Electronic Health Record

What is an Electronic Health Record?

longitudinal electronic record of patient health data generated by one or more encounters in any care delivery setting

What do EHRs normally Include?

patient demographics, progress notes, problems, medications, vital signs, past medical history, immunisations, lab data, and radiology reports

What is Interoperability?

the ability of 2 or more components/systems to exchange information and use the information that has been exchanged

What is Syntactic Interoperability?

allows 2 or more systems to communicate and exchange data

What is Semantic Interoperability?

ensures not just the format, but also the meaning of the data is understood

What does FHIR stand for?

fast healthcare interoperability resources

What is FHIR?

web-based standard / framework for secure exchange of electronic healthcare information across disparate sources

What does ICD stand for?

International Statistical Classification of Diseases and Related Health Problems

What is ICD?

identifies a set of health conditions and health practices and tries to assign alphanumeric codes to them

What does SNOMED-CT stand for?

Systematized Nomenclature of Medicine (Clinical Terms)

What is SNOMED-CT?

a standardised shared medical vocabulary for electronic health records

What does MIMIC stand for?

Medical Information Mart for Intensive Care

What is MIMIC?

large, freely-available database comprising de-identified health-related data from patients who were admitted to the critical care units of the Beth Israel Deaconess Medical Centre

What is an Electronic Medical Record?

single provider's digital representation of a patient's health chart

What is an Electronic Patiient Record?

patient-centric system that allows patients to manage their own health information

What are the Benefits of EHRs?

• Improved access and sharing of patient information

• Enhanced clinical decision-making

• Better continuity of care

• Research and population health opportunities

What are the Challenges of EHRs?

• Data entry burden and workflow issues

• Privacy and security concerns

• Interoperability and system integration challenges

• Cost and training requirements

• Data quality

What is an EHR System?

any system where the appliance or software allows to store, intermediate, export, import, convert, edit or view personal EH data that belongs to the priority categories of personal EH data

What Functions should EHR Systems Offer?

• store and provide access to health information of patients

• be able to work in-sync with the original workflow of the healthcare organisation

• be able to work effectively, saving time of care providers by keeping things concise

• support provision of reminders, prompts, and alerts

• empower patients to access their health information, enabling them to be involved in their own healthcare

• enable exchange of data in known/standard formats for interoperability of healthcare applications

• provide administrative tools, such as scheduling systems, for improving efficiency of clinical practices