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Electronic Health Records

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Biomedical Informatics

Abstract

This chapter introduces and reviews electronic health record (EHR) systems as essential core health information technology (IT). It describes current and potential future EHR functionality and discusses some of the challenges and controversies for these systems. EHRs include both traditional and newer capabilities for direct patient care and population health, as well as innovative Health IT working in concert with EHRs. Today’s EHR landscape includes challenges around EHR data entry, increased patient participation in EHR data entry, certified EHRs with increased inter-operability, and a number of regulatory requirements often leveraging EHRs.

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Notes

  1. 1.

    The terms “electronic health record” (EHR) and “electronic health record system” (EHRS or EHR system) are often used interchangeably, with no generally agreed upon distinction. The terms “electronic medical record” (EMR) and “electronic medical record system” (EMRS or EMR system) have also been used but many have moved towards using the term “health” versus “medical” as these systems are being used broadly across the continuum of care by a multitude of roles; again, the distinctions between EMR and EMRS are not generally agreed upon. The term “computer-based record system” has also been used in the past. In this chapter, and throughout the book, we will use the term “electronic health record”, with the acronyms “EHR” and “EHRs” to designate the singular and plural forms, respectively.

  2. 2.

    Certification of Health IT, Testing Process & Test Methods, 2015 Edition Test Method. 7 https://www.healthit.gov/topic/certification-ehrs/2015-edition-test-method (Accessed 6/4/2020).

  3. 3.

    Digital Imaging and Communications in Medicine, 7 https://www.dicomstandard.org/ (Accessed 6/4/2020).

  4. 4.

    JPEG from Wikipedia, the free encyclopedia, 7 http://en.wikipedia.org/wiki/JPEG (Accessed 6/4/2020).

  5. 5.

    Certification of Health IT, Testing Process & Test Methods, 2015 Edition Test Method. 7 https://www.healthit.gov/topic/certification-ehrs/2015-edition-test-method (Accessed 6/4/2020).

  6. 6.

    Logical Observation Identifiers Names and Codes (LOINC®) from Regenstrief. 7 http://loinc.org/ (Accessed 6/4/2020).

  7. 7.

    SNOMED Clinical Terms® (SNOMED CT®) Five-step briefing. 7 https://www.snomed.org/snomed-ct/ (Accessed 6/4/2020).

  8. 8.

    The Unified Code for Units of Measure. 7 http://unitsofmeasure.org/ (Accessed 6/4/2020).

  9. 9.

    RxNorm Overview. 7 http://www.nlm.nih.gov/research/umls/rxnorm/overview.html (Accessed 6/4/2020).

  10. 10.

    RxTerms. 7 https://wwwcf.nlm.nih.gov/umlslicense/rxtermApp/rxTerm.cfm (Accessed 6/4/2020).

  11. 11.

    7 https://ivdconnectivity.org/fda-encourages-livd (Accessed 6/4/2020).

  12. 12.

    Health Level Seven International, 7 http://www.hl7.org/ (Accessed 6/4/2020).

  13. 13.

    7 https://github.com/nextgenhealthcare (Accessed 6/4/2020).

  14. 14.

    NextGen Connect Integration Engine. 7 https://www.nextgen.com/products-and-services/integration-engine and 7 https://github.com/nextgenhealthcare (Both accessed 6/4/2020).

  15. 15.

    7 https://cloud.google.com/speech-to-text/

  16. 16.

    The Joint Commission: Documentation assistance provided by scribes. 7 https://www.jointcommission.org/en/standards/standard-faqs/nursing-care-center/record-of-care-treatment-and-services-rc/000002210/ (Accessed 6/4/2020).

  17. 17.

    7 https://www.hl7.org/fhir/questionnaire.html (Accessed 6/4/2020).

  18. 18.

    7 http://hl7.org/fhir/uv/sdc/2019May/ (Accessed 6/4/2020).

  19. 19.

    7 http://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis (Accessed 6/4/2020).

  20. 20.

    125 SNOMED CT groupers published as online supplement to open-access article above in reference #3. 7 https://www.thieme-connect.de/media/10.1055-s-00035026/201803/supmat/10-1055-s-0038-1668090-s180031ra.pdf (Accessed 6/4/2020).

  21. 21.

    See Problem List MD at 7 https://problemlist.org (Accessed 6/4/2020).

  22. 22.

    7 https://ucum.nlm.nih.gov/ucum-lhc/demo.html (Accessed 6/4/2020).

  23. 23.

    Certification of Health IT, Testing Process & Test Methods, 2015 Edition Test Method. 2015 Edition Certification Regulations – 170.315(a) (1, 2, 3, 4): Computerized Provider Order Entry and Drug-drug and Drug-allergy checks for CPOE 7 https://www.healthit.gov/topic/certification-ehrs/2015-edition-test-method (Accessed 6/4/2020).

  24. 24.

    Certification of Health IT, Testing Process & Test Methods, 2015 Edition Test Method, Clinical Decision Support. 2015 Edition Certification Regulations - 170.315(a)(9): Clinical Decision Support 7 https://www.healthit.gov/test-method/clinical-decision-support-cds#ccg (Accessed 6/4/2020).

  25. 25.

    HL7 Version 3 Standard: Context Aware Knowledge Retrieval Application (“Infobutton”), Knowledge Request, Release 2. 7 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=208 (Accessed 6/4/2020).

  26. 26.

    FHIRPath STU1 Release. [Internet]. 2019 [cited 01/29/2019]. Available from: 7 http://hl7.org/fhirpath/ (Accessed 6/4/2020).

  27. 27.

    Health Level 7. Clinical quality language (CQL) standard. [Internet]. 2018 [cited 01/29/2019]. Available from: 7 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=400 (Accessed 6/4/2020).

  28. 28.

    7 https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/telehealthsrvcsfctsht.pdf (Accessed 6/4/2020).

  29. 29.

    eCHN electronic Child Health Network. 7 http://www.echn.ca/ (Accessed 6/4/2020).

  30. 30.

    Kentucky Health Information Exchange Frequently Asked Questions. 7 http://khie.ky.gov/Pages/faq.aspx?fc=010 (Accessed 6/4/2020).

  31. 31.

    7 https://www.ruralcenter.org/resource-library/methods-used-to-enable-interoperability-among-us-non-federal-acute-care-hospitals (Accessed 6/4/2020).

  32. 32.

    eHealth Exchange. 7 https://ehealthexchange.org/ (Accessed 6/4/2020).

  33. 33.

    7 https://www.healthdatamanagement.com/news/connect-nhin-direct-what-are-they (Accessed 6/4/2020).

  34. 34.

    7 http://wiki.directproject.org/Main_Page (Accessed 6/4/2020).

  35. 35.

    7 https://www.healthit.gov/sites/default/files/analysis_of_existing_trust_arrangements_printable.pdf (Accessed 6/4/2020).

  36. 36.

    7 https://www.healthit.gov/sites/default/files/page/2019-04/FINALTEFCAQTF41719508version.pdf (Accessed 6/4/2020).

  37. 37.

    7 https://grants.nih.gov/grants/guide/notice-files/NOT-HS-19-020.html (Accessed 6/4/2020).

  38. 38.

    7 https://grants.nih.gov/grants/guide/notice-files/NOT-OD-19-122.html (Accessed 6/4/2020).

  39. 39.

    7 https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=3516 (Accessed 6/4/2020).

  40. 40.

    7 https://ecqi.healthit.gov/cql-clinical-quality-language (Accessed 6/4/2020).

  41. 41.

    7 https://www.hl7.org/fhir/fhirpath.html (Accessed 6/4/2020).

  42. 42.

    7 CMS.gov. Patients Over Paperwork. 7 https://www.cms.gov/About-CMS/story-page/patients-over-paperwork.html (Accessed 6/4/2020).

  43. 43.

    We have included examples from various systems in this chapter, both developed by users and commercially available, to illustrate a portion of the functionality of EHRs currently in use.

  44. 44.

    CDS hooks HL7 group. 7 http://wiki.hl7.org/index.php?title=201809_CDS_Hooks (Accessed 6/4/2020).

  45. 45.

    7 https://www.regenstrief.org/resources/clinical-learning/ (Accessed 6/4/2020).

  46. 46.

    7 https://www.lri.fr/presentation_en.php (Accessed 6/4/2020).

  47. 47.

    7 https://www.ncpdp.org/NCPDP/media/pdf/NCPDPEprescribingBasics.pdf (Accessed 6/4/2020).

  48. 48.

    7 https://searchhealthit.techtarget.com/definition/DICOM-Digital-Imaging-and-Communications-in-Medicine (Accessed 6/4/2020).

  49. 49.

    7 https://www.edibasics.com/edi-resources/document-standards/hipaa (Accessed 6/4/2020).

  50. 50.

    HIPAA for professionals. 7 https://www.hhs.gov/hipaa/for-professionals/index.html (Accessed 6/4/2020).

  51. 51.

    7 https://www.healthit.gov/sites/default/files/hitech_act_excerpt_from_arra_with_index.pdf (Accessed 6/4/2020).

  52. 52.

    7 CMS.gov: MACRA. 7 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html (Accessed 6/4/2020).

  53. 53.

    H.R.34 – 114th Congress. 7 https://www.congress.gov/bill/114th-congress/house-bill/34 (Accessed 6/4/2020).

  54. 54.

    EHR Intelligence. Top 5 Most Expensive Implementations of 2017. 7 https://ehrintelligence.com/news/top-5-most-expensive-ehr-implementations-of-2017 (Accessed 6/5/2020).

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Authors and Affiliations

  1. Department of Surgery and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA

    Genevieve B. Melton

  2. Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD, USA

    Clement J. McDonald

  3. Clinical Excellence Research Center, Stanford University,, Stanford, CA, USA

    Paul C. Tang

  4. Department of Biomedical Informatics, Columbia University Medical Center, New York, NY, USA

    George Hripcsak

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  1. Biomedical Informatics, Columbia University, New York, NY, USA

    Edward H. Shortliffe

  2. Informatics Institute, University of Alabama at Birmingham, Birmingham, AL, USA

    James J. Cimino

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Melton, G.B., McDonald, C.J., Tang, P.C., Hripcsak, G. (2021). Electronic Health Records. In: Shortliffe, E.H., Cimino, J.J. (eds) Biomedical Informatics. Springer, Cham. https://doi.org/10.1007/978-3-030-58721-5_14

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