HCIS 140 Week 2 What Is an EHR? Example

Eight Things a Record Must Do: Defining the Electronic Health Record Through One Patient's Chart and the Core Functions Set Out by the Institute of Medicine

[Student Name]

University of Phoenix

HCIS/140: Fundamentals of Electronic Health Records

Week 2 Assignment

[Instructor Name]

[Date]

The patient and the chart described are composites written for a model paper; definitions and findings come from the sources listed.

A man of 64 living with diabetes and a weak heart has been seen by his primary care physician, a cardiologist, a hospital emergency department and a diabetes educator in the past year. Each of them read and added to his electronic health record. What exactly is that record, what does it hold and what is it expected to do? This paper answers by opening his chart section by section and comparing what it holds with the functions an expert committee said an EHR system should perform.

Defining the EHR

An electronic health record is a digital version of a patient's health information, created and managed by authorized clinicians and staff, that is designed to be shared across the organizations involved in the patient's care (Office of the National Coordinator for Health Information Technology, 2019). It differs from an electronic medical record, which typically holds one practice's data and is used mainly within that practice, and from a personal health record, which the patient controls and fills from sources the patient chooses.

Demographics and Insurance

The chart opens with his name, date of birth, address, phone numbers, emergency contact, preferred language and insurance. Front desk staff maintain this section, and billing depends on it. Errors here ripple everywhere: a wrong insurance number causes a denied claim, and a wrong phone number means a missed call about a lab result.

Problem List

His problem list shows type 2 diabetes, chronic heart failure with reduced ejection fraction, chronic kidney disease stage 3 and a history of a heart attack. Because it is structured data rather than free text, the system can count every patient with diabetes, remind clinicians about eye exams and pass accurate diagnoses to coders.

Medications and Allergies

His medication list includes metformin, an SGLT2 inhibitor, a beta blocker and a diuretic, along with a sulfa allergy. The list is reconciled at each visit and hospital discharge. When a clinician tries to prescribe a drug that interacts with one on the list or conflicts with the allergy, the system warns them.

Vital Signs, Results and Imaging

Weights, blood pressures, A1C results, kidney function tests and an echocardiogram report sit in their own sections, displayed as trends. His cardiologist can see at a glance that his weight rose five pounds in a week before his emergency visit.

Notes, Orders and Documents

Each encounter produces a note describing the history, examination, assessment and plan. Orders for tests, medications and referrals are entered electronically and tracked until completed. Scanned documents, such as outside records and signed consent forms, are attached.

Immunizations and Preventive Care

His flu and pneumococcal vaccines are recorded and reported to the state registry. Preventive care reminders flag his overdue diabetic eye exam.

The Eight Core Functions

In 2003 an Institute of Medicine committee identified eight core capabilities an electronic health record system should provide (Institute of Medicine, 2003). His chart shows each of them. Health information and data: the demographic, problem, medication and allergy sections. Results management: lab and imaging results delivered and displayed as trends. Order entry and management: electronic orders and prescriptions. Decision support: the drug interaction warning and the eye exam reminder. Electronic communication and connectivity: messages among his clinicians and the referral to the diabetes educator. Patient support: the education materials in his portal. Administrative processes: scheduling and billing data. Reporting and population health: his inclusion in the clinic's diabetes registry and quality reports. The eight functions show that an EHR is not a filing cabinet on a screen but a set of tools that act on the information it holds.

How Recently This Became Normal

Electronic records with these functions were rare until recently. A national survey from 2008 found comprehensive records in fewer than one hospital in fifty and electronic medication ordering in about one in six (Jha et al., 2009). Federal incentives and requirements changed that within a decade.

What the Record Cannot Do on Its Own

The record depends on the people using it. If a clinician copies an old note forward without updating it, the record repeats outdated facts. If an outside hospital uses a system that does not exchange data, the record has gaps. If alerts fire too often, clinicians learn to ignore them. And the record cannot make sense of information no one entered, such as a medication the patient stopped without telling anyone.

Privacy and Access Controls

Because many people touch the record, access is controlled by role. The front desk can see demographics and schedules but not therapy notes; a coder can read the documentation needed to code but cannot change clinical entries; clinicians see what they need to treat. Every view and change is logged, and the organization audits access to catch people looking at records without a reason. Some information, such as substance use disorder treatment records from specialized programs, carries additional federal protections that limit how it may be shared. These controls allow a record designed for sharing to remain private at the same time.

The Patient's View

The man with heart failure also sees part of his own record through the portal: his medication list, recent results, visit summaries and messages from his care team. Since his emergency visit, he checks his weight trend and lab values between appointments, which lets him spot a gain early and call the clinic. The portal turns the record from something kept about the patient into something he can use.

Who Uses the Record

Physicians and nurse practitioners document and order, nurses record vital signs and give medications, pharmacists check prescriptions, coders assign codes from documentation, billers submit claims, quality staff pull reports and the patient reads portions through the portal. Each user sees the part of the record relevant to their role, controlled by access permissions.

Conclusion

An electronic health record is a shared, structured record of a patient's health information, distinct from a single practice's EMR and from a patient-controlled PHR. One patient's chart shows its sections at work and the eight functions they support, while also showing that the record is only as good as the people and connections behind it.

References

Institute of Medicine. (2003). Key capabilities of an electronic health record system: Letter report. The National Academies Press. https://doi.org/10.17226/10781

Jha, A. K., DesRoches, C. M., Campbell, E. G., Donelan, K., Rao, S. R., Ferris, T. G., Shields, A., Rosenbaum, S., & Blumenthal, D. (2009). Use of electronic health records in U.S. hospitals. New England Journal of Medicine, 360(16), 1628-1638. https://doi.org/10.1056/NEJMsa0900592

Office of the National Coordinator for Health Information Technology. (2019). What is an electronic health record (EHR)? HealthIT.gov. https://www.healthit.gov/faq/what-electronic-health-record-ehr