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Electronic Health Records

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In an age of iPads, smartphones, and minute-by-minute Facebook updates, does a visit to your doctor’s office sometimes seem like a trip back in time? Does your doc scribble notes onto sheets of paper and then slide them into an ever-expanding folder that gets stored in a huge file case?

Although many doctors still keep notes in files, more and more patients are seeing laptops instead of clipboards in the exam room. Doctors and hospitals are turning to new health information technology, and while these changes won’t happen overnight, they are coming.

Top Things to Know About Electronic Health Records

Understanding EHRs

Electronic health records (EHR) — also called electronic medical records (EMR) — help patients as well as health professionals. That’s because they make it easier for you (and your parents, depending on your age) to see your health records.

An EHR is a computerized collection of a patient’s health records. EHRs include information like your age, gender, ethnicity, health history, medications, allergies, immunization status, lab test results, hospital discharge instructions, and billing information.

Because electronic health records are digital, they can be shared easily among your various health care providers. So, for example, if you see a dermatologist and an asthma specialist in addition to your primary care doctor, all these doctors (and their nurses and other caregivers) will see the same records.

If one doctor orders a lab test, they all see the results. If one doctor puts you on a new medication, the others get to see what it is — which is good for you, because there’s less chance of one doctor prescribing a medication that could adversely interact with another medication and cause problems.

The Benefits of EHRs

Because EHRs improve how well your doctors talk to each other and coordinate your treatment, they can enhance your overall care. Here are some of the ways they can help:

  • Access by multiple health providers. Because it can be accessed by logging onto a computer, your EHR “travels” with you from doctor’s office to doctor’s office. This can be helpful in an urgent setting. If someone’s unconscious and cannot tell an emergency room doctor about an allergy to penicillin, the ER doc will know from looking at that person’s EHR. EHRs also make it easier for your primary doctor to coordinate with any specialists he or she might refer you to. Everything they need to know about you and your health is right at their fingertips.
  • No more handwriting mishaps. There are lots of jokes about doctors’ handwriting. But the drawbacks to handwritten charts go beyond hard-to-read handwriting. When doctors and nurses take notes, they’re more likely to abbreviate to save time, and there’s always a risk they’ll forget what they meant or that someone else looking at the chart won’t understand the abbreviation and have to find out what it means. EHR software helps clinicians be both detailed and fast by providing a series of prompts and dropdown menus to click through.
  • Efficiency. When information is kept together in one central file, it helps doctors avoid ordering tests that another doctor has already ordered. Let’s say you go to your primary doctor because your knee hurts. If he or she orders an X-ray and then refers you to an orthopedic expert for treatment, that expert can also see the same X-ray. Then, if you need physical therapy, the therapist can see it too — along with both your doctor’s notes and the specialist’s notes.
  • Education. Being able to see your medical files lets you take part in your own health care. You can view test results, keep track of things like glucose if you have diabetes or lung function if you have asthma, review your medical team’s instructions, and even check for errors.
  • Security. There’s always the chance that paper records can get lost or misfiled or somehow damaged. For example, paper medical records for thousands of patients were destroyed by Hurricane Katrina in 2005. There’s less chance of this happening with electronic records — and most are password protected, so if they do get lost other people won’t have access to them.

Can Everybody See My Records?

No. A federal law called the Health Insurance Portability and Accountability Act (HIPAA) specifies who is allowed to see your medical records.

So you shouldn’t worry, for example, if your nosy neighbor happens to work in the same hospital where you receive treatment. HIPAA bars that person from snooping into your records. In fact, if Nosy Neighbor attempts to poke around in your classified information, it would likely trip an alarm within the hospital’s computer system and start a trace on who tried to look at that information.

Part of HIPAA called the Security Rule lays out standards protecting the way electronic health records are stored or transferred. So if your doctor’s office or hospital transmits health information electronically, they are required by law to have safeguards in place to limit access to only those who are permitted to see it.

Doctors encourage teens to get involved in making health care decisions, and understanding EHRs are a great way to do that. Looking at yours can help you get an idea of what’s involved in managing your own medical care.

Some systems may even let you interact with your doctor or nurse online (providing a way to ask questions through the system, for example) and might even allow you to set up and manage appointments. If your doctor’s office uses EMRs, ask how you can participate!

Reviewed by: Elana Pearl Ben-Joseph, MD
Date reviewed: March 2011