What is the difference between standard and electronic health record systems?

The differences between EMR and EHR have largely eroded but speak to the maturation of health IT use among providers.

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May 30, 2017 - The terms electronic medical record (EMR) and electronic health record (EHR) have become widely synonymous, but they did not start that way and some still argue that a distinction between is necessary to restate.

Healthcare organizations and providers have a greater tendency to still use EMR when discussing the health IT system in use by clinicians in the treatment of patients, but many have gravitated toward saying EHR when describing this technology. And there is ample evidence to suggest that the shift is the byproduct of a nationwide effort to promote health data exchange and interoperability.

While EHR is common parlance nowadays, that was not always the case. With EMR usage waning for a large portion of the healthcare industry, an understanding of the EMR/EHR difference demonstrates how far the industry has come — and the progress still needed to be made.

Rationale behind different definitions

Ironically, the federal agency with the responsible for promoting the adoption of certified EHR technology (CEHRT) over the past seven years has very little say on the subject of EMR versus EHR.

CMS provides this tidbit of insight on the subject relative to the EHR Incentive Programs:

Sometimes people use the terms "Electronic Medical Record" or "EMR" when talking about Electronic Health Record (EHR) technology. Very often an Electronic Medical Record or EMR is just another way to describe an Electronic Health Record or EHR, and both providers and vendors sometimes use the terms interchangeably. For the purposes of the Medicare and Medicaid Incentive Programs, eligible professionals, eligible hospitals and critical access hospitals (CAHs) must use certified EHR technology.

CEHRT implementation and adoption have been, are, and will be necessary for receiving incentive payments in federal quality reporting programs now that the Quality Payment Program has emerged to replace the EHR Incentive Programs, Physician Quality Reporting System (PQRS), and Value Modifier (ONC) for eligible clinicians (i.e., professionals under meaningful use).

But this explanation from CMS does not provide much in the way of a rationale other than the interchangeable use of the two terms.

However, the federal agency responsible for overseeing health IT certification — ONC — summed up the differences between the two as well as personal health records in response to a frequently asked question (emphasis theirs):

Electronic Medical Records

Electronic medical records (EMRs) are digital versions of the paper charts in clinician offices, clinics, and hospitals. EMRs contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. EMRs are more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.

Electronic Health Records

Electronic health records (EHRs) are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians involved in a patient’s care and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. EHRs also share information with other health care providers, such as laboratories and specialists. EHRs follow patients – to the specialist, the hospital, the nursing home, or even across the country.

Personal Health Records

Personal health records (PHRs) contain the same types of information as EHRs—diagnoses, medications, immunizations, family medical histories, and provider contact information—but are designed to be set up, accessed, and managed by patients. Patients can use PHRs to maintain and manage their health information in a private, secure, and confidential environment. PHRs can include information from a variety of sources including clinicians, home monitoring devices, and patients themselves.

In a contribution to the federal agency’s official blog in 2011, two former ONC leaders — Peter Garrett and Joshua Seidman, PhD — elaborated on the significance of preferring EHR to EMR:

While it may seem a little picky at first, the difference between the two terms is actually quite significant. The EMR term came along first, and indeed, early EMRs were “medical.” They were for use by clinicians mostly for diagnosis and treatment.

In contrast, “health” relates to “The condition of being sound in body, mind, or spirit; especially…freedom from physical disease or pain…the general condition of the body.” The word “health” covers a lot more territory than the word “medical.” And EHRs go a lot further than EMRs.

The post went on to define the terms in line with distinctions made in 2006 HIMSS Analytics white paper. That research is the one most often cited in comparisons of EMR and EHR and famously includes breakdown of the research group’s EMR Adoption Model built on distinctions between the two.

“Many people in the US healthcare industry, our government, and the press use the terms electronic medical record (EMR) and electronic health record (EHR) interchangeably,” wrote authors Dave Garets and Mike Davis. “However, these terms describe completely different concepts, both of which are crucial to the success of local, regional, and national goals to improve patient safety, improve the quality and efficiency of patient care, and reduce healthcare delivery costs.”

According to the pair, the EMR is the foundation on which EHR interoperability is built. “EHRs are reliant on EMRs being in place, and EMRs will never reach their full potential without interoperable EHRs in place.”

How the record is used and by whom dictate the use of EMR or EHR to describe it.

“The EMR is the legal record created in hospitals and ambulatory environments that is the source of data for the EHR,” they stated. “The EHR represents the ability to easily share medical information among stakeholders and to have a patient's information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payers/insurers, including the government.”

The authors of the HIMSS Analytics noted at the time that few hospitals had implemented complete EMR solutions, implying that it was premature to use EHR as a substitute for EMR.

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Importance of legal distinction

From a covered entity’s standpoint, HIPAA requires that providers and business associates ensure the privacy and security of protected health information (PHI).

In 2011, the American Health Information Management Association (AHIMA) provided guidance on the legal health record in light of the expanding contents of patient records made possible by new forms of health IT, such as EHR systems († signals an AHIMA best practice):

The legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization. An organization's legal health record definition must explicitly identify the sources, medium, and location of the individually identifiable data that it includes (i.e., the data collected and directly used in documenting healthcare or health status).† The documentation that comprises the legal health record may physically exist in separate and multiple paper-based or electronic systems.

The organization urged covered entities to consider the components of EHR technology that generate patient health data, storage capacity and cost, and the ability the EHR system to produce readable electronic and paper copies of the legal health record.

Around the same time, AHIMA issued the third edition of its health IT pocket glossary and made a clear distinction between EMR and EHR (emphasis added):

Electronic medical record (EMR): An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization

Electronic health record (EHR): An electronic record of 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

Neither definition speaks to the legal record, leaving open the possibility that either could contribute to this set of documents and data elements pertaining to a provider’s treatment of a patient. Taken together with AHIMA’s guidance on the legal record which includes no mentions of EMR and instead prefers EHR, the former acronym may be too narrow for an industry looking to establish a learning health system.

One size does not fit all?

Depending on the makeup of a healthcare organization, providers could be using a diversity of health IT systems to generate and manage patient data technology and coordinate care with providers in other departments using different systems. What’s more, providers participating in population health management or value-based care could be partnering with members of the care team who are not clinicians.

In a patient-centered world, the term EHR appears most capable of grasping the comprehensive nature of the patient experience across the care continuum. All providers are liable for their contributions to the complete picture of a patient’s health, indicating a need for EHR technology to properly track the provenance of medical data and decision-making.

“An EHR achieves a rare trifecta: It's a win for three parties. It's a win for the clinic because it saves time over the old method (attaining charts from other health care organizations, taking down verbal information from patients, and so on). Less time lost will translate into more time with patients,” Dignity Health’s Rami Hashish, PhD, DPT, wrote in 2015.

While the term EHR gets the nod from most of the healthcare industry, perhaps another phrase is more fitting. EHR adoption has risen significantly since the start of the EHR Incentive Programs only a handful of years ago. There are now patients whose entire medical history is digital and record will grow as they develop and mature.

Providers want a comprehensive view of a patient’s health is a provider. And new sources of health data are emerging — genomics, wearables, and patient-generated data. With healthcare moving into more settings beyond traditional brick-and-mortar settings, the industry is better suited to thinking in terms of a longitudinal health record combining the EHRs a patient is likely to contribute to the generation of over his lifetime.

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