Before discussing Electronic Health Record (EHR) systems, it is worth resolving the confusion between EHR and EMR. The standard definitions are that the EMR is the digital version of a paper medical record - the record written by the physician (and their staff) looking after a patient, usually stored at the clinic where the patient was seen. The EHR, by contrast, is the type of system used across different clinics and often across more than one healthcare organisation. A national system of medical data about patients would therefore usually be called an EHR; a small system used by a family doctor's office would usually be called an EMR. This also implies that EHRs depend on interoperability standards for sharing records, often stored according to internationally agreed templates such as the HL7 CDA or FHIR formats.
Like most things in digital health, however, the terms have evolved rather than been set down from above. Different vendors use the terms differently, and many people in the field use them interchangeably. The US Certified Health IT Product List (CHPL) describes systems both as EMR and EHR depending on the vendor.
The HL7 Functional Model
One useful way of describing what an EHR is supposed to do is the EHR System Functional Model (FM), developed by HL7. The FM sets out the functions of EHR systems in three sections:
- Direct Care functions - those involved in the provision of individual patient care: managing clinical history (including allergy lists and medications), managing orders (such as lab tests), and coordinating and reporting care (communicating with other providers through messages and reports).
- Administrative Support functions - managing patient demographics, communicating with patients (for example to arrange appointments), and managing healthcare-provider information.
- Information and Infrastructure functions - how data within the EHR is stored and managed: when and how records are archived or restored, how privacy and security are managed, and interoperability with other systems.
Why EHRs have been hard to implement
Using an EHR system might seem straightforward - digitising medical records should save time retrieving notes, increase legibility, and enable sharing across everyone involved in a patient's care. In practice, EHRs have been some of the latest and most difficult hospital information systems to adopt. Many hospitals around the world still rely on paper notes even while they have implemented a PAS, PACS, laboratory information system (LIS), and so on.
The widespread adoption of EHRs in the US only took off after a multi-billion-dollar incentive programme by the federal government. The UK government also tried to drive EHR adoption and spent more than £14 billion in the process but ultimately failed to deliver the promised system. EHRs are challenging to implement for multiple reasons: technical performance in acute clinical settings, increased workload for front-line clinicians, difficulty integrating with other systems, and the high cost being hard to justify from a cost-benefit perspective. Paper has long been a simple and effective tool for doctors to record what they need to know about a patient, and replacing it with an EHR has been a difficult process.
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