Electronic Health Records
Article Translations: (Spanish)
What Is an EHR?
Most U.S. hospitals, doctors' offices, and medical centers store health information electronically, thanks to the adoption of health information technology (HIT). An electronic health record (EHR), or electronic medical record (EMR), is a digital collection of a patient's health details.
Information stored within an EHR can include a patient's:
- medical history (including immunization status, test results, and growth and development records)
- health insurance and billing information
- other health-related data
Because it's stored digitally, health care providers within a facility can share the information, or send it quickly to another facility if a patient sees another health provider.
How Is Information Accessed?
Most hospitals have a unique EHR database that's accessible from every computer. To open a patient's health record, a doctor, nurse, or other health care provider logs into the system with a username and password or thumbprint identification.
Often, providers can access EHR information remotely by logging into their work network via the Internet.
What Are the Benefits?
- Safely store data. Digital data storage helps preserve health information. Every change made within an EHR is tracked, as is the ID of the person who made it and when. Pages can't be removed from the record. A paper record could get lost, misfiled, or damaged.
- Prevent medical errors. Some systems help doctors prescribe drugs by doing the correct calculations for drug dosages. They also check for and alert doctors about potentially harmful drug interactions, allergies, or possible allergic reactions. And patients can avoid getting extra X-rays or lab tests because each test result is recorded, stored, and easily checked.
- Save time. More than one person can work on the record at the same time. So a doctor can review test results while a nurse enters vital signs and the billing office submits paperwork to an insurance provider. Prescriptions can be "e-prescribed" through the EHR and sent right to a pharmacy, saving a patient time.
- Save space. Thanks to EHRs, huge file rooms may soon be part of the past. This space can be used as care-related areas — perhaps a few extra patient rooms or another imaging center.
- Empower patients. Parents can be active parts of their child's care (or their own) when they have improved access to their medical files. They can view test results, see a provider's instructions for home care, and even check for errors.
Is Patient Privacy Protected?
Yes. A federal law called the Health Insurance Portability and Accountability Act (HIPAA) identifies who's allowed access to medical records. Specifically, HIPAA protects:
- any information that your doctors, nurses, or other health care providers put in the medical record
- conversations between doctors and others about your family's care or treatment
- information about your family in the health insurance carrier's computer system
- billing information
So don't worry if, for example, your nosy neighbor works in the same hospital where your child gets treatment. HIPAA bars anyone from snooping into patient records. In fact, if someone tries to view classified information, it might trip an alarm in the computer system and start a trace on who tried to look at that information.
In many EHR systems, hospital employees have access only to parts of the EHR. The rest of the record is secure and private. If a user's session is inactive for a few minutes, the system may automatically log off to prevent others from viewing the information.
Part of HIPAA called the Security Rule protects the storage and transfer of EHRs. Any provider who sends health information that way must, for example, use safeguards that make sure it is accessed only by those allowed to see it.
Can I Access My Child's Files?
Yes. As with paper charts, you have the right to view your child's medical information. Many health care facilities provide ways for patients and their families to access the system via a patient portal.
Ask if your health care provider offers this service. You'll probably need to register and create a username and password. You can view things like your child's medical history, family history, allergies, and prescriptions. But physician notes, test results that haven't been reviewed, and most psychiatric evaluations are hidden. If your child is a teenager, more areas may be hidden to protect your teen's privacy.
If your health care facility doesn't offer access to EHRs, you can ask for a paper or digital (CD or flash drive) copy of the file. Digital copies can be stored on software known as a Personal Health Record (PHR), either on your own device or online. Some online PHRs are free. Others have setup fees and monthly maintenance costs.
With these accounts, you're responsible for keeping the records up to date. This may take some work, but it's a good way to make sure your child's medical information is in one place. Patient-owned records can be a big help for parents whose kids have chronic conditions or get care from different providers.
Note: All information is for educational purposes only. For specific medical advice, diagnoses, and treatment, consult your doctor.
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