An electronic version of a patient’s medical history, containing comprehensive information about the patient’s health status and medical treatment over time. It includes patient demographics, progress notes, medications, allergies, immunization records, laboratory test results, and other pertinent clinical information.
The ability of different EHR systems and healthcare software applications to communicate, exchange data, and use the information that has been exchanged effectively. Interoperability is crucial for seamless patient care across different healthcare settings and organizations.
A set of criteria and objectives established by the Centers for Medicare & Medicaid Services (CMS) in the United States to encourage the adoption and meaningful use of EHRs by healthcare providers. Meeting these criteria qualifies healthcare providers for incentive payments.
The electronic sharing of healthcare-related information among different healthcare organizations, allowing them to access and securely exchange patient information electronically. HIE facilitates coordinated and efficient patient care across various healthcare settings.
Tools and technologies integrated into EHR systems that provide healthcare professionals with evidence-based clinical knowledge and patient-specific information to assist in making informed decisions about patient care. CDS helps improve clinical outcomes, enhance patient safety, and reduce medical errors.
Measures and protocols implemented to safeguard the confidentiality, integrity, and availability of patient health information stored in EHR systems. Data security and privacy are critical to maintaining patient trust and compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
A chronological record that provides a comprehensive history of all access and modifications made to electronic health records. Audit trails enhance accountability, transparency, and the ability to track and investigate unauthorized access or changes to patient health information.
The use of telecommunications technology, such as video conferencing and remote monitoring, to deliver healthcare services remotely. EHR integration with telemedicine platforms enables healthcare providers to conduct virtual consultations, monitor patients remotely, and exchange health information securely.
An online platform that allows patients to access their EHRs, communicate with healthcare providers, schedule appointments, view lab results, request prescription refills, and participate in their healthcare management. Patient portals promote patient engagement, empowerment, and self-management of health information.
The process of enhancing the quality and accuracy of clinical documentation in EHRs to ensure that healthcare providers accurately capture and reflect the patient’s clinical status, diagnoses, treatments, and outcomes. Effective CDI practices support better communication among healthcare providers, optimize reimbursement, and mitigate legal and regulatory risks.