ELECTRONIC HEALTH RECORD (EHR)

Although the terms electronic health record (EHR) and electronic medical
record (EMR) are often used interchangeably, the electronic health record (EHR) is a
more global concept that includes the collection of patient information documented
by a number of providers at different facilities regarding one patient.
The EHR uses multidisciplinary (many specialties) and multi-enterprise (many
facilities) recordkeeping approaches to facilitate record linkage, which allows
patient information to be created at different locations according to a unique
patient identifier or identification number. The electronic health record:

● Provides access to complete and accurate patient health problems, status, and
treatment data.
● allows access to evidence-based decision support tools (e.g., drug interaction
alerts) that assist providers with decision making.
● automates and streamlines a provider’s workflow, ensuring that all clinical information
is communicated.
● Prevents delays in healthcare response that result in gaps in care (e.g., automated
prescription renewal notices).
● Supports the collection of data for uses other than clinical care (e.g., billing, outcome
reporting, public health disease surveillance/reporting, and quality management).
The electronic medical record (EMR) has a more narrow focus because it is the
patient record created for a single medical practice using a computer, keyboard,
a mouse, optical pen device, voice recognition system, scanner, and/or touch
screen. The electronic medical record:
● Includes a patient’s medication lists, problem lists, clinical notes, and other documentation.
● allows providers to prescribe medications, order and view results of ancillary tests
(e.g., laboratory, radiology).
● alerts the provider about drug interactions, abnormal ancillary testing results, and
when ancillary tests are needed.
Total practice management software (TPMS) (Figure 2-1) is used to generate the EMR,
automating the following medical practice functions:
● Registering patients
● Scheduling appointments
● Generating insurance claims and patient statements
● Processing payments from patient and third-party payers
● Producing administrative and clinical reports


Health insurance is a contract between a policyholder and a third-party payer or government program
for the purpose of providing reimbursement of all or a portion of medical and heath care costs.
The history of healthcare reimbursement can be traced back to 1860, when the Franklin Health
Assurance Company of Massachusetts wrote the first health insurance policy.

Subsequent years, through the present, have seen significant changes and advances in healthcare insurance and reimbursement, from the development of the first Blue Cross and Blue Shield plans to
legislation that resulted in government healthcare programs (e.g., to cover individuals age 65 and
older), payment systems to control healthcare costs (e.g., diagnosis-related groups), and regulations
to govern privacy, security, and electronic transaction standards for healthcare information.
A patient record (or medical record) documents healthcare services provided to a patient, and healthcare providers are responsible for documenting and authenticating legible, complete, and timely
entries according to federal regulations and accreditation standards.

The records include patient demographic (or identification) data, documentation to support diagnoses and justify treatment provided, and the results of treatment provided. The primary purpose of the record is to provide for continuity of care, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment. The problemoriented record (POR) is a systematic method of documentation that consists of four components: database, problem list, initial plan, and progress notes (documented using the SOAP format).


The electronic health record (EHR) is a global concept (as compared with the EMR) that includes the
collection of patient information documented by a number of providers at different facilities regarding
one patient. The EHR uses multidisciplinary (many specialties) and multi-enterprise (many
facilities) recordkeeping approaches to facilitate record linkage, which allows patient information
to be created at different locations according to a unique patient identifier or identification number.