EHR:
An Electronic Health Record (EHR) is a digital version of a patient’s medical history.
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.
It maintains data related to patient care such as demographics, problems, medications ,
physician’s observations, vital signs, medical history, laboratory data, radiology reports,
personal statistics, progress notes, and billing data.
Electronic Medical Record (EMR):
Older term that is still widely used.
It has typically come to mean the actual clinical functions of the software such as
drug interaction checking, allergy checking, encounter documentation, and more.
The EHR system automates the data management process of complex clinical
environment.
It can generate a complete record of a patient’s detail.
EHR has several advantages over paper-based systems.
Storage and retrieval of data is obviously more efficient using EHRs.
It helps to improve quality and convenience of patient care, increase patient participation
in the healthcare process, improve accuracy of diagnoses and health outcome.
Usually, EHR is maintained within an institution, such as a hospital, clinic, or physician’s
office.
In 2011, 54% of physicians had adopted an EHR system
History of EHR:
Modern EHR can provide additional functionalities that could not be performed using
paper-based systems.
In the 1960s, Larry Weed, an American physician, researcher, educator, and
entrepreneur, developed the Problem Oriented Medical Record.
Data retrieval was much faster using digital format.
EHR Adoption has more than doubled since 2008 As of 2017, 86% of office-based
physicians had adopted any EHR 80% had adopted a certified EHR.
Components of EHR:
The main purpose of EHR is to support clinical care and billing.
Most modern EHR systems are designed to integrate data from different components
such as administrative, nursing, pharmacy, laboratory, radiology, and physician’ entries,
etc
1.Administrative System Components:
Administrative data such as patient registration, admission, discharge, and transfer data
are key components of the EHR.
It also includes name, demographics, employer history, etc., along with the patient billing
information.
Social history data such as marital status, home environment, daily routine, dietary
patterns, sleep patterns, exercise patterns, tobacco use, alcohol use, drug use
family history data such as personal health history, hereditary diseases, father, mother
and sibling(s) health status, age, and cause of death can also be a part of it.
Apart from the fields like “comments” or “description,”
During the registration process, a patient is generally assigned a unique identification key
comprising of a numeric or alphanumeric sequence.
This key helps to link all the components across different platforms.
For example, lab test data can create an electronic record; and another record is
created from radiology results.
Both records will have the same identifier key to represent a single patient.
It is often referred to as the medical record number or master patient index (MPI).
2.Laboratory System Components & Vital Signs:
laboratory systems are stand-alone systems that are interfaced to the central EHR system.
It is a structured data that can be expressed using standard terminology and stored in the
form of a name-value pair.
Lab data plays an extremely important part in the clinical care process, providing
professionals the information needed for prevention, diagnosis, treatment, and health
management.
About 60% to 70% of medical decisions are based on laboratory test results.
A physician can easily compare the results from previous tests.
The most common coding system used to represent the laboratory test data is Logical
Observation Identifiers Names and Codes (LOINC)
Many hospitals use their local dictionaries as well to encode variables.
simple concepts “weight” and “height,”- e.g., kilograms, grams, and pounds for weight;
centimeters, meters, inches, and feet for height
Vital signs are the indicators of a patient’s general physical condition. It includes pulse,
breathing rate, blood pressure, body temperature, body mass index (BMI), etc.
3. Radiology System Components:
In hospital radiology departments, radiology information systems (RIS) are used for
managing medical imagery and associated data.
RIS is the core database to store, manipulate, and distribute patient radiological data.
It uses Current Procedural Terminology (CPT) or International Classification of Diseases
(ICD) coding systems to identify procedures and resources.
Generally, an RIS consists of patient tracking, scheduling, result reporting, and image
tracking capabilities.
An RIS can generate an entire patient’s imagery history and statistical reports for patients
or procedures.
4. Pharmacy System Components:
In hospitals and clinics, the pharmacy department’s responsibility is to maintain the inventory,
prescription management, billing, and dispensing medications.
The pharmacy component in EHR will hold the complete medication history of a patient such as
drug name, dosage, route, quantity, frequency, start and stop date, prescribed by, allergic
reaction to medications, source of medication, etc.
Pharmacies are highly automated in large hospitals. Again, it may be independent of central
EHRs.
The Food and Drug Administration (FDA) requires all the drugs to be registered and reported
using a National Drug Code (NDC).
5. Computerized Physician Order Entry (CPOE):
Computerized Physician Order Entry (CPOE) is a very important part of EHRs.
It is a system that allows a medical practitioner to enter medical orders and instructions for the
treatment of a patient.
For example, a doctor can electronically order services to laboratory, pharmacy, and radiology
services through CPOE.
Then it gets propagated over a network to the person responsible for carrying out these orders.
As a digital system, CPOE has the potential to reduce medication related errors.
It is possible to add intelligent rules for checking allergies, contradictions, and other alerts.
CPOE can help in patient-centered clinical decision support.
Clinical Decision Support Systems (CDSS) are interactive software systems designed to assist
healthcare professionals in making clinical decisions by providing relevant information, analysis,
and recommendations based on patient data.
CDSS are frequently classified as knowledge-based or non-knowledge based.
If used properly, CPOE decreases delay in order completion, reduces errors related to
handwriting or transcriptions, allows order entry at point-of-care or off-site, provides error
checking for duplicate or incorrect doses or tests, and simplifies inventory and positing of
charges
6.Clinical Documentation:
A clinical document contains the information related to the care and services provided to the
patient.
It increases the value of EHR by allowing electronic capture of clinical reports, patient
assessments, and progress reports.
A clinical document may include
• Physician, nurse, and other clinician notes
• Relevant dates and times associated with the document
• The performers of the care described
• Flow sheets (vital signs, input and output, and problems lists)
• Perioperative notes
• Discharge summaries
• Transcription document management
• Medical records abstracts
• Consents (procedural)
• Medical record/chart tracking
•Release of information (including authorizations)
• Staff credentialing/staff qualification and appointments documentations
• Chart deficiency tracking
• Utilization management
• The intended recipient of the information and the time the document was written
• The sources of information contained within the document
Clinical documents are important because documentation is critical for patient care, serves as
a legal document, quality reviews, and validates the patient care provided.
Well-documented medical records reduce the re-work of claims processing, compliance with
CMS (Centers for Medicare and Medicaid Services).
A clinical document needs to be patient centered, accurate, complete, concise, and timely to
serve these purposes.
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Coding Systems:
Standards play an important role in enhancing the interoperability of health
information systems and the purposeful use of EHR systems.
Collecting and storing information following standard coding systems provide better
and accurate analysis of the data, seamless exchange of information, improved
workflow, and reduced ambiguity.
A complete healthcare system is complex and requires various EHR.
To create an interoperable EHR, standardization is critical in the following four major
areas:
• Applications interaction with the users
• System communication with each other
• Information processing and management
• Consumer device integration with other systems and application.
There are three organizations mainly responsible for developing the related standards:
Health Level Seven (HL7),
Comit´e Europeen deNormalisation-Technical Committee (CEN-TC),
and the American Society of Testing and Materials (ASTM).
HL7 develops healthcare-related standards that are widely used in North America.
CEN-TC is a prominent standard developing organization working in 19 member states
in Europe.
Both HL7 and CEN-TC collaborate with ASTM.
International Classification of Diseases (ICD):
The International Classification of Diseases (ICD) is used to standardize
mortality (death) statistics.
This includes a format for reporting causes of death on a person's death
certificate.
The conditions are then translated into medical codes. The rules for coding are in
the current revision of the ICD.
ICD stands for International Classification of Diseases, which is the United Nations-
sponsored World Health Organization’s (WHO) official coding standard for diseases,
diagnoses, health management, and clinical purpose.
Historical synopsis:
In 1860- Florence Nightingale - systematic collection of hospital data.
in 1893-It first appeared as the International List of Causes of Death - International
Statistical Institute- Bertillon- French physician.
In 1898, the American Public Health Association (APHA)- recommended revising
the system every 10 years.
The sixth revision included morbidity and mortality conditions, and its title was
modified to reflect the changes: International Statistical Classification of Diseases,
Injuries and Causes of Death (ICD).
Since the creation of WHO in 1948, WHO has maintained ICD.
WHO published ICD-6 in 1949, and it was the first coding system in which morbidity
was incorporated. It also included mental disorders for the first time.
CMS announced in 2022 that the ICD-10-CM and ICD-10-PCS codes sets will
now update twice a year, in April and October.
ICD-9:
ICD ninth revision is the most popular coding system published by WHO in 1978.
ICD-9-CM is a widely adopted coding system that establishes codes for
disease diagnoses and procedures, and is the most widely used coding
system of its kind in the world.
The system is modeled after the World Health Organization
(WHO) International Classification of Diseases (Ninth Revision) (ICD-9).
The unique codes that are assigned allow for accurate billing of services in
the outpatient and inpatient clinical setting, data collection, and inventory.
ICD-9-CM:
Its clinical modification, ICD-9-CM, was published by the U.S. Public Health Services
The modified version had expanded the number of diagnostic codes and developed a
procedure coding system.
It has more than 13,000 codes and uses more digits representing the codes compared to
ICD-9.
It is the system that is used to encode all the diagnoses for healthcare services in the
United States.
It is maintained by the National Center for Health Statistics (NCHS) and the Center for
Medicare and Medicaid Services.
The ICD-9-CM code set is organized in three volumes and consists of tabular lists and
alphabetical indices.
• Volume 1: Disease and Injuries Tabular List
• Volume 2: Disease and Injuries Alphabetical Index
• Volume 3: Procedures Tabular List and Alphabetic Index
NCHS has the responsibility to update Volumes 1 and 2, and CMS maintains Volume 3.
The major updates take effect on October 1 every year and minor updates occur on April
1.
ICD-10 :
The tenth version was endorsed by WHO in 1990 during the 43rd World Health Assembly.
The first full version of ICD-10 was released in 1994.
The first step of implementing ICD-10 was taken by NCHS.
International Classification of Diseases, Tenth Revision (ICD-10) is a system used by physicians to
classify and code all diagnoses, symptoms and procedures for claims processing.
The major differences between ICD-10 and ICD-9-CM:
• ICD-10 has 21 categories of diseases; while ICD-9-CM has only 19 categories.
• ICD-10 codes are alphanumeric; while ICD-9-CM codes are only numeric.
• ICD-9-CM diagnoses codes are 3–5 digits in length, while ICD-10-CM codes are 3–7 characters
in length
• Total diagnoses codes in ICD-9-CM is over 14,000; while ICD-10-CM has 68,000.
• ICD-10-PCS procedure codes are 7 characters in length; while ICD-9-CM procedure codes are
3–4 numbers in length.
• ICD-10-PCS total number of codes is approximately 87,000. The number of procedure codes in
ICD-9-CM is approximately 4,400.
ICD 9 ICD 10
Contains around 13,000 codes Contains around 68,000 codes
Code length is 3 to 5 characters Code length is 3 to 7 characters
Digit one can be either alpha or
First digit is always alpha
numeric
Addition of new codes has limitations More flexibility in adding new codes
