What is the type of health record that is created and maintained by the patient?

Clinical decision support system

EHRs should be used to arrive at the patient’s diagnosis and treatment plan. However, often, the chart of a patient with multiple conditions is so detailed that healthcare provider does not even have the time to review it in its entirety. This problem is further compounded when the patient has visited several providers for his care. A simple EHR will store all information; an intelligent one will highlight and show the important portions.

However, a warning is required here. What may be deemed as important for one user may be the reverse for another. A well-functioning clinical decision support system takes into account the patients’ information and indicates the best course of action based on current guidelines. Thus analytics can serve to reduce the time needed by the provider to arrive at the treatment plan. However, for this to work, it is essential that the algorithms that run behind the CDSSs run as per current clinical judgment and guidelines. The reason why a certain course is recommended should be transparent (and NOT a black box). Furthermore, these need to be updated as guidelines and opinions change. These sticky points are often the reason behind mistrust in CDSS among physicians.

Electronic Health Record

A national electronic health record (EHR) or exchange will provide seamless and immediate access for multiple health care providers to integral parts of a patient's record regardless of where the original record was created or stored. It will solve the problem of disseminating difficult airway information to any health care provider at any time in any location. The American Recovery and Reinvestment Act of 2009 provided funding to support the national implementation of an EHR system. Furthermore, in 2009, the Health Information Technology for Economic and Clinical Health Act was passed to improve the performance of the health care system; this act included support for state initiatives and created a common platform for health information exchange across the country. However, according to the Healthcare Information and Management Systems Society, as of 2013, only 1.8% of hospitals had a complete electronic record.70 At present, the EHR system in the United States cannot satisfy the need for immediate national or international access to and dissemination of patients’ difficult airway information.

Until an EHR-based national difficult airway registry is created, we have opted to use a national and international difficult airway information system that is already fully functional to support difficult airway patient management after discharge: the MedicAlert Foundation. This 501(c)3 nonprofit organization, founded in 1956, is the foremost national and international emergency medical information system, with 4 million members worldwide. In 1992, the National Difficult Airway/Intubation Registry was created within the MedicAlert Foundation. To our knowledge, it is the only difficult airway/intubation registry operating at a national level in the United States. The phrase “difficult airway/intubation” was adopted as the standard nomenclature to be engraved on MedicAlert identification bracelets, necklaces, and wallet cards. Additional airway management information is maintained in an emergency medical information record, accessible through a 24/7 emergency response service center (Andrew Wigglesworth, President and CEO, MedicAlert Foundation International, personal communication, 2010). The registry's intent is to ensure that difficult airway information is immediately available to emergency responders in the field, and to hospital-based clinicians treating patients with difficult airways. The mission of National Difficult Airway/Intubation Registry garnered support from the ASA in 1979, the World Federation of Societies of Anaesthesiologists in 1992, the American Academy of Otolaryngology–Head and Neck Surgery Foundation in 1993 (Dr. Charles Cummings), and the Society for Airway Management (SAM) in 1995.

In 2015, MedicAlert reported that over 12,000 patients were enrolled in the National Difficult Airway/Intubation Registry.6 A 2010 survey of over 700 registry members found that 11.2% had had another episode of care in which difficult airway/intubation was a factor (Andrew Wigglesworth, President and CEO, Medic­Alert Foundation International, personal communication, 2010). This percentage highlights the need for difficult airway patients to have 24/7 access to information about previous successful and unsuccessful airway management techniques that will improve the chances of a positive outcome and decrease the number of unsuccessful intubation attempts associated with an increased rate of complications.3

The electronic health record timeline and a promise

EHRs were initially developed and used at academic centers in the early to mid-1960s. Most of the academic institutions with these electronic records developed and maintained the platforms themselves. An early example would be the Massachusetts General Hospital’s Computer Stored Ambulatory Record (COSTAR), which came online in the late 1960s. COSTAR was a set of modules that allowed the scheduling and registration of patients, clinical information storage, among other functionality that we take for granted in today’s electronic medical records [8]. The U.S. Department of Veterans Affairs began using an EHR in the 1970s, across the Veteran Health System (VHA), allowing it unrestricted access to any veteran’s records in the system [9]. Epic was founded in 1979 [10] and also Cerner Systems in 1979 [11]. These two industry juggernauts combined make up almost 50% of the hospital electronic medical records market in the United States, according to the Office of the National Coordinator [12].

In 2008, less than 10% of the hospitals in the United States had an electronic health record [1]. The HITECH Act was a portion of the American Recovery and Reinvestment Act, which totaled 787 billion dollars [13]. The Act formally propelled the adoption of EHRs by healthcare practices by introduced legislation. Of the money allocated, 18 billion dollars was earmarked to allow the Centers for Medicare and Medicaid Services (CMS) to incentivize the transition to, and meaningful use of EHRs, with the goal of increasing structured data, improving the efficiency and quality of care allotted, improve population health, privacy, and security protection of patient health information (PHI) [14].

CMS and the Office of the National Coordinator (ONC) have established standards for electronic health records. Being a Certified EHR Technology (CEHRT) allows the purchaser of that product and the end-users, to understand that the said product meets a defined standard, and contains a certain technological capability and functionality [15]. The HITECH Act was integral in framing the creation of the Certified EHR Technology rule.

Choosing an electronic health record (EHR)

The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009. Starting in 2011, eligible professionals could receive incentive payments up to a total of 5 years if they could demonstrate “meaningful use” of certified electronic health records (EHRs). Providers faced up to 5% penalties if they did not demonstrate meaningful use beginning in 2015. As a result, adoption of electronic health records increased during this time.30–34 Even plastic surgeons who do not treat many Medicare patients have increasingly adopted electronic health records and practice management software. The EHR market continues to evolve. The market is anticipated to consolidate, as rules, regulations and functionality demands increase in this space. However, many EHRs were designed with the primary care physician in mind and thus can be lacking in key features desired or required by the average plastic surgeon. In addition, many programs require a significant upfront investment of both time and money. Physicians and office staff may experience challenges in implementation and training with new EHR systems, sometimes with a considerably steep learning curve, requiring significant allocation of staffing time before the EHR is fully operational for the office's needs. Thus, the choice of EHR can be crucial. Below are some key considerations regarding the EHR itself that should be taken into account when choosing an EHR system.

Combining secondary data sources with primary data collection

EHR or administrative claims data sources may be lacking the data needed to comprehensively address specific research questions, allow adequate adjustment for confounding, and perform sensitivity analyses. An increasingly popular approach is to use the electronic data to the extent possible and supplement with primary data collection. This often includes data needed to more accurately and validly define outcomes or disease and exposure in pRCTs, and may also include patient reported outcomes (PROs). Such PROs may be targeted to assessing symptoms or the impact of symptoms on health-related quality of life, and are not typically part of routine clinical care. However, PROs may be important in addressing the research question and can be integrated into electronic medical record systems for a seamless approach to data collection in a specific study.

Electronic Medical Records for the Office-Based Center

Electronic Health Record (EHR), also called the Electronic Medical Record (EMR), and often used interchangeably, received it first real validation in an Institute of Medicine's (IOM) report in 1991.5

The EMR has become the core technology and is the center of patient care provided today. Process workflow for patient care is built into the EMR and drives the efficiency and viability of the organization. The information can be accessed from anywhere at anytime and by all the required individuals including the patient. The EMR is intended to meet the triple aim of “Quality, Safety, and Efficiency.” The EMR should make running your practice simpler, more efficient, and focused on patient care. EMRs are mandated today, and it is nearly impossible to function without one.

Hundreds of EMR systems are available on the market, and choosing one is not an easy task. Once chosen, the proper installation and training of the staff to use the software to its maximum potential are critical to its success. Integration of the workflow processes of the practice with the EMR is vital and often leads to frustration, increasing inefficiencies and economic loss within the practice. This is contrary to what was expected. Introduction of EMR in the practice is resulting in early retirement of senior physicians and one of the leading causes of physician burnout.

Data model to knowledge model

EHRs in their most basic definition are databases; data collected and organized into a data model using a set or sets of labels and relationships between individual datum. How these data are interpreted requires specific knowledge about the how the concepts held in the database may be related to one another (e.g., for an arterial blood test for pH, a rule such as ‘if the pH is > 7.4, then …’). Such clinical rules are often designed on medical standards of care, but similar rules can be constructed for length of patient stay, frequency of visits to the emergency department, number of cigarettes smoked daily, etc. To make the contents of the database (and its data model) meaningful, a knowledge model or ontology needs to be applied to it. Commonly, the definition of an ontology is that it is a set of concepts used in defining a knowledge base, and how these concepts are meaningfully arranged.

What is a health record type?

What is a medical record of a patient?

Which type of health record contains information about the means by which the patient arrived?

What are the two types of content of the health record?