How Do You Define EHR?

ONC has been using the term EHR prodigiously for the last several years and many in the industry have followed suit. I understand the difference between EHRs, PHRs, and EMRs, but I had never read how the ONC defines and differentiates them.

An EHR (electronic health record) is a more comprehensive term than an EMR (electronic medical record.) An EHR includes notes from multiple practices and implies sharing of patient data. EHRs are about portability of health data across practices, between providers, and to patients themselves. EHRs are certified for meaningful use (MU). Both EMRs and EHRs — at least according to ONC websites — have clear benefits ( here and here) for providers and patients. The ONC also has definitions for PHR, which not surprisingly is a patient-controlled version of a health record.

This is very obvious to most people, especially HIStalk readers, but I find that’s not the case for most people outside of health IT. Personally I use and prefer the term EHR, but I find myself falling back to using EMR when I talk to non-HIT people, including non-informaticist physicians. Most people outside the HIT niche don’t understand or appreciate the difference between EHR and EMR. I always think those people just nod along when I say EHR, assuming it’s another term for EMR.

EHRs again according to ONC, also "go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care." The only specifics of that broader view seem to be notes from other providers or lab results or pharmacy data, basically other forms of traditional clinical data. Nowhere on the ONC sites or blogs did I find the EHR broader patient view referring to patient-reported and generated data. EHRs are starting to integrate, or talk about integrating, self-reported data, and companies are cropping up to try to combine self-reported data with EHRs.

This discussion was relevant last week at the Rock Health CEO Summit during a session on EHRs as a platform for building apps. With the growth of big data warehousing and analytics platforms, Health Catalyst being the one that is getting the most press these days, where does that leave the EHR as a platform for development of apps?

As Malay Gandhi from Rock Health pointed out, the EHR is the clinical documentation layer. As purely a point-of-care documentation layer, it begs the question of, will the EHR actually represent the broader view of the patient? The broader view of the patient includes continuously reported data, data that enables contextual messaging and powerfully short feedback loops. If we’re going to ever successfully engage patients at scale, we need this data.

EHRs were built to document point-of-care, face-to-face encounters. They were built for fee-for-service. That is the way in which they are used today. But, three important trends are coming to healthcare that change all that.

The first is that the point of care is being redefined. A better way to say it is that the point of care is no longer a location or a clearly defined event with start and stop. It’s no longer limited to the patient sitting in front of a doctor in an office or ED. It’s now inclusive of virtual visits from services like DirectDermatology and Zipnosis, automated follow-up with services like Healthloop and Wellbe, retail pharmacy appointments, employer health risk assessments, group nutrition sessions with services from companies like Omada Health, intelligent data collection through services like Tonic Health, messaging campaigns and SMS-based data collection, through kiosks like those from higi and AmericanWell, along with a host of others.

In the process of deploying and scaling these new services, the traditional point of care — the place that EHRs were built for — is becoming much less important. Over time, the point of care will become less and less relevant and the corresponding data collected and platform used at the point of care will become less and less important.

The second big trend is around patient-reported data. There’s some overlap here with the changes above around point of care, but I call this trend out separately for things like Fitbit, MyFitnessPal, MangoHealth, and LoseIt!. We’re going to see more and more tracking data integrated into care and we’re already seeing it with payers, employers, direct primary care, and some more progressive providers.

The third big trend is the growth of genetics and truly personalized care. This is another massive data set.

These three big trends fundamentally broaden the data and insights into patients. If you look at these trends, it ties perfectly to the potential value of big data in healthcare. Big data becomes powerful as you add additional dimensions to the subject. In this case, the subject is the patient and the trends outlined above are all about adding dimensions to patients.

I would argue that the data coming into healthcare — the data that is not part of traditional EHRs — is much more powerful than the data currently in EHRs. That "new" data is going to be growing exponentially over time, making that "old" EHR data relatively less important.

When I think about that, I wonder why the EHR is the platform of the future? If you talk to vendors building new services and technology to support the trends above (and I talk to them a lot), they’ll invariably tell you that one of their biggest headaches and challenges is integrating with EHRs. The process of integration is hugely expensive and delays deployments.

It’s not only the EHRs pushing this integration directly. It’s the hospitals and health systems, too. The only reason for a hospital to push EHR integration and EHRs as the core platform is because EHRs represent the largest software expense of most healthcare organizations. They can’t exactly relegate a billion-dollar purchase to a documentation layer. Good luck selling that to the board and CFO.

This may just be semantics. Electronic health records are lumped into Meaningful Use and certification, so the term EHR is always associated with certain EHRs today. For me, I always associate with the biggest enterprise EHRs because they are the ones that represent the largest market share. But if you redefine EHR and look beyond traditional point of care data and MU, the EHR becomes something different and potentially transformative. But that’s not what I read as ONC’s definition of EHR.


Travis Good is an MD/MBA and co-founder of Catalyze. More about me.

  • Mobile Man

    Wow! About time someone started making the distinction. In some ways, we’re racing “back to the future”…

    Obviously we need these “electronic filing cabinets” – can’t do anything “smart” with data that’s not digitized, but as you astutely point out, it’s just the beginning!

    Can’t help the fact that we overpaid for that functionality – water under the bridge. But, we can make sure we keep forging ahead on all angles with the technologies (and approaches) that will really start to make a difference in the way hospitals practice healthcare.

  • E-Health Records

    Thanks for taking the time to delve into the distinctions. We’re excited to be a part of the mHealth community working to make EHR software accessible to all. Until the cost hurdle is reduced, the transformational potential of these tools will remained stifled. With hardware costs and cloud computing cost dropping, we are well on our way to seeing EHRs realize their true potential, globally.

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