History of Electronic Health Records

Instructor: Jennifer Mitchell

Jennifer is a clinical professor for nursing students in critical care and has several years of experience in teaching nursing.

Health records have undergone many changes over the past thirty years. From paper documentation to the use of electronic tablets, the way we document healthcare has changed and progressed over time. Let's review the history of electronic health records now.

Before Electronic Health Records

Health records have undergone many changes over the last thirty years or so. In the 1980s, all patient health records, from vital signs to medication lists, were on paper. These documents would be bound and sent to a medical records department or storage. When a healthcare provider would need to review these medical records, a request would be sent to find the records and deliver them to the requesting provider. This would take hours to days to retrieve and would cause delays in treatment.

Paper Medical Records
Paper Medical Records

Documentation on paper would also be challenging in that sometimes handwriting was difficult to read, leading to inaccurate data and misinformation. This would also lead to delays in treatment. As advances in computers came, so did advances in health records.

Computers Begin to Intervene

The 1990s brought about scanning of documents, so health records could be recorded on paper then scanned into a computer system. This helped healthcare providers access health records without waiting on a request for a paper chart. They could more expediently analyze what medications a patient was taking, what a previous diagnosis was, how up to date immunizations were, and what surgeries or procedures a patient had undergone. There would be some documentation in a computer, but most of what was entered would be orders for labs and radiology and results from those tests.

In the '90s, if you had received treatment at a different facility than your usual medical practice, your records would need to be retrieved from the other facilities, which would have to be done by fax or courier. Retrieving these records was still challenging and could delay treatment.

The Electronic Age

The early 2000s were when electronic health records (EHRs) came to the forefront. Healthcare providers and nurses could document vital signs, patient assessments, and lab results directly into a computer for easy storage and later access. This new process made it easier for healthcare providers at hospitals and medical offices to access past records for patients as well as identify medication interactions, immunization records, previous diagnoses, and patient histories.

This would be especially important for those patients with several different healthcare providers and specialists caring for them and various prescribed medications. The use of EHR would also identify when duplicate orders were entered, saving time and money. The ability to send and receive records from other facilities was also becoming easier, eliminating the need for faxing or waiting on documents.

The Advancing Market

In the 2010s, the EHR has advanced to paperless systems. When you last visited your healthcare provider, did the nurse or healthcare provider use an electronic tablet when they asked you why you were visiting? If so, all of your information as well as all vital signs, lab reports, and radiology results can be entered into an electronic tablet, which communicates with the computer system using an encrypted system to record your information into your health record! The use of electronic tablets allows healthcare providers to access your health information and enter data while they're at your side.

Doctor Using Tablet
Doctor Using Tablet

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