ELECTRONIC HEALTH

RECORD
Dr.Nikita Dhange
 An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs
are real-time, patient-centered records that make information available instantly and
securely to authorized users. An EHR system is built to go beyond standard clinical data
collected in a provider’s office and can be inclusive of a broader view of a patient’s care.
❏ One of the key features of an EHR is that health information can be created and
managed by authorized providers in a digital format capable of being shared with other
providers across more than one health care organization.
❏ The EHR automates and streamlines the clinician's workflow. The EHR has the ability
to generate a complete record of a clinical patient encounter - as well as supporting
other care- related activities directly or indirectly via interface - including evidence-
based decision support, quality management, and outcomes reporting.
❏ EHR systems are made up of the electronic patient "chart" and typically include
functionality for computerized provider order entry (CPOE), laboratory and imaging
reporting, and medical device interfaces
EHRs are a vital part of health IT and can:
● Contain a patient’s medical history, diagnoses, medications,
treatment plans, immunization dates, allergies, radiology images, and
laboratory and test results.
● Included in this information are patient demographics, progress
notes, problems, medications, vital signs, past medical history,
immunizations, laboratory data and radiology reports.
● Allow access to evidence-based tools that providers can use to make
decisions about a patient’s care.
● Automate and streamline provider workflow.
 Basic Terminology:
The following is a list of basic terms you will need to know as you navigate the EHR market:
1. Certification - This relates to a national effort to "certify" various requirements for EHR software. The
Certification Commitee for Health Information Technology (CCHIT) is tasked with determining what basic
"must have" features EHR systems contain in order to be "certified."
2. Electronic Health Record (EHR) - This term refers to computer software that physicians use to track all
aspects of patient care. Typically this broader term also encompasses the practice management functions of
billing, scheduling, etc.
3. Electronic Medical Record (EMR) - This is an older term that is still widely used. It has typically come to
mean the actual clinical functions of the software such as drug interaction checking, allergy checking,
encounter documentation, and more.
4. Integrated EHR - This refers to an EHR that is integrated with practice management software. Typical choices
include purchasing a fully integrated product which performs all the functions of practice management
software, or a stand-alone EHR which is compatible with an existing practice management system.
5. Structured and unstructured data entry - There are several ways of entering data into your EHR as you
practice. These include dictating straight into the software (voice recognition), templates, and writing
(handwriting recognition).
6. Templates - Pre-structured portions of the software for common and/or basic visits. These templates fill in a
standard set of data which you may then customize for each individual visit. Templates can be used with
dictation, writing, or choosing among a menu of options formulated for each specific template.
TYPES OF ELECTRONIC HEALTH RECORD SYSTEMS:
I. Server-based EHR: Server based means the records are stored on a server local to our network.
Everything is kept in house on our own hardware
II. II. Cloud-based EHR: Cloud based is where the program and records are stored on a remote server
operated by a third party vendor. Healthcare providers are finding that it is much more cost
effective to implement and update EHRs in the cloud because it removes the constant need for new
hardware
III. III. Custom EHR: Custom EHR is specially developed for a specific healthcare organization, which is
in contrast with broadly used mass-market software. It gives us the best custom EHR – we can get at
a reasonable price.
IV. IV. Proprietary EHR: Proprietary EHR is software that is privately owned by a proprietor. That means
someone owns the intellectual property rights to the code that makes the system run. The owner
may be a company or an individual developer. Proprietary EHR is also known as closed-source EHR.
This is in contrast to free and open-source EHR, which lets you view, edit, and redistribute the code.
Example of proprietary EHRs are: EPIC, CERNER, CARECLOUD, ATHENAHEALTH, GE CENTRICITY
V. V. Open-source EHR: Open-source EHR is computer software that's distributed with its source code
available for modification. That means it usually includes a license for programmers to change the
software in any way they choose: They can fix bugs, improve functions, or adapt the software to
suit their own needs. If a EHR is open-source, its source code is freely available to its users. example
of open-source EHRs are: OpenEMR, OpenMRS, OpenEHR, OpenDental.
Potential Productivity and Financial Improvement
❏ Fewer chart pulls
❏ Improved efficiency of handling telephone messages and medication refills
❏ Improved billing
❏ Reduced transcription costs
❏ Increased formulary compliance and clearer prescriptions leading to fewer pharmacy call backs
❏ Improved coding of visits Potential Benefits: Job Satisfaction Improvement
❏ Fewer repetitive, tedious tasks
❏ Less "chart chasing"
❏ Improved intra-office communication
❏ Access to patient information while on-call or at the hospital
❏ Easier compliance with regulations
❏ Demonstrable high-quality care Quality of Care Improvement
❏ Easier preventive care leading to increased preventive care services
❏ Point-of-care decision support
❏ Rapid and remote access to patient information
❏ Easier chronic disease management
❏ Integration of evidence-based clinical guidelines Customer Satisfaction Improvement
❏ Quick access to their records
❏ Reduced turn-around time for telephone messages and medication refills
❏ A more efficient office leads to improved care access for patients
❏ Improved continuity of care (fewer visits without the chart)
❏ Improved delivery of patient education materials
CHALLENGES:
❏ These included usability issues, such as poor information display,
complicated screen sequences and navigation, and mismatch between
user workflow in the EHR and clinical workflow. - The latter problems
resulted in interruptions and distraction, which can contribute to
medical error.
❏ Additional safety hazards included data entry errors created by the
use of copy- forward, copy-and-paste, and electronic signatures, lack of
clarity in sources and date of information presented, alert fatigue, and
other usability problems that can contribute to error.
STEPS TO SUCCESSFUL ELECTRONIC HEALTH RECORD (EHR)
IMPLEMENTATION: Implementing an Electronic Health Record
(EHR) is a multi-step process that will impact all staff members.
As with any new process, a learning curve is involved. Having a
solid plan can save hours of stress for everyone on your team.
Here are ten essential steps to take for a successful EHR
Implementation.
1) BUILD YOUR ELECTRONIC HEALTH RECORD (EHR) IMPLEMENTATION
TEAM IMPLEMENTATION PROCESS
2) PREPARE THE SOFTWARE
3) DETERMINE YOUR HARDWARE NEEDS
4) CONSIDER THE PATIENT TREATMENT ROOM LAYOUT
5) TRANSFER DATA
6) CREATE WORKFLOWS
7) WHAT TO DO WHEN YOUR EHR IS DOWN
8) HAVE A TRAINING PROGRAM IN PLACE
9) DECIDE ON LAUNCH APPROACH – “BIG BANG” OR INCREMENTAL?
10) GATHER FEEDBACK FOR CONTINUAL IMPROVEMENT
There are several ways to improve the current state of the EHR system. One approach
improves on the current phenotyping process, either by making it more accurate or by
reducing the knowledge engineering effort.
 We refer to the latter as ‘high-throughput phenotyping’. The term could be applied to the
current state of the art because even a manually generated query can be run on a large
database, but we suggest reserving the term for truly high throughput approaches that do
not require years to generate a handful of phenotypes.
 A high-throughput approach should generate thousands of phenotypes with minimal
human intervention such that they could be maintained over time
 Phenotype is a shareable and reproducible algorithm precisely defining a condition,
disease, complex patient characteristic, or clinical event using only data processed by a
computer, principally EHR data. APPROACH Fig: Phenotyping and discovery
EHRs vs. paper records:
Pros and cons While many agree that, overall, EHRs offer more benefits than paper
health records, EHRs are not without their flaws. Below are some of major differences
between paper and electronic records: Cost: Large healthcare organizations may have to
pay $1 billion or more to purchase and install EHR systems, and it may take months to
implement the technology. There are also associated long-term digital storage costs with
EHRs. Paper records require more human administrative maintenance in terms of storing
the files and arranging for access to them, and there are physical space costs involved.
Readability and accuracy: With paper records, physicians' penmanship may be difficult to
read, which could lead to inaccuracies. Furthermore, with paper records, often there is
not enough room for a physician to write everything down legibly. With EHRs, there is
basically an unlimited amount of space, and typing and natural language processing
eliminate many concerns about illegibility.
Time:
Some providers have reported that EHRs have saved them anywhere from 10 to 20 hours
per week in documentation, giving them more time with their patients. However, others
argue that EHRs pose a learning curve and force providers to become data entry staff.
Access: The process of sharing paper records can be more arduous than sharing digital
patient information; it includes finding the paper record -- possibly, in a large warehouse --
and then either mailing, faxing or scanning copies which is easier in case of EHR systems.
Environment: Going digital with patient records saves a lot of paper because a patient's
medical record is usually made up of hundreds, and sometimes even thousands, of pages.
Security: Some believe that paper records can be more vulnerable to being compromised
due to a break in, loss of a paper record due to human error, or damage to paper records
because of a natural disaster. However, EHRs have had their fair share of cybersecurity data
breaches involving thousands of medical records.
STAND ALONE EHR
● Hospital Information System can be defined as a subsystem hospital with a socio-
technological development, which covers all information processing as well as the role of
clinicians.
● The Stand Alone Module (SAM) should regularly update the contents of each folder for
each computer, thus ensuring that in each service or each medical office, there is a minimal
clinical electronic version of the patient’s process.
● This goal is reached through a synchronizing model. The synchronizing is made on fixed
hours, but it is turned on always a critical information is updated through EHR or another
system.
● This ensures that information is always updated regardless the time when some
unpredictable failure occurs such as no network, there is no connectivity to databases, there
may be no electric power and the machine is connected to a UPS. Fig: HIS Stand Alone
Module Architecture.
❏ This module presents a solution to keep the quality in healthcare units in
case of HIS failures.
❏ The Stand-Alone Module was designed to always be available to be used by
health professionals. Thus, the health professionals might use the module
when there is one of these three situations: unavailability of systems
application servers; crashes of management database; and unavailability of
the communications infrastructure. PROS CONS 1. Your databases will be
integrated and accessible 1. EHR does not provide a "best of breed" solution
for every department 2. Your staff will only have to master one system 2. EHR
systems don't come cheap 3. Meaningful Use attestation will be simpler
EHR STANDARD IN INDIA:
❏ Government of India intends to introduce a uniform system for maintenance of Electronic Medical
Records / Electronic Health Records (EMR / EHR ) by the Hospitals and healthcare providers in the
country.
❏ An Expert committee was set up to develop EMR / EHR Standards for adoption / implementation in
the country. Draft EMR / EHR Standards were hosted on the website of the Ministry soliciting comments
from the stakeholders and general public.
❏ After due consideration of the recommendation of the Committee and the comments received
thereon, the 'Electronic Health Record Standards for India' have been finalised and approved by the
Ministry of Health and Family Welfare, Government of India.
❏ The Ministry of Health and Family Welfare has notified Electronic Health Record (EHR) Standards
Version 2016 for India in December 2016 (whilst the earlier version of EHR Standards was notified in
September 2013) with an intent to bring standardisation and homogeneity, inter- operability in capture,
storage, transmission & use of healthcare information across various Health IT systems.
What are the Challenges faced by Indian healthcare establishments in the implementation of EHR?
1) Lack of a common understanding between the clinicians and the software development teams on the
essential functionalities of EHRs often leads to overlooking the clinical components that would help in
efficient and effective care delivery.
2) Health care in India is provided in a multi-lingual context however most EHRs do not have multi lingual
capabilities.
3) Relative lack of computer literacy amongst healthcare professionals and EHRs lacking user centred
design for ease of use.
4) ack of uniformity in EHR software despite the availability of EHR standards 2016 and an enabling
environment created by the Government through the national EHR resource centre at CDAC, Pune.
5) Lack of synergy between healthcare providers resulting in non-interoperability.
6) Lack of Operating System agnostic EHR and mobility extensions as apps.
7) Lack of awareness around privacy and health information security protocols.
8) Hardly any functionality to electronically monitor and report on clinical outcomes to a central nodal
agency.
Overcoming Challenges and Leveraging the Opportunities for EHR in India:
1) To improve usability, natural data input such as handwriting, voice could be considered in the EHR.
2) An inter-exchange format for Indian standards and Indian language support could be built
progressively.
3) Sensitization of the workforce through training of doctors and nurses and making it incentive based
and compulsory for career progression.
4) Sensitise healthcare workers on importance of EHR.
5) Introducing data science and health informatics as a part of curriculum in medical and allied health
education.
6) Build synergy between healthcare professionals and software developers. A national repository of
user centred EHR design elements and a national health data dictionary with common data models.
7) Use standard clinical workflow guidelines and including clinical workflow guidelines for developing
EHR solutions.
8) EHRs to have functionality of directly porting data into clinical registries as well as outcome
monitoring dashboards.
 In India, the IT adoption in Healthcare is estimated to be only five percent and EHR adoption in
government healthcare facilities is very slow or almost non-existent but the private sector is
aggressive in their plans.
❏ To gain insight into the functioning of the healthcare centers with respect to use of information
technology and their effectiveness in healthcare delivery, a survey was done.
❏ This survey was undertaken in five taluks (A taluk is a town that serves as headquarters for several
villages and possibly additional towns) of Gadag district and six taluks of Bagalkot district to assess the
ground realities in healthcare centers by evaluating various parameters that would influence the
quality of healthcare delivery system in these districts MATERIAL AND METHODS Out of the total 107
facilities, 83 facilities participated in the assessment that accounts to 77.6 % of assessment coverage.
A questionnaire consisting of a set of 86 questions related to patient load, medical record formats,
hospital infrastructure and staffing information was used for this assessment. Responses to the
questionnaire were tabulated. The responses were used to depict the results and draw inferences.
Healthcare facilities (HC) cater to an average of 70 patients per day. The variance in this number is
significant with some interior HCs catering to less than 10 patients per day and more than 100
patients per day at the Taluk Level Hospitals. Quality of healthcare depends on the efficiency of the
doctors as they have to attend to at least 35 patients on an average daily. Use of health information
technologies like EHRs has the potential to improve. A Workflow Solution for Electronic Health
Records to Improve Healthcare Delivery Efficiency in Rural India (CASE STUDY)
Quality of Care Most HCs agreed that there are no facilities available to accurately record a patient’s
history. In fact, some HCs reported instances of patients having been administered wrong medication
due to lack of patient history. Most patients had also had to wait for longer periods of time to receive
either the treatment or diagnosis as they had to wait for their records, or diagnostic centres to extract
data from archives. PATIENT RECORDS The Medical Records Department (MRD) stores files for an
average of 5 years. Data recorded regarding patients information in the Medical Records (MR) includes
Name, Age, Sex, DOB, Occupation, Diagnosis and Treatment. In some cases, additional information like
allergies, and food habits were also recorded. 20 HCs reported that the hospital Pharmacist maintains
the medical records. In some HCs there are no full time employees for maintaining the records. Most of
the HCs spend a lot of efforts (time/money) on maintaining paper based patient records. Employable
EHR As the research is oriented towards Rural india, there is a need for using a simple and pragmatic
EHR which excludes non- essential data. This kind of simplification will aid in motivating people –
doctors, technicians and patients – to use this EHR. The EHR so designed is called an Employable EHR
(EEHR). The following sections provide details on the Employable EHR.
The administrative content includes: 1. Identification – Patient’s full name, Medical record number,
Address, Mother’s maiden name 2. Lifestyle indicators – Education level, rofession, allergies, chronic
illnesses, Marital status, Food type, smoking, alcohol The clinical content includes 1. Complaints,
Physical examination results 2. Drugs prescribed, inpatient history 3. lab reports: pathology /
radiology / ECG / EEG / EMG
The WebEHR system:
1. Allows for the storing all of the Administrative & Clinical Content, Patient visit information, Prescription
report and Inpatient & Discharge Information and reproduce them for formatted display or in paper form
for study.
2. Supports generation of statistical information for mining the general health conditions of public. Allows
concurrent access from multiple locations.
3. Allows concurrent access from multiple locations. WebEHR is capable of containing chronological
information on:
1. Symptoms, complaints, healthcare requests as expressed by the patient
2. Type of events such as first visit for treatment, follow-up visit
3. Vital and common Health parameters such as: Weight, Blood Pressure, Temperature
4. Diagnosis, instructions and suggestions by treating Physician
5. Information that became available including the source of such information or basis for such inference
6. Medicines prescribed by the Physician
7. Lab tests ordered by the Physician
8. Lab test results obtained from various medical devices of a diagnostic center including reference values
9. Therapeutic interventions
10.In-patient treatment log of the patient
11.Patient’s own log of health diary
Health Kiosk The patient will be able to:
1. Register their name if it is first visit.
2. Take a printout of their record to the doctor.
3. Doctor will examine the patient, diagnose and prescribe treatment. The doctor
can also suggest for additional tests. This is done on the EHR printout of the
patient.
4. If additional tests are suggested the patient takes this prescription to the lab and
brings the test reports back to the doctor. Doctor prescribes the treatment.
5. On the receipt of the requisite diagnosis and prescribed treatment, the patient
will bring back the record to the kiosk for updation of EHR. In the above manner,
this way the kiosk will be able to maintain the EHRs of all the patients in the rural
areas
 The advantage of this system is that the patients, doctors and other medical professionals need not
know about computers and software and there is no hindrance for the EHR usage.
● The system provides connectivity between the Healthcare Centers through a web-based interface.
● Automatic updating of the data and data storage will be facilitated by instantaneous entry of data
from any given point. Subsequently, this system will provide the ability to use patient health records
and statistical data for training and educating medical, paramedical and administrative personnel.
This data and the knowledge created will help in analysis of the health conditions for the particular
demography that aids in planning for better healthcare delivery.
CONCLUSION OF THE STUDY: The benefits of implementing such a system are:
1. Healthcare awareness of patient increases.
2. Demographic information will be available for planning better healthcare delivery.
3. Addresses the issue of patient mobility as patient information is available for all healthcare
centers as it is web enabled. The risk of losing data and data confidentiality is reduced because of
non centralized database. By deploying such a kiosk in different healthcare centers in rural India,
we can increase the usage of EHRs thereby increasing the efficiency of Healthcare Delivery and
reducing the cost of healthcare. Currently the kiosk is operational in one of the healthcare centers
in Karnataka.
CONCLUSION:
❏ EHRs are able to improve patient care by aiding in diagnosis by giving providers
access to patients' complete health information, which provides a comprehensive
view and helps clinicians diagnose problems sooner.
❏ EHRs can help reduce medical errors, improve patient safety and support better
outcomes. While EHRs do contain and transmit data, they also manipulate patient
information in meaningful ways and provide that information to the provider at the
point of care.
❏ Those considering adopting EHRs in family practice should reflect on the following
issues: expectations of EHRs and what is needed to use the software, level of
commitment to implementation and adoption of EHRs, availability of someone
willing to take a leadership or champion role, and potential EHR users’ baseline
knowledge of and experience with computers
RECOMMENDATIONS FOR FUTURE STUDIES AND DECISIONS
It is clear that steps still need to be taken to ensure that all hospitals across the
country whether small or big and regardless of the areas they are serving all
benefit for EHR.
Some of the recommendations that can be considered for future practice and
discussion particularly about this issue include:
1. Conducting and more researches that explore some of the challenges
associated with the adoption of EHR systems in local areas.
2. Health care institutions wishing to adopt or improve EHR systems within their
organization should pay close attention to clinical decision support about the
matter.
3. It is essential to look at the issue of technological advancement in rural areas
which has been a significant hindrance to EHR adoption.