The electronic collection, aggregation, and reporting of health-related information has been a central theme in the effort to improve the quality, safety, efficacy, and cost of health care in the United States. In the efforts to promote and implement information technology in health care, variations in common terminology have created confusion. Below is an attempt to distinguish language used to describe an electronic database of health-related information.

An EMR (electronic medical record) is generally defined as the set of databases (or repositories) that contains the health information for patients within a given institution or organization. Thus, an EMR contains the aggregated datasets gathered from a variety of clinical service delivery processes, including laboratory data, pharmacy data, patient registration data, radiology data, surgical procedures, clinic and inpatient notes, preventive care delivery, emergency department visits, billing information, and so on.

Furthermore, an EMR contains clinical applications that can act on the data contained within this repository; -- for example, a clinical decision support system (CDSS), a computerized provider order entry system (CPOE), a controlled medical vocabulary, or a results-reporting system. In general terms, EMRs are clinician-focused in that they enhance or augment the workflow of clinicians or administrators. EMRs are said to be interoperable if they are able to exchange (transmit and receive) data using standardized data transmission (coding and messaging) formats (standards).

An EHR (electronic health record) extends the notion of an EMR to include the concept of cross-institutional data sharing. Thus, an EHR contains data from a subset of each institution's EMR (that is agreed upon by the institution). An EHR may also reside "entirely within one institution" and link the various affiliated practice sites together. The EHR is generally patient focused and spans episodes of care rather than a single encounter. An EHR can only be present if the participating sites all have an EMR in place that is interoperable.

Implementation of an EHR also creates issues related to identification of stakeholders within a community or region and getting their buy-in, legal issues related to cross-institutional data sharing, security and privacy of shared records over potentially insecure network lines, and patient access to and augmenting their own data in electronic format (using the web, for example).

Traditionally, the EMR vendor community has created systems that conform only to proprietary database formats, making it difficult for them to send and receive data from other (potentially competing) products. The medical informatics community has realized the need for interoperability and thus has created standards for data coding and communication. Recently, the Office of the National Coordinator for Health IT (ONC) announced several major initiatives to harmonize standards and create a certification process for EMRs so that different products can interoperate better and be easily and objectively compared. This will enable decision-makers to adopt EMRs more easily.

In 2006, the U.S. Department of Health and Human Services (HHS) recognized initial criteria for certification of ambulatory EHR systems as recommended by the Certification Commission for Healthcare Information Technology (CCHIT). These criteria will help reduce barriers for ambulatory providers to adopt EHR systems by ensuring confidence in purchased products. CCHIT certified products also meet requirements set forth by HHS in final physician self-referral law and Antikickback statute rules, providing access to external means of implementing EHR systems.

Many small practices and community health centers (CHCs) realize that the cost of adopting a traditional EMR (that is hosted within the practice) is too excessive at this stage and are evaluating ASP (application service provider) models. These are "subscription-based" models for EMRs, whereby the application runs on the computer system (server) of an ASP provider (a company that hosts the EMR). This approach substantially reduces the cost for the practice. In addition, the risks associated with security and privacy protection are undertaken by the host company and not the practice. Some practitioners dislike this approach because their data then reside with the host company.

One of the many projects funded by AHRQ, HIT-based Regional Medication Management Pharmacy System, employs a community-based ASP to deploy health IT solutions across a 14 critical access hospital (CAH) network. The ASP was formed by the CAHs in order to pool resources and work collaboratively to achieve a shared vision. The CAHs span a large geographic region in Minnesota, and together they have been able to achieve more than separate small, rural providers.

For lessons emerging from AHRQ-funded EMR/EHR projects, click here.

The Agency for Healthcare Research and Quality (AHRQ) has funded organizations across the country that are implementing and evaluating electronic medical and health record systems. Some of these include:

Title: CCHS-East Huron Hospital CPOE Project
Primary Investigator: Michael Waggoner
State: OH

Title: Collaborative EHR Implementation to Bridge the Continuum of Care in Rural Iowa
Primary Investigator: Sylvia Getman 
State: IA

Title: Connecting Healthcare in Central Appalachia
Primary Investigator: Polly M. Bentley
State: KY

Title: Creating an Evidence Base for Vision Rehabilitation
Primary Investigator: Cynthia Stuen 
State: NY

Title: Crossing the Quality Chasm in Eastern Rural Kern County
Primary Investigator: Kiki Nocella
State: CA

Title: Electronic Records to Improve Care for Children
Primary Investigator: Richard Shiffman
State: CT

Title: Enhancing Patient Safety through a Universal EMR System
Primary Investigator: Thomas H. Johnson
State: PA

Title: Enhancing Quality in Patient Care (EQUIP) Project
Primary Investigator: Fred Rachman
State: IL

Title: Holomua Project-Improving Patient Hand-Offs in Hawaii
Primary Investigator: Christine Sakuda
State: HI

Title: Impact of Health Information Technology on Clinical Care
Primary Investigator: John Hsu
State: CA

Title: Implementing an Ambulatory Electronic Medical Record and Improving Shared Access
Primary Investigator: Michael DeLuca
State: IL

Title: Improving Health Care Quality via IT
Primary Investigator: Robert A. Pezzulich
State: VT

Title: Improving HIT Implementation in a Rural Health System
Primary Investigator: Daniel B. Mingle
State: ME

Title: Improving Patient Safety/Quality with HIT Implementation
Primary Investigator: John G. Reiling
State: WI

Title: IT Systems for Rural Indian Clinic Health Care
Primary Investigator: Susan L. Dahl
State: CA

Title: Louisiana Rural Health Information Technology Partnership
Primary Investigator: Paul A. Salles
State: LA

Title: Metro DC Health Information Exchange (MeDHIX)
Primary Investigator: Thomas L. Lewis
State: MD

Title: Nursing Home IT: Optimal Medication and Care Delivery
Primary Investigator: Susan D. Horn
State: UT

Title: Project InfoCare
Primary Investigator: Peggy Esch
State: MO

Title: Rural Community Partnerships-EMR Implementation Project
Primary Investigator: R'Nee Mullen
State: ID

Title: Rural Iowa Redesign of Care Delivery with EHR Functions
Primary Investigator: Don Crandall
State: IA

Title: Santa Cruz County Diabetes Mellitus Registry
Primary Investigator: F. Wells Shoemaker
State: CA

Title: HIT Service Integration
Primary Investigator: Craig Mathews
State: LA

Title: Statewide Implementation of Electronic Health Records
Primary Investigator: David W. Bates
State: MA

Title: Taconic Health Information Network and Community THINC
Primary Investigator: John A. Blair III
State: NY

Title: The Chronic Care Technology Planning Project
Primary Investigator: John M. Branscombe
State: ME

Title: Tulare District Hospital Rural Health EMR Consortium
Primary Investigator: Paul D. Galloway
State: CA

EHR project leaders and managers are concerned with Participation, Functionality, Performance, and Quality (from Dan Mingle, Improving HIT Implementation in a Rural Health System). Participation involves project management, vendor selection, and user acceptance (buy-in). Functionality is getting the EHR to work technically, including any interfaces to other health IT systems or networks and implementation of proper privacy and security components. Performance involves integrating the EHR system into workflow in addition to ensuring that the system is performing at optimal levels. Quality focuses on clinical practice transformation, including user training/acceptance, impact on clinical outcomes, and ROI.

Because all of these concerns are important to the success of an EHR system, implementation requires significant time and resources no matter the size of the organization. This is why quality, especially ROI and impact on clinical outcomes, is so important. EHR systems must be worth the investment before small and medium-sized organizations can risk scarce resources.

One well-cited study shows a positive ROI of $86,400 in year 5 per provider for a full implementation within an ambulatory setting. Another study shows a positive ROI of $1.1 million in year 1. Analysis on a national level shows a net savings to physicians of almost $10 billion when efficiency and safety improvements are considered. Another national study looking at standards-based health information exchange (HIE) implementations estimates a $77.8 billion annual savings (commentary on that conclusion can be found here).

However, other analyses paint a different picture. A Markle Foundation workgroup recently found that implementation of an interoperable EHR in small practices would result in a net lossof $20,000 per doctor per year. So the value equation is very complex and depends on several variables including geographic region and vendor.