Electronic Health Records

Over the past decade, health care providers have been transitioning from paper to computerized medical records.

Central to the digitalization of medical records are electronic health records (EHRs), defined as an "electronic record of health-related information on an individual that includes patient demographics and clinical health information, such as medical history and problem lists. EHRs have the capacity to provide clinical decision support, to support physician order entry, to capture and query information relevant to health care quality, and to exchange electronic health information with, and integrate such information from other sources." (2009 ARRA, pg. 115)

EHRs can be used by hospitals and health care professionals across the health care continuum, including behavioral health and long-term care settings. Read the chart below to learn more about how certified health IT can help health care professionals and consumers improve care delivery, quality, and safety:

EHRs Can Give Health Care Professionals:

• Secure access to information: Instant access to information about a patient's medical history, allergies, and medications, which can help with making decisions sooner instead of waiting for information from duplicative test results.
• Information sharing and coordinated care: Ways to securely share information with patients and their caregivers so they can more fully take part in decisions about their health care.
• More accurate prescribing: Safer, more reliable prescribing of controlled substances like opioids.
• Patient safety tools: Decision support and medical alerts to reduce medical errors, which improves patient safety and better supports patient outcomes.
• Better follow-up: The ability to better coordinate the care they provide to patients with complex, chronic medical conditions.
• Increased efficiencies: Improvements in medical practice management by increasing practice efficiencies and cost savings.
• Population management: Analyze systematic data for an entire population of patients to look more meaningfully at the needs of patients, offer better health care, and even prevent disease.

EHRs Can Give Health Care Consumers:

• Secure access to information: Full and accurate information about all of their medical evaluations, follow-up information after an office visit or a hospital stay, including self-care instructions and reminders for other follow-up care.
• Information sharing and coordinated care: Sending records electronically during referrals allows easier access to follow-up care with specialists. When a primary care physician and a specialist have all have electronic access to the most accurate and up-to-date information, they can make the best possible decisions, even in a crisis.
• Faster prescriptions: The convenience of e-prescriptions electronically sent to pharmacy.
• Reduced unnecessary tests: Doctors may order tests or procedures that are either unnecessary or duplicative. Having results recorded in an EHR can result in potential cost savings, and reduced need to fill out the same forms at each office visit.
• Better follow up: Direct access to all relevant lab results in one place in a way that preserves privacy and security, which can enable better tracking of results over time.
• Secure communications: Many patient portals offer online, secure messaging to your providers, which may help identify serious health conditions like diabetes and obesity.

Meaningful Use of Certified EHRs

The American Recovery and Reinvestment Act authorizes the Centers for Medicare and Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming "meaningful users" of a certified EHR. The act also established the Office of the National Coordinator for Health IT (ONC), which creates the technical standards for federally certified EHRs and other health IT products.

Office of the National Coordinator for Health Information Technology (ONC)

Regulates technical standards for the certification of safe and secure health IT products.

Centers for Medicare & Medicaid Services (CMS)

Regulates requirements used by providers to demonstrate the meaningful use of health IT products.

The ONC certification process helps to assure health care professionals and hospitals the systems they invest in have certain capabilities, like electronic prescribing, secure messaging, and the interoperable sharing of health information for a referral or transition of care. The ONC defines the technical requirements for health IT modules and the process where health IT is certified and tested for vital functionality.

Read below for additional tools for understanding your EHR:

EHR Selection and Adoption

For an introduction to the selection, adoption, and optimization of your EHR, see the ONC Health IT Playbook section on EHRs.

Certified Health IT Product List

The ONC Certified Health IT Product List, or CHPL, is a comprehensive list of health IT modules, which includes EHR systems certified through the ONC Health IT Certification Program. Health IT modules appear on CHPL after they have been tested and certified to the ONC Health IT Certification Program. Practices (including behavioral health and long-term care) can use the CHPL to identify the certified health IT modules they use and, if necessary, to generate the CMS EHR Certification ID required for participation in federal incentive and quality reporting programs. (The CHPL website is optimized for the Google Chrome and Mozilla Firefox web browsers.)

EHR Contract Guidance

The ONC has developed a downloadable EHR Contract Guide to help health care professionals and other decision-makers understand how to manage risks in EHR contracts, so they can maximize the value of health IT investments. It offers strategies and recommendations for negotiating best practice EHR contract terms and illustrates how legal issues might be addressed in a contract by providing example contract language.

EHR Issues

When providers have issues with their certified health IT products, the ONC recommends several steps to take in their Provider Complaint Process. If the ONC determines that a health IT product doesn’t comply with its certification requirements, it deems that health IT product non-conforming and posts the information on the CHPL.

EHR Capabilities and Limitations

In 2016, the Enhanced Oversight and Accountability final rule (81 FR 72404) updated the ONC Health IT Certification Program to provide enhanced oversight and health IT developer accountability to protect public health and safety while also strengthening transparency and accountability. The ONC now requires health IT developers (including EHR vendors) to comply with enhanced transparency requirements associated with their products. These disclosures, available on the CHPL, help buyers and users better understand the capabilities and limitations of health IT products.

More Information

For more information on certified EHRs and Meaningful Use requirements, visit ONC Health IT Website for Providers and Professionals and the CMS Promoting Interoperability Program's site.

For organizations in need of technical assistance, contact MetaStar.

Have a question? Send us an email at eHealth@wi.gov.