Overview of Electronic Health Records

A core component of any health information technology (HIT) implementation is the electronic health record (EHR). EHRs have been created by a number of software vendors and some have been developed internally by healthcare organizations. While the feature sets available in EHRs may vary in detail, the core components include demographics, medications, allergies, immunizations, laboratory data, radiology reports, vital signs, problem lists, and progress notes. EHRs are, in effect, longitudinal records of current and past medical history. The availability of these data within a centralized system allows the compilation of data across multiple patient records, which directly supports outcome tracking and quality improvement. These data can also be used to drive clinical decision support systems.

[1]  W. Berry,et al.  A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population , 2009, The New England journal of medicine.

[2]  Melissa Steward.  Electronic Medical Records , 2005, The Journal of legal medicine.

[3]  Paul E. Johnson,et al.  Impact of Electronic Health Record Clinical Decision Support on Diabetes Care: A Randomized Trial , 2011, The Annals of Family Medicine.

[4]  Chuntao Wu,et al.  Do Hospitals and Surgeons With Higher Coronary Artery Bypass Graft Surgery Volumes Still Have Lower Risk-Adjusted Mortality Rates? , 2003, Circulation.

[5]  Susan R. Kirsh,et al.  Building a Diabetes Registry from the Veterans Health Administration's Computerized Patient Record System , 2008, Journal of diabetes science and technology.

[6]  David W. Bates,et al.  Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial , 2012, J. Am. Medical Informatics Assoc..

[7]  Amy M. Knight,et al.  The Hybrid Progress Note , 2013, American journal of medical quality : the official journal of the American College of Medical Quality.

[8]  H. Mcdonald,et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. , 2005, JAMA.

[9]  N. Terry,et al.  The Emergence of National Electronic Health Record Architectures in the United States and Australia: Models, Costs, and Questions , 2005, Journal of medical Internet research.

[10]  Catherine L. Liang,et al.  Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. , 2009, Archives of internal medicine.

[11]  Kevin Chen-Chuan Chang,et al.  Case report: Enhancing laboratory report contents to improve outpatient management of test results , 2010, J. Am. Medical Informatics Assoc..

[12]  Stefan L. Zimmerman,et al.  Informatics in radiology: automated structured reporting of imaging findings using the AIM standard and XML. , 2011, Radiographics : a review publication of the Radiological Society of North America, Inc.

[13]  William E. Trick,et al.  Case Report: Use of Clinical Decision Support to Increase Influenza Vaccination: Multi-year Evolution of the System , 2008, J. Am. Medical Informatics Assoc..

[14]  S. Trent Rosenbloom,et al.  Implementing Pediatric Growth Charts into an Electronic Health Record System Rosenbloom Et Al., Implementing Pediatric Growth Charts into an Ehr System , 2022 .