The use of digital health record keeping is growing; however, there are key differences in defining these terms.
- An application environment that is composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized practitioner order entry, and clinical documentation applications. This environment supports the patient’s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and mange healthcare delivers.
- Health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.
- An electronic health record (EHR) is a secure, integrated collection of a person’s encounters with the health care system; it provides a comprehensive digital view of a patient’s health history.
- A longitudinal electronic record of patient health information generated by one or more encounters in any care deliver setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports and images. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface; including evidence-based decision support, quality management, and outcomes reporting.
- Health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
- An electronic personal health record ('ePHR') is a universally accessible, layperson comprehensible, lifelong tool for managing relevant health information, promoting health maintenance, and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools. The ePHR is owned, managed, and shared by the individual or his or her legal proxy(s) and must be secure to protect the privacy and confidentiality of the health information it contains. It is not a legal record unless so defined and is subject to various legal limitations.
- Usually used when referring to the version of the health/medical record owned by the consumer/patient.
- An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.