An electronic health record (EHR) provides the independent physician with a patient’s medical data that had been previously recorded on paper and stored in file folders. Of course, EHRs do much more than just provide a patient’s medical record. There are many common EHR features that benefit both the independent physician and the patient.
The office of Health Information Technology (Health IT) defines an EHR system as one that is “built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:
- Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
- Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
- Automate and streamline provider workflow.
Easy access to digital information is a prime feature of an EHR solution. Independent physicians have the ability to input and review a patient’s information during the patient visit. The physician can then collaborate seamlessly with other providers to provide coordinated care. EHRs eliminate the need to request records from specialty providers, laboratories, or healthcare facilities, and then wait for those records to be faxed.
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Additionally, EHRs provide the opportunity for patients to access their own medical information. Patient portals encourage patients to be more actively involved in their own healthcare, by reviewing their data and asking questions or clarifying instructions with their independent physician. Communication is another common EHR feature that enables both patients and physicians to send messages electronically and securely.
EHRs also enable the independent physician to document visit notes, order lab tests, e-prescribe, and write referrals in any order, all from the same screen. With easy access to a patient’s medical history, the independent physician can holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time.
Most importantly, EHRs feature the ability to quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.
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