Electronic health record#Usefulness for research

The terms EHR, electronic patient record (EPR), and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist.{{sfn|Kubben|Dumontier|Dekker|2018|p=3}} The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR.{{cite journal | vauthors = Habib JL |url=http://dbt.consultantlive.com/display/article/1145628/1581538 |title=EHRs, meaningful use, and a model EMR |journal=Drug Benefit Trends |year=2010 |volume=22 |issue=4 |pages=99–101 }}{{cite journal | vauthors = Kierkegaard P |year=2011 |title= Electronic health record: Wiring Europe's healthcare |journal=Computer Law & Security Review |volume=27 |issue=5 |pages=503–515 |doi=10.1016/j.clsr.2011.07.013 }}

EMRs are essentially digital versions of the paper documents used in a clinician’s office, typically functioning as an internal system within a practice. An EMR includes the medical and treatment history of patients treated by that specific practice.{{Cite journal |last1=Heart |first1=Tsipi |last2=Ben-Assuli |first2=Ofir |last3=Shabtai |first3=Itamar |date=2017-03-01 |title=A review of PHR, EMR and EHR integration: A more personalized healthcare and public health policy |url=https://www.sciencedirect.com/science/article/abs/pii/S2211883716300624 |journal=Health Policy and Technology |volume=6 |issue=1 |pages=20–25 |doi=10.1016/j.hlpt.2016.08.002 |issn=2211-8837}}

In contrast, a personal health record (PHR) is an electronic application for recording individual medical data that the individual patient controls and may make available to health providers.{{cite web|title=What is a personal health record?|url=http://www.healthit.gov/providers-professionals/faqs/what-personal-health-record|website=HealthIT.gov|publisher=Office of the National Coordinator for Health IT|access-date=2015-07-24|archive-date=25 July 2015|archive-url=https://web.archive.org/web/20150725072321/http://www.healthit.gov/providers-professionals/faqs/what-personal-health-record|url-status=dead}}

While there is still considerable debate around the superiority of electronic health records over paper records, the research literature paints a more realistic picture of the benefits and downsides.{{cite journal | vauthors = Greenhalgh T, Potts HW, Wong G, Bark P, Swinglehurst D | title = Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method | journal = The Milbank Quarterly | volume = 87 | issue = 4 | pages = 729–788 | date = December 2009 | pmid = 20021585 | pmc = 2888022 | doi = 10.1111/j.1468-0009.2009.00578.x }}

The increased transparency, portability, and accessibility acquired by the adoption of electronic medical records may increase the ease with which they can be accessed by healthcare professionals, but also can increase the amount of stolen information by unauthorized persons or unscrupulous users versus paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Insurance Portability and Accountability Act (HIPAA) and by large-scale breaches in confidential records reported by EMR users."Griffin Hospital reports of dozens of patient medical records breaches", CtPost.com, 29 March 2010Kate Ramunni; "UCLA hospital scandal grows" Los Angeles Times, 5 August 2008 Concerns about security contribute to the resistance shown to their adoption.{{weasel inline|date=March 2015}}

Handwritten paper medical records may be poorly legible, which can contribute to medical errors.{{cite web | author = Institute of Medicine | year=1999 | url= http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf | title=To Err Is Human: Building a Safer Health System (1999) | publisher=The National Academies Press | access-date=28 February 2017}} Pre-printed forms, standardization of abbreviations, and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication. Medication is an intervention that can turn a person's status from stable to unstable very quickly. With paper documentation it is very easy to not properly document the administration of medication, the time given, or errors such as giving the "wrong drug, dose, form, or not checking for allergies," and could affect the patient negatively. It has been reported that these errors have been reduced by "55-83%" because records are now online and require specific steps to avoid these errors.{{cite journal | vauthors = Agrawal A | title = Medication errors: prevention using information technology systems | journal = British Journal of Clinical Pharmacology | volume = 67 | issue = 6 | pages = 681–686 | date = June 2009 | pmid = 19594538 | pmc = 2723209 | doi = 10.1111/j.1365-2125.2009.03427.x }}

Electronic records may help with the standardization of forms, terminology, and data input.{{cite book |last=Walker |first=Mark |date=2024 |title=Digital Health: How modern technology is changing medicine and healthcare |url=https://www.researchgate.net/publication/378547929 |location=Sheffield, UK |publisher=Sicklebrook publishing |isbn=9781446755969}}{{cite journal | title=Electronic Health Record Error Prevention Approach Using Ontology in Big Data | year=2015 | journal=2015 IEEE 17th International Conference on High Performance and Communications (HPCC) | url=http://webpage.pace.edu/kg71231w/docs/HPCC2015-1.pdf | access-date=7 November 2016 | archive-date=12 January 2017 | archive-url=https://web.archive.org/web/20170112001014/http://webpage.pace.edu/kg71231w/docs/HPCC2015-1.pdf | url-status=dead }} Digitization of forms facilitates the collection of data for epidemiology and clinical studies.{{cite web | publisher = EMR Software Pro | year = 2011 | url = http://emrsoftwarepro.com/health-information-exchanges-and-the-emr-selection-process/ | title = EMR Software Information Exchange, January 25, 2011 | access-date = 3 August 2013 | archive-date = 2 January 2020 | archive-url = https://web.archive.org/web/20200102131338/http://emrsoftwarepro.com/health-information-exchanges-and-the-emr-selection-process/ | url-status = dead }}"Health Information Exchanges and Your EMR Selection Process", New England Journal of Medicine, 25 January 2011 However, standardization may create challenges for local practice. Overall, those with EMRs that have automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.{{Cite journal|date=30 March 2009|title=Clinical Information Technologies and Inpatient Outcomes|journal=Medical Benefits|volume=26|pages=6, 8|id={{ProQuest|207235826}}}}

EMRs can be continuously updated (within certain legal limitations: see below). If the ability to exchange records between different EMR systems were perfected ("interoperability"Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601)), it would facilitate the coordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management, and public health communicable disease surveillance.{{cite web |publisher=Healthcare Information and Management Systems Society |year=2003 |url=http://www.himss.org/content/files/EHRAttributes.pdf |title=EHR Definition, Attributes and Essential Requirements |quote=152 KiB |access-date=28 July 2006 |url-status=dead |archive-url=https://web.archive.org/web/20060519133651/http://www.himss.org/content/files/EHRAttributes.pdf |archive-date=19 May 2006}} However, it is difficult to remove data from its context.

Providing patients with information is central to patient-centered health care and has been shown to positively affect health outcomes.{{Cite journal |last1=Ammenwerth |first1=Elske |last2=Neyer |first2=Stefanie |last3=Hörbst |first3=Alexander |last4=Mueller |first4=Gerhard |last5=Siebert |first5=Uwe |last6=Schnell-Inderst |first6=Petra |date=2021-02-26 |editor-last=Cochrane Consumers and Communication Group |title=Adult patient access to electronic health records |journal=Cochrane Database of Systematic Reviews |language=en |volume=2021 |issue=2 |pages=CD012707 |doi=10.1002/14651858.CD012707.pub2 |pmc=8871105 |pmid=33634854}} Providing patients access to their health records, including medical histories and test results via an EHR, is a legal right in some parts of the world.

There is evidence that patient access may help patients understand their conditions and actively involve them in their management. For example, granting people who have type 2 diabetes access to their electronic health records may help these people to reduce their blood sugar levels.{{cite journal |vauthors=Neves AL, Freise L, Laranjo L, Carter AW, Darzi A, Mayer E |date=December 2020 |title=Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis |journal=BMJ Quality & Safety |volume=29 |issue=12 |pages=1019–1032 |doi=10.1136/bmjqs-2019-010581 |pmc=7785164 |pmid=32532814}}{{Cite journal |date=2020-10-21 |title=Sharing electronic records with patients led to improved control of type two diabetes |url=https://evidence.nihr.ac.uk/alert/sharing-electronic-records-with-patients-led-to-improved-control-of-type-two-diabetes/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_42103 |s2cid=242149388}}{{Cite journal |year=2022 |title=What is digital health technology and what can it do for me? |url=https://evidence.nihr.ac.uk/collection/what-is-digital-health-technology/ |doi=10.3310/nihrevidence_53447 |s2cid=252584020 |website=NIHR Evidence}}

Challenges with sharing the electronic health record with patients include a risk of increased confusion or anxiety if a person does not understand or cannot contextualize the testing results. In addition, many EHRs are not designed for people of all educational levels and do not consider the needs of those with a lower level of education or those who are not fluent in the language. Accessing the EHR requires a level of proficiency with electronic devices, which adds to a disparity for those without access or for those who have a mental or physical illness that restricts their access to the electronic system.

{{see also|Interoperability}}

Electronic medical records could also be studied to quantify disease burdens – such as the number of deaths from antimicrobial resistance{{cite journal | vauthors = Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, etal | collaboration = Antimicrobial Resistance Collaborators | title = Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis | language = English | journal = Lancet | volume = 399 | issue = 10325 | pages = 629–655 | date = February 2022 | pmid = 35065702 | pmc = 8841637 | doi = 10.1016/S0140-6736(21)02724-0 }} – or help identify causes of, factors of, links between,{{cite journal |last1=Kuan |first1=Valerie |last2=Denaxas |first2=Spiros |last3=Patalay |first3=Praveetha |display-authors=et al. |title=Identifying and visualising multimorbidity and comorbidity patterns in patients in the English National Health Service: a population-based study |journal=The Lancet Digital Health |date=29 November 2022 |volume=5 |issue=1 |pages=e16–e27 |doi=10.1016/S2589-7500(22)00187-X |pmid=36460578 |s2cid=254129048 |language=English |issn=2589-7500|doi-access=free }}{{cite journal |last1=Levine |first1=Kristin S. |last2=Leonard |first2=Hampton L. |last3=Blauwendraat |first3=Cornelis |last4=Iwaki |first4=Hirotaka |last5=Johnson |first5=Nicholas |last6=Bandres-Ciga |first6=Sara |last7=Ferrucci |first7=Luigi |last8=Faghri |first8=Faraz |last9=Singleton |first9=Andrew B. |last10=Nalls |first10=Mike A. |title=Virus exposure and neurodegenerative disease risk across national biobanks |journal=Neuron |date=19 January 2023 |volume=111 |issue=7 |pages=1086–1093.e2 |doi=10.1016/j.neuron.2022.12.029 |pmid=36669485 |pmc=10079561 |language=English |issn=0896-6273|doi-access=free}}

• News article about the study: {{cite journal |last1=Kozlov |first1=Max |title=Massive health-record review links viral illnesses to brain disease |url=https://www.nature.com/articles/d41586-023-00181-3 |access-date=15 February 2023 |journal=Nature |date=23 January 2023 |volume=614 |issue=7946 |pages=18–19 |language=en |doi=10.1038/d41586-023-00181-3 |pmid=36690772 |bibcode=2023Natur.614...18K |s2cid=256193462 |archive-date=6 February 2023 |archive-url=https://web.archive.org/web/20230206084328/https://www.nature.com/articles/d41586-023-00181-3 |url-status=live }} and contributors to diseases,{{cite journal | vauthors = Solomon DH, Liu CC, Kuo IH, Zak A, Kim SC | title = Effects of colchicine on risk of cardiovascular events and mortality among patients with gout: a cohort study using electronic medical records linked with Medicare claims | journal = Annals of the Rheumatic Diseases | volume = 75 | issue = 9 | pages = 1674–1679 | date = September 2016 | pmid = 26582823 | pmc = 5049504 | doi = 10.1136/annrheumdis-2015-207984 }}{{cite journal | vauthors = Newschaffer CJ, Bush TL, Penberthy LT | title = Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data | journal = Journal of Clinical Epidemiology | volume = 50 | issue = 6 | pages = 725–733 | date = June 1997 | pmid = 9250271 | doi = 10.1016/S0895-4356(97)00050-4 }}{{cite journal |last1=Spiranovic |first1=Caroline |last2=Matthews |first2=Allison |last3=Scanlan |first3=Joel |last4=Kirkby |first4=Kenneth C. |title=Increasing knowledge of mental illness through secondary research of electronic health records: opportunities and challenges |journal=Advances in Mental Health |date=2 January 2016 |volume=14 |issue=1 |pages=14–25 |doi=10.1080/18387357.2015.1063635 |s2cid=57541937 |issn=1838-7357}} especially when combined with genome-wide association studies.{{cite journal | vauthors = Byun J, Schwartz AG, Lusk C, Wenzlaff AS, de Andrade M, Mandal D, Gaba C, Yang P, You M, Kupert EY, Anderson MW, Han Y, Li Y, Qian D, Stilp A, Laurie C, Nelson S, Zheng W, Hung RJ, Gaborieau V, Mckay J, Brennan P, Caporaso NE, Landi MT, Wu X, McLaughlin JR, Brhane Y, Bossé Y, Pinney SM, Bailey-Wilson JE, Amos CI | display-authors = 6 | title = Genome-wide association study of familial lung cancer | journal = Carcinogenesis | volume = 39 | issue = 9 | pages = 1135–1140 | date = September 2018 | pmid = 29924316 | pmc = 6148967 | doi = 10.1093/carcin/bgy080 }}

This may enable increased flexibility, improved disease surveillance, better medical product safety surveillance,{{cite journal |last1=Desai |first1=Rishi J. |last2=Matheny |first2=Michael E. |last3=Johnson |first3=Kevin |last4=Marsolo |first4=Keith |last5=Curtis |first5=Lesley H. |last6=Nelson |first6=Jennifer C. |last7=Heagerty |first7=Patrick J. |last8=Maro |first8=Judith |last9=Brown |first9=Jeffery |last10=Toh |first10=Sengwee |last11=Nguyen |first11=Michael |last12=Ball |first12=Robert |last13=Dal Pan |first13=Gerald |last14=Wang |first14=Shirley V. |last15=Gagne |first15=Joshua J. |last16=Schneeweiss |first16=Sebastian |title=Broadening the reach of the FDA Sentinel system: A roadmap for integrating electronic health record data in a causal analysis framework |journal=npj Digital Medicine |date=20 December 2021 |volume=4 |issue=1 |page=170 |doi=10.1038/s41746-021-00542-0 |pmid=34931012 |pmc=8688411 |language=en |issn=2398-6352}} better public health monitoring (such as for evaluation of health policy effectiveness),{{cite journal |last1=Hoelscher |first1=Deanna M. |last2=Ranjit |first2=Nalini |last3=Pérez |first3=Adriana |title=Surveillance Systems to Track and Evaluate Obesity Prevention Efforts |journal=Annual Review of Public Health |date=20 March 2017 |volume=38 |issue=1 |pages=187–214 |doi=10.1146/annurev-publhealth-031816-044537 |pmid=28125393 |language=en |issn=0163-7525|doi-access=free }}{{cite journal |last1=Paul |first1=Margaret M. |last2=Greene |first2=Carolyn M. |last3=Newton-Dame |first3=Remle |last4=Thorpe |first4=Lorna E. |last5=Perlman |first5=Sharon E. |last6=McVeigh |first6=Katherine H. |last7=Gourevitch |first7=Marc N. |title=The state of population health surveillance using electronic health records: A narrative review |journal=Population Health Management |date=1 June 2015 |volume=18 |issue=3 |pages=209–216 |doi=10.1089/pop.2014.0093 |pmid=25608033 |issn=1942-7891}} increased quality of care (via guidelines{{cite journal |last1=Moloney |first1=Max |last2=Digby |first2=Geneviève |last3=MacKinnon |first3=Madison |last4=Morra |first4=Alison |last5=Barber |first5=David |last6=Queenan |first6=John |last7=Gupta |first7=Samir |last8=To |first8=Teresa |last9=Lougheed |first9=M. Diane |title=Primary care asthma surveillance: a review of knowledge translation tools and strategies for quality improvement |journal=Allergy, Asthma & Clinical Immunology |date=17 January 2023 |volume=19 |issue=1 |pages=3 |doi=10.1186/s13223-022-00755-2 |pmid=36650578 |pmc=9843861 |s2cid=255966861 |issn=1710-1492 |doi-access=free }} and improved medical history sharing), and novel life-saving treatments.

Privacy: For such purposes, electronic medical records could potentially be made available in securely anonymized or pseudonymized{{cite journal | vauthors = Al-Zubaidie M, Zhang Z, Zhang J | title = PAX: Using Pseudonymization and Anonymization to Protect Patients' Identities and Data in the Healthcare System | journal = International Journal of Environmental Research and Public Health | volume = 16 | issue = 9 | pages = 1490 | date = April 2019 | pmid = 31035551 | pmc = 6540163 | doi = 10.3390/ijerph16091490 | doi-access = free }} forms to ensure patients' privacy is maintained,{{cite journal | vauthors = Tamersoy A, Loukides G, Nergiz ME, Saygin Y, Malin B | title = Anonymization of longitudinal electronic medical records | journal = IEEE Transactions on Information Technology in Biomedicine | volume = 16 | issue = 3 | pages = 413–423 | date = May 2012 | pmid = 22287248 | pmc = 3779068 | doi = 10.1109/TITB.2012.2185850 }}{{cite journal | vauthors = Loukides G, Gkoulalas-Divanis A, Malin B | title = Anonymization of electronic medical records for validating genome-wide association studies | journal = Proceedings of the National Academy of Sciences of the United States of America | volume = 107 | issue = 17 | pages = 7898–7903 | date = April 2010 | pmid = 20385806 | pmc = 2867915 | doi = 10.1073/pnas.0911686107 | doi-access = free | bibcode = 2010PNAS..107.7898L }}{{cite journal | vauthors = Chevrier R, Foufi V, Gaudet-Blavignac C, Robert A, Lovis C | title = Use and Understanding of Anonymization and De-Identification in the Biomedical Literature: Scoping Review | language = EN | journal = Journal of Medical Internet Research | volume = 21 | issue = 5 | pages = e13484 | date = May 2019 | pmid = 31152528 | pmc = 6658290 | doi = 10.2196/13484 | doi-access = free }}{{cite journal | vauthors = Puri V, Sachdeva S, Kaur P |title=Privacy preserving publication of relational and transaction data: Survey on the anonymization of patient data |journal=Computer Science Review |date=1 May 2019 |volume=32 |pages=45–61 |doi=10.1016/j.cosrev.2019.02.001 |s2cid=133142770 |language=en |issn=1574-0137}} even if data breaches occur. There are concerns about the efficacy of some currently applied pseudonymization and data protection techniques, including the applied encryption.{{cite news |last1=Beuth |first1=Patrick |title=Alle gesetzlich Versicherten betroffen: Bürgerrechtler klagen gegen Weitergabe von Gesundheitsdaten |url=https://www.spiegel.de/netzwelt/netzpolitik/buergerrechtler-klagen-gegen-weitergabe-von-gesundheitsdaten-a-9e2d37e3-857a-4209-9015-98f1f05d0bcd |access-date=6 March 2023 |work=Der Spiegel |date=29 April 2022 |language=de}}{{cite journal |last1=Shah |first1=Shahid Munir |last2=Khan |first2=Rizwan Ahmed |title=Secondary Use of Electronic Health Record: Opportunities and Challenges |journal=IEEE Access |date=2020 |volume=8 |pages=136947–136965 |doi=10.1109/ACCESS.2020.3011099 |s2cid=210920454 |issn=2169-3536|arxiv=2001.09479 |bibcode=2020IEEEA...8m6947S }}

Documentation burden: While such records could enable avoiding duplication of work via records-sharing, documentation burdens for medical facility personnel can be a further issue with EHRs. This burden could be reduced via voice recognition, optical character recognition, other technologies, physician involvement in software changes, and other means{{cite journal |last1=Sunjaya |first1=Anthony Paulo |title=Uplifting Primary Care Through the Electronic Health Record |journal=The Annals of Family Medicine |date=1 July 2022 |volume=20 |issue=4 |pages=303–304 |doi=10.1370/afm.2860 |pmid=35879075 |pmc=9328708 |language=en |issn=1544-1709}}{{cite journal |last1=Guo |first1=Uta |last2=Chen |first2=Lu |last3=Mehta |first3=Parag H |title=Electronic health record innovations: Helping physicians – One less click at a time |journal=Health Information Management Journal |date=September 2017 |volume=46 |issue=3 |pages=140–144 |doi=10.1177/1833358316689481 |pmid=28671038 |s2cid=31329786 |language=en |issn=1833-3583}}{{cite journal |last1=Dymek |first1=Christine |last2=Kim |first2=Bryan |last3=Melton |first3=Genevieve B |last4=Payne |first4=Thomas H |last5=Singh |first5=Hardeep |last6=Hsiao |first6=Chun-Ju |title=Building the evidence-base to reduce electronic health record–related clinician burden |journal=Journal of the American Medical Informatics Association |date=23 April 2021 |volume=28 |issue=5 |pages=1057–1061 |doi=10.1093/jamia/ocaa238|pmid=33340326 |pmc=8068419 }}{{cite journal |last1=Goodrum |first1=Heath |last2=Roberts |first2=Kirk |last3=Bernstam |first3=Elmer V. |title=Automatic classification of scanned electronic health record documents |journal=International Journal of Medical Informatics |date=1 December 2020 |volume=144 |pages=104302 |doi=10.1016/j.ijmedinf.2020.104302 |pmid=33091829 |pmc=7731898 |language=en |issn=1386-5056}} which could possibly reduce the documentation burden to below paper-based records documentation and low-level documentation.

{{See also|Artificial intelligence in healthcare}}

File:GNU Health patient main screen.png

Theoretically, free software such as GNU Health and other open-source health software could be used or modified for various purposes that use electronic medical records, i.e., via securely sharing anonymized patient treatments, medical history, and individual outcomes (including by common primary care physicians).{{cite web | vauthors = Falcón L |title=Tackling the beast: Using GNU Health to help the fight against the {{!}} Joinup |url=https://joinup.ec.europa.eu/collection/ehealth/news/tackling-beast-using-gnu-health-help-fight-against |website=joinup.ec.europa.eu |access-date=8 April 2021 |language=en |date=9 April 2020}}

• Decision support: Electronic health records could support clinical decision-support systems.{{cite journal |last1=Jayaraman |first1=Prem Prakash |last2=Forkan |first2=Abdur Rahim Mohammad |last3=Morshed |first3=Ahsan |last4=Haghighi |first4=Pari Delir |last5=Kang |first5=Yong-Bin |title=Healthcare 4.0: A review of frontiers in digital health |journal=WIREs Data Mining and Knowledge Discovery |date=March 2020 |volume=10 |issue=2 |doi=10.1002/widm.1350 |s2cid=211536793 |language=en |issn=1942-4787}}
• Personalized medicine: They could be used among other biodata for digital twins (also called health avatars) for personalized medicine.{{cite journal |last1=Björnsson |first1=Bergthor |last2=Borrebaeck |first2=Carl |last3=Elander |first3=Nils |last4=Gasslander |first4=Thomas |last5=Gawel |first5=Danuta R. |last6=Gustafsson |first6=Mika |last7=Jörnsten |first7=Rebecka |last8=Lee |first8=Eun Jung |last9=Li |first9=Xinxiu |last10=Lilja |first10=Sandra |last11=Martínez-Enguita |first11=David |last12=Matussek |first12=Andreas |last13=Sandström |first13=Per |last14=Schäfer |first14=Samuel |last15=Stenmarker |first15=Margaretha |last16=Sun |first16=X. F. |last17=Sysoev |first17=Oleg |last18=Zhang |first18=Huan |last19=Benson |first19=Mikael |title=Digital twins to personalize medicine |journal=Genome Medicine |date=31 December 2019 |volume=12 |issue=1 |pages=4 |doi=10.1186/s13073-019-0701-3 |pmid=31892363 |pmc=6938608 |issn=1756-994X |doi-access=free }}{{Cite journal |last1=Swinckels |first1=Laura |last2=Bennis |first2=Frank C. |last3=Ziesemer |first3=Kirsten A. |last4=Scheerman |first4=Janneke F. M. |last5=Bijwaard |first5=Harmen |last6=Keijzer |first6=Ander de |last7=Bruers |first7=Josef Jan |date=2024-08-20 |title=The Use of Deep Learning and Machine Learning on Longitudinal Electronic Health Records for the Early Detection and Prevention of Diseases: Scoping Review |journal=Journal of Medical Internet Research |language=EN |volume=26 |issue=1 |pages=e48320 |doi=10.2196/48320|doi-access=free |pmid=39163096 |pmc=11372333 }}
• mHealth integration: They could be coupled with mHealth mobile applications and wearable technology.
• Screening: Artificial intelligence systems could use this data, as well as other integrated data, to screen for potential diseases via multimodal learning.{{cite news |title=New AI technology integrates multiple data types to predict cancer outcomes |url=https://medicalxpress.com/news/2022-08-ai-technology-multiple-cancer-outcomes.html |access-date=1 February 2023 |work=medicalxpress.com |language=en}}
• Syndromic surveillance: Real-time analysis and data mining of the records could be used, along with other data, in syndromic surveillance to rapidly identify common exposures among patients suspected of being part of an outbreak, for epidemic forecasting{{cite journal |last1=Desai |first1=Angel N. |last2=Kraemer |first2=Moritz U. G. |last3=Bhatia |first3=Sangeeta |last4=Cori |first4=Anne |last5=Nouvellet |first5=Pierre |last6=Herringer |first6=Mark |last7=Cohn |first7=Emily L. |last8=Carrion |first8=Malwina |last9=Brownstein |first9=John S. |last10=Madoff |first10=Lawrence C. |last11=Lassmann |first11=Britta |title=Real-time Epidemic Forecasting: Challenges and Opportunities |journal=Health Security |date=1 August 2019 |volume=17 |issue=4 |pages=268–275 |doi=10.1089/hs.2019.0022 |pmid=31433279 |pmc=6708259 |issn=2326-5094}} and for early outbreak detection,{{cite journal |last1=Sundermann |first1=Alexander J. |last2=Miller |first2=James K. |last3=Marsh |first3=Jane W. |last4=Saul |first4=Melissa I. |last5=Shutt |first5=Kathleen A. |last6=Pacey |first6=Marissa |last7=Mustapha |first7=Mustapha M. |last8=Ayres |first8=Ashley |last9=Pasculle |first9=A. William |last10=Chen |first10=Jieshi |last11=Snyder |first11=Graham M. |last12=Dubrawski |first12=Artur W. |last13=Harrison |first13=Lee H. |title=Automated data mining of the electronic health record for investigation of healthcare-associated outbreaks |journal=Infection Control & Hospital Epidemiology |date=March 2019 |volume=40 |issue=3 |pages=314–319 |doi=10.1017/ice.2018.343 |pmid=30773168 |pmc=8189294 |language=en |issn=0899-823X}}{{cite journal |last1=Hripcsak |first1=G. |last2=Soulakis |first2=N. D. |last3=Li |first3=L. |last4=Morrison |first4=F. P. |last5=Lai |first5=A. M. |last6=Friedman |first6=C. |last7=Calman |first7=N. S. |last8=Mostashari |first8=F. |title=Syndromic Surveillance Using Ambulatory Electronic Health Records |journal=Journal of the American Medical Informatics Association |date=1 May 2009 |volume=16 |issue=3 |pages=354–361 |doi=10.1197/jamia.m2922|pmid=19261941 |pmc=2732227 }}{{cite journal |last1=Meckawy |first1=Rehab |last2=Stuckler |first2=David |last3=Mehta |first3=Adityavarman |last4=Al-Ahdal |first4=Tareq |last5=Doebbeling |first5=Bradley N. |title=Effectiveness of early warning systems in the detection of infectious diseases outbreaks: a systematic review |journal=BMC Public Health |date=29 November 2022 |volume=22 |issue=1 |pages=2216 |doi=10.1186/s12889-022-14625-4 |pmid=36447171 |pmc=9707072 |issn=1471-2458 |doi-access=free }}{{cite journal |last1=Hopkins |first1=Richard S. |last2=Tong |first2=Catherine C. |last3=Burkom |first3=Howard S. |last4=Akkina |first4=Judy E. |last5=Berezowski |first5=John |last6=Shigematsu |first6=Mika |last7=Finley |first7=Patrick D. |last8=Painter |first8=Ian |last9=Gamache |first9=Roland |last10=Vilas |first10=Victor J. Del Rio |last11=Streichert |first11=Laura C. |title=A Practitioner-Driven Research Agenda for Syndromic Surveillance |journal=Public Health Reports |date=July 2017 |volume=132 |issue=1_suppl |pages=116S–126S |doi=10.1177/0033354917709784 |pmid=28692395 |pmc=5676517 |s2cid=2088189 |language=en |issn=0033-3549}} especially in identified potential pandemic pathogen (PPP) hotspot regions and potentially as a means for pandemic prevention.
• Vaccination deployment: Interoperable, collaboratively developed, standardization-based health records systems could increase the speed of vaccination campaigns and reduce their costs or workloads. According to Dr. Bob Kocher, as of 2021, there are "1,000 different electronic health record systems in the U.S.,{{globalize inline|date=March 2023}} and almost every hospital and clinic has a slightly different system tailored to its own needs" which caused difficulties and delays during COVID-19 vaccinations, with similar problems being reported in other countries.{{cite news |title=Electronic Health Records May Be Delaying COVID-19 Vaccinations |url=https://www.npr.org/sections/coronavirus-live-updates/2021/02/10/966279323/electronic-health-records-may-be-delaying-covid-19-vaccinations |access-date=6 March 2023 |work=NPR |date=February 2021}}{{cite news |title=COVID-19 vaccine rollout may be delayed - with IT system 'failing constantly' |url=https://news.sky.com/story/covid-19-vaccine-rollout-may-be-delayed-with-it-system-failing-constantly-12164829 |access-date=6 March 2023 |work=Sky News |language=en}}
• Medical outcomes data: Such records could also be used to match patients to clinical trials with software,{{cite journal |last1=Klein |first1=Harry |last2=Mazor |first2=Tali |last3=Siegel |first3=Ethan |last4=Trukhanov |first4=Pavel |last5=Ovalle |first5=Andrea |last6=Vecchio Fitz |first6=Catherine Del |last7=Zwiesler |first7=Zachary |last8=Kumari |first8=Priti |last9=Van Der Veen |first9=Bernd |last10=Marriott |first10=Eric |last11=Hansel |first11=Jason |last12=Yu |first12=Joyce |last13=Albayrak |first13=Adem |last14=Barry |first14=Susan |last15=Keller |first15=Rachel B. |last16=MacConaill |first16=Laura E. |last17=Lindeman |first17=Neal |last18=Johnson |first18=Bruce E. |last19=Rollins |first19=Barrett J. |last20=Do |first20=Khanh T. |last21=Beardslee |first21=Brian |last22=Shapiro |first22=Geoffrey |last23=Hector-Barry |first23=Suzanne |last24=Methot |first24=John |last25=Sholl |first25=Lynette |last26=Lindsay |first26=James |last27=Hassett |first27=Michael J. |last28=Cerami |first28=Ethan |title=MatchMiner: an open-source platform for cancer precision medicine |journal=npj Precision Oncology |date=6 October 2022 |volume=6 |issue=1 |page=69 |doi=10.1038/s41698-022-00312-5 |pmid=36202909 |pmc=9537311 |language=en |issn=2397-768X|doi-access=free}} reducing the burden on users to partake in research and making previously siloed primary care data more valuable to society at larger or other patients.

Ambulance services in Australia, the United States, and the United Kingdom have introduced EMR systems.{{cite web | url = http://emergencymedicalparamedic.com/emr-for-paramedics | title = EMR in Ambulances | work = Emergency Medical Paramedic | date = 5 May 2011 | access-date = 4 June 2011 }}{{cite journal | vauthors = Porter A, Badshah A, Black S, Fitzpatrick D, Harris-Mayes R, Islam S, Jones M, Kingston M, LaFlamme-Williams Y, Mason S, McNee K, Morgan H, Morrison Z, Mountain P, Potts H, Rees N, Shaw D, Siriwardena N, Snooks H, Spaight R, Williams V | display-authors = 6 | date = 2020 | title = Electronic health records in ambulances: the ERA multiple-methods study. | journal = Health Services and Delivery Research | volume = 8 | issue = 10 | pages = 1–140 | doi = 10.3310/hsdr08100 | pmid = 32119231 | s2cid = 216157261 | doi-access = free | hdl = 2164/13775 | hdl-access = free }} EMS Encounters in the United States are recorded using various platforms and vendors in compliance with the NEMSIS (National EMS Information System) standard.{{Cite web|url=http://nemsis.org/index.html|title=NEMSIS - National EMS Information System|website=nemsis.org|access-date=2017-05-31|archive-url=https://web.archive.org/web/20170608222052/http://www.nemsis.org/index.html|archive-date=8 June 2017|url-status=dead}} The benefits of electronic records in ambulances include patient data sharing, injury/illness prevention, better training for paramedics, review of clinical standards, better research options for pre-hospital care and design of future treatment options, data-based outcome improvement, and clinical decision support.{{cite report | url = http://www.ambulance.vic.gov.au/annualreport0809/VACIS.htm | title = Ambulance Victoria Annual Report | archive-url = https://web.archive.org/web/20110720105401/http://www.ambulance.vic.gov.au/annualreport0809/VACIS.htm | archive-date=20 July 2011 | work = Ambulance Victoria | date = 4 October 2009 | access-date = 4 June 2011 }}

EHRs enable health information to be used and shared over secure networks to:

• Track care (e.g., prescriptions) and outcomes (e.g., blood pressure)
• Trigger warnings and reminders
• Send and receive orders, reports, and results
• Decrease billing processing time and create more accurate billing systems

• Facilitate Health Information Exchange{{cite web |url=https://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm |title=Electronic Health Records: What's in it for Everyone? |publisher=Cdc.gov |date=2011-07-26 |access-date=4 September 2013 |archive-url=https://web.archive.org/web/20130401204416/http://www.cdc.gov/about/grand-rounds/archives/2011/July2011.htm |archive-date=1 April 2013 |url-status=dead }} - a technical and social framework that enables information to move electronically between organizations

Using an EMR to read and write a patient's record is not only possible through a workstation but, depending on the type of system and health care settings, may also be possible through mobile devices that are handwriting capable,{{cite web|title=Handwriting and mobile computing experts|url=http://www.medscribbler.com/handwriting_electronic_medical_records.html|website=Medscribbler|publisher=Scriptnetics|access-date=20 August 2008|archive-url=https://web.archive.org/web/20080919190857/http://www.medscribbler.com/handwriting_electronic_medical_records.html|archive-date=19 September 2008}} such as tablets and smartphones. Electronic medical records may include access to personal health records (PHR) which makes individual notes from an EMR readily visible and accessible to consumers.{{citation needed|date=April 2015}}

Some EMR systems automatically monitor clinical events by analyzing patient data from an electronic health record to predict, detect, and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results, and any other data from ancillary services or provider notes.{{Cite web |url=http://rods.health.pitt.edu/Technical%20Reports/2002%20JAMIA%20Event%20monitors%20in%20PHS.pdf |title=M958 revision-Event monitors in PHS 1-02-02.PDF |access-date=3 August 2013 |archive-url=https://web.archive.org/web/20120227201101/http://rods.health.pitt.edu/Technical%20Reports/2002%20JAMIA%20Event%20monitors%20in%20PHS.pdf |archive-date=27 February 2012 |url-status=dead }} This type of event monitoring has been implemented using the Louisiana Public Health Information Exchange, which links statewide public health with electronic medical records. This system alerted medical providers when a patient with HIV/AIDS had not received care in over twelve months. This system greatly reduced the number of missed critical opportunities.{{cite journal | vauthors = Herwehe J, Wilbright W, Abrams A, Bergson S, Foxhood J, Kaiser M, Smith L, Xiao K, Zapata A, Magnus M | display-authors = 6 | title = Implementation of an innovative, integrated electronic medical record (EMR) and public health information exchange for HIV/AIDS | journal = Journal of the American Medical Informatics Association | volume = 19 | issue = 3 | pages = 448–452 | year = 2011 | pmid = 22037891 | pmc = 3341789 | doi = 10.1136/amiajnl-2011-000412 }}

Within a meta-narrative systematic review of research in the field, various different philosophical approaches to the EHR exist. The health information systems literature has seen the EHR as a container holding information about the patient and a tool for aggregating clinical data for secondary uses (billing, audit, etc.). However, other research traditions see the EHR as a contextualized artifact within a socio-technical system. For example, actor-network theory would see the EHR as an actant in a network,{{cite journal |doi=10.1177/016224399702200401 |title=Of Forms, Containers, and the Electronic Medical Record: Some Tools for a Sociology of the Formal |year=1997 | vauthors = Berg M |journal=Science, Technology, & Human Values |volume=22 |issue=4 |pages=403–433|s2cid=109278148}} and research in computer-supported cooperative work (CSCW) sees the EHR as a tool supporting particular work.

Several possible advantages to EHRs over paper records have been proposed, but there is debate about the degree to which these are achieved in practice.{{cite journal | vauthors = Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HW | title = Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study | journal = BMJ | volume = 340 | pages = c3111 | date = June 2010 | pmid = 20554687 | doi = 10.1136/bmj.c3111 | doi-access = free }}

Several studies call into question whether EHRs improve the quality of care.{{cite web | vauthors = Gabriel B | year=2008 | url=http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1203/page/1.htm | title=Do EMRs Make You a Better Doctor? | publisher=Physicians Practice | access-date=23 August 2009 | archive-date=8 June 2010 | archive-url=https://web.archive.org/web/20100608190834/http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1203/page/1.htm | url-status=dead }}{{cite web | vauthors = Manos D | date = 14 December 2009 | url = http://www.healthcareitnews.com/news/electronic-health-records-not-panacea-researchers-say | title = Electronic health records not a panacea | work = Healthcare IT News }}{{cite web | vauthors = Silverstein S | year=2009 | url=http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009 | title=2009 a pivotal year in healthcare IT | publisher=Drexel University | access-date=5 January 2010 | archive-date=10 December 2010 | archive-url=https://web.archive.org/web/20101210013248/http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009 | url-status=dead }}{{cite journal | vauthors = Himmelstein DU, Wright A, Woolhandler S | title = Hospital computing and the costs and quality of care: a national study | journal = The American Journal of Medicine | volume = 123 | issue = 1 | pages = 40–46 | date = January 2010 | pmid = 19939343 | doi = 10.1016/j.amjmed.2009.09.004 | citeseerx = 10.1.1.176.937 }} One 2011 study in diabetes care, published in the New England Journal of Medicine, found evidence that practices with EHR provided better quality care.{{cite journal | vauthors = Cebul RD, Love TE, Jain AK, Hebert CJ | title = Electronic health records and quality of diabetes care | journal = The New England Journal of Medicine | volume = 365 | issue = 9 | pages = 825–833 | date = September 2011 | pmid = 21879900 | doi = 10.1056/NEJMsa1102519 | s2cid = 25101954 | doi-access = free }}

EMRs may eventually help improve care coordination. An article in a trade journal suggests that since anyone using an EMR can view the patient's full chart, it cuts down on guessing histories and seeing multiple specialists, smooths transitions between care settings, and may allow better care in emergency situations.{{cite web |url=http://www.healthit.gov/providers-professionals/improved-care-coordination |title=Improve Care Coordination using Electronic Health Records | Providers & Professionals |publisher=HealthIT.gov |access-date=4 September 2013 |archive-date=23 March 2018 |archive-url=https://web.archive.org/web/20180323034143/https://www.healthit.gov/providers-professionals/improved-care-coordination |url-status=dead }} EHRs may also improve prevention by providing doctors and patients better access to test results, identifying missing patient information, and offering evidence-based recommendations for preventive services.{{cite web |publisher=Agency for Healthcare Research and Quality | url=https://innovations.ahrq.gov/profiles/primary-care-patients-use-interactive-preventive-health-record-integrated-electronic-health |title=Primary Care Patients Use Interactive Preventive Health Record Integrated With Electronic Health Record, Leading to Enhanced Provision of Preventive Services |date=2013-06-19 |access-date=9 July 2013}}

The steep price and provider uncertainty regarding the value they will derive from adoption in the form of return on investment significantly influences EHR adoption.{{cite web |title= Health Information Technology in the United States: The Information Base for Progress |publisher= Robert Wood Johnson Foundation, George Washington University Medical Center, and Institute for Health Policy |year= 2006 |url= http://www.rwjf.org/files/publications/other/EHRReport0609.pdf |access-date= 17 February 2008 |archive-url= https://web.archive.org/web/20061106061421/http://www.rwjf.org/files/publications/other/EHRReport0609.pdf |archive-date= 6 November 2006 |url-status= dead }} In a project initiated by the Office of the National Coordinator for Health Information, surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente and not in small physician offices. They challenged the Rand Corporation's estimates of savings.

"Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example, the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians."{{cite report | url = http://www.cbo.gov/doc.cfm?index=9168 | title = Evidence on the costs and benefits of health information technology. | work = Congressional Budget Office | date = May 2008 }}

One CEO of an EHR company has argued if a physician performs tests in the office, it might reduce his or her income.{{cite journal| vauthors = Shah S |title=Column: Why MDs Dread EMRs |journal=Journal of Surgical Radiology |url=http://www.surgisphere.com/SurgRad/issues/volume-1/1-july-2010--pages-1-60/119-column-why-mds-dread-emrs.html |url-status=dead |archive-url=https://archive.today/20120910224010/http://www.surgisphere.com/SurgRad/issues/volume-1/1-july-2010--pages-1-60/119-column-why-mds-dread-emrs.html |archive-date=10 September 2012}}

Doubts have been raised about cost saving from EHRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.{{cite web | title = Information Technology: Not a Cure for the High Cost of Health Care | work = Knowledge@Wharton | date = 10 June 2009 | url = http://knowledge.wharton.upenn.edu/article.cfm?articleID=2260 }}{{cite web | vauthors = Verghese A | title = The Myth of Prevention | work = The Wall Street Journal | date = 20 June 2009 | url = https://www.wsj.com/articles/SB10001424052970204005504574235751720822322 }}

In 2022, the chief executive of Guy's and St Thomas' NHS Foundation Trust, one of the biggest NHS organisations, said that the £450 million cost over 15 years to install the Epic Systems electronic patient record across its six hospitals, which will reduce more than 100 different IT systems down to just a handful, was "chicken feed" when compared to the NHS's overall budget.{{cite news |title=£450m cost of US records system is 'chicken-feed' says trust CEO |url=https://www.hsj.co.uk/technology-and-innovation/450m-cost-of-us-records-system-is-chicken-feed-says-trust-ceo/7032111.article |access-date=22 May 2022 |publisher=Health Service Journal |date=18 March 2022}}

The implementation of EMR can potentially decrease the identification time of patients upon hospital admission. Research by the Annals of Internal Medicine showed that since the adoption of EMR, a relative decrease in time by 65% has been recorded (from 130 to 46 hours).{{cite journal | vauthors = Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG | display-authors = 6 | title = Systematic review: impact of health information technology on quality, efficiency, and costs of medical care | journal = Annals of Internal Medicine | volume = 144 | issue = 10 | pages = 742–752 | date = May 2006 | pmid = 16702590 | doi = 10.7326/0003-4819-144-10-200605160-00125 | doi-access = free | author7-link = Sally C. Morton }}

The Healthcare Information and Management Systems Society, a very large U.S. healthcare IT industry trade group, observed in 2009 that EHR adoption rates "have been slower than expected in the United States, especially compared to other industry sectors and other developed countries. Aside from initial costs and lost productivity during EMR implementation, one key reason is lack of efficiency and usability of EMRs currently available."{{cite web|title=7 big reasons why EHRs consume physicians' days and nights | date=15 May 2019 | publisher=The American Medical Association |url=https://www.ama-assn.org/practice-management/digital/7-big-reasons-why-ehrs-consume-physicians-days-and-nights}}{{cite web | vauthors = Belden JL, Grayson R, Barnes J | title = Defining and testing EMR usability: Principles and proposed methods of EMR usability evaluation and rating. | work = Healthcare Information and Management Systems Society (HIMSS) | date = June 2009 | url = http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf | archive-url = https://web.archive.org/web/20120322070808/http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf | archive-date=22 March 2012 }} The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers.{{cite report | title = NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records | pages = 9–10 | work = National Institute of Standards and Technology | date = September 2011 | url = https://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf }} The U.S. military's EHR, AHLTA, was reported to have significant usability issues.{{Cite web |url=http://www.usmedicine.com/articles/electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress.html |title=U.S. Medicine – The Voice of Federal Medicine, May 2009. |access-date=27 January 2012 |archive-url=https://web.archive.org/web/20111007172656/http://www.usmedicine.com/articles/electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress.html |archive-date=7 October 2011 |url-status=dead }} Furthermore, studies such as the one conducted in BMC Medical Informatics and Decision Making showed that although the implementation of electronic medical records systems has been a great assistance to general practitioners, there is still much room for revision in the overall framework and the amount of training provided.{{cite journal | vauthors = Bouamrane MM, Mair FS | title = A study of general practitioners' perspectives on electronic medical records systems in NHSScotland | journal = BMC Medical Informatics and Decision Making | volume = 13 | pages = 58 | date = May 2013 | pmid = 23688255 | pmc = 3704757 | doi = 10.1186/1472-6947-13-58 | doi-access = free }} It was observed that the efforts to improve EHR usability should be placed in the context of physician-patient communication.{{cite journal | vauthors = Fiks AG, Alessandrini EA, Forrest CB, Khan S, Localio AR, Gerber A | title = Electronic medical record use in pediatric primary care | journal = Journal of the American Medical Informatics Association | volume = 18 | issue = 1 | pages = 38–44 | date = 2011 | pmid = 21134975 | pmc = 3005866 | doi = 10.1136/jamia.2010.004135 }}

However, physicians are embracing mobile technologies such as smartphones and tablets at a rapid pace. According to a 2012 survey by Physicians Practice, 62.6 percent of respondents (1,369 physicians, practice managers, and other healthcare providers) say they use mobile devices in the performance of their job. Mobile devices are increasingly able to sync up with electronic health record systems, allowing physicians to access patient records from remote locations. Most devices are extensions of desktop EHR systems, using a variety of software to communicate and access files remotely. The advantages of instant access to patient records at any time and place are clear, but raise security concerns. As mobile systems become more prevalent, practices will need comprehensive policies that govern security measures and patient privacy regulations.{{cite web | url = http://www.physicianspractice.com/mobile-health/content/article/1462168/2087697 | title = EHRs Go Mobile | archive-url = https://web.archive.org/web/20120910040122/http://www.physicianspractice.com/mobile-health/content/article/1462168/2087697 | archive-date=10 September 2012 | vauthors = Torrieri M | work = Physicians Practice | date = July–August 2012 }}

Other advanced computational techniques allow EHRs to be evaluated at a much quicker rate. Natural language processing is increasingly used to search EMRs, especially through searching and analyzing notes and text that would otherwise be inaccessible for study when seeking to improve care.{{cite journal | vauthors = Turchin A, Florez Builes LF | title = Using Natural Language Processing to Measure and Improve Quality of Diabetes Care: A Systematic Review | journal = Journal of Diabetes Science and Technology | volume = 15 | issue = 3 | pages = 553–560 | date = May 2021 | pmid = 33736486 | pmc = 8120048 | doi = 10.1177/19322968211000831 }} One study found that several machine learning methods could be used to predict the rate of a patient's mortality with moderate success, with the most successful approach including using a combination of a convolutional neural network and a heterogenous graph model.{{Cite journal | vauthors = Wanyan T, Honarvar H, Azad A, Ding Y, Glicksberg BS |date=2021-09-08 |title=Deep Learning with Heterogeneous Graph Embeddings for Mortality Prediction from Electronic Health Records |journal=Data Intelligence |volume=3 |issue=3 |pages=329–339 |doi=10.1162/dint_a_00097 |issn=2641-435X |arxiv=2012.14065|s2cid=229679954}}

When a health facility has documented its workflow and chosen its software solution, it must consider the hardware and supporting device infrastructure for the end users. Staff and patients must engage with various devices throughout a patient's stay and charting workflow. Computers, laptops, all-in-one computers, tablets, mouse, keyboards and monitors are all hardware devices that may be utilized. Other considerations include supporting work surfaces and equipment, wall desks or articulating arms for end users to work on. Another important factor is how all these devices will be physically secured and how they will be charged so that staff can always utilize them for EHR charting when needed.

The success of eHealth interventions largely depends on the adopter's ability to fully understand workflow and anticipate potential clinical processes prior to implementations. Failure to do so can create costly and time-consuming interruptions to service delivery.{{cite journal | vauthors = Granja C, Janssen W, Johansen MA | title = Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature | journal = Journal of Medical Internet Research | volume = 20 | issue = 5 | pages = e10235 | date = May 2018 | pmid = 29716883 | pmc = 5954232 | doi = 10.2196/10235 | doi-access = free }}

Per empirical research in social informatics, information and communications technology (ICT) use can lead to both intended and unintended consequences.{{cite book | vauthors = Kling R, Rosenbaum H, Sawyer S | title = Understanding And Communicating Social Informatics: A Framework For Studying And Teaching The Human Contexts of Information And Communication Technologies | page = 23 | publisher = Information Today Inc | date = 15 September 2005 | isbn = 978-1-57387-228-7}}{{cite journal | vauthors = Sawyer S, Rosenbaum H | title = Social informatics in the information sciences: Current activities and emerging directions. | journal = Informing Science | date = 2000 | volume = 3 | issue = 2 | page = 94 | url = http://www.inform.nu/Articles/Vol3/v3n2p89-96r.pdf }}{{cite book | vauthors = Tenner E | title = Why Things Bite Back: Technology and the Revenge of Unintended Consequences | isbn = 978-0-679-74756-7 | date = 1997 | publisher = Knopf Doubleday Publishing }}

A 2008 Sentinel Event Alert from the U.S. Joint Commission, the organization that accredits American hospitals to provide healthcare services, states, "As health information technology (HIT) and 'converging technologies'—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate. Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design."{{cite journal | author = USA Joint Commission on Accreditation of Healthcare Organizations | title = Safely implementing health information and converging technologies | journal = Sentinel Event Alert | issue = 42 | pages = 1–4 | date = December 2008 | pmid = 19108351 }} The Joint Commission cites as an example the United States Pharmacopeia MEDMARX database,{{cite web | url = https://www.medmarx.com/docs/about.pdf | title = MEDMARX Adverse Drug Event Reporting database | access-date = 7 February 2012 | archive-date = 21 December 2016 | archive-url = https://web.archive.org/web/20161221162827/https://www.medmarx.com/docs/about.pdf | url-status = dead }} where of 176,409 medication error records for 2006, approximately 25 percent (43,372) involved some aspect of computer technology as at least one cause of the error.

The British National Health Service (NHS) reports specific examples of potential and actual EHR-caused unintended consequences in its 2009 document on the management of clinical risk relating to the deployment and use of health software.{{cite web | title = Health informatics – Guidance on the management of clinical risk relating to the deployment and use of health software (formerly ISO/TR 29322:2008(E)). DSCN18/2009 | quote = Examples of potential harm presented by health software, Annex A, p. 38 | url = http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009/0160182009specification.pdf | archive-url = https://web.archive.org/web/20140715182907/http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009/0160182009specification.pdf | archive-date=15 July 2014 }}.

In February 2010, an American Food and Drug Administration (FDA) memorandum noted that EHR unintended consequences include EHR-related medical errors from (1) errors of commission (EOC), (2) errors of omission or transmission (EOT), (3) errors in data analysis (EDA), and (4) incompatibility between multi-vendor software applications or systems (ISMA), citing various examples. The FDA also noted that the "absence of mandatory reporting enforcement of H-IT safety issues limits the numbers of medical device reports (MDRs) and impedes a more comprehensive understanding of the actual problems and implications."{{cite web | title = Internal FDA Report on Adverse Events Involving Health Information Technology | url = https://www.scribd.com/huffpostfund/d/33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology | archive-url = https://web.archive.org/web/20150906180311/https://www.scribd.com/huffpostfund/d/33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology | archive-date=6 September 2015 }}{{cite web | work = FDA memo. | id = table 4, page 3, Appendix B, p. 7–8 (with examples), and p. 5, summary. Memo obtained and released by Fred Schulte and Emma Schwartz at the Huffington Post Investigative Fund, now part of the Center for Public Integrity, in a 3 August 2010 article | title = FDA, Obama digital medical records team at odds over safety oversight | url = http://www.iwatchnews.org/2010/08/03/7096/fda-obama-digital-medical-records-team-odds-over-safety-oversight | archive-url = https://web.archive.org/web/20111112112700/http://www.iwatchnews.org/2010/08/03/7096/fda-obama-digital-medical-records-team-odds-over-safety-oversight | archive-date=12 November 2011 }}

A 2010 Board Position Paper by the American Medical Informatics Association (AMIA) contains recommendations on EHR-related patient safety, transparency, ethics education for purchasers and users, adoption of best practices, and re-examination of regulation of electronic health applications.{{cite journal | vauthors = Goodman KW, Berner ES, Dente MA, Kaplan B, Koppel R, Rucker D, Sands DZ, Winkelstein P | display-authors = 6 | title = Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force | journal = Journal of the American Medical Informatics Association | volume = 18 | issue = 1 | pages = 77–81 | year = 2010 | pmid = 21075789 | pmc = 3005880 | doi = 10.1136/jamia.2010.008946 }} Beyond concrete issues such as conflicts of interest and privacy concerns, questions have been raised about how the physician-patient relationship would be affected by an electronic intermediary.{{cite web | url = http://www.thenewatlantis.com/publications/doctors-go-digital | vauthors = Rowe JC | title = Doctors Go Digital | work = The New Atlantis | date = 2011 }}{{cite journal | vauthors = Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH | title = The extent and importance of unintended consequences related to computerized provider order entry | journal = Journal of the American Medical Informatics Association | volume = 14 | issue = 4 | pages = 415–423 | year = 2007 | pmid = 17460127 | pmc = 2244906 | doi = 10.1197/jamia.M2373 }}

During the implementation phase, cognitive workload for healthcare professionals may be significantly increased as they familiarize themselves with a new system.{{cite journal | vauthors = Colligan L, Potts HW, Finn CT, Sinkin RA | title = Cognitive workload changes for nurses transitioning from a legacy system with paper documentation to a commercial electronic health record | journal = International Journal of Medical Informatics | volume = 84 | issue = 7 | pages = 469–476 | date = July 2015 | pmid = 25868807 | doi = 10.1016/j.ijmedinf.2015.03.003 | s2cid = 205287049 }}

EHRs are almost invariably detrimental to physician productivity, whether the data is entered during the encounter or sometime thereafter.{{cite web | title = 8 top challenges and solutions for making EHRs usable | publisher = American Medical Association | date = 16 September 2014 | url = https://www.ama-assn.org/practice-management/digital/8-top-challenges-and-solutions-making-ehrs-usable | access-date = 12 April 2020}} It is possible for an EHR to increase physician productivity {{cite journal | pmc=6822893 | year=2019 | last1=Aguirre | first1=R. R. | last2=Suarez | first2=O. | last3=Fuentes | first3=M. | last4=Sanchez-Gonzalez | first4=M. A. | title=Electronic Health Record Implementation: A Review of Resources and Tools | journal=Cureus | volume=11 | issue=9 | pages=e5649 | doi=10.7759/cureus.5649 | doi-access=free | pmid=31700751 }} by providing a fast and intuitive interface for viewing and understanding patient clinical data and minimizing the number of clinically irrelevant questions,{{Citation needed|reason=My own analysis, frankly needs some fleshing out|date=October 2018}} but that is almost never the case.{{Citation needed|reason=Needs data|date=October 2018}} The other way to mitigate the detriment to physician productivity is to hire scribes to work alongside medical practitioners, which is almost never financially viable.{{Citation needed|reason=Need data on scribes|date=October 2018}}

As a result, many have conducted studies like the one discussed in the Journal of the American Medical Informatics Association, "The Extent And Importance of Unintended Consequences Related To Computerized Provider Order Entry," which seeks to understand the degree and significance of unplanned adverse consequences related to computerized physician order entry and understand how to interpret adverse events and understand the importance of its management for the overall success of computer physician order entry.{{cite journal | vauthors = Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH | title = The extent and importance of unintended consequences related to computerized provider order entry | journal = Journal of the American Medical Informatics Association | volume = 14 | issue = 4 | pages = 415–423 | date = 2007 | pmid = 17460127 | pmc = 2244906 | doi = 10.1197/jamia.M2373 }}

In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received.{{cite journal | vauthors = Evans RS | title = Electronic Health Records: Then, Now, and in the Future | journal = Yearbook of Medical Informatics | volume = Suppl 1 | issue = Suppl 1 | pages = S48–S61 | date = May 2016 | pmid = 27199197 | pmc = 5171496 | doi = 10.15265/IYS-2016-s006 }} Concerns include issues of privacy and security.{{cite web|url=http://www.e-health-insider.com/news/3343/opposition_calls_for_rethink_on_data_storage |title=Opposition calls for rethink on data storage |publisher=e-Health Insider (UK) |date=December 2007 |url-status=dead |archive-url=https://web.archive.org/web/20090107055610/http://www.e-health-insider.com/news/3343/opposition_calls_for_rethink_on_data_storage |archive-date=7 January 2009}}{{cite web|url=http://www.e-health-insider.com/news/3384/german_doctors_say_no_to_centrally_stored_patient_records |title=German doctors say no to centrally stored patient records |publisher=e-Health Insider (UK) |date=January 2008 |url-status=dead |archive-url=https://web.archive.org/web/20081012074601/http://www.e-health-insider.com/news/3384/german_doctors_say_no_to_centrally_stored_patient_records |archive-date=12 October 2008}}

In the European Union (EU), a new directly binding instrument, a regulation of the European Parliament and of the council, was passed in 2016 to go into effect in 2018 to protect the processing of personal data, including that for purposes of health care, the General Data Protection Regulation.

Threats to health care information can be categorized under three headings:

• Human threats, such as employees or hackers.
• Natural and environmental threats, such as earthquakes, hurricanes, and fires.
• Technology failures, such as a system crashing.

These threats can either be internal, external, intentional, or unintentional. Health information systems professionals consider these particular threats when discussing ways to protect patients' health information. It has been found that there is a lack of security awareness among health care professionals in countries such as Spain.{{cite journal | vauthors = Fernández-Alemán JL, Sánchez-Henarejos A, Toval A, Sánchez-García AB, Hernández-Hernández I, Fernandez-Luque L | title = Analysis of health professional security behaviors in a real clinical setting: an empirical study | journal = International Journal of Medical Informatics | volume = 84 | issue = 6 | pages = 454–467 | date = June 2015 | pmid = 25678101 | doi = 10.1016/j.ijmedinf.2015.01.010 }} The Health Insurance Portability and Accountability Act (HIPAA) has developed a framework to mitigate the harm of these threats that is comprehensive but not so specific as to limit the options of healthcare professionals who may have access to different technology.{{cite book | vauthors = Wager K, Lee F, Glaser J |title=Health Care Information Systems: A Practical Approach for Health Care Management | url = https://archive.org/details/healthcareinform00wage | url-access = limited |edition=2nd |publisher=Jossey-Bass |pages=[https://archive.org/details/healthcareinform00wage/page/n282 253]–254 |year=2009 |isbn=978-0-470-38780-1}} With the increase of clinical notes being shared electronically due to the 21st Century Cures Act, an increase in sensitive terms used across the records of all patients, including minors, are increasingly shared amongst care teams, complicating efforts to maintain privacy.{{Cite journal |last1=Lee |first1=Jennifer |last2=Yang |first2=Samuel |last3=Holland-Hall |first3=Cynthia |last4=Sezgin |first4=Emre |last5=Gill |first5=Manjot |last6=Linwood |first6=Simon |last7=Huang |first7=Yungui |last8=Hoffman |first8=Jeffrey |date=2022-06-10 |title=Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study |journal=JMIR Medical Informatics |language=en |volume=10 |issue=6 |pages=e38482 |doi=10.2196/38482 |issn=2291-9694 |pmc=9233261 |pmid=35687381 |doi-access=free }}

Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on 13 April 2000 to establish rules on the use, disclosure, and collection of personal information. The personal information includes both non-digital and electronic forms. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.{{cite web|title=Personal Information Protection and Electronic Documents Act – Implementation Schedule|publisher=Office of the Privacy Commissioner of Canada|date=1 April 2004|access-date=12 February 2008|url=http://www.privcom.gc.ca/legislation/02_06_02a_e.asp|archive-url=https://web.archive.org/web/20080907224309/http://www.privcom.gc.ca/legislation/02_06_02a_e.asp|archive-date=7 September 2008|url-status=dead}} There are four provinces where this law does not apply because their privacy laws were considered similar to PIPEDA: Alberta, British Columbia, Ontario, and Quebec.

The COVID-19 pandemic in the United Kingdom led to radical changes. NHS Digital and NHSX made changes, said to be only for the duration of the crisis, to the information sharing system GP Connect across England, meaning that patient records are shared across primary care. Only patients who have specifically opted out are excluded.{{cite news |title=Radical relaxation of GP records and booking rules |url=https://www.hsj.co.uk/primary-care/radical-relaxation-of-gp-records-and-booking-rules/7027486.article |access-date=8 June 2020 |publisher=Health Service Journal |date=24 April 2020}}

Legal liability in all aspects of health care was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys in the USA{{cite web| url=http://www.newsbatch.com/tort-lawyerinc.html|title=Lawyers Per 100,000 Population 1980–2003|publisher=Congressional Budget Office| access-date=10 July 2007}} and changes in the tort system caused an increase in the cost of every aspect of health care, and health care technology was no exception.{{cite web| url=http://www.newsbatch.com/tort.htm|title=Tort reform|publisher=News Batch|date=May 2011 |access-date=4 December 2013}}

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.{{cite web|url=http://www.healthimaging.com/content/view/5885/89/ |title=Bigger focus on compliance needed in EMR marketplace |publisher=Health Imaging News |date=2007-02-05 |url-status=dead |archive-url=https://web.archive.org/web/20070929011946/http://www.healthimaging.com/content/view/5885/89/ |archive-date=29 September 2007}} Similarly, the implementation of electronic health records can carry significant legal risks.{{cite news| url=http://www.huffingtonpost.com/ben-kerschberg/how-electronic-health-rec_b_806793.html|title=Ben Kerschberg, Electronic Health Records Dramatically Increase Corporate Risk|work=Huffington Post|date=2010-01-10 |access-date=4 December 2013}}

Liability is of special concern for small EHR system makers, which may be forced to abandon markets based on the regional liability climate.{{cite web |url=http://docs.mirrormed.org/index.php/Medical_Manager_History |title=Medical Manager History |url-status=dead |archive-url=https://web.archive.org/web/20060722000959/http://docs.mirrormed.org/index.php/Medical_Manager_History |archive-date=2006-07-22 |access-date=4 December 2013}}{{Unreliable source?|failed=y|date=October 2011}} Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal challenges.

Electronic documentation of patient visits and data could open physicians to an increased incidence of malpractice suits. Disabling physician alerts, selecting from dropdown menus, and using templates can encourage physicians to skip a complete review of past patient history and medications and thus miss important data.

Another potential problem is electronic time stamps. Many physicians are unaware that EHR systems produce an electronic time stamp every time the patient record is updated. If a malpractice claim goes to court, the prosecution can request a detailed record of all entries made in a patient's electronic record. Waiting to chart patient notes until the end of the day and making addendums to records well after the patient visit can be problematic in that this practice could result in less than accurate patient data or indicate possible intent to illegally alter the patient's record.{{cite web | url = http://www.physicianspractice.com/risk-management/content/article/1462168/2042414 | title = Can Technology Get You Sued? | archive-url = https://web.archive.org/web/20120917133105/http://www.physicianspractice.com/risk-management/content/article/1462168/2042414 | archive-date=17 September 2012 | vauthors = Schwartz SK | work = Physicians Practice | date = March 2012 }}

In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.{{cite journal | vauthors = Dunlop L |date=2007-04-06 |title=Electronic HeaĠlth Records: Interoperability Challenges and Patient's Right for Privacy |journal = Shidler Journal of Computer and Technology | volume = 3 | issue = 16 |url=http://www.lctjournal.washington.edu/Vol3/a016Dunlop.html |url-status=dead |archive-url=https://web.archive.org/web/20071027134228/http://www.lctjournal.washington.edu/Vol3/a016Dunlop.html |archive-date=27 October 2007}} In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.{{cite web|url=http://www.gklaw.com/publication.cfm?publication_id=496|title=Newly Issued Final Rules under Stark and Anti-kickback Laws Permit Furnishing of Electronic Prescribing and Electronic Health Records Technology|publisher=GKLaw|date=August 2006|access-date=30 October 2011|archive-date=22 March 2016|archive-url=https://web.archive.org/web/20160322034017/http://www.gklaw.com/publication.cfm?publication_id=496|url-status=dead}}{{Unreliable source?|failed=y|date=October 2011}}{{cite web |url=http://www.ssd.com/publications/pub_detail.aspx?pubid=9675 |title=New Stark Law Exceptions and Anti-Kickback Safe Harbors For Electronic Prescribing and Electronic Health Records |publisher=SSDlaw |date=August 2006 |url-status=dead |archive-url=https://web.archive.org/web/20080605171802/http://www.ssd.com/publications/pub_detail.aspx?pubid=9675 |archive-date=5 June 2008}}{{Unreliable source?|failed=y|date=October 2011}}

In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes to the technical makeup of the EHR implementation in question, especially when fundamental legal incompatibilities are involved. Exploring these issues is, therefore, often necessary when implementing cross-border EHR solutions.{{cite web |url=http://www.epsos.eu/about-epsos/work-plan-new.html#c501 |title=epSOS: Legal and Regulatory Issues |quote=European Patient Smart Open Services Work Plan |url-status=dead |archive-url=https://web.archive.org/web/20090803202538/http://www.epsos.eu/about-epsos/work-plan-new.html |archive-date=2009-08-03 |access-date=4 December 2013}}

The United Nations World Health Organization (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, the WHO contributes to minimum requirements definitions for developing countries.{{cite web|url=http://whqlibdoc.who.int/wpro/2002/9290610050.pdf|title=Medical Records Manual|date=March 2001|publisher=World Health Organization|access-date=31 March 2012|archive-url=https://web.archive.org/web/20120710033438/http://whqlibdoc.who.int/wpro/2002/9290610050.pdf|archive-date=10 July 2012|url-status=dead}}

The United Nations-accredited standardization body International Organization for Standardization (ISO) however has reviewed and adopted certain standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1{{cite web|url=http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=46087|title=ISO/HL7 10781:2009|publisher=International Organization for Standardization|access-date=31 March 2012}} and subsequent set of detailing standards.{{cite web| vauthors = Favreau A |title=Electronic Primary Care Research Network |url=http://www.license.umn.edu/Products/Electronic-Primary-Care-Research-Network__Z08118.aspx |publisher=Regents of the University of Minnesota |url-status=dead |archive-url=https://web.archive.org/web/20120502073610/http://www.license.umn.edu/Products/Electronic-Primary-Care-Research-Network__Z08118.aspx |archive-date=2012-05-02 |access-date=4 December 2013}}

The majority of the countries in Europe have made a strategy for the development and implementation of electronic health record systems. This would mean greater access to health records by numerous stakeholders, even from countries with lower levels of privacy protection. The implementation of the Cross-Border Health Directive and the European Commission's plans to centralize all health records are of prime concern to the EU public who believe that the health care organizations and governments cannot be trusted to manage their data electronically and expose them to more threats.

The idea of a centralized electronic health record system was poorly received by the public who are wary that governments may use of the system beyond its intended purpose. There is also the risk for privacy breaches that could allow sensitive health care information to fall into the wrong hands. Some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information. These safeguards add protection for records that are shared electronically and give patients some important rights to monitor their medical records and receive notification for loss and unauthorized acquisition of health information. The United States and the EU have imposed mandatory medical data breach notifications.{{cite journal |doi=10.1016/j.clsr.2012.01.003 |title=Medical data breaches: Notification delayed is notification denied |year=2012 | vauthors = Kierkegaard P |journal=Computer Law & Security Review |volume=28 |issue=2 |pages=163–183}}

The purpose of a personal data breach notification is to protect individuals so that they can take all the necessary actions to limit the undesirable effects of the breach and to motivate the organization to improve the security of the infrastructure to protect the confidentiality of the data. U.S. law requires the entities to inform the individuals in the event of a breach while the EU Directive currently requires breach notification only when the breach is likely to adversely affect the privacy of the individual. Personal health data is valuable to individuals and it is therefore difficult to assess whether a breach will cause reputational or financial harm or adversely affect one's privacy.

The breach notification law in the EU provides better privacy safeguards with fewer exemptions, unlike the US law, which exempts unintentional acquisition, access, or use of protected health information and inadvertent disclosure under a good faith belief.

• ASC X12 (EDI) – transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
• CEN's TC/251 provides EHR standards in Europe, including:
• EN 13606, communication standards for EHR information.
• CONTSYS (EN 13940), supports continuity of care record standardization.
• HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• Continuity of Care Record – ASTM International Continuity of Care Record standard.
• DICOM – an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association).
• HL7 (HL7v2, C-CDA) – a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems.
• Fast Healthcare Interoperability Resources (FHIR) – a modernized proposal from HL7 designed to provide open, granular access to medical information.
• ISO – ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures.
• xDT – a family of data exchange formats for medical purposes that is used in the German public health system.

The U.S. federal government has issued new rules of electronic health records.{{cite news| url=https://www.nytimes.com/2010/07/14/health/policy/14health.html | work=The New York Times | title=U.S. Issues Rules on Electronic Health Records | vauthors = Pear R | date=13 July 2010}}

• openEHR: an open community-developed specification for a shared health record with web-based content developed online by experts. Strong multilingual capability.
• Virtual Medical Record: HL7's proposed model for interfacing with clinical decision support systems.
• SMART (Substitutable Medical Apps, reusable technologies): an open platform specification to provide a standard base for healthcare applications.{{cite web |title=About |url=http://www.smartplatforms.org/about-2/ |work=smartplatforms.org |access-date=20 March 2012 |url-status=dead |archive-url=https://web.archive.org/web/20120410095417/http://www.smartplatforms.org/about-2/ |archive-date=10 April 2012}}

A common data model (CDM) is a specification that describes how data from multiple sources (e.g., multiple EHR systems) can be combined. Many CDMs use a relational model (e.g., the OMOP CDM). A relational CDM defines names of tables and table columns and restricts what values are valid.

• Sentinel Common Data Model: Initially started as Mini-Sentinel in 2008. Use by the Sentinel Initiative of the USA's Food and Drug Administration.
• OMOP Common Data Model: A model that defines how electronic health record data, medical billing data, or other health care data from multiple institutions can be harmonized and queried in unified way. It is maintained by Observational Health Data Sciences and Informatics consortium.
• PCORNet Common Data Model: First defined in 2014 and used by PCORI and People-Centered Research Foundation.
• Virtual Data Warehouse: First defined in 2006 by HMO Research Network. Since 2015, by Health Care System Research Network.

Each health care environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system. Many first-generation EHRs were designed to fit the needs of primary care physicians, leaving certain specialties significantly less satisfied with their EHR system.{{citation needed|date=April 2015}}

An ideal EHR system will have record standardization but also interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization, which can often be done so that a physician's input interface closely mimics previously utilized paper forms.{{cite web |url=http://www.praxisemr.com/downloads/why_praxis_downloads/Charting_Bass_Ackward.pdf |date=31 March 2006 | vauthors = Reynolds CL |title=Paper on Concept Processing |access-date=4 December 2013}}

Providers have reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.{{cite journal |vauthors=Maekawa Y, Majima Y |title=Issues to be improved after introduction of a non-customized Electronic Medical Record system (EMR) in a Private General Hospital and efforts toward improvement |journal=Studies in Health Technology and Informatics |volume=122 |pages=919–920 |year=2006 |pmid=17102464}} Customizing the software when released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.{{cite journal | vauthors = Tüttelmann F, Luetjens CM, Nieschlag E | title = Optimising workflow in andrology: a new electronic patient record and database | journal = Asian Journal of Andrology | volume = 8 | issue = 2 | pages = 235–241 | date = March 2006 | pmid = 16491277 | doi = 10.1111/j.1745-7262.2006.00131.x | doi-access = free }}

However, customization can have its disadvantages. Implementing a customized system may incur higher initial costs, as more time must be spent by both the implementation team and the healthcare provider to understand the workflow needs. Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.The Digital Office, September 2007, vol 2, no.9. HIMSS{{Unreliable source?|failed=y|date=October 2011}}{{cite journal | vauthors = Rollins G | title = The perils of customization | journal = Journal of AHIMA | volume = 77 | issue = 6 | pages = 24–28 | date = June 2006 | pmid = 16805294 }}{{Unreliable source?|failed=y|date=October 2011}}

An important consideration when developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to a consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be-developed retrieval systems, and how to ensure the physical and virtual security of the archives.{{Citation needed|date=February 2010}}

Additionally, considerations about the long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that "choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information."{{cite journal | vauthors = Mandl KD, Szolovits P, Kohane IS | title = Public standards and patients' control: how to keep electronic medical records accessible but private | journal = BMJ | volume = 322 | issue = 7281 | pages = 283–287 | date = February 2001 | pmid = 11157533 | pmc = 1119527 | doi = 10.1136/bmj.322.7281.283 }}

The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time.{{Cite web|date=February 2020|title=Where do I Find Medical Record Retention Laws for My State?|url=https://www.harmonyhit.com/where-do-i-find-medical-record-retention-laws-for-my-state/|url-status=live|access-date=September 3, 2021|website=Harmony Healthcare IT|archive-url=https://web.archive.org/web/20210711204222/https://www.harmonyhit.com/where-do-i-find-medical-record-retention-laws-for-my-state/ |archive-date=11 July 2021 }} Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."{{cite journal | vauthors = Ruotsalainen P, Manning B | title = A notary archive model for secure preservation and distribution of electrically signed patient documents | journal = International Journal of Medical Informatics | volume = 76 | issue = 5–6 | pages = 449–453 | year = 2007 | pmid = 17118701 | doi = 10.1016/j.ijmedinf.2006.09.011 }}

In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.{{Citation needed|date=February 2010}}

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that "the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."{{cite journal | vauthors = Olhede T, Peterson HE | title = Archiving of care related information in XML-format | journal = Studies in Health Technology and Informatics | volume = 77 | pages = 642–646 | year = 2000 | pmid = 11187632 }}

When care is provided at two different facilities, it may be difficult to update records at both locations in a coordinated fashion. Two models have been used to satisfy this problem: a centralized data server solution and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks). However, synchronization programs for distributed storage models are only useful once record standardization has occurred. Merging of already existing public health care databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve health care delivery.{{cite journal | vauthors = Papadouka V, Schaeffer P, Metroka A, Borthwick A, Tehranifar P, Leighton J, Aponte A, Liao R, Ternier A, Friedman S, Arzt N | display-authors = 6 | title = Integrating the New York citywide immunization registry and the childhood blood lead registry | journal = Journal of Public Health Management and Practice | volume = Suppl | pages = S72–S80 | date = November 2004 | pmid = 15643363 | doi = 10.1097/00124784-200411001-00012 | citeseerx = 10.1.1.331.2171 }}{{cite journal | vauthors = Gioia PC | title = Quality improvement in pediatric well care with an electronic record | journal = Proceedings. AMIA Symposium | pages = 209–213 | year = 2001 | pmid = 11825182 | pmc = 2243516 }}{{cite journal | vauthors = Williams SD, Hollinshead W | title = Perspectives on integrated child health information systems: parents, providers, and public health | journal = Journal of Public Health Management and Practice | volume = Suppl | pages = S57–S60 | date = November 2004 | pmid = 15643360 | doi = 10.1097/00124784-200411001-00009 }}

{{Globalize|date=March 2024|2=EU}}

The sharing of patient information between health care organizations and IT systems is changing from a "point to point" model to a "many to many" one. The European Commission is supporting moves to facilitate cross-border interoperability of e-health systems and to remove potential legal hurdles. To allow for global shared workflow, studies will be locked when they are being read and then unlocked and updated once reading is complete. This enables Radiologists to serve multiple health care facilities and read and report across large geographical areas, thus balancing workloads. The biggest challenges will relate to interoperability and legal clarity. In some countries, it is almost forbidden to practice teleradiology. The variety of languages spoken is a problem, and multilingual reporting templates for all anatomical regions are not yet available. However, the market for e-health and teleradiology is evolving more rapidly than any laws or regulations.{{cite journal | vauthors = Pohjonen H | url = http://www.diagnosticimaging.com/articles/images-can-now-cross-borders-what-about-legislation | title = Images can now cross borders, but what about the legislation? | journal = Diagnostic Imaging Europe | date = June–July 2010 | volume = 26 | issue = 4 | pages = 16 | access-date = 9 November 2013 | archive-date = 14 February 2020 | archive-url = https://web.archive.org/web/20200214115902/http://www.diagnosticimaging.com/articles/images-can-now-cross-borders-what-about-legislation | url-status = dead }}

See Electronic health records in the United States

In 2011, Moscow's government launched a major project known as UMIAS as part of its electronic healthcare initiative. UMIAS - the Unified Medical Information and Analytical System - connects more than 660 clinics and over 23,600 medical practitioners in Moscow. UMIAS covers 9.5 million patients, contains more than 359 million patient records, and supports more than 500,000 different transactions daily. Approximately 700,000 Muscovites use remote links to make appointments every week.{{cite web

|url=http://gov.cnews.ru/news/line/index.shtml?2013/04/23/526742

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}}{{Cite web|url=https://www.mos.ru/en/news/item/22776073/|title = New programmes and the best doctors, or how Moscow healthcare is being developed / News / Moscow City Web Site| work=Moscow City Web Site | date=15 April 2017 }}

The European Commission wants to boost the digital economy by enabling all Europeans to have access to online medical records anywhere in Europe. With the new [https://health.ec.europa.eu/ehealth-digital-health-and-care/european-health-data-space-regulation-ehds_en European Health Data Space (EHDS) Regulation], steps are being taken toward a centralized European health record system.

However, the concept of a centralized supranational central server raises concern about storing electronic medical records in a central location. The privacy threat posed by a supranational network is a key concern. Cross-border and interoperable electronic health record systems make confidential data more easily and rapidly accessible to a wider audience and increase the risk that personal data concerning health could be accidentally exposed or easily distributed to unauthorized parties by enabling greater access to a compilation of the personal data concerning health, from different sources, and throughout a lifetime.{{cite journal |doi= 10.1016/j.clsr.2011.07.013 |title=Electronic health record: Wiring Europe's healthcare |year=2011 | vauthors = Kierkegaard P |journal=Computer Law & Security Review |volume=27 |issue=5 |pages=503–515}}

{{Further|Electronic health records in England|Patient record access in the United Kingdom}}The Lloyd George envelope digitisation project aims to have all paper copies of all historic patient data transferred onto computer systems. As part of the rollout, new patients will no longer be given a transit label to register when moving practices. Not only is it a step closer to a digital NHS, the project reduces the movement of records between practices, freeing up space in practices that are used to store records as well as having the added benefit of being more environmentally friendly.https://pcse.england.nhs.uk/services/medical-records/digitisation/

Lyniate was selected to provide data integration technologies for Health and Social Care (Northern Ireland) in 2022. Epic Systems will supply integrated electronic health records with a single digital record for every citizen. Lyniate Rhapsody, already used in 79 NHS Trusts, will be used to integrate the multiple health and social care systems.{{cite news |title=Northern Ireland to become first UK country with connected electronic patient record |url=https://www.homecareinsight.co.uk/northern-ireland-to-become-first-uk-country-with-connected-electronic-patient-record/ |access-date=27 October 2022 |publisher=Home Care Insight |date=5 September 2022}}

In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s, and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording.Gill, M. (2007) Attitudes to clinical audit in veterinary practice, Royal Veterinary College elective project, unpublished work There are more than ten PMS providers currently in the UK. Collecting data directly from PMSs for epidemiological analysis abolishes the need for veterinarians to manually submit individual reports per animal visit and therefore increases the reporting rate.{{cite journal |doi=10.1136/inpract.31.7.356 |title=Disease surveillance in small animal practice |year=2009 | vauthors = Carruthers H | journal = In Practice |volume=31 |issue=7 |pages=356–358|s2cid=71415659 }}

Veterinary electronic medical record data are being used to investigate antimicrobial efficacy, risk factors for canine cancer, and inherited diseases in dogs and cats in the small animal disease surveillance project [http://www.rvc.ac.uk/VetCOMPASS 'VetCOMPASS'] (Veterinary Companion Animal Surveillance System) at the Royal Veterinary College, London, in collaboration with the University of Sydney (the VetCOMPASS project was formerly known as VEctAR).{{cite web | title = VEctAR (Veterinary Electronic Animal Record) (2010) | url = https://www.rvc.ac.uk/VetCOMPASS | archive-url = https://web.archive.org/web/20130228191639/https://www.rvc.ac.uk/VetCOMPASS | archive-date = 28 February 2013 | url-status = dead }}{{cite journal | vauthors = Brodbelt D, Midleton S, O'Neil D, Sumers J, Church D | title = Companion Animal Practice Based Disease Surveillance in the UK | journal = Épidémiologie et Santé Animale | date = 2011 | volume = 59–60 | pages = 38–40 | url = https://www.rvc.ac.uk/Media/Default/VetCompass/Documents/CompanionanimalpracticebaseddiseasesurveillanceintheUK-1.pdf }}

A letter published in Communications of the ACM{{cite journal | vauthors = Kartoun U | title = A Leap from Artificial to Intelligence | department = Letters to the editor | journal = Communications of the ACM | date = January 2018 | volume = 61 | issue = 1 | pages = 10–11| doi = 10.1145/3168260 }} describes the concept of generating synthetic patient populations and proposes a variation of the Turing test to assess the difference between synthetic and real patients. The letter states: "In the EHR context, though a human physician can readily distinguish between synthetically generated and real live human patients, could a machine be given the intelligence to make such a determination on its own?"

Further, the letter states: "Before synthetic patient identities become a public health problem, the legitimate EHR market might benefit from applying Turing Test-like techniques to ensure greater data reliability and diagnostic value. Any new techniques must thus consider patients' heterogeneity and are likely to have greater complexity than the Allen eighth-grade-science-test is able to grade."{{Cite news| vauthors = Metz C |date=2019-09-04 |title=A Breakthrough for A.I. Technology: Passing an 8th-Grade Science Test|language=en-US|work=The New York Times |url= https://www.nytimes.com/2019/09/04/technology/artificial-intelligence-aristo-passed-test.html |access-date=2021-05-12|issn=0362-4331}}

{{Portal|Medicine}}

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• Electronic health records in the United States
• Electronic health records in England
• Clinical documentation improvement
• European Institute for Health Records (EuroRec)
• Health informatics
• Health information management
• Health information technology
• Health Information Technology for Economic and Clinical Health Act
• Hospital information system
• List of open-source health software
• Masking (Electronic Health Record)
• Medical imaging
• Medical privacy
• Medical record
• Personal health record
• Personally Controlled Electronic Health Record, the Australian government's shared electronic health summary system{{cite journal | vauthors = Mendelson D | title = HealthConnect and the duty of care: a dilemma for medical practitioners | journal = Journal of Law and Medicine | volume = 12 | issue = 1 | pages = 69–79 | date = August 2004 | pmid = 15359551 }}
• Picture archiving and communication system
• Radiological information system
• Solid (web decentralization project) Health[https://www.csail.mit.edu/research/solid-social-linked-data Investigating Decentralized Management of Health and Fitness Data]

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{{Reflist|30em}}

• {{cite book|last1=Kubben|first1=P.|last2=Dumontier|first2=M.|last3=Dekker|first3=A.|title=Fundamentals of Clinical Data Science|publisher=Springer International Publishing|year=2018|isbn=978-3-319-99713-1|url=https://books.google.com/books?id=Cw2BDwAAQBAJ&pg=PA3|access-date=2025-02-04}}

{{Prone to spam|date=September 2013}}

• [https://web.archive.org/web/20081012012937/http://www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf Can Electronic Health Record Systems Transform Health Care?]
• [http://www.chcf.org/topics/view.cfm?itemID=133551 Open-Source EHR Systems for Ambulatory Care: A Market Assessment] {{Webarchive|url=https://web.archive.org/web/20100115232831/http://www.chcf.org/topics/view.cfm?itemID=133551 |date=15 January 2010 }} (California HealthCare Foundation, January 2008)
• [https://www.healthit.gov/newsroom/about-onc US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC)]
• [http://healthit.ahrq.gov/emr US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology]
• [http://www.digitalpreservationeurope.eu/publications/briefs/security_aspects.pdf Security Aspects in Electronic Personal Health Record: Data Access and Preservation] – a briefing paper at Digital Preservation Europe

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Category:Electronic identification