EHR Definitions

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Definitions used in the whitepaper

2.1 Electronic Health Records (EHR)

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 (Source: HIMSS).

2.2 Electronic Medical Record (EMR)

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians
and staff within one health care organization (Source: The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms, released on April 28, 2008).

An EMR is an application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. 

This environment supports the patient’s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO). 

The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO (Source: HIMSS).

2.3 Personal Health Records (PHR)

A universally accessible, layperson comprehensible, lifelong tool for managing relevant health information, promoting health maintenance and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools. 

The ePHR is owned, managed, and shared by the individual or his or her legal proxy(s) and must be secure to protect the privacy and confidentiality of the health information it contains. It is not a legal record unless so defined and is subject to various legal limitations (Source: HIMSS). 

Some EHRs offer patients/consumers the ability to view their records through web portals or the ability to export data to a PHR.

2.4 Health Information Technology (HIT)

HIT encompasses a broad array of technologies involved in managing and sharing patient information electronically, rather than through paper records. 

HIT performs information processing using both computer hardware and software for the entry, storage, retrieval, sharing, and use of health care information (Source: Alliance for Health Reform). 

EHR, EMR and PHR are examples of HIT.