Most Important Components of EHR - TrueNorth ITG (2024)

The adoption of electronic health records (EHRs) in the medical industry has a number of benefits.

In fact, 78% of physicians & practice managers using EHR reported enhanced patient care and 65% said it had alerted them to a potential medication error. Approximately 50% added that EHR use helped them with clinical benefits and patient communication.

Not only do EHRs practically eliminate manual, paper-based record keeping, they also come with the advantage of enabling access to a patient’s health profile. Centralized records help keep tabs on patient demographics, physician notes, current medication, past medical history, laboratory details, radiology reports, and more.

This, in turn, has a direct impact on the quality of care and medical diagnosis. Furthermore, such clinical decision support tools reduce healthcare delivery costs as they’re able to assist physicians in flagging potential patient issues.

So how do EHRs achieve this? Let’s take a closer look.

The Most Important Components of an EMR System

The general components of an EHR system comprise several elements that assist in building a birds eye view of a patient’s medical profile. These include:

Patient Management Component

This key component of EHRs includes mostly administrative functions such as new patient registration, admission, facility transfer, and discharge.

For example when a new patient registers with the facility, it is essential that the receptionist (or admin) ask for details such as contact information, home address, insurance details, employment information, emergency contact, and demographics (age, gender, weight, height, etc).

After registration is complete, the system should generate a unique ID which is also referred to as a medical record number. This helps the EHR in recording all future encounters under that number so things like medical observations, tests, procedures, assessments, and diagnosis are collected and stored.

Clinical Component

The clinical EHR component builds on the patient management aspect. Clinical components are the meat and potatoes of an EHR system as they engender decision support tools and interactions.

This component of an EHR enables physicians to document key information such as patient history, operative notes, consults, and more.

Clinical components of an EHR can also include sub components for pharmacy and nursing details.

Pharmacy systems help keep track of prescriptions and drugs prescribed across the patient’s admission cycle. The nursing component collects and records all essential patient information such as vital signs and weight to build a medication administration record.

Laboratory Components

The laboratory component of an EHR helps to bring all patient lab results under a unified umbrella. It has the capability to integrate with the lab department directly, allowing technicians to upload results onto the EHR and provide billing information which can later be processed by the administration.

This assists physicians in determining the correct diagnosis for their patient and helps finance recover the right costs.

It’s possible for the laboratory component to exist as a standalone system too. That’s because laboratory tools can be complex and may require their own vendor. However, in that case the existing EHR usually includes a link to the laboratory information system – allowing users to log on to the laboratory system from within the core software suite.

Radiology Components

Radiology components of an EHR system assist in managing patient workflows and image archival systems.

Billing System

Billing records are an important part of hospital profitability, productivity, and efficiency. That’s why they’re one of the key components of an EHR system as they can track all the charges that a patient occurs while undergoing care.

Insurance companies require precise details of these charges in order to process claims. In the past, manual paper records wouldn’t go into such granular detail leading to the possibility of lower or rejected claims. Thankfully, that’s one of the things that EHRs prevent.

The billing component can do a lot more than just accurately track expense details. Since it’s constantly collecting data from a variety of sources across the healthcare facility, the component can help build out dashboards to monitor key performance indicators and other analytical reports.

The finance department can further leverage this information to track historical revenue, billing by department, costs, and areas for improvement. In previous years this data was much harder to capture due to the reliance on manual and paper-based processes which made it possible for things to slip through the cracks.

EHRs are worth the investment

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 paved the way for EHR adoption by providing several incentives and benefits, but it’s clear that the software’s advantages make it a worthy choice in the first place.

In the past, paper charts were used to record test results, insurance information, and other patient data. This approach was unwieldy and inefficient, leading to reduced health care outcomes.

The HITECH Act encourages providers to adopt full-fledged EHR systems and not just a bare-bones package. That’s because they’re proven to help with error reduction, cost containment, and better care provision.

EHRs entail a high upfront cost as well as time for training key stakeholders and upgrading essential systems, but they’re worth the effort. If you are interested in learning more, contact TrueNorthITG for more information.