Basic Components of an Electronic Health Record

The basic key components of an EHR include:

1. Patient Management Component:

This component is required for patient registration, admission, transfer and discharge (ADT) functionality. Patient registration includes key patient information such as demographics, insurance information, contact information etc. When a patient is registered in an EHR for the first time, a unique ID (often called “Medical Record Number”) is generated. Whenever a patient has an encounter with the organization, another unique “encounter” number is generated. In a “best of breed” EHR environment, this component may also generate a Master Patient Index (MPI).

2. Clinical Component:

This component can house multiple sub-components e.g. Computerized Provide Order Entry (CPOE), electronic documentation, nursing component etc.

CPOE allows providers to enter orders that are needed for patient management directly in the computer. This component can make use of clinical decision support tools such as drug-drug, drug-allergy, and drug-diagnoses interactions. This module also allows providers to enter multiple orders from order sets.

Electronic documentation by providers allows them to document notes such as History & Physical, consults, discharge summaries, operative notes etc. Multiple tools may be used to enable electronic documentation such as templates, speech recognition and transcription services.

The pharmacy system allows for maintaining a drug formulary, filling prescriptions and crosschecking any orders that are placed by providers in the EHR.

Nursing component allows for collection of key patient information such as vital signs, input and output etc. This component also allows for medication administration record (MAR), barcode medication charting and nursing documentation.

3. Laboratory component:

Lab components are typically divided into two subcomponents; 1) Capturing results from lab machines, and 2) Integration with orders, billing and lab machines. The lab component may either be integrated with the EHR or exist as a standalone product.

4. Radiology Information System:

Radiology information system (RIS) and Picture Archiving & Communications System (PACS) are used to manage patient workflow, ordering process, results and the images themselves.

5. Billing System

The billing system (hospital and professional billing) is used to capture all charges generated in the process of taking care of patients. These charges generate claims, which is submitted to insurance companies, tracked and completed.

Overlaid on top of the core application layers is generally a data layer, which is fed data by the EHR. This data layer allows healthcare professionals to monitor Key Performance Indicators, view dashboards with relevant business data, and run analytical reports to monitor and improve the performance of the health care organization. One of the successes of using the data captured by EHR's is the ability to track organizational expenses, inventory, and revenue cycle performance. These basic tasks were very complicated in the pre-EHR era.

One of the biggest challenge today around managing electronic health record data is in obtaining clean, discreet data that can be used for analytics. Natural language processing and other tools are being developed to solve some of these problems.

We are in the early years of using this technology in healthcare. Organizations are trying to rebuild paper processes in the EHR, the government regulations are suppressing innovation, and this is leaving healthcare providers frustrated and disenfranchised. It will be a long time before healthcare is able to reengineer it's processes and adopt this technology to its fullest.