An Electronic Health Record (EHR) is a shared longitudinal health summary shared across clinical stakeholders to improve patient care.

Summary

An EHR contains a subset of the clinical information recorded about the patient. This might include:

• Key patient demographics
• Event summaries: summarizing an episode of care (for example a discharge summary from a stay in hospital)
• Alerts and allergies
• Investigations (pathology/radiology results)

As the EHR is a summary it may not include more detailed information held by contributing care providers. For example the nursing progress notes may have been recorded by the hospital in the patient chart but may not have been included in the event summary for the hospital admission.

Shared Governance and legal issues aside, an EHR logically 'owned' by a wide range of stakeholders including:

• the patient (EHRs should provide appropriate patient access)
• the patient's primary physician/general practitioner
• other relevant community clinicians
• public and private hospitals
• state and national governments

Standards Based

By its very nature an EHR needs to be interoperable with other electronic medical records. Interoperability is likely to be based on standards such as HL7 Version 3 Resource Information Model, HL7 Version 3 Clinical Document Architecture and EN13606 EHR Communication standard.

National EHRs

National EHRs are in the process of being implemented in countries such as the UK (National Programme for IT), Canada (Infoway) and Australia (HealthConnect).

For more information on EHR services please visit the Gillogley Services web site.

Peter Gillogley is the Director of Gillogley Services.