How to Use Electronic Health Records

A Comprehensive Guide for Healthcare Providers

Electronic health records (EHR) have become an indispensable tool in modern healthcare. An EHR is a digital version of a patient's paper medical chart that doctors and other health care providers use to record important medical information. EHRs help automate and streamline workflows, enhance care coordination and improve quality of care as well as patient safety.

To get the most value out of EHRs, healthcare providers need to understand the basics, benefits, implementation process and best practices for EHR adoption and use.

What are Electronic Health Records?

An EHR is a systematic collection of electronic health information about an individual's lifetime that can be shared across different health care settings. It usually includes the patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images and laboratory tests. EHRs contain much more comprehensive details about a patient than a traditional paper medical record and allow authorized healthcare providers and medical professionals quick access to important information from any location.

Importance of EHR in Modern Medical Practice

EHRs help shift the focus from reactive care to preventative care and empower patients to take a more active role in managing their health. They improve clinical documentation workflow and enable better coordination between various healthcare professionals involved in a patient's care. EHR systems also facilitate population health management, clinical research and reducing duplication of tests - all contributing to quality of care.

Understanding the Basics of Electronic Health Records (EHR)

There is a distinction between Electronic Medical Records and EHRs. An EMR contains scanned clinical documentation while an EHR adds functionality like clinical decision support and health information exchange. Paper medical records posed several limitations that increased with scale. EHR systems addressed issues like searchability, access across locations, data integration and interoperability.

A basic EHR system digitally captures demographics, test results and billing information while more comprehensive systems also provide clinical support tools, order entry modules and chronic disease registries. Some essential EHR components are problem lists, medication lists, allergy tracking and clinical notes.

Benefits of EHR in Healthcare

EHRs improve care coordination between primary care physicians, specialists and ambulatory care teams through shared access to information. Clinical data can be tracked longitudinally to monitor outcomes and detect issues earlier. Electronic documentation streamlines workflows and reduces transcription errors. Vital signs and immunization details are readily available without searching paper charts.

EHR clinical decision support nudges best practices and alerts doctors to important updates. Patients can access test results and communicate securely with providers using online portals. Studies found EHRs improved preventative care adherence, chronic disease management and reduced hospital readmissions. The technology also enhances physician-patient interactions through functions like shared visit summaries.

Who Uses EHR?

Primary care physicians, specialists, nurses and allied health professionals leverage EHRs in their medical practices. Healthcare organizations ranging from small physician clinics to large hospitals use EHR systems. Acute care teams, long-term facilities, primary care networks and specialty units adopt EHRs tailored to their needs. Ambulatory providers benefit from templates and order sets optimized for outpatient care.

Key Features and Functionalities

Medication reconciliation, computerized physician order entry and clinical documentation are core clinical EHR features. Systems come with pre-built templates for common notes, discharge summaries and referrals. Modules track specialist referrals, lab orders and surgical procedures. Medication lists integrate with drug interaction checkers.

Patient portals give patients online access to lab results, visit summaries and the ability to request prescription renewals or appointments. Population health tools pull aggregate analytics on chronic conditions or provider performance metrics. Quality reporting extracts data for measures like preventative screening adherence. Interfaces exchange information between lab systems, imaging databases and other providers.

Implementation and Training

A thorough needs assessment, functional requirements document and user acceptance testing lay the groundwork. Training should focus on optimizing workflows, addressing disruptions and maximizing usage. A phased roll-out strategy eases the transition. Common barriers are poor usability, lack of perceived value and inadequate training. Compensating early adopters and identifying power users to champion change helps the process.

Research shows more thorough training correlates with fewer usage errors and issues. An optimized curriculum incorporating hands-on demos and role playing helps staff acclimate. Continued follow-up after go-live picks up stragglers. Addressing resistance early with a compelling business case pays off in the long run.

Levels of EHR Adoption

In basic systems, data entry may be slow due to limited clinical functions compared to a fully-loaded EHR. Mid-range offerings deliver clinical modules plus clinical documentation capabilities. Comprehensive systems provide advanced analytics, population health tools and interfaces that promote interoperability.

Adoption levels vary according to provider type and organization size. Larger practices and hospital networks tend to be ahead of small independent clinicians in EHR utilization. Specialty departments often lag behind primary care in advanced usage. Government mandates have accelerated adoption within certain care settings.

Uses of EHR in Different Healthcare Settings

Electronic Health Records (EHRs) standardize workflows across a hospital system, but departmental variance exists. Here are some examples of how different departments use EHRs:

Specialty	Focus	Digital Solutions
Radiology	Electronic access and sharing of scan images using digital systems.	Secure storage and viewing of scan images (e.g., x-rays, MRIs, CTs) on connected devices, facilitating collaboration.
Cardiology	Maximizing electronic trend data and replacing faxed outputs.	Generation and sharing of graphs showing key vitals over time, streamlining communication compared to faxing.
Psychiatry	Documentation of diagnosis and intervention history using digital records.	Digital records capturing a patient's mental background and care plan, allowing progress tracking and coordination across specialties.
Rehabilitation	Extraction of functionality metrics longitudinally using digital tools.	Digital tools documenting patients' movement and daily living, enabling outcome comparisons and facilitating inter-team collaboration on progress.
Primary Care	Emphasis on preventative documentation through structured logging.	Digital records including family histories, allergies, medications, supporting health surveillance and coordination.
Acute Care	Utilization of condition-specific guidance and antibiotic stewardship alerts.	Standard treatment blueprints and medication safety prompts to streamline common care.
Nursing Homes	Digitization of status assessments and changes for residents.	Digital files tracking residents' signs, medications, and condition changes, strengthening cooperation between nursing homes and clinical settings.
Emergency Rooms	Rapid access to diagnostic data during crises.	Digital history and test result access, along with diagnostic database searching, facilitating swift diagnosis in emergency situations.
Telehealth Portals	Enablement of care beyond facilities through virtual meetings.	Virtual meetings connecting patients and providers (e.g., doctors, therapists) for extended services in the comfort of patients' homes.

How to Use Electronic Health Records

Navigating an EHR system takes some practice, but following key steps can help providers hit the ground running:

1. Log In: Access the EHR with unique login credentials to view your patient roster.
2. Pull Up Patient Charts: Find individual records through search or by scrolling your list of scheduled appointments.
3. Review Clinical History: Check previous diagnoses, medications, allergies, tests, and procedures in the comprehensive digital file.
4. Document Visits: Note any new symptoms, exam findings, diagnoses or management plans from your encounter to update records.
5. Order Tests and Prescriptions: Electronically prescribe medications, request lab work or imaging, and track order status.
6. Communicate with Colleagues: Send internal messages, consults, or referrals as needed to coordinate multidisciplinary care.
7. Sign Off: Electronically review and finalize completed tasks, orders, and chart entries before logging out.

Safety and Quality Control

The deployment of electronic health records (EHRs) can significantly help reduce clinical errors due to the implementation of smarter prescribing checks, which have led to a decrease in adverse drug events. Additionally, the completeness and accuracy of chief complaints, medication reconciliations, and discharge summaries have improved through EHR implementations.

While EHRs have many potential benefits, it is important to note that they are not perfect. Alert fatigue is a real concern, and it is important for healthcare organizations to take steps to reduce the number of non-actionable alerts that clinicians receive. Additionally, EHRs must be implemented and used correctly in order to be effective in reducing errors.

To enhance data integrity and ensure that health information remains reliable, it is important to appoint clinical informaticists who can extract insights from structured data. Medical records technicians can also monitor datasets for missing information and discrepancies, which can further improve data accuracy. Audit logs can track access and changes for compliance reporting.

The Future of EHR

The future of EHRs promises even more advancements that could further improve health outcomes and the healthcare experience. These visions include:

• Artificial intelligence (AI) is seen to enhance clinical documentation capabilities through predictive text, encounter summaries, and image recognition.
• Blockchain technology will secure health information exchange across disparate ledgers.
• Mobile applications will deliver patient portals, telehealth visits, and remote monitoring tools.
• Wearables will integrate biometric readings into comprehensive patient profiles.
• Interfaces will increasingly bridge non-traditional data sources from fitness trackers and genomic analyses into clinical decision making.
• National EMS databases compiling pre-hospital information will aid emergency handoffs and outcomes tracking.
• Precision medicine will tailor therapies and prevention to individual molecular profiles as genomic sequencing becomes routine.
• Remote patient monitoring and predictive analytics will detect health changes proactively to intervene earlier.
• Digital therapeutics will partner mobile apps with providers for optimized chronic care support with continuous data loops.
• The future envisions seamless, secure information flow empowering personalized care delivery.

Key Takeaways

EHR momentum continues to transform healthcare through digitization. Challenges remain but technology undeniably enhances clinical operations and patient experiences when properly applied. The longitudinal records created enable higher quality, coordinated and efficient care compared to traditional paper records.

Ongoing refinements will optimize workflows, simplify interfaces and boost user satisfaction levels further. Healthcare's future depends on continued EHR advancements promoting prevention, research and interoperable digital health ecosystems. Widespread adoption holds immense promise for revolutionizing medical practice through information.

Get Started with Your Electronic Health Record Today

You've learned about the many benefits electronic health records can provide your practice. Don't wait to start improving care coordination, tracking outcomes and empowering patients with Calysta EMR.

Our intuitive electronic medical records system is designed specifically for maximizing clinician and patient experiences. A dedicated implementation consultant will ensure a smooth transition from paper to digital. Ongoing support is provided to help optimize workflows and extract insights from your data.

Calysta EMR is committed to supporting you every step of the EHR journey. Contact us today to schedule a personalized demonstration and start reaping the rewards of digitization!