp increase in behavioral health needs laid bare by the opioid crisis and COVID-19 pandemic has highlighted the need for behavioral health EHRs to become more integrated with ambulatory and inpatient EHRs3.
Electronic health records are particularly useful in emergency medicine settings where providers must make rapid, often life-or-death decisions based on limited information. Emergency physicians need their EHR systems to allow rapid, real-time access to patient information and to help coordinate care while patients transition to other hospital departments or care settings. They require tools like speech-to-text or drag-and-drop to quickly enter patient data.
Public health agencies also use EHR systems to monitor disease outbreaks, track vaccination rates, and analyze healthcare data. EHR systems can provide public health officials with patient information across different populations and, for example, alert them when certain people may need a vaccination. This can help agencies develop more effective strategies for preventing or mitigating future outbreaks and epidemics.
EHR systems are designed with security and privacy features to protect patients' confidential medical information. EHR software developers use a variety of security measures to safeguard patient data, including encryption, firewalls, access controls like two-factor authentication, and audit logs. To mitigate the risk of cyberattacks, EHR systems are constantly monitored and updated with the latest security protocols to stay ahead of potential threats.
Additionally, healthcare organizations and providers must adhere to strict regulations and standards regarding the security and privacy of patient health information. For example, in the United States, healthcare organizations are required to comply with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA sets standards for the security and privacy of protected health information (PHI). The more recent Health Information Technology for Economic and Clinical Health Act (HITECH) expanded the definition of PHI, established penalties for non-compliance, and required notifications to interested parties in the event of a data breach. Ultimately, EHR systems have proven to be more secure than exchanging patient data on paper and consensus is that the benefits of implementing them far outweigh the risks.
EHR systems make healthcare easier for both patients and healthcare providers. Here are some ways EHRs can improve the healthcare experience:
When an EHR is hosted by a vendor, this also decreases the practice’s IT burden and cost in an increasingly complex technology environment. Still, because some doctors may practice in settings such as patient homes or nursing homes where internet connectivity is unreliable, it’s important to have a fall-back plan.
CGM APRIMA uses its unique replication technology, for example, to allow a provider to see patients with or without an internet connection. Using replication technology, CGM APRIMA can save new data when no internet connection is available, uploading it later on when the connection is restored.
Transitioning to an EHR system is a complex process, but most healthcare stakeholders agree that it is well worth the effort. If the process seems daunting, the experts at a trusted source such as CompuGroup Medical can help make it easier.
Here are some general steps that organizations can take to transition to an EHR system:
Before implementing an EHR system, it's important to assess your organization's readiness for the change. This includes evaluating factors such as the organization's current technology infrastructure, staffing levels, and workflows.
After a readiness assessment, it's time to choose an EHR vendor that meets the organization's specific needs. This involves researching vendors, evaluating EHR features, comparing costs, and talking with current clients.
Once an EHR vendor has been chosen, the vendor should work with your organization to develop a project plan that outlines the steps required to successfully implement the EHR system. This includes planning for system configuration, data migration, and training.
Proper training is critical to the success of an EHR implementation. Your vendor should develop a comprehensive training plan that includes all staff members who will be using the EHR system. The EHR vendor should provide thorough documentation and software user guides and schedule training sessions that work around the schedules of users in a busy practice. Training videos can also be helpful to refer to after the initial training has concluded.
Mature EHR companies and practices also recognize that learning is ongoing. In order to best benefit from all the capabilities of their EHR system, practices should set aside time to invest in ongoing training and attend vendor webinars, review online materials published in client support portals, or even attend user events.
Adopting an EHR system requires careful planning, training, and implementation to ensure a smooth transition. Having the right EHR vendor for your needs can make the process much easier and help your organization begin realizing the benefits of the system.
Every EHR system requires ongoing monitoring to evaluate its effectiveness. This includes evaluating how the system is being used, identifying areas for improvement, and making necessary adjustments to ensure the system is meeting the organization's needs.
So, what is an EHR? Electronic health records are a critical tool for healthcare providers to deliver better quality care to patients, improve safety, and enhance efficiency. EHRs enable healthcare providers to access complete and accurate patient information which can help them make better treatment decisions and involve patients in their own healthcare journey.
EHRs enable clinicians to share information with other healthcare providers which can improve coordination of care and reduce the risk of duplicative tests and medical errors. As technology has advanced, EHRs have become an indispensable tool for all types of healthcare professionals.
Ready to find the right EHR for your practice?
Contact us to learn more about CGM APRIMA EHR and Practice Management.
1 About Health Level Seven International | HL7 International. https://www.hl7.og/about/
2 Sutton, R.T., Pincock, D., Baumgart, D.C. et al. An overview of clinical decision support systems: benefits, risks, and strategies for success. npj Digit. Med. 3, 17 (2020). https://doi.org/10.1038/s41746-020-0221-y
3 U.S. Department of Health & Human Services. (2022, December 2). HHS Roadmap for Behavioral Health Integration [Press release]. https://www.hhs.gov/about/news/2022/12/02/hhs-roadmap-for-behavioral-health-integration-fact-sheet.html
