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Appendix: Common Terms in
Health Information TechnologyHealth information technology (health IT) is a broad term that is commonly used to describe the use of computers and electronic applications in providing and documenting medical care. The most common health IT terms include several types of health records—the electronic medical record (EMR), the electronic health record (EHR), and the patient health record (PHR)—as well as computerized physician order entry (CPOE), clinical decision support (CDS), electronic prescribing (e-prescribing), and interoperability. EMRs, particularly those in hospitals, in many cases include CPOE and CDS applications. Also part of the health IT landscape are the health information exchanges (HIEs) and regional health information organizations (RHIOs).1
The electronic medical record is equivalent to the paper-based medical record that a health care provider maintains for a patient. The National Alliance for Health Information Technology defines it as "[a] computer-accessible resource of medical and administrative information available on an individual collected from and accessible by providers involved in the individual’s care within a single care setting." The EMR contains demographic information and clinical data (related to the practice of medicine) on the individual, including information about medications, the patient’s medical history, and the doctor’s clinical notes (Moshman Associates, Inc., and Booz Allen Hamilton, 2006). The EMRs currently in use vary considerably. Basic systems include patient information, doctors’ clinical notes, and results from diagnostic tests. Systems that are more sophisticated also include such features as e-prescribing and warnings about drug and allergy interactions. The most advanced EMRs add CPOE (see below), registry functions that support population management, and clinical decision support.2 The variation in what different EMRs can provide has complicated measurements of the rate of their adoption and led to seemingly contradictory estimates.
An electronic health record is defined as "[a] computer-accessible, interoperable [see below] resource of clinical and administrative information pertinent to the health of an individual." An EHR differs from an EMR in that information is drawn from multiple clinical and administrative sources and used primarily by a broad spectrum of clinical personnel involved in the individual’s care, enabling them to deliver and coordinate care and promote the person’s wellness. Any ambulatory-care EMR that meets the certification requirements of the Certification Commission for Healthcare Information Technology (see Box 1 for more information) and that includes access to data sources beyond the physician’s office would be termed an electronic health record with the EMR embedded in it. Despite their differences, the terms "EMR" and "EHR" are often used interchangeably.
A personal health record is another type of electronic record that is distinguished in part by who controls it: A PHR is controlled by the patient, whereas the EHR is controlled by the provider. The PHR is defined as "[a] computer-accessible, interoperable [see below] resource of pertinent health information on an individual. Individuals manage and determine the rights to the access, use, and control of the information. The information originates from multiple sources and is used by individuals and their authorized clinical and wellness professionals to help guide and make health decisions." In contrast to the EHR, in which providers enter data, people who use a PHR manage the data contained in it. As a result, the quality and comprehensiveness of the information in a PHR vary considerably, depending on how much effort the patient wishes to expend and his or her access to data.
PHRs may and frequently do include data on insurance claims for medical services that the patient has received. (Some health insurance plans now provide PHRs to their members and insert their claims data.) By comparison, EHRs typically contain data that are more clinical in nature, such as the physician’s notes on treatment or services provided. (They may also contain data from other providers if the patient was referred to a specialist.) In essence, the PHR’s data are broad but not especially deep, whereas the EHR’s data are less broad but much deeper. The PHR, however, has the potential to be the basis for the electronic health record, the repository for all health data on a particular patient.
Many health plans and some employers now offer the use of PHRs to their members or employees, but while such a record can be a benefit to consumers, it may also raise questions about who owns the record, how it can be used, and whether the data in the record can be transferred if the person switches health plans or employers. Firms such as Google and Microsoft are now (or soon will be) offering a PHR product.
A payer-based health record (PBHR), yet another type of electronic health record, is owned and administered by a health plan. It includes whatever data are available to the health plan but primarily those related to claims. It may also include demographic information provided by the patient at the time of enrollment. It does not contain clinical notes; however, owing to the increasing amount of data required in submitting claims to payers, a PBHR may comprise laboratory results, radiological readings, prescriptions, and complete reports for inpatient and outpatient hospital care, as well as other types of information. A PBHR may be useful—for example, when a patient visits a hospital emergency room—because hospital staff can access the record to obtain critical data on the patient, such as information that could help prevent adverse drug events.
Computerized physician order entry systems are electronic applications that physicians use to order medications, diagnostic (laboratory and radiology) tests, and ancillary services (Poon and others, 2004). Typically, such systems are used in hospitals, often with an EHR; however, many outpatient EHRs also provide CPOE functions. Because EHRs and CPOE are so often connected in hospitals, a facility’s health IT system may be described as either an EMR, an EHR, or a CPOE system, adding to the confusion over what system the hospital is actually using. (Studies that examine the effects of health IT in hospitals often measure reductions in duplicate orders for laboratory tests, and those reductions are possible only if the hospital has both an EHR and a CPOE system.)
Clinical decision support systems are often used in combination with CPOE functions in hospitals to assist physicians with decisionmaking by providing reminders, suggestions, and support in diagnosing and treating diseases and conditions. The range of features that CDS systems offer includes drug-dosing assistance, checks for drug allergies and drug-drug interactions, access to the latest evidence-based protocols, reminders about preventive-medicine tests, and guidance for complex antibiotic management programs. Both CPOE and CDS systems vary considerably in their complexity and capabilities.
E-prescribing is the electronic transfer of a prescription from the prescribing physician’s office to the pharmacy, which allows a patient to make only a single trip to the pharmacy to pick up the prescription once it has been filled. E-prescribing has received a great deal of attention but is not very common. Many physicians who have EHRs in place could easily generate prescriptions using the electronic record—and thus benefit from the CDS function that many EHRs include—but in the end they often print out a prescription for the patient to take to the pharmacy. Using the EHR to generate a paper prescription may reduce transcription errors and reduce the physician’s time and effort, but the patient must still deliver the prescription to the pharmacy.
Interoperability describes the capacity of one health IT application to share information with another in a computable format (that is, for example, not simply by sharing a PDF [portable document format] file). Sharing information within and across health IT tools depends on the use of a standardized format for communicating information electronically—both among the components that constitute a doctor’s office EHR (clinical notes, lab results, and radiological imaging and results) and among providers and settings that use different health IT applications. An interoperable health IT system would allow a hospital physician to view the contents of an EHR from a patient’s primary care physician and enable the primary care physician in turn to view all notes and diagnostic tests from the patient’s hospital visit. Interoperability is the feature that would allow the creation of a single comprehensive medical record that could follow a person throughout his or her life and from one geographic area to another.
A key component of interoperability is the establishment of a health information exchange, an "information highway" of sorts. An HIE is defined as "the electronic movement of any and all health-related data according to an agreed-upon set of interoperability standards, processes and activities across nonaffiliated organizations in a manner that protects the privacy and security of that data; and the entity that organizes and takes responsibility for the process." Without such an arrangement, a physician could still receive lab results in a computable format and use e-prescribing, but a hospital could not, for example, access information on a patient that is stored in the physician’s office EHR. Health information exchanges are even less common than EHRs; however, some integrated health care delivery systems, such as Intermountain Healthcare in Utah and southern Idaho and the Veterans Health Administration, share information within their networks and operate much like health information exchanges. However, because they have access only to data within the network, they may not have a comprehensive view of a patient’s record.
A regional health information organization is defined as "a multi-stakeholder governance entity that convenes non-affiliated health and healthcare-related providers and the beneficiaries they serve, for the purpose of improving health care for the communities in which it operates. It takes responsibility for the processes that enable the electronic exchange of interoperable health information within a defined contiguous geographic area."
The definitions included here draw heavily on an interim draft document prepared by the National Alliance for Health Information Technology, with guidance from BearingPoint, Inc. The effort is funded by the Office of the National Coordinator for Health Information Technology to achieve consensus on definitions for five health IT terms: electronic health record, electronic medical record, personal health record, regional health information organization, and health information exchange.
Registries generally track patients who have a particular disease or who have received a specific treatment. They collect additional information (such as measures of health status or test results) that is typically not contained in insurance claims records.
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