The History of Electronic Health Records

Electronic Health Records History

Since 2014, healthcare practitioners have been required to maintain electronic health records, or EHRs. However, there has long-been a need to maintain records of patient-related information, even before everything became digital. Take a moment to learn more about the history of EHRs and how we got from paper to electronic recordkeeping.

Life before EHRs

Before the 1960s, all medical records were on paper and kept in folders or various manual filing systems. These files usually included basic patient info that included:

• Records of in-person visits
• Patient basics – e.g., name, date of birth, Social Security number, etc.
• Any notes or orders provided by a physician or other medical specialist
• Test results, prescriptions ordered, and anything else relevant

It was common for these records to be filed based on a chart numbering system, the patient’s last name, or patient Social Security numbers. It was also often necessary for medical practices to set aside enough space to keep physical copies of the files in cabinets or on a various shelves.

Early Electronic Records Systems

In the mid-1960s, what’s considered the first EHR system was developed, referred to as a clinical information system. Later in the same decade, the Health Evaluation through Logical Processing (HELP) system was developed through a collaboration between the University of Utah and 3M. Other electronic records technologies came along in the 1970s, which convinced some government agencies to adopt such systems. The Department of Veteran Affairs was the first U.S. agency to take this step with what they referred to as the Decentralized Hospital Computer Program.

Recognizing a Broader Need for EHRs

By the time the 1980s arrived, it became clear there was a need for the broader adaption of electronic records for health-related purposes. A 1991 report by the Institute of Medicine was one of the first significant reports to recommend the conversion of traditional patient records to electronic ones. The Office of the National Coordinator of Health Information Technology further emphasized the need to take this step in 2004 to reduce errors and oversights and maintain patient safety.

EHR Systems Today

As mentioned above, EHRs were officially mandated in 2014. Because there were lingering concerns about patient privacy, HIPAA regulations were updated as well to account for the process of transferring patient data to electronic systems. EHRs are largely considered secure today due to the safeguards included in the systems commonly used by hospitals, medical practices, and other health service providers. The main challenges with EHRs today include:

• Ensuring correct codes are entered
• Accurately transferring any patient-related info that may be in written form to electronic form
• Making sure information from other sources – e.g. the patient’s pharmacy – is included and correct

How Medical Transcription Services Can Help

Accuracy is important with electronic health records. This is why it can be helpful, especially if you have a busy medical practice and an assortment of patient data to enter or double-check, to take advantage of medical transcription services. Doing so means essential patient information will be correctly entered, which is beneficial for your patients and your practice.