Electronic Health Records: What You Need to Know

An electronic health record (EHR) is a digital record of a patient’s health information. It replaces or expands on the traditional paper charts used by healthcare providers.

Unlike a paper chart, an EHR can track health information over time. This gives authorized healthcare professionals a broader view of a patient’s health history. Information can also be available across different care settings when systems allow secure sharing.

EHR systems are the software used to create, store and manage these records. They have become a standard part of the healthcare industry. In 2024, 95% of U.S. office-based physicians used an EHR. About 91% used an EHR certified to meet federal requirements.

EHRs can hold information such as diagnoses, medications, test results and clinical notes. This gives healthcare professionals easier access to the information they need during patient care.

The information in an EHR varies by system and healthcare setting. It also depends on the type of care a patient receives.

An electronic health record may include:

• Patient demographics, such as age and contact information
• Medical history and diagnoses
• Medications and prescriptions
• Allergies
• Immunizations
• Tests and lab results
• Vital signs
• Clinical and progress notes
• Treatment plans
• Radiology and imaging information
• Insurance and billing information

Bringing this information together gives healthcare professionals a clearer view of a patient’s health. They can see relevant details without relying on separate paper files or disconnected records.

An EHR system stores patient health information in a digital format. Healthcare staff can add new information during or after a patient visit.

Authorized staff can then view and update the record. This gives them access to current patient information when providing care.

EHR systems can also help staff:

• Order tests and medications
• View test results
• Check alerts about patient care
• Send information to other providers
• Communicate with patients through online portals

EHRs can connect patient care with other daily tasks. These may include billing, scheduling and managing patient records.

EHR Interoperability

EHR interoperability means different health systems can share and use information. This matters when a patient sees more than one healthcare provider.

For example, a patient may visit a doctor, specialist and hospital. Each provider may use a different EHR software. Interoperability can help important health information move between those systems. This can give each provider a clearer view of the patient’s care.

Systems often use common data standards to share information. These standards help each system read and understand the same data.

In 2023, 70% of non-federal acute care hospitals used all four types of data exchange. These include sending, receiving, finding and adding health information to their systems.

However, some barriers still remain. Different systems may store or organize information in different ways. This can make sharing patient information harder.

EHR vs. EMR: What’s the Difference?

EHRs and EMRs both store patient health information in a digital format. However, there are some differences between them.

An electronic medical record (EMR) is a digital version of a patient chart. It usually focuses on care from one provider or healthcare organization.

An EHR provides a broader view of a patient’s health over time. It is also designed to support information sharing across different care settings.

This makes data sharing a key difference in the EHR vs. EMR comparison. An EMR may stay within one organization. An EHR can make information available to other authorized providers.

The terms EHR and EMR are sometimes used interchangeably. Their exact meaning can also vary between healthcare organizations and software providers.

The benefits of electronic health records can reach both patients and healthcare teams. EHRs can make health information easier to access, share and manage.

Easier Access to Patient Information

EHRs keep key patient information in one digital record. This reduces the need to search through paper files or separate records.

Faster access can also help providers make informed care decisions.

Better Coordination of Care

Patients may receive care from several healthcare providers. EHR solutions can make it easier for authorized providers to share important health information.

This can keep care consistent across different settings and may also reduce repeated tests and procedures.

More Efficient Healthcare Workflows

EHRs can reduce some manual work for healthcare teams. Staff can manage many common tasks within the same system.

These tasks may include:

• Recording patient information
• Ordering tests
• Sending prescriptions
• Viewing results
• Managing billing information

This can save time and reduce repeated administrative work.

Greater Patient Involvement

Many EHR systems include online patient portals. These portals give patients direct access to parts of their health record.

Patients may be able to:

• View test results
• Check medications
• Review care plans
• Send messages to their healthcare provider

Patient portal usage has significantly grown in the U.S. In 2024, 65% of people were offered and accessed their online medical records. In 2014, that figure was 25%.

These benefits can make health information easier to manage and share. They can also give patients more access to their own health information.

EHR systems offer many benefits, but they also create new challenges. Healthcare organizations need to consider security, technology, costs and staff needs.

Privacy and EHR Security

EHRs contain private patient information. Healthcare organizations need to protect this data from misuse, loss and theft.

Common EHR security measures include:

• Strong passwords and login checks
• Limits on who can access patient data
• Encryption to protect stored and shared data
• Security updates and system monitoring
• Staff training on safe data handling

Access controls can limit patient information to people who need it for their work. This can reduce unnecessary access to sensitive data.

Cyberattacks and data breaches remain a concern. In 2023, HHS received 732 reports of large healthcare data breaches. Together, these breaches affected about 113.2 million people.

Healthcare organizations must also follow the privacy and data rules that apply to them. These rules can affect how patient information is stored, accessed and shared.

Interoperability Challenges

Different electronic health record systems do not always work well together. Systems may store or organize data in different ways.

This can make it harder to share patient information. Missing or separate records can also slow down work and affect care between providers.

Adoption and Workflow Challenges

Moving to a new EHR system can take time and planning. Staff may also need support while they learn new ways of working.

Common challenges include:

• Upfront and ongoing costs
• Staff training
• Moving clinical data from old systems
• Changes to existing workflows
• Staff resistance to new systems
• Technical support and maintenance

Planning for these issues can make the move to a new system easier.

A successful EHR implementation starts with careful planning. Organizations should first review their needs and current workflows.

When choosing and setting up an EHR system, consider:

• How easy the system is to use
• Whether it has the right features
• How well it connects with other systems
• Whether it can support future needs
• How it protects patient data
• How existing data will move to the new system

Data migration also needs careful planning. Organizations may need to move patient records from an older system into the new EHR. Teams should check that important information transfers correctly before the system goes live.

Testing is also important. Staff can test common tasks before launch to find problems early.

Organizations should set clear rules for access and security. Staff also need training before using the system. Ongoing support can help teams adjust to new tools and workflows.

After launch, teams should track how the system is working. They can then fix problems and improve workflows over time.

Some organizations may use healthcare outsourcing for certain EHR-related tasks. This can reduce the amount of administrative work handled by internal teams.

Any outside team with access to patient data needs proper training. They must also follow the organization’s privacy, security and compliance requirements.

EHR systems will likely become more connected over time. Shared data standards can make it easier to exchange information between healthcare systems.

EHRs are also connecting with more healthcare tools and technologies. AI and automation may help with tasks such as data entry and other routine work.

These changes also bring new security needs. Healthcare organizations must continue to protect patient data and control who can access it.

As digital healthcare grows, managing the work around these systems can require more support. Specialized partners can help take on administrative and operational tasks.

Horatio provides healthcare outsourcing services through trained support teams. These teams can work within existing healthcare systems, processes and security requirements. This can help internal teams manage routine work while keeping patient data and compliance needs in mind.

Learn more about Horatio’s healthcare outsourcing solutions today.

How Do You Learn to Use Electronic Health Records?

EHR training depends on the system and the employee’s role. Different staff members may use different parts of the system.

Training may include:

• Training from the EHR provider
• Employee onboarding
• Medical practice systems
• Guides and training materials
• Supervised hands-on training

Training should continue as systems and workflows change. This helps staff stay familiar with new tools and features.

What Is Included in an Electronic Health Record?

An EHR can include a patient’s medical information, diagnoses and medications. It may also contain allergies, immunizations, test results, clinical notes and treatment plans.

The exact information depends on the EHR system and healthcare setting. See our section on what information is included in an electronic health record above for more detail.

Are Electronic Health Records Secure?

EHR security uses safeguards to protect private patient information. These can include access controls, login checks, encryption and system monitoring.

No digital system is free from security risks. Healthcare organizations need to protect EHR data and follow the privacy and security rules that apply to them.