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TopConcepts And Background
In this section, after a brief history, the issue of definition and several dimensions of electronic health records will be tackled. If the first known medical records can be traced to Hippocrates and the goals he attributed to these records were to describe accurately the course of a disease and gives a probable cause of it; the electronic dimension of these records can be traced back to the 1960s in some hospitals that started a more systematic recording and use of patients’ data by services and doctors. But it is still more recently, in the 1990s, with the ever wider use of internet and online databases that the electronic health record emerged as a new tool in the public health systems of OECD countries.
There are different definitions of electronic health record, depending on the theoretical perspective or even the main user or the political point of departure taken in the implementation process. Even so, here and in the literature on the subject, the electronic health record has become and is the generic term. Other focuses like electronic medical record (or registry) and the electronic patient record are based on either the perspective of the user or the subject of the information. All these expressions are part of the general move from traditional management of health and medicine to electronic health and medicine or e-health (written more and more frequently ehealth as its use spreads across countries and within national health and health care systems).
To settle the record straight, the definition of the Electronic Health Record that can serve as a consensus for the current exposition as well as a starting point for further research is the one given by the International Standards Organization (document ISO/TR 20514:2005) as a “repository of information regarding the health status of a subject of care, in computer processable form” (ISO 2005, p.2).
Key Terms in this Chapter
Governmentality: This concept is coming from Foucault as being a “particular rationality for governing the population which has become ubiquitous in modern societies” as defined by Villadsen (2011 , 125).
Privacy: Means a personnel right inherent to human dignity. Includes intimacy, private life and honor people. Consequently individuals have the right to informational self-determination, that is, individuals have the right to determine and control the use of your personal data.
Health Information: This concept means all kinds of information (present or future) directly or indirectly linked to a person's health, or clinical and family history, whether that person is alive or deceased.
Patient Information: It is the same as Health information.
Electronic Health Record (EHR and also Electronic Health Registry): See also electronic patient registry, medical electronic record. This is the creation of digital information, its storing, management, transmission, access, modification and use across a health care unit, several units or even a whole system of health care. In its basic generic form, the definition of EHR, according to the document ISO/TR 20514:2005 of the ISO – International Standards Organization, can be stated as followed: “repository of information regarding the health status of a subject of care, in computer processable form” ( ISO 2005 ).
eHealth or E-Health: A concept comprising all applications used at the level of information technology, including the Internet, to enable more efficient patient care, thereby improving access and the quality of management of clinical processes. The Electronic Health Record is part of this set of tools.
Technical Definition of Electronic Health Record: “The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter—as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting” taken from the Health Information and Management Systems Society. EHR: electronic health record. http://www.himss.org/ASP/topics_ehr.asp AU26: The URL http://www.himss.org/ASP/topics_ehr.asp has been redirected to http://www.himss.org/library/ehr/?navItemNumber=13261. Please verify the URL. . Accessed February 15, 2011.
Health: Health, according to the World Health Organization, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.