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Textbook of Digital Health

Your companion for studying digital health and informatics

Electronic Health Record (EHR) Systems

From Chapter 2 of the "Textbook of Digital Health" by Dr Chris Paton:

Before we begin our discussion of electronic health record (EHR) systems, we must first resolve some of the confusion differentiating between electronic medical record (EMR) and EHR systems. The standard definitions are that the EMR is the digital version of a paper medical record, i.e., the record written by the physician (and/or their staff) looking after a patient. The EMR, then, is usually a digital version of a medical record stored at the clinic where the patient saw their doctor. The EHR, on the other hand, is usually referred to as the type of system used across different clinics and even across more than one healthcare organisation. A national system of medical data about patients would therefore usually be called an EHR, whereas a small system used by a family doctor’s office would usually be called an EMR. This also implies that EHRs might rely on interoperability standards for sharing the records, meaning that they are often stored according to internationally agreed data templates such as the HL7 CDA or FHIR formats.

Like most things in digital health, however, the terms have evolved rather than been set down from above. This means that different vendors of systems might use the terms EMR and EHR differently, and many people working in the field might use the terms interchangeably. When I examine the Certified Health IT Product List (CHPL) database of usability studies of DHTs later in this thesis, we shall see that they are described both as EMR and EHR depending on the vendor.

One useful way of looking at what an EHR is supposed to do is by consulting the EHR system functional model (FM), developed by the health level seven (HL7) international standards body. The FM sets out the functions of EHR systems in a systematic way to support the development and assessment of EHR systems. The FM is described in three sections: 1) Direct Care functions; 2) Supportive functions; and 3) Information and Infrastructure functions.

The “Direct Care” functions of an EHR system (according to HL7) are those functions that are involved in the provision of individual patient care such as managing the clinical history (including allergy lists and medications), managing orders (such as lab tests) and managing the care coordination and reporting involved in direct patient care (such as communicating with other healthcare providers through messages and reports).

The “Administrative Support Functions” of an EHR system include managing the patient’s demographic information, communicating with patients (perhaps to arrange appointments) and managing the information associated with healthcare providers.

The “Information and Infrastructure” functions are there to assist in how data within the EHR is stored and managed such as when and how records should be archived or restored and how the privacy and security and the information is managed. These functions also dealt with interoperability between the EHR and other information systems.

The use of an EHR system by a hospital might seem like a straightforward idea. Surely digitising the medical records will save time retrieving notes, increase legibility and enable sharing of information across everyone involved in a patient’s care? The reality is that EHR systems have been some of the latest and most difficult types of information systems to be adopted in hospitals. Many hospitals around the world still rely on paper-based medical notes even while they have implemented a PAS, PACS, LIS, etc. As described above, the adoption of EHR systems only took off after a huge multi-billion-dollar incentive programme by the US government. The UK government also tried to encourage the adoption of EHR systems and spent more than £14 billion in the process but ultimately failed to deliver the promised system. So why are EHR systems so challenging to implement? There are multiple reasons, and we will go on to discuss this in some detail in this thesis but include difficulties with technical performance in acute clinical settings, increased workload for front-line clinicians, difficulties integrating with other systems and the high cost is often hard to justify from a cost-benefit perspective. Paper has long been a simple and effective tool for doctors to record what they needed to know about a patient. The introduction of an EHR system that replaces this tool has been a difficult process.

Paton, C (2024). Textbook of Digital Health.