Not that long ago, doctors and nurses would write notes in a patient's chart —
often a sheaf of papers fastened to a clipboard — during an office visit. These
notes then would be added to the patient's ever-expanding medical file, which was
physically stored on the premises. Until the digital age, there was no other way to
store a patient's medical record.
But that was then.
Today, more and more patients can expect to see computers instead of clipboards
when they hop onto the exam-room table, thanks to the adoption of health information
technology (HIT) by U.S. health care providers and hospitals.
These days, the majority of hospitals, doctors' offices, and medical centers
nationwide store health information electronically. Soon, all of them will, and the
days of the clipboard will be done for good.
What Is an EHR?
An electronic health record (EHR), also called electronic
medical record (EMR), is a computerized collection of a patient's health
details. But it's more than just that — it's a way of storing and organizing
patient information. Like hospital charts, EHR patient files are divided into sections
where health care providerys and staff can find the information they need to provide
patient care or perform administrative tasks.
Information stored within an EHR can include a patient's medical history (including
immunization status, test results, and growth and development records), health insurance
and billing information, and other health-related data.
Because it's stored digitally, the information can be shared easily among a patient's
various health care providers within a facility, and can be sent quickly from one
facility to another if a patient finds a new health provider.
How Is Information Accessed?
Most hospitals have their own unique EHR databases that are set up to be accessible
from every computer. To open a patient's health record, a doctor, nurse, or other
health care provider would log in to the system with a username and password or thumbprint
Often, providers can access information remotely (such as from an off-site computer)
by logging in to their work's network system via the Internet and accessing the EHR.
Systems are directly accessible over the Internet, too.
What Are the Benefits?
Everyone knows the jokes about doctors' unreadable handwriting. But the advantages
of EHRs go way beyond issues of legibility. EHRs also can:
Safely store data. Digital data storage helps to preserve health
information. Every change that is made within an EHR is tracked along with the ID
of the person who made it and the time. Pages cannot be removed from the record. With
paper records, there's always the chance they'll get lost or misfiled or somehow damaged.
Paper medical records for thousands of patients in Louisiana, Mississippi, and Alabama,
for example, were destroyed by Hurricane Katrina in 2005 — and most of that
information was never recovered.
Prevent medical errors. Many medical errors are preventable by
using EHRs. For example, some systems help doctors prescribe drugs by performing the
correct calculations needed for drug dosages. They also monitor for and alert doctors
of potentially harmful drug interactions, allergies, or possible allergic reactions.
And patients can avoid getting extra X-rays or lab tests because each test result
is recorded, stored, and easily referenced.
Save time. More than one person can work on the record at the
same time, so there's less time waiting to hand off the record to another person.
So a doctor can review test results while a nurse is entering vital signs and the
billing office is submitting paperwork to an insurance provider through the system.
Additionally, since prescriptions can be "e-prescribed" through the EHR and sent to
a pharmacy directly, it saves patients time later on.
Save space. Thanks to EHRs, huge file rooms may soon become a
relic of the past. This valuable office space within the hospital can be converted
into care-related areas — perhaps a few extra patient rooms or another imaging
Empower patients. Parents can be active participants in their
child's care (or their own) when they have improved access to their medical files.
That means they can view test results, review a provider's instructions for home care,
and even check for errors.
Is Patient Privacy Protected?
Yes. A federal law called the Health Insurance Portability and Accountability Act
(HIPAA) identifies who's allowed access to medical records. Specifically, HIPAA protects:
any information that your doctors, nurses, or other health care providers put
in the medical record
conversations between doctors and others about your family's care or treatment
So you shouldn't worry if, for example, your nosy neighbor happens to work in the
same hospital where your child receives treatment. HIPAA bars anyone from snooping
into patient records. And depending on the EHR system, attempts to access classified
information might trip an alarm within the institution's computer system and could
Also, in many EHR systems, hospital employees only have access to the parts of
the EHR required to do their job. This helps keep the rest of the record secure and
private. And after a user's session has been inactive for a few minutes, the system
may automatically log off to prevent others from viewing the information.
In addition, a provision of the law (called the Security Rule) specifically addresses
the security of EHRs by establishing national standards for protecting certain health
information that is stored or transferred in electronic form. Any provider who transmits
health information electronically is required by law, for example, to have safeguards
(hardware, software, etc.) in place to limit access to that information to those permitted
to see it.
Can I Access My Child's Files?
Yes. Just like with old-fashioned paper charts, you have the right to view your
child's medical information. Not all health care facilities provide ways for patients
and their families to log in to the system, but many do.
If your health care provider offers this service, ask what's required of you. You'll
probably need to register into the system and provide a username and password. Things
like your child's medical history, family history, allergies, and prescription medications
will be viewable, but any physician notes, test results that haven't been reviewed,
and most psychiatric evaluations will be hidden. And, if your child is a teenager,
it's likely that more areas will be hidden to protect your teen's privacy.
If your health care facility does not yet offer access to EHRs, you still can request
a paper or digital (CD or flash drive) copy of the file. Digital copies can be stored
on software known as a Personal Health Record (PHR), either on your home computer
or online. Some online PHRs are free, while others have initial setup fees and monthly
With these accounts, you'll be responsible for keeping your records up to date.
While this may take some work, it's a good way to make sure that all of your child's
medical information is in one place. Patient-owned records are especially useful for
managing the care of kids with chronic conditions and those who receive care at multiple