Electronic Health Record Systems
Electronic Health Record (EHR) Systems are computer applications that support the clinical and patient workflow functions of a health center or medical office. EHR systems have several “modules” with functionality to support the clinical workflow of a health care facility. Typical functional modules include:
- Patient Demographic Data: Supports the collection of patient information.
- Clinical History Documentation: Supports the collection of patient’s family, social and medical history.
- Clinical Visit/Encounter Documentation: Supports the collection of clinical information obtained during an office visit, such as vital signs, chief complaint, provider documentation, physical examination, impression and plan.
- Medication Management: Supports the collection of information regarding current medications, medication allergies and facilitates electronic prescribing, medication administration and medication reconciliation activities.
- Orders and Results Management: Supports the ability for the provider to place an order and document results for a lab test, diagnostic test, medication and/or procedure.
- Charge Capture: Supports the ability to generate charges for a visit based on documentation and orders placed, and in some cases send the billing data to a billing system.
- Workflow Management: Includes tools for users to manage the current day’s schedule and tasks, such as approving orders and signing off on notes.
- Reporting: Supports the ability to run reports to assist with managing daily patient flow, proactively managing patient flow and other aggregate information needed to support your organization.
- Scanning: Supports the ability to scan paper documents and attach them to the electronic chart.
- Patient Portal: Supports the ability for the patient to log into a secure website and fill out forms, request an appointment, view their chart (or portions of their chart) and communicate with a provider.
EHR systems can be stand alone, but are typically found in conjunction with a Practice Management System, which is used for registration, scheduling and billing purposes. An EHR may have its own integrated Practice Management Functionality (Figure 1) or be interfaced to a standalone Practice Management System (Figure 2).
Pediatric Specific EHR Functionality
The pediatrics specialty requires some additional or enhanced EHR functionality. In addition to the standard EHR functionality listed above, pediatric systems generally include the following:
- Well Child Exam Templates: Includes well child exam templates by age group.
- Sick Visit Templates for Common Pediatric Problems: Includes standard templates for common pediatric illness, injury, first aid and triage.
- Immunization Management: Supports the ability to track immunizations needed, immunizations given, including detailed information about administration of immunizations. Interfaces with Immunization registries.
- Growth Charts: Growth charts that accommodate child growth records. Height, weight and other parameters to be measured should be easy to enter and then automatically plotted on the growth charts.
- Asthma Flow Charts/Action Plans: Supports ability to track asthma action plans and peak flow charts.
- Weight-Based Dose Calculators: Supports the ability to calculate medications dosing using age and weights.
- School, Sports and Camp Forms Management: Supports the ability to utilize the data collected in templates to be printed out in formats required by various agencies.
- Confidential Documents for Adolescent Assessments: Ability to designate all or part of a chart as confidential for staff viewing and parental access.
- Consent Management: Ability to track consents needed for various types of treatment.
A school-based health center (SBHC) may use some or all of the functionality available in an EHR system and will greatly benefit from the features found in pediatric systems. View the Special Considerations/Configuration for SBHCs resource which includes some of the key clinical functions of an SBHC, the functionality in an EHR system that will support the task and a discussion of any special configuration that might be needed specifically for an SBHC.