Electronic-based Patient Health Record (EHR)
(Redirected from Inpatient EMR)
Jump to navigation
Jump to search
An Electronic-based Patient Health Record (EHR) is a health record that is an electronic-based person record (that can be stored and accessed electronically).
- AKA: Computerised Patient Record, Digital Medical Record.
- Context
- It can (typically) contain documents such as reports from care providers, test results and pharmacy information.
- It can (typically) be a Privacy-Sensitive Record.
- It can (typically) be a member of an EHR Data Base.
- It can (typically) contain Personally Identifying Information (PII) (personally identifying medical information (PHI)).
- It can range from being an In-Patient EHR to being an Ambulatory EHR.
- It can be managed and stored by a EHR System.
- …
- Example(s):
- a Clinical Study Participant Health Record.
- an HL7 Electronic Health Record (in an HL7 standard).
- an FHIR Electronic Health Record (in an FHIR standard).
- …
- Counter-Example(s):
- See: Clinical Research Data, Clinical Terminology, Clinical Trial, OpenEHR.
References
2023
- chat
- Several standard formats exist for recording electronic health records (EHRs). These standards are designed to ensure that health information can be accurately and securely exchanged between different healthcare systems and providers. Some of the most widely used EHR standards include:
- Health Level Seven (HL7) - This is a widely recognized standard for the exchange, integration, sharing, and retrieval of electronic health information. HL7 is used to encode and transmit various health records, including patient demographic information, clinical observations and assessments, medication and treatment information, and diagnostic information.
- Fast Healthcare Interoperability Resources (FHIR) - This is a newer standard that is designed to make it easier to exchange healthcare data between different systems and devices. FHIR uses a modern web-based approach and is designed to be easy to implement and use.
- Digital Imaging and Communications in Medicine (DICOM) - This is a standard that is used for exchanging medical images and related information. DICOM is widely used in radiology and other imaging specialties to ensure that images can be shared and viewed across different systems.
- Clinical Document Architecture (CDA) - This is a standard that is used to exchange clinical documents, such as discharge summaries, progress notes, and other clinical reports. CDA is designed to ensure that clinical documents can be exchanged between different healthcare providers and systems in a consistent and accurate manner.
- International Classification of Diseases (ICD) - This standard is used to classify and code diseases, injuries, and other health conditions. ICD is used by healthcare providers, researchers, and public health officials to track and monitor disease prevalence and trends.
- Overall, these EHR standards are designed to improve the accuracy, completeness, and interoperability of health information, making it easier for healthcare providers to share and access important patient data and improve the quality and safety of patient care.
- Several standard formats exist for recording electronic health records (EHRs). These standards are designed to ensure that health information can be accurately and securely exchanged between different healthcare systems and providers. Some of the most widely used EHR standards include:
2021
- (Wikipedia, 2021) ⇒ https://en.wikipedia.org/wiki/electronic_health_record Retrieved:2021-11-8.
- An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information. For several decades, electronic health records (EHRs) have been touted as key to increasing of quality care. Electronic health records are used for other reasons than charting for patients, today, providers are using data from patient records to improve quality outcomes through their care management programs. EHR combines all patients demographics into a large pool, and uses this information to assist with the creation of “new treatments or innovation in healthcare delivery” which overall improves the goals in healthcare. Combining multiple types of clinical data from the system's health records has helped clinicians identify and stratify chronically ill patients. EHR can improve quality care by using the data and analytics to prevent hospitalizations among high-risk patients. EHR systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is up-to-date, accurate and legible. It also allows open communication between the patient and the provider, while providing “privacy and security.” It can reduce risk of data replication as there is only one modifiable file, which means the file is more likely up to date and decreases risk of lost paperwork and is cost efficient. Due to the digital information being searchable and in a single file, EMRs (electronic medical records) are more effective when extracting medical data for the examination of possible trends and long term changes in a patient. Population-based studies of medical records may also be facilitated by the widespread adoption of EHRs and EMRs.
2011a
- (HIMSS, 2011) ⇒ http://www.himss.org/ASP/topics_ehr.asp
- QUOTE: The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. 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.
2011b
- (Open Clinical, 2011) ⇒ http://www.openclinical.org/emr.html
- QUOTE: Terms used in the field include electronic medical record (EMR), electronic patient record (EPR), electronic health record (EHR), computer-based patient record (CPR) etc. These terms can be used interchangeably or generically but some specific differences have been identified. For example, an Electronic Patient Record has been defined as encapsulating a record of care provided by a single site, in contrast to an Electronic Health Record which provides a longitudinal record of a patient’s care carried out across different institutions and sectors. But such differentiations are not consistently observed.
2011c
- (Bratus et al., 2011) ⇒ Sergey Bratus, Anna Rumshisky, Alexy Khrabrov, Rajenda Magar, and Paul Thompson. (2011). “Domain-specific Entity Extraction from Noisy, Unstructured Data Using Ontology-guided Search.” In: International Journal on Document Analysis and Recognition. doi:10.1007/s10032-011-0149-5O
- QUOTE: Domain-specific knowledge is often recorded by experts in the form of unstructured text. For example, in the medical domain, clinical notes from electronic health records contain a wealth of information.
2010a
- (Roberts, Gaizauskas et al., 2010) ⇒ Angus Roberts, Robert Gaizauskas, Mark Hepple, George Demetriou, Yikun Guo, Ian Roberts, and Andrea Setzer. (2010). “Building a Semantically Annotated Corpus of Clinical Texts.” In: Journal of Biomedical Informatics, 42 (5). doi:10.1016/j.jbi.2008.12.013
2010b
- (Vancouver Coastal Health, 2010) ⇒ http://www.vch.ca/about_us/information_requests/request_health_records/
- Everyone treated at one of our facilities has an health record. These records contain documents such as reports from care providers, test results and pharmacy information.
You can request records for yourself or a person whose records you have authorization to access.
- Everyone treated at one of our facilities has an health record. These records contain documents such as reports from care providers, test results and pharmacy information.
2008
- (DesRoches et al., 2008) ⇒ Catherine M. DesRoches, Eric G. Campbell, Sowmya R. Rao, Karen Donelan,, Timothy G. Ferris, Ashish Jha, Rainu Kaushal, Douglas E. Levy, Sara Rosenbaum, Alexandra E. Shields, and David Blumenthal. (2008). “Electronic Health Records in Ambulatory Care — A National Survey of Physicians.” In: The New England Joural of Medicine, 39(1) doi:10.1056/NEJMsa0802005
2002
- (Waegemann, 2002) ⇒ C. Peter Waegemann. (2002). “The Vision of Electronic Health Records.” In: The Journal of Medical Practice Management, 18(2)