Standards Watch | The Electronic Health Record: A Recent HL7 Standardization Effort

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The terms Electronic Medical Record (EMR), Computerized Patient Record (CPR) and Electronic Health Record (EHR), are used interchangeably when people speak of an electronic patient health record, however, they have different meanings representing their evolution.

The Computerized Patient Record (CPR) systems really started to be implemented in the early 1990s, even though the concept dates back to the 1980s. The major push for implementation was a 1991 publication by the Institute of Medicine (IOM). The CPR was basically a replacement of paper-based records in an electronic format. Some institutions were actually scanning the documents when data entry was not available or applicable.


The Electronic Medical Record (EMR) captures and manages the patient information that was initially acquired in electronic format. It allows for better management because its contents can be represented in different manners, such as conducting a search. Access and presentation is much easier as well. The EMR is the state-of-the art patient file.

The Electronic Health Record (EHR), on the other hand, is the true, lifetime health record, which spans different institutions, and is basically owned by the patient. It can be exchanged among different providers.

Standards for CPRs are not widely implemented, and most systems are incompatible. Of course, this creates problems when this information needs to be exchanged between different institutions. There also is no dominant vendor in the field, and therefore, no default standard is available.

One of the requirements for exchanging medical records is a uniform medical vocabulary. For example, the word hypertension has several common terms used to describe it. The most extensive

common medical vocabulary is managed by the College of American Pathologists (CAP), called SNOMED - CT (Systemized Nomenclature of Medicine - Clinical Terms), and is made available by the National Library of Medicine (NLM), to facilitate the sharing of medical records.


The Institute of Medicine (IOM) has been charged with developing a standard definition of the EHR. The HL7 standards organization is performing the work, allowing it to become an ANSI-based standard. This standard is not a fully detailed specification, but rather a so-called DSTU: Draft Standard for Trial Use, which contains a functional definition of the EHR. A second ballot was just sent out, and results can be expected to be discussed at the upcoming HL7 meeting in San Antonio. One of the major drivers behind the EHR is the U.S. government, promising a different reimbursement rate for those institutions that support an EHR.

The Institute of Medicine specifies the requirements for the EHR based on five criteria:

  1. Improve patient safety: Tens of thousands of people die each year in the U.S. as a result of preventable, adverse events due to improper healthcare.
  2. Support the delivery of effective patient care: Provide it to the ones who need it, and not to the ones who do not. Approximately half of all Americans receive recommended healthcare consistent with evidence-based medicine.
  3. Facilitate the management of chronic conditions: Persons with chronic healthcare problems account for more than 75 percent of all healthcare spending, more than half of them have three or more different providers who send out conflicting information, order duplicate tests, and seem to work totally uncoordinated.
  4. Improve efficiency: Healthcare costs are rising; patients are paying more out-of-pocket costs, and receiving fewer benefits.
  5. Implementation Feasibility: This takes into account the available software as well as the time-to-market for new functions.

The requirements of the EHR include eight "core functionalities" as follows:

  • Health Information & Data Examples include information about patient allergies to prevent adverse drug reactions, previous lab test results to prevent duplication, alerts and reminders for drug administration, and abnormal test results at the point of care. It was noted that "information overload" is not a good thing, therefore, the user interface should be balanced, i.e. not too much, and not too little. 
  • Results Management Electronic availability, for example, of lab tests and radiology reports, including previous results will improve efficiency and decrease costs. 
  • Order entry & Management Lost orders and ambiguous handwriting have a major impact on workflow. Simple medication order entry has shown to reduce the