The Electronic Health Record: What Every Information Manager Should Know: Records Are a Vital Part of the Patient Care Environment. Secure, Accurate Records Are Necessary, Although Increasingly Challenging, as They Migrate to an Electronic Environment

Article excerpt

The need to better manage health information is indisputable. Since a 2000 report from the Institute of Medicine estimated that as many as 98,000 U.S. patients die annually due to preventable medical errors--many due to lack of access to complete patient information--subsequent studies have confirmed that inadequate information systems in U.S. clinics, hospitals, and physician practices affect the quality of care patients receive.

Recognizing that patient treatment information--electronic and paper--is often scattered at various locations and in unlinked computers, President George W. Bush has focused on digitizing the healthcare industry. In 2004, Bush appointed the nation's first National Health Information Technology Coordinator with a 10-year goal of creating an interoperable health information infrastructure that would ensure that most Americans have secure electronic health records (EHR), and healthcare workers have quick, reliable access to them. This envisioned national health information infrastructure (NHIN) features electronic data exchange, which is dramatically changing the work of those involved in communicating and disseminating personal medical information and can improve the quality of health care, reduce healthcare costs, and improve communication among healthcare providers.

Defining the 'Electronic Health Record'

In the book Electronic Health Records: A Practical Guide for Professionals and Organizations, M. K. Amatayakul writes that

"[t]he electronic health record is not a simple computer application; rather it represents a carefully constructed set of systems that are highly integrated and require a significant investment in time, money, process change, and human factor reengineering."

To migrate from a hard-copy format to an EHR system, these components are needed:

* [Physician] order communication/ results retrieval (OC/RR)

* Electronic document/content management (ED/CM)

* Clinical messaging

* Point-of-care (POC) charting, or patient-care documentation

* Computerized physician/provider order entry and electronic prescribing

* Electronic medical administration record

* Clinical decision support

* Provider-patient portals and health information exchange

* Personal health records

* Population health

Currently, different configurations are being used to collect information for an electronic format. Some healthcare facilities collect information from multiple computerized programs throughout the facility. For example, lab, pharmacy, radiology, POC documentation systems, and finance are connected. Here, the record is kept in an electronic format, and a physical medical record is not kept in the traditional file room of the health information department. The occasional stray hard copy form is scanned and then indexed into the electronic record.

Another model for EHR is a hybrid system in which parts of the record are electronic from the point of service (as those mentioned above), but hard-copy documents are used in some areas of the healthcare facility. In that case, the health information department acquires the hard-copy document and then scans and indexes the document into the electronic file.

Although all hard-copy and electronic systems are open to errors from humans entering information, the hybrid system has more possibilities for error. Its scanning and indexing process, for example, can more easily lead to indexing errors and misfiles when there is no bar code for indexing. Once "lost," electronic documents are more difficult to find than hard copies.

Therefore, some facilities bar code documents to reduce human error. In those systems, scanning the document automatically places it in the correct section of the electronic record. In some hybrid systems, hard-copy documents contain bar codes that reduce human error in the placement of the scanned document. …