The Ever-Evolving EHR

 The Ever-Evolving Electronic Health Record

Julie U. Sykora


May 24, 2010

David Stibbards


Like an endangered species, the traditional hard-copy medical record is experiencing its final days, out-performed by the electronic health record (EHR).  Health care providers need information fast and they need easy access without compromising patient care.  The paper medical record was neither fast, nor easily accessed.  A single record represented a single episode, which allowed the likelihood of mistakes or missing information such as medications and allergies.  Patient treatment was inevitably delayed as only one person at a time had access and the paper medical record did not allow for pertinent information such as diagnostic studies and decision support systems.  The contemporary medical record must function in a way that allows sharing and integration of information among many users in many places.  A fully functioning EHR that meets the demands and expectations of today’s health care information management is a work in progress (Hebda & Czar, 2009). 

Given the paper medical record’s disadvantages, the theory of an EHR was contemplated for years (Silverman, 1998), but only in the last 15 years was the transmission and storage of large quantities of information feasible in a cost-effective way (Stibbards, 2010).  Historically, the terms, EMR and EHR, were used interchangeably and caused confusion even among principal health care institutions.  In 2006, HIMSS (Healthcare Information and Management Systems Society) defined the EMR and EHR separately.  According to Hebda and Czar (2009), HIMSS defined the EMR as “The legal record created in hospitals and ambulatory environments that is the source of data for the EHR” (p. 293).  Healthcare Information and Management Systems Society (2010) stated: “The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.  Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports.  The EHR automates and streamlines the clinician’s workflow.  The EHR has the ability to generate a complete record of a clinical patient encounter –as well as supporting other care-related activities directly or indirectly via interface –including evidence-based decision support, quality management, and outcomes reporting” (EHR, para. 1).  In addition, not only would the patient have access to his/her EHR, but the patient could also addend it.  In 2003, HIMSS indicated the EHR, rich with information, would be capable of generating many useful reports, allowing health care providers to manage issues like budgeting, billing, health disease tracking, and quality management. 

The task of developing an EHR that encompassed its hard-won definition was daunting.  The Department of Health and Human Services founded the EHR Collaborative, composed of eight notable healthcare organizations, tasked to elicit timely contributions from the health care community to implement EHR standards.          

HIMSS, a member of the EHR Collaborative, recognized the EMR as a vital component of the EHR and developed the EMR Adoption Model (Table 1), consisting of eight stages to chronicle a health care organization’s progress toward a paperless process.

 Table 1

EMR Adoption Model

 © 2009 HIMSS Analytics

Stage 0: The organization has not installed all of the key ancillary department systems (e.g. laboratory, pharmacy, radiology).

Stage 1: Major ancillary clinical systems are installed.

Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine (CDS) for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage. The hospital is health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.

Stage 3: Nursing/clinical documentation is required; nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry. Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organization’s intranet.

Stage 4: Computerized Practitioner Order Entry (CPOE) for use by any clinician is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE with physicians entering orders and completed the previous stages, then this stage has been achieved.

Stage 5: The closed loop medication administration environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration.

Stage 6: Full physician documentation/charting is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full complement of PACS systems provides medical images to physicians via an intranet and displaces all film-based images.

Stage 7: The hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its EMR environment. Clinical data warehouses are being used to analyze patterns of clinical data to improve quality of care and patient safety. Clinical information can be readily shared via standardized electronic transactions with all entities.

 As seen in Table 2, in the first quarter of 2010, 50% of 5,000 hospitals reached Stage 3 of the EMR Adoption Model, indicating entry of orders by physicians as the next objective (HIMSS Analytics, LLC, 2008). 

            Table 2

            EMRAM Trended Summary

EMRAM Trended 2009 Final Q1 2010
Stage 7 0.7% 0.7%
Stage 6 1.6% 1.8%
Stage 5 3.8% 5.0%
Stage 4 7.4% 7.7%
Stage 3 50.9% 50.0%
Stage 2 16.9% 16.5%
Stage 1 7.2% 6.9%
Stage 0 11.5% 11.4%
Total Hospitals n = 5235 n = 5223

                        © 2009 HIMSS Analytics

 Now that the cost of implementing an HIT infrastructure is no longer prohibitive due to government incentives and lower cost of technology, perhaps resistance to change is the final hurdle to a fully realized electronic health record. 


Healthcare Information and Management Systems Society. (2010). HIMSS. Retrieved from

Hebda, T., & Czar, P. (2009). Handbook of informatics for nurses and healthcare professionals (4th ed.). Upper Saddle River, NJ: Prentice Hall.

HIMSS Analytics, LLC. (2008). HIMSS Analytics. Retrieved from

Silverman, D. (1998). The electronic medical record system: health care marvel or morass?. Physician Executive, 24(3), 26-30. Retrieved from MEDLINE with Full Text database.

Stibbards, D. (2010, May 14). Re: week 2 – DQ1 [msg. 36]. Message posted to http://University of Phoenix class forum HCI/500—Health Care Informatics course website.

Note:  This is a paper I wrote during my graduate studies. 


About Julie

My credentials include a Master's Certificate in Health Informatics, a CHPSE certification (Certified HIPAA Privacy and Security Expert), and certification in HL7 (Health Level 7). The multidisciplinary approach to equipping myself to enter the healthcare IT sector is consistent with my professional background in sales, management, healthcare, and recruiting. I also have a BA in Organizational Psychology from the University of Michigan, which as been invaluable in my professional life for exceling in sales, change management, and laying down an excellent foundation from which I was able to build effective communication skills with professionals of all levels.

Posted on March 19, 2011, in Education and Training, EMR/EHR and tagged , , , , , , , , , , , , . Bookmark the permalink. Leave a comment.

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