What’s in My Electronic Health Record (EHR) and Who Can Access It?

What’s in My Electronic Health Record (EHR) and Who Can Access It?

Understanding and harnessing the powerful potential of EHRs

 

The U.S. and much of the world is undergoing a profound transformation in how medical and health records are created, stored, used and shared. The digitization of health records has been a huge and expensive undertaking, but at least in the U.S., almost 99% of health systems, hospitals and medical groups now use some type of electronic health record (EHR) or electronic medical record (EMR) system.

The reason behind this transformation is driven partly by the promise of potential improvements in healthcare and health outcomes. Many health IT proponents believe that with more data available in digital form, we’ll be able to more quickly improve our health systems, diagnostics and treatment. Digital records also bring us closer to the promise of precision, personalized medicine.

 

What is an EHR?

An EHR, or electronic health record, is a digital compilation of your health information. But EHR is much more than just a digital version of your medical charts. In fact, they’re much more than just medical records.

EHR is much more than just a digital version of your medical charts. In fact, they’re much more than just medical records.

EHR vs. EMR

Many people, even healthcare industry people, often use the term EHR and EMR interchangeably. But there is an important distinction between the two terms, which has not always been clear or recognized.

In the past, your medical records were probably the only health records you had. But as people began generating more health- and wellness-related data – that were not technically medical records – the distinction between EHR and EMR has become more apparent and important.

Strictly speaking, EMR refers to your patient records, typically produced every time you were a patient at hospital, health clinic or doctor’s office. However, the term EMR also applies to any information and data you generated when interacting with a healthcare professional – even when you weren’t in a healthcare or medical facility:

  • Paramedic. For example, when you are treated by paramedics, they routinely complete a report about the care they provided, regardless of whether they brought you to a hospital. Their reports typically become part of your EMR.
  • Home visits. Many homebound and elderly patients receive in-home care from caregivers and medical practitioners. The patient records they produce from those home visits also become part of your EMR.
  • Telehealth. Many health plans and medical systems are increasingly turning to telehealth or telemedicine services to lower expenses, by lowering the instances of unnecessary hospital visits. Trained healthcare professionals, usually nurses, nurse practitioners or even doctors, staff these phone calls to answer questions and even write prescriptions. Patient records produced by these telehealth sessions also become part of your EMR.

 

EHR and Telehealth 

Hopefully, this gives you an understanding of how broad the definition of medical records and EMRs have become.

But how does EMR compare with EHR?

Simply put, your EHR includes your EMR – plus many other health-related data not produced by hospitals or medical professionals. From your exercise and diet records to data from your wearables and medical devices, today’s EHR can encompass much more data than traditionally found in medical records.

 

What can I find in my EMR?

Continuing the focus on your medical records, here are more items you’ll find in your EMR file:

  • Administrative and billing data: from your provider and insurance companies. This allows you to trace back your visits and review your claims history.
  • Patient demographics: this includes your date of birth, gender, and contact info. This allows your providers to identify you, as well as making it easy for them to contact you.
  • Progress notes: this includes everything your physician documents about you; details about your visit, your doctor’s observations, and management plan(s).
  • Vital signs: this includes your basic health parameters; blood pressure, body temperature, heart rate and breath rate
  • Medical histories: this includes any prior doctor visits, hospitalizations, treatments or surgeries you may have underwent.
  • Diagnoses: any of your active or prior diagnoses, the treatment plan for each and their outcome.
  • Medications: the list of medications that you are currently on or have previously been prescribed.
  • Immunization: all the immunizations you have received, as well as reminders of any upcoming shots you need to take.
  • Allergies: this makes note of all the food and drug allergies you have, as well as any previous allergic reactions, and how they were managed.
  • Radiology images: this may include X-rays, MRIs, PET and CT scans that your physician ordered.
  • Lab and test results: this encompasses any lab tests ordered by your healthcare provider, this can include your complete blood count, metabolic and lipid panels, liver and kidney function tests.

 

PHR vs EHR

While EMRs form only a part of EHRs, a more apt comparison exists between personal health records (PHR) and EHR. In fact, your EHR is essentially the electronic version of your PHR.

As we note in our deep dive into PHRs, your PHR is the collection of available information, data and statistics about your health. As such, your PHR and EHR includes an array of health-related data that is often not found in your EMR:

  • Annotations. Your own personal notes and annotations to your medical files are part of your PHR and EHR, but not your medical records.
  • Health diary. Similar to annotations, your health journal or diary are part of your PHR and EHR.
  • Apps. Whether you’re using the Weight Watchers or the Nike Training Club, these apps generate a stream of tracked data, which are usually not part of your EMR.
  • Fitness devices. Fitness devices like Fitbit and Apple watches likewise generate a lot of health and wellness data, which are typically not included in your EMR.
  • Medical devices. Patients with medical devices like home blood pressure monitors and glucose monitors produce data that may be included in your EMR, but is often not.

These are just a few of the non-EMR data that can be included in your PHR and EHR.

 

Metadata and analytics

Using an electronic records system generates significantly more data than a similar paper chart. When your healthcare provider used to complete your patient charts by hand, your medical record was limited to whatever was manually recorded into your patient file.

The advent of digitization, however, added metadata and analytics to your medical and health records:

  • Metadata. When data is added to your EMR today, your EMR also records metadata information such as IP addresses, server timestamps, GPS locations, identities of everyone who views your file (even if they don’t add anything), revisions, deletions and even where previous deleted versions can be found.
  • Analytics. Digitized data makes advanced analytics and even machine learning possible. Comparing your data with the records of millions of other patients can uncover important warning signs about your personal health that isolated medical providers may not easily realize. This can produce recommendations and health programs tailored for specific individuals.

Metadata and analytics results are typically not part of your EMR. But they are important elements for advanced EHR systems.

Today, almost all new medical records produced in the U.S. are in electronic form.

 

The digitization of health records

According to the Office of the National Coordinator for Health Information Technology (HIT), which is part of the U.S. Department of Health and Human Services (HHS), 96 percent of hospitals and 78 percent of physicians’ offices use EHRs – as of 2016!

Today, almost all new medical records produced in the U.S. are in electronic form.

This transformation is partly the result of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act. At the time that HITECH was passed, fewer than one in 10 hospitals and 17 percent of physicians used EHRs.

HITECH was passed as part of the larger American Recovery and Reinvestment Act and represented the first time that the American government had committed federal resources to accelerate the pace of healthcare technology. The federal government used financial incentives to encourage EHR adoption, including direct subsidies.

 

Who Gets To Access and View My EHR?

First, let’s answer this question by focusing on just your medical records – the EMR portion of your EHR.

To begin, you have access to your EMR. In fact, your healthcare providers are required by federal regulations to provide you with copies of your medical records in the format you request (i.e. paper or electronic).

Your healthcare provider also has access to the patient medical records they have on file for you. As we discuss later, the fact that they generated your patient data implies some degree of ownership. This means that almost everyone in that health system could have access to your EMR file kept by that health system.

Practically speaking, however, the Health Insurance Portability and Accountability Act (HIPAA) calls on any entity that has controls health data to limit access to that information. Only employees and personnel who have a valid reason for accessing and viewing that medical record should do so.

HIPAA also requires healthcare providers and other covered entities handling medical and health data to inform patients how their records are being used.

 

Sharing My EMR Data

According to HIPAA, healthcare providers must first get permission from the patient before sharing medical and health records with a third party. Here are common examples of third-party medical records sharing:

  1. Second opinions. If you want to get a second opinion from a specialist at a different health system or network, you would need to request and authorize the sharing of your EMR.
  2. New providers. Many companies switch health plans (and provider networks) every few years. If you switch to a new healthcare provider or primary physician, you may need to authorize the transfer of copies of your EMR to your new provider.
  3. Personal data release. If you want a relative or friend to access your health records, particularly in case of emergencies, you will need to authorize such releases as well.

The beauty of today’s EMR and EHR systems is that it makes it easier for you to share data as needed. For example, if you’re on vacation and have to visit an out-of-town hospital for an emergency, that hospital can now obtain your EMR file from your primary physician in seconds. As long as your current provider and that out-of-town hospital use EMR or EHR systems that follow established protocols, they can share files over the Internet – with your permission.

However, there are exceptions to this permission requirement. There are, in fact, some cases in which your healthcare provider shares portions of your medical information without obtaining your permission:

  • Government agencies. The Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration (SSA) can examine portions of your medical records to ensure you qualify for certain benefits. When you apply for benefits, however, you may receive notification of their intent to gather some of your healthcare information.
  • School records. Your child’s school can share immunization and other records with the state repository without your permission, though they will often give you notice.
  • Health insurance. You typically give health insurers permission to access portions of your medical and healthcare records when you obtain health insurance. But insurers may share it with other entities as part of their process.

 

Who can access and view my EHR and PHR?

After reviewing the regulations for medical records above, we can now turn to the bigger picture of EHR and PHR. The answer is that it’s largely up to you, but not completely.

For starters, HIPAA doesn’t apply to most non-medical EHR records. For example, the health data produced by your Fitbit machines or weight loss apps are typically not part of HIPAA. That’s the case with many health and wellness applications.

And as health apps proliferate – they now number in the hundreds of thousands – the question of protecting my health data privacy becomes more urgent.

 

EHR and Health Devices + Apps 

For now, your non-HIPAA covered health data is essentially protected by you and the agreements you have with your app providers and other data-generating providers. Start by checking the privacy policies and user agreements with your apps. You should also consider how much of your EHR is shared by these different parties, from medical devices to your personal trainer.

As the volume of our non-medical (and non-HIPAA-covered) EHR continues to grow, more of our EHR information could theoretically be more open than we realize. That is why the need for greater protection for health data privacy – and perhaps the expansion of the two-decades-old HIPAA regulations – is becoming more urgent.

 

Who owns my EHR?

This is a tricky question. There are actually two dimensions to this question worth considering:

  1. Who legally owns your EHR?
  2. And who SHOULD own your EHR?

As we noted in the preceding section, the issue of privacy is growing in importance. And data privacy is intertwined with the question of data ownership.

When it comes to medical records, it depends on the state you live in. Only New Hampshire has given patients ownership over the information in their medical records. But 21 other states have passed regulations that gives primary ownership of patient records to the hospital or healthcare provider that produced your medical records.

The majority of state governments are still silent over the question of who owns medical records, let alone EHR.

 

Who should own our EHR?

In many ways, the U.S. is playing catch-up with Europe and Canada when it comes to data privacy and ownership. Europe’s recent General Data Protection Regulation (GDPR) has shifted the balance significantly in favor of consumers when it comes to privacy for all personal data – not just health information.

Europe and Canada have already started dealing with the question of who should own your personal data. And they are siding with you, the consumer.

U.S. healthcare consumers are currently working under HIPAA, a regulation created before the…

  • Emergence of Google,
  • Widespread adoption of social media,
  • Growth of the Internet of Things (IoT), and
  • Evolution of mobile applications

So while the question of who legally owns your medical data is fragmented based on your state, the question of who should own your medical and all your health data is now an issue that all Americans must address and decide.

 

One way to return control of the healthcare journey back to us, the consumers, is to return control and ownership of health data, especially EHR, back to the patient.

 

Why ownership of our health data is important

The American healthcare system faces many daunting challenges. Many believe that it is in crisis, with skyrocketing healthcare costs making our current system unsustainable.

We believe that one reason for the current state of our U.S. healthcare system is the current model of our system, which has removed much of the control and decision-making from patients and healthcare consumers. One way to return control of the healthcare journey back to us, the consumers, is to return control and ownership of health data, especially EHR, back to the patient.

There is a growing movement to transform our healthcare system and individual health journeys to one driven by patients and consumers. We invite you to join us in this movement to reshape U.S. healthcare.

 

Full HIPAA Compliance Verification for HealthChampion

Full HIPAA Compliance Verification for HealthChampion

HealthChampion Continues Meeting High Standards for Consumer Protection

For Immediate Release

HealthChampion — the world’s first platform giving people unprecedented control over their healthcare information to improve their individual health goals and outcomes — is now fully HIPAA compliant.

With the fundamental belief that people should be able to access their own health data as easily as their credit score, HealthChampion is developing an app that enables consumers to do precisely that. In addition, HealthChampion — from the very beginning — also focused on the highest level of protection for people’s health data.

“Health data is personal and highly sensitive. That’s why every one of our staff members — from IT to marketing — went through extensive, vigorous HIPAA compliance training. Each new hire will, as well,” says Nick Biernat, Manager of Information Services and Compliance at HealthChampion.

The HIPAA Seal of Compliance is the entire health care industry’s third-party HIPAA verification. There is no formal HIPAA compliance certification from the federal government or subsidiary regulatory agencies. U.S. health care professionals rely on companies such as the Compliancy Group to demonstrate their compliance.

“App users deserve to know how their data is being used,” adds Terrence M. Ryan, HealthChampion CEO. “We are accountable to consumers and hold ourselves to the highest standard of security, promising to safeguard their personal health information. In fact, we hope all app developers in this sector will take their customers’ privacy seriously and also become HIPAA compliant.”

About HealthChampion: HealthChampion is building the world’s first people-driven healthcare platform to give consumers unprecedented control over their healthcare while providing the highest level of security and privacy. Combining technology, artificial intelligence, predictive analytics, and health scoring, we’re enabling consumers to own their medical records, spend less for quality care, and achieve optimal health. This breakthrough technology will provide users with more insights into their health, connecting them with providers and specialists around the world, and drive precision medicine. HealthChampion is headquartered in Chicago, IL, with an office in Milwaukee, WI. Our team includes the founders and leaders of Knightsbridge Solutions (acquired by former HP Enterprises), LaunchPoint/ Discovery Health Partners (Inc. 500 and Crain’s Fast50 multi-year awardee) and Tricast Health.

Contact: pr@healthchampion.com

# # #

What are Personal Health Records?

What are Personal Health Records?

Why Consumers Need to Take Control of Their PHR

Remember the last time you were sick and had to go to your doctor or even hospital? The nurses and physicians probably bombarded you with questions, conducted physical exams and maybe even ran some blood tests. Their notes, test results, diagnoses, prescriptions and treatment all went into your healthcare provider’s health record files, electronic health record (EHR) or electronic medical record (EMR) system. 

Those provider health records are a part of your personal health record (PHR), but they’re not the only elements of your PHR. And unfortunately, too often your PHR is not very personal. 

What is a Personal Health Record?

Your personal health record (PHR) is the collection of available information, data and statistics about your health.

PHR graph

 

But as discussed below, PHR goes way beyond your hospital or medical records. It includes all available data about and useful for your health. That means that your PHR includes your own observations and experiences.  

Most Americans have hundreds, if not thousands, of pages of PHR available – and are generating even more every day. 

PHR and Big Data

You may have heard the statistic that 90% of all data stored today was generated the past two years. Our increasing use of the Web and social media, the increasing prevalence of Internet-connected devices, and even the act of analyzing your personal health information is generating even more data about your health. 

Millions of Americans use at least one of the hundreds of thousands of health apps now available in app stores or the web. Whether you’re using Weight Watchers’ weight loss app, Apple Health’s health information app or My Fitness Pal’s exercise tracker, all these apps not only collect the data you input, but they’re also generating metadata, such as the time of day you inputted the information, what IP address you used when adding data, and what device or browser you used. 

Needless to say, not all of that metadata is necessarily useful to your personal health. But it does go to show how much data about your health is being produced every day. For instance, the more people conduct DNA tests on themselves, the more the tests generate a large pool of genetic health information, benefiting you and everyone involved. 

Personal Health Records

Why is Your PHR Important?

Your personal health record is your most valuable asset, perhaps your most valuable. With our increasing body of knowledge about healthcare and use of advanced analytics, more health data can result in health benefits for you, your family and your community: 

  • Precision. More data about your personal health history, activities and lifestyle brings us closer to the dream of personalized, precision medicine. Instead of relying on general rules, physicians and practitioners can better diagnose your specific conditions and offer more precise prescriptions for your body and needs. 
  • Predictive. Combined with advanced analytics, increasing research archives for your community and your comprehensive PHR, health professionals can better estimate your risk for future chronic conditions and diseases. This knowledge can allow you to take steps to head off those conditions and enjoy a longer, healthier life. 
  • Prescriptive. It doesn’t stop with predictions. A comprehensive health record also allows medical and healthcare professionals to develop better health plans for improving and maintaining your health. 
  • Legacy. Finally, consider the benefits of being able to share your extensive health records with your children, grandchildren and family members. Your health records, especially your family history chronic and acute illnesses, can help complete the hereditary and genetic portrait of your family members’ health profile. That body of knowledge could be one of the most valuable assets you can give to your children. 

Creating Your PHR File

Building a complete personal health file has traditionally been a difficult task. For starters, up until recently, it was all on paper. Until recently, your healthcare provider (doctors, dentists, optometrists, etc.) didn’t always provide you with your complete session record. 

But there’s good news. Recent federal regulations, new technology and the continued digitization of health and medical records has made it easier for consumers to gather together all their medical and other personal records. For starters, healthcare providers in the U.S. are now required to provide patients with their complete medical records – either in paper or digital format – upon request. 

Technology has also made it possible for easy electronic transfer of all your medical records. Physicians and nurses from different hospitals have already been able to share your files electronically for years. Now, consumers are demanding the same access to their health data. 

Start with Medical Health Records

As you begin compiling your PHR file, start with your personal medical records: 

  • Recent providers. Contact your current physician, pharmacist, doctor, optometrists, therapist and other healthcare provider and ask for your complete record. Often, you can obtain it in digital form, which can make for easier storage. 
  • Health insurers. Contact your health insurers to obtain your full claims records. 
  • Previous providers. Your claims records and your current providers’ health records will often mention previous or other healthcare providers you’ve used. If so, don’t hesitate to contact them for your health records. 

The Problem with EHRs

EHRs (Electronic Health Records) have a long-promised future that has yet to deliver. Though frequently touted as the cornerstone to improved outcomes, a tool to reduce administrative inefficiencies, and a conduit to lower the cost of care, the reality is EHRs were never intended as tools for patient care.

They were designed as and still exist primarily as a tool for payers (primarily health insurance companies) to get paid – end of story.

Should they really be the lynch pin of our medical data strategy? Do patients and providers want to leave one of their most important assets, their data, at the hands of payers?

Summarizing and Indexing

After compiling all your personal health documents, you now need to summarize and index them to make them useful. Don’t worry if this seems like a daunting task. The good news is that with the digitization of health data, this is now easier to do. 

As you begin to organize your health file, create an index or “go to” file for key information you’ll need in case of emergency or reference 

  • Contact information. Create a directory of all your healthcare providers, from primary physician and hospital system to your dentist and therapist. Also remember to record and maintain your health insurance information. 
  • Allergies and reactions. Record any known allergies you have, as well as when you last tested for them. Remember to include food allergies, but also previous reactions to medication. 
  • Medication. Review our current medication regimen, including any non-prescribed medication you’re taking (such as vitamins, herbs, cannabis and aspirin). Also include medication you’ve taken in the past but are not now using. 
  • Surgeries. It’s always helpful to have ready a handy list of all your previous surgeries and injuries. 
  • Chronic illnesses. If you or a family member suffer from a chronic condition – such as diabetes, high blood pressure, obesity or asthma – create a handy index or section that can help you quickly manage that chronic condition. 
  • Immunization record. By tracking your immunization record, you and your doctor can quickly check for any vaccinations or boosters you or your family member may need. Also, if you plan to travel to a foreign country, vaccinations may be required and your immunization record can provide a handy checklist. 
  • Family history. Finally, consider building a family health tree. A history of chronic conditions or congenital conditions on either side of your family tree can help your doctor develop a better health plan for you. This family health tree can also be a valuable gift to your family and children. 

Expanding Your Personal Health File

These medical records, whether electronic or on paper, are only part of your health story. Your PHR include all your medical records, but they encompass so much more. Luckily, your PHR can be enhanced and enriched using multiple sources that most of us use nowadays. Some of these sources include: 

  • Annotations. Don’t be afraid to add personal notes to your health records. These annotations can serve to jog your memory about previous exams or files. But they can also expand your provider’s understanding of your health. 
  • Health journal. Many people suffering from chronic or major illnesses use journals to track their struggle conditions. These journals can be a valuable part of your personal health file – both for yourself and your physicians. According to Demiris and Afrin, frequent monitoring and recording of your health and activity can lead to the early detection of some illnesses, allowing you to act early on. Medical devices. Modern medical devices – from heart monitors and pacemakers to CPAP and home hemodialysis (kidney) machines – produce a stream of data and often are connected to the Internet. That data can be useful for monitoring, but also to alert both patients and providers whenever readings require immediate attention. 
  • Fitness devices. From the new exercise machines at your local gym to the apps on your cellphone or watch, your fitness devices are likewise producing a stream of data as it monitors your activities. Even bathroom scales can now be connected to the Internet of Things (IoT). 
  • Wearables. Monitoring chips embedded into your clothes, shoes and equipment are becoming more commonplace, especially for athletes and the physically active. But they can also be useful tools for monitoring the health of seniors and those individuals dealing with a chronic condition. The data those wearables produce can all be compiled and included in your PHR file. 
  • Physical training. Do you use a coach or trainer? The more professional ones will maintain a record of your session. The more tech-savvy ones use digital apps. Don’t overlook the fact that your exercise regimen and evolution can be important parts of your personal “whole health” record. 
  • Diet and nutrition. Whether you’re using the Weight Watchers, Jenny Craig, Noom, My Fitness Pal or any of the hundreds of diet apps, you’re tracking important data about your nutritional health. Even if you don’t use an app, your diet and nutrition records can be helpful parts of your PHR. For example, looking back at this PHR data, you can see what worked to help you lose weight or what types of food triggered a reaction.

Going Digital: Turning Your PHR into EHR

In 2009, the U.S. Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act. Its mandate was to help improve the healthcare industry by eliminating expensive healthcare inefficiencies and improve patient outcomes. The HITECH Act did this by requiring U.S. healthcare providers to make the switch to electronic records.  

This Act provided hospitals and health systems with financial incentives to encourage and accelerate EHR adoption. Research published in Health Affairs in 2017 found that EHR adoption by hospitals in the years 2008 to 2010 was at 3.2 percent. However, in the half decade that followed, 2011 to 2015, hospital adoption of EHRs rose to 14.2 percent. 

A decade after HITECH’s passing, almost 99% of all new hospital and healthcare provider records are digitizedDigitizing medical records now allows for the easy exchange of information from one doctor or medical professional to another. But it now opens the door for patients to have more immediate access to their medical records.

Personal Health Records

Becoming a Health Champion

There’s one more reason why patients and consumers should begin building and managing their family’s complete personal health files. Our healthcare system is in major need of a transformation, and we believe it starts with patients once again taking control of their healthcare journey. 

The most important area that patients can control is their health data. All of it. For too long, many assume that since your hospital or doctors controlled all your healthcare records, they basically owned your medical data. 

By taking advantage of electronic records, consumers now have the opportunity to can reclaim ownership of their PHR. By taking control of their health data, patients can gain greater control their health journey and decisions. And as true health champions, they can help lead the transformation of our healthcare arena into a people-driven healthcare ecosystem. 

Suzi Meschbach

Suzi Meschbach

Suzi Meschbach

Managing Partner, Solutions

Suzi Meschbach is responsible for the overall direction of product and related strategy. Suzi’s career has centered on the healthcare industry at the intersection of technology and IT. As a serial entrepreneur, she has founded and worked at several companies in the healthcare space. Once such company, IntellaTriage, consists of a network of nurses across the country who are easily accessible to people online when in need of help.

When Suzi isn’t busy working, she can be found tending to her garden, traveling and spending time with her three grandchildren.

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With clinical experience in surgery, and clinical research at the University of Illinois at Chicago, Fahad bridges medical knowledge and healthcare communications. He has published numerous papers and posters that have been presented at local and national conferences.

Fahad’s skills extend beyond medical communications – he is also fluent in Arabic. Away from work, he enjoys reading journals to stay abreast of medical trends, as well as cooking for friends, traveling, exercising regularly, completing puzzles, and petting dogs.

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