Electronic health records (EHRs), the digital version of paper charts that contain the medical and treatment history of patients are critical in automating healthcare providers’ patient records and offering high-quality patient care. EHRs contain detailed information about a patient’s health comprising of the medical history, diagnoses, medications used, immunization dates, allergies, and laboratory and test reports that help healthcare providers get instant access to the patient’s health condition and empower them to provide quick quality healthcare.
EHR solutions facilitate documenting patient data in the form of electronic health records that are both economical and environmentally friendly. The data in EHRs which is accessible to authorized health care providers is critical in improving patient safety, quality of care, and offering evidence-based treatment. Hence, it is essential that people working with the help of hospital management software and EHRs understand the various terms used in EHRs. Here, we walk you through a few important and widely used terms in the documentation of patient data in electronic health records.
- Electronic health record – It is a comprehensive set of patient data inclusive of demographic, clinical, social, and financial aspects of a single patient stored in an electronic form that can be accessed by authorized persons across multiple health organizations.
- Certified electronic health record – A certified electronic health record is a health record that has been certified by the Office of the National Coordinator (ONC). The certification is awarded after reviewing and determining that the EHR is compliant with the technological capability, functionality, and security standards as required by ONC–Authorized Testing and Certification Body.
- Electronic medical record – This is a patient’s health record stored digitally that can be accessed by persons of a single healthcare organization.
- Meaningful Use – It is a federal incentive program by the Centers for Medicare and Medicaid Services that provides guidelines and regulations for healthcare providers with the minimum requirements that they must adhere to in the use of EHRs in order to be qualified for the payments.
- Health Information Exchange – This is a process through which patients and various people involved in providing healthcare (doctors, nurses, pharmacists, radiologists, etc.) get to access a patient’s critical medical information digitally across organizations as per nationally recognized standards. Sharing of a patient’s data through Health information exchange (HIE) facilitates high-quality and safe patient care at an increased speed while reducing costs.
- Interoperability – The ability of various health information systems within an organization or across multiple organizations to effectively deliver healthcare is referred to as interoperability.
These are some of the basic and most commonly used terms in the implementation of EHRs. Healthcare providers should choose the best EHR solutions providers to maximize their meaningful use purpose and implement EHRs with the highest levels of safety and accuracy. Choose nimble, one of the best providers of EHR Solutions in Hyderabad for your EHR requirements.