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EHRs and Unicorns


Like the unicorn, which is well-defined in terms of its features and attributes, EHRs don’t actually exist.

You have seen the ads. You have been to the seminars. You have sat through the demos and read the marketing literature. You may even “own” one. They are called EHRs, or Electronic Health Record systems. But like the unicorn, which is well-defined in terms of its features and attributes, EHRs don’t actually exist.

There are many different kinds of electronic systems that collect, store, and manage patient health records electronically. These are divided into three primary categories, according to most industry experts’ definitions:

Personal Health Records (PHRs): This is an electronic health record created and maintained by the patients themselves. It may take the form of an online record, or it may be on a portable memory device like a USB key or memory card that the patient carries with them. Some payers and some employers provide PHRs to their members/employees. Some PHRs can be interfaced with EMRs such that data can be transferred between the PHR and the provider’s systems.

Electronic Medical Records (EMRs): This is a system maintained by the practice, and primarily for the practice’s benefit. It differs from a practice management (PM) system in that it contains clinical data, such as patient and family health history, diagnoses, medication history, allergies, etc. Some EMRs allow patient input and interaction, either through a PHR or a patient portal. Generally speaking, they also have the ability to store, display and manage test results such as labs, x-rays, etc. They usually also support provider entry such as e-prescribing and may contain decision support tools.

Electronic Health Records (EHRs): This system is similar to an EMR but differs in one critical way. It is supposed to allow the medical record to follow the patient across different boundaries of care, and not have to have the patient have to face the proverbial clipboard when they go, say, from a primary care physician to a specialist, or from a physician to a lab or imaging center.

Within some large integrated health systems that have spent years implementing the same system throughout all their practices, clinics, labs, and hospitals, such as Intermountain Health in Utah, or Kaiser in some markets, true EHR functionality exists, where patient information can flow across different boundaries of care. But those are the exception, rather than the rule.

There are several reasons why EHRs may sound good on paper but why they don’t really exist generally within the healthcare space:

Most providers and clinics have not yet implemented a fully functional EHR. They may have purchased (or been sold) something with that name, but unless and until they have implemented it in a fully functional way, with all internal- and external-facing modules, it generally cannot generate, transmit, or receive data from other providers’ systems. Most providers and clinics still have largely paper-based record systems. That kind of obviates the “E” in EHRs.

Most EHR systems are not truly interoperable without costly interfaces or intermediate “middleware” systems. Although certain standards such as HL7 make interoperability theoretically possible, it is rarely achieved in actual implementation. HL7 only makes interoperability a possibility; it does not create the interoperability or the actual data streams.

There are issues and opportunities for duplication of data or data corruption, because the rules and standards to allow for the security and hand off of information are not yet fully mature. There are huge issues around trying to determine such things as the Master Patient Record. For example, if Provider 1 has a patient listed as Betty Smith, and Provider Two has a patient listed as Betty J. Smith, how do they determine if that is the same person, and avoid setting up duplicate records? And which provider’s system controls the “real” patient information? Lastly, if one of the practices changes Betty Smith’s data, does that automatically flow into the other provider’s system? Who checks its accuracy/validity?

Sharing the data requires some sort of independent data interchange functionality. Some Health Information Exchanges (HIEs) are currently being created, which allow for the sharing of EHR data, but unless and until they are up and running across the healthcare horizon in a broad and functional way, providers will not be able to support the seamless flow of electronic health information for patients.

The term EMR has been around for many years. When ARRA/HITECH was announced in February 2009, it referenced EHRs. It seems that all EMR vendors simply did a mass change of all their EMR literature, changing “EMR” to “EHR.” But little else changed, other than the name.

So EHRs are much like the proverbial Unicorn, which almost everyone can describe but which apparently no one has actually seen.

If you have seen a unicorn … or an EHR…please jump in with your comments.

Learn more about Marion K. Jenkins and our other contributing bloggers here.

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