THE ELECTRONIC HEALTH RECORD
Electronic health records (EHRs) allow for accurate, electronic documentation of current and past medical problems, procedures, laboratory test results, and medical treatments. EHR systems have the potential to improve communication between practitioners and patients, improve patient compliance, facilitate quality improvement, and reduce medical errors;1 however, the implementation of EHRs also has increased physician burden and rates of physician burnout and resulted in some unexpected and harmful consequences.
EHRs have been commercially available since the 1970s, but their widespread adoption has been more recent, driven in part by financial encouragement from the Office of the National Coordinator for Health Information and Technology (ONC) and other legislation (Table 8-1). In 2009, President Obama signed into law the Health Information Technology for Economic and Clinical Health Act (HITECH), which was part of the federal stimulus legislation known as the American Reinvestment and Recovery Act of 2009 (ARRA).2 Its purpose was to improve the quality, safety, and cost of health care by incentivizing adoption of health care information technology.
TABLE 8-1Major Legislation Related to EHR Use. ||Download (.pdf) TABLE 8-1 Major Legislation Related to EHR Use.
Health Information Technology for Economic and Clinical Health Act (HITECH) to establish Office of the National Coordinator for Health Information Technology (ONC)
Health Insurance Portability and Accountability Act (HIPAA)
Food and Drug Administration Safety and Innovation Act (FDASIA)
Medicare Electronic Health Records Incentive Program (Meaningful Use)
Patient Protection and Affordable Care Act (PPACA)
Access to Records Remotely
One of the most notable benefits of the EHR includes remote access to patient medical records across multiple care settings, providing greater care coordination.3 Physicians can view a patient’s entire chart, including provider notes, current medications, radiographic data, insurance information, laboratory test results, and procedure reports, from any location at any time prior to making decisions regarding triage, refilling prescriptions, and providing medical advice. In the past, a paper medical record was only available to one user at a time; now multiple users can access and document in a chart simultaneously. Patient records now require less physical storage space and can be stored/accessed indefinitely. The EHR allows for cost-effective backup and has markedly reduced the number of lost records.4
Computerization has made patient notes more legible. When clinical records were handwritten, up to 15% of patient records had issues with legibility.5 Not only are illegible notes inaccessible to auditors, ...