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EMR, EHR and PHR – and Now aEMR and H/HIS – What’s with These Systems?

Posted on May 4, 2016 by Dennis Giokas

A lot has changed since the initial blog post on this topic five years ago. The nature of the systems supporting clinicians and patients has matured significantly. For example, many now have advanced functionality beyond simple record keeping and some have patient-centred functions. In addition, the scope of these systems now covers a broader user base – one beyond their original users. The description of these digital health solutions has become quite complex, especially when we consider users, care settings, the data, functionality and technology.

In Canada, there are a number of labels for digital health records in common use. Unfortunately, the definition of these terms varies throughout the world and this creates confusion, within and outside the industry. Interestingly, once we break down definitional barriers we find there is a lot of commonality and growing overlap among these systems.

In the original blog post two dimensions were used for differentiation. The first was the completeness of the information. The second was the custodian of the health information (e.g., the entity holding the information, not necessarily the owner of the information, which is typically the citizen). The first dimension, completeness, is being blurred. Why? Many of the systems are gradually holding a more complete view of the information as health information networks and interoperability grow.

So what are the dimensions? I feel one predominant dimension to distinguish these systems continues to be custodian. A new dimension is the care setting of the solution.

The three terms in the previous blog post continue to be commonly used – electronic medical record (EMR), electronic health record (EHR) and personal health record (PHR). In this updated blog post I have introduced three other systems worth discussing. The first two are health information systems (HeIS) and hospital information systems (HIS), and are together known as H/HIS in Infoway shorthand. The third is ambulatory EMR (aEMR).

Let’s look at each of these in a little more detail.

  1. Electronic Health Record – a health record under the custodianship of the health system used in support of multiple care settings. The definition of this record was part of the original EHR Solution Blueprint and has withstood the test of time. Learn more in our updated Digital Health Blueprint.

    An EHR provides each individual in Canada with a secure and private lifetime record of his/her key health history and care within the health system. The record is available electronically to authorized health providers and the individual anywhere, anytime in support of high quality care. This record is designed to facilitate the sharing of data across the continuum of care, across health care delivery organizations and across geographical areas.

    This is often described as a patient-centric health record for the sharing of health information.

  2. Electronic Medical Record – a record under the custodianship of a health care provider, or providers, that is used in a community physician practice setting. Typical use is by clinicians within a primary care practice or specialist physician practice.

    An EMR is a computer-based medical record specific to one clinician’s (e.g., physician) practice or organization. It is the record clinicians maintain on their own patients which detail demographics, medical and drug history, diagnostic information such as laboratory results, and findings from diagnostic imaging. It has office management functions such as billing and scheduling.

    More advanced EMRs include order entry for medications and tests, alerts, reminders, and clinical decision support. Some integrate population health analytics. Emerging are patient-centred capabilities directly into the EMR for booking appointments, viewing of data and secure communication with clinicians.

    This is often described as a provider-centric or health organization-centric health record of a patient in support of the provider’s interactions or encounters with the patient.

  3. Hospital Information System – a record under the custodianship of a health care organization. It is used in an inpatient setting such as acute care, continuing care and long term care.

    An HIS is a computer-based medical record specific to the inpatient setting’s organization. It is typically used by the facility’s multi-disciplinary care team for patient record keeping. It is the repository for information from ancillary systems within the organization such as diagnostic test (e.g., laboratory and imaging) and pharmacy. It holds consultant reports, pre- and post-operative reports, and nursing observations and reports, among others. In addition, it is used for order entry for medications and tests, alerts, reminders, and clinical decision support. These systems typically support hospital operational functions such as facility scheduling (e.g., operating room, diagnostic imaging), bed management, human resource management, and billing. Clinical, operational and financial analytics and reporting capabilities are also supported. Emerging are patient-centred capabilities directly into the HIS for booking appointments and viewing data and for secure communication with the clinicians.

    This is often described as a provider-centric or health organization-centric health record of a patient in support of the provider’s interactions or encounters with the patient.

  4. Ambulatory Electronic Medical Record – a record under the custodianship of a health care organization. It is used in an outpatient setting that has a direct affiliation with an inpatient facility.

    An aEMR is a computer-based medical record specific to an outpatient organization (clinic) that often has a direct affiliation with an inpatient facility. Ambulatory care covers a wide range of health care services that are provided for patients who are not admitted overnight. The clinic offers multiple specialties and/or services. The system that is typically deployed in the ambulatory setting is an HIS. This is either accomplished with the base HIS application, or with HIS product “modules” that are ambulatory specific. aEMRs are typically used by a multi-disciplinary care team in outpatient clinics. Some clinical services within the clinic (e.g., laboratory, imaging and pharmacy) may be provided by the inpatient facility. Hence information integration, i.e., the tethering of the aEMR system to the HIS with those ancillary services, is a differentiating characteristic of the aEMR.

    This is often described as a provider-centric or health organization-centric health record of a patient in support of the provider’s interactions or encounters with the patient.

  5. Personal Health Record – a health record under the custodianship of a patient, which might include a family member or caregiver. It is used in any setting where individuals are managing their own care.

    A PHR is a computer-based medical record that holds all or a portion of the relevant health information about individuals over their lifetime. Information sources include the health system and the circle of care for the individual. Therefore, the PHR is often integrated with the EMR, aEMR, HIS and EHR used by those clinicians and delivery organizations. The individual, family members or caregivers may input relevant information. Finally, information from medical devices the individual may be using outside a clinical setting may be stored in the PHR.

    This is often described as a patient-centric health record for wellness, self-care, health education, coaching, and patient-centred interactions with the health system.

So what then is a health information system? (Not a term I am really fond of, by the way.) It is an emerging concept and approach to deployment of clinical information systems. What I am seeing is a gradual expansion of the clinical scope of these health information systems. I’ve seen instances where the same system is deployed broadly across settings such as inpatient care, ambulatory care, long term care, community physician offices (general practitioner and specialist), community care, and to the individual. Think of it as an amalgamation of all five systems described above.

  1. Health Information System – a record under the custodianship of an integrated delivery network such as a multi-function health care delivery organization or a health region. The system is deployed broadly across clinical settings and to patients wherever they are.

    An HeIS is a system implemented as a shared service across the geographic region of an integrated delivery network. It supports most, if not all, of the core health care delivery services that are information technology enabled. The system may be an integrated system from a single vendor or be made up of modules that are integrated from multiple vendors. The users include clinicians, administrators and patients. This system covers clinical, operational and financial record keeping along with embedded advanced functions such as order entry, clinical decision support, e-referral, care plans and analytics. It supports patient-centred access to those capabilities in addition to wellness functions, self-care, health education, coaching, and patient-centred interactions with the health system.

    This is often described as a provider-centric or health organization-centric health record of a patient in support of the integrated delivery network’s interactions or encounters with the patient while also being a patient-centric health record.

I would conclude that the lines between these system definitions is becoming increasingly blurred along the lines of data held, geographic and organizational breadth, functionality and authorized users supported. Perhaps when we revisit these again we will (I hope) dispense with all of these terms and settle on one simple, all-inclusive term, such as EHR.

What do you think? What trends are you seeing?

Have a comment about this post? We’d love to hear from you.


Dennis GiokasDennis Giokas

Dennis Giokas is Chief Technology Officer for Infoway and heads up the Innovation Ecosystem Group. The group is chartered with establishing the vision, thought leadership and investment in digital health ecosystems and solutions in new areas of opportunity.

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