George Mason University

Online Health Records

By Bruce Slater, MD, MPH
University of Wisconsin School of Medicine and Public Health


This presentation will compare the history of paper and electronic patient records, describe the major elements of the electronic health record and explain how electronic health records are different to the paper patient chart


Healthcare lags behind many aspects of our lives in automated information use. Although computers are used in financial transactions and clinicians use the web for medical and non-medical information searching, only a minority of physicians use it for storing records.


Electronic Patient Record or EPR and the Electronic Medical Record or EMR are two names for a similar concept. Physicians typically talk about Electronic Medical Records while nurses, public health and more holistically oriented commentators use the Electronic Patient Record description.
The Computer-based Patient Record, CbPR or CPR for short is the name chosen by the Institute of Medicine in it’s landmark report in 1991 promoting the use of computer systems in Health Care. In addition to medical and non-medical health information, the CPRS incorporates and enables communication, education, analysis and quality control into a single comprehensive birth to death nationwide system. Ultimately we have backed off a vision of a monolithic national system in favor of many systems hosted by healthcare organizations that are able to communicate via national standards and information interchange networks. The missing aspect of patient input is included in the most recent moniker Electronic Health Record or EHR.

After the rise of the stand-alone personal computer we re-discovered the power of linking computers together. Instead of linking dumb terminals to mainframes, we divided the power of the main frame into a Client-Server pair connected over a Local Area Network (LAN). The client handles the presentation of data to the user and the Server stores files and does database lookups and serves the data or results back to the client for action.
In the ASP or Application Service Provider model, the internet has made it possible to move even more of the processing to a remote site. Intended for small scale operations that cannot afford a full client-server EHR an ASP company will purchase the EHR license, the hardware and the expertise to it and then offer “slices” of the full functionality to individual practices. Subscribers do not have the large up-front costs of the full software license, expensive fault-tolerant servers and expertise of the full support model. ASP companies can fully exploit the robust applications by selling 100% of the EHR capacity to many small users. Properly done the ASP model can be a win for both subscribers and service providers.

History of Physical Records

When humans discovered that certain of their group had special powers to heal the sick and comfort the dying they designated them shaman. All cultures gave their shaman special dispensation to access intimate aspects of the human body and use potentially dangerous procedures and potentially poisonous treatments. Shaman trained apprentices by the oral tradition to follow their practices. When writing became common place it still took centuries until written records were kept in hospitals. It seems we have always been behind the technological time. These hospital records were kept in ward notebooks and they documented the condition of patients, results of tests and opinions of consultants for the current episode of care. For the patients in an early 1800’s hospital, a physician could look back to previous ward book entries, but records were not generally organized by individual patients. Florence Nightingale is credited with keeping patient-oriented health records in the Crimean War in the 1850’s. As healthcare became more technical and involved many different specific tests and treatments in the 1950’s, practitioners began to sort the results by their source. So-called source oriented documentation prevailed for decades in hospitals and outpatient records. Dr. Larry Weed promoted the concept of medical records that guide and teach in what he called problem oriented medical records. He organized his in- and outpatient notes by the (S) subjective or historical aspect; the (O) objective observations that were independent of what the patient said; the (A) assessments or assertions of diagnoses or problems and the (P) plan both therapeutic and diagnostic. Using the mnemonic of S.O.A.P. all students have been taught for the last 20 years to keep records in this problem-oriented way. Creating this kind of record while listening and examining the patient enables providers to have a running list of issues that must be addressed in the visit. Although Dr. Weed anticipated implementing problem oriented medical record in a computer, ironically the SOAP notes inspired by him have increased the volume of paper records as well as inspiring electronic versions. As the paper record becomes more voluminous and central to patient care the lost and incomplete paper chart has become a chronic challenge to every health care delivery system.

History of Virtual Records

Dr. Weed always intended his Problem Oriented Medical Record to be based in a computer. The linkages between the problem list and individual problem based progress notes can only be done virtually. Expecting providers to manually track problem numbers between problem lists and progress notes has led to incomplete records in almost every instance. To make this possible Weed created the PRoblem Oriented Medical Information System or PROMIS. Unfortunately the promise of PROMIS was not realized. Success depended on a very strict use of rigid text boxes and required fields. Providers, on the other hand, tend to talk informally with patients and ideally have patient-centered not just problem oriented interviews. The rigidity of PROMIS was not well accepted by practicing doctors and the software never caught on. Another effort shortly after in the early 70’s was made at the Massachusetts General Hospital. It was intimately related to the development of MUMPS (MGH Utility Multi-Purpose System) programming language. Many applications were developed in this language. The COmputer-STored Ambulatory Record or COSTAR was one of them. This was very strongly problem-oriented, used a data dictionary to codify the data that it contained and had a very sophisticated query generating system to extract data from the database. In addition, it was public domain. Unfortunately, it’s strong points also became it’s downfall. Because it was public domain, no company successfully standardized and carried all of the variations that became available, into the future. For many years it was the system of choice for public institutions without a budget to support proprietary systems. Many COSTAR systems, especially at MGH and Nebraska have prospered and assisted in patient care for over 20 years. MUMPS, however, lends itself to spaghetti (or excessively branching) code which is essentially impossible to maintain by a team of programmers. As programming languages progressed to 3rd and 4th generation and true object-oriented approaches, MUMPS usage for new projects ended. Therefore no new MUMPS programmers are being tutored and COSTAR is fading after a long and illustrious career.

Practice Partner started life as a DOS-based EMR with a proprietary database format. It has progressed to a MS Windows interface, and is available with an Oracle database. It is sold through a national network and has been around for many years. It uses the typical “tab” metaphor to mirror the look and feel of a paper chart. This is the same metaphor that has been used in many EMRs since the windows interface has become available. Practice Partner has been around long enough for interfaces to have been built to major national labs. The company leverages the advantages of a large population of users on the same system to aggregate clinical data and form a research network. They also offer benchmarking services between and among the large population of users. They have developed web access to their product, a patient portal and have offered it as an ASP solution. Medicalogic is another system founded and programmed by a physician and born as a DOS program. It is now available as a client server Oracle based system. The Windows version was called Logician and has a strong user group and shares templates among users. It has been purchased by McKesson and folded into their Centricity line of software. EPIC or EPICare is written in a language similar to MUMPS and has a proprietary database. For small practices it is very expensive. For very large practices, it can be economical and has had its biggest success in massive networks like Kaiser Permanente. It does have a windows interface and web versions. It seems the common denominator for many existing systems and some new systems is a web orientation.

Elements of Paper Medical Record

“The Chart” is what providers ask for first. In the outpatient setting, it has the lifetime history of the patient, unless you only have the 5th of 5 volumes. If the file clerk doesn’t check and brings you the 4th of 5 volumes, it doesn’t help much at all. In the inpatient setting, there is no lifetime history. To the “modern hospital”, as in the first hospitals, only the current episode of care has any meaning. Because hospitals generate massive amounts of paper, it would be impractical to present the user with a lifetime record. They couldn’t likely carry it around anyway. As any paper folder has a tendency to tear and degenerate, a trade off in quality of materials has too be made. Expensive folders last longer, but cost more. The filing system used has to be chosen carefully. Most small operations file by last name. This creates a problem when people marry or otherwise change names. It requires all of the diverse cultures to adopt the Judeo-Christian format of names which can cause confusion. Most large systems require patients to have a medical record number (MRN). Some hospitals call it a “history number”. This frees the system from reliance on names. Unfortunately it creates its own conundrums. Duplicate MRNs can represent up to 20% of charts. Information filed under a duplicate is unavailable to the treating provider. To prevent the size of the medical records department from increasing and taking over the whole care setting, some thinning must be done. Charts of patients not seen in a certain time, usually 3-5 years are boxed and removed to an archive location where square footage is not as expensive. Unfortunately if the patient returns from a long absence and needs care, there will be a delay in retrieving the previous information. As you can imagine the archiving process offers multiple opportunities for losing information. A careful record of which charts go where and when was the last visit was must be kept. Among active records, tracking exactly where a chart is constitutes a large part of a medical record technician’s time. If a chart is pulled from the shelf for a phone call and then returned to the file room, it must be retrieved for a scheduled visit. If the scheduled visit is in urgent care the same day, it requires an extraordinary system to get it to where the patient and provider are meeting. Bar codes on each chart can help, but add a layer of work and expense in keeping track of them. The physical folder becomes a marker for itself. The only way to know if you have the information is to hold it in your hand. Of course, the physical folder can only be in one place at one time. Auditing a chart takes it out of circulation. When a provider holds a chart as a reminder to follow-up on a patient, that makes the chart unavailable for other caregivers. For the very sick patient, in the hospital setting it is very common to have 3 or 4 individuals with an interest or need to have the chart at the same time.

Realizing that paper charts were a poor basis for a sophisticated information system, medical records professionals tried to improve them by adding additional labels and flags. A physical patient folder is not intrinsically identified until a physical label with either a name or number is placed on it. A sticker is placed when a file is accessed for the first time in a given year. This is used to indicate when the folder should be archived. Allergy warnings are placed on the outside of the folder, but may not be kept up to date or reviewed by all providers and therefore are ineffective in their purpose. Sometimes birth dates are put on folders. Some departments place insurance information on folders. All of these are symptoms of an inadequate information system starting with the paper folder. Within the paper record there is typically an insurance form filled out with insurance account numbers, next of kin, sponsor information and in many practices there is an initial history form. All these forms contain information that changes. They contain a mixture of administrative and clinical information. The chart is typically the purview of clinical professionals and doesn’t routinely get routed to administrative personnel to keep the information up to date. The clinical information recorded at intake is a snapshot at best and doesn’t fit into the usual workflow of the provider. One of the quality markers looked for in audits of patient charts is a problem list that is up to date. The paper problem list is either ignored or inadequate. For simple problems providers don’t feel it necessary to put everything on the list. For complex patients with multiple interacting problems, there is no good way to represent the relationships between the problems. As an additional disincentive, in a capitated environment the complex patients are reimbursed at the same rate as simple patients and therefore there is no time to do the additional paper work of keeping the problem, medication and allergy lists up to date. Looking for a progress note or lab result related to a problem list item is all but impossible in most paper based systems.

Within paper records whether they are true source oriented, which is rare today, or nominally “problem oriented”, there are dividers in the chart which indicate where the documents come from. In essence all paper charts have to be source oriented.

Progress notes, lab results, radiology results, consultant notes are all kept in separate divided areas of the chart. Providers frequently like to compare lab results over time. If lab results were filed with the progress notes that generated them, that would not be possible. Also lab results related to multiple problems are ordered and reported together, so it is essentially impossible to have true problem oriented paper records. In order for billing to be supported, each progress note and consultation report must include much redundant information. This generates massive amounts of text for documentation purposes only which does not contribute to a provider’s understanding of the patient’s problems. While searching for relevant information, this boilerplate text just gets in the way.

Another bad habit made necessary by paper records is the recording of clinical information on lab and x-ray result documents. Ideally every provider would request the chart to be pulled from the record room to document the results of every lab and x-ray. In this way the notes relevant to the care of the patient could be appended to the progress note that generated the test or x-ray order. When subsequent providers or students review the chart, they can follow the notes that the provider makes to guide their understanding of the provider’s thinking process and teach students the “why” of what they did. This is in the best tradition of Dr. Weed’s vision of medical records that guide and teach. In the real world, providers look at a result and try to remember the patient, make a note on the report itself about what is to be done, or document that they discussed the finding with the patient all without benefit of the rest of the chart. Pulling the chart each time would double or triple the work that the already stretched medical records departments do. If the provider elects to keep the chart until the results come back, another inadequate situation develops. If the patient delays getting the test done, the chart could sit for a long period of time and be unavailable for patient care or audit or administrative functions. The medical records personnel are judged on what percentage of charts they can deliver and these sequestered records are not available. Chart sweeps to open doctors’ offices and pick up piles of charts are sometimes done which completely destroys the reminder function of the paper record. Many providers have a “shadow record” where they keep reminder information which must be duplicated to the paper record at some point. There is no theoretical scenario in which paper records could be made ideal even with massive personnel support.

Elements of Electronic Records

Although electronic systems that are truly “paperless” are few, as more of the patient record function is moved to networked computers, it becomes more of a virtual record. Most practices that use electronic records still print and file documents in a traditional paper chart to satisfy legal requirements for pen and ink signatures. Legislation that has legalized electronic signatures in some areas has helped move electronic records forward. A virtual record does not have a physical location. It is pure information. You can not point to a standalone computer or even a network server as the location of the information. In some systems part of the information is embedded in the client software or browser and other parts in the server database. Replication of databases and backups create equivalent copies in multiple places.

In a virtual record there is no limit to the number and kinds of flags and labels that can be applied to a patient’s record. The physical paper file no longer has to be the marker. Multiple volumes are not an issue. You no longer have to decide on a single filing system. All records are filed by a primary key which by definition has no relation to anything specific about the patient. Charts are not filed by Social Security Numbers, history numbers, MRN, birthdays, phone numbers or names. Because of this ANY of the foregoing can be used to locate records, which should be purpose of “filing” records. When you have a virtual record the concept of an enterprise master patient index (EMPI) starts to make sense. The EMPI keeps track of each specific system’s identifying information for the entity known as the person. Creating duplicate records for the same patient is much less likely when all the details are brought to the attention of the registration clerk.

Instead of duplicating computer based demographic and insurance information into paper forms in a paper chart, the virtual record simply links to the actual information in a table. This is where the owner of the information will be keeping it up to date. When all information users reference a single information source, less mistakes and re-dos are necessary resulting in a higher quality, more efficient service.

A problem oriented patient record starts to make sense if it is electronic. You can use the problem list as an index of the medical record. All references to a problem can be accessed by linking from the problem list. The medication list is always up to date because that is how medications are prescribed and refilled. The allergy checking function becomes a prominent part of practice by fading to the background, but becomes 100% effective.

Instead of depending on a few preset dividers to organize the information in the chart, a provider can choose any number of ways or “views” for his or her charts or for a particular chart. “Thinning” a chart is when a medical records professional tries to imagine what a provider no longer wants to see and takes it out of the the paper chart. With a virtual record each provider can create any number of ad-hoc thinned charts.

The progress note function can be divided into various purposes. At some point, payers will realize Evaluation and Management (E&M) coding is passé and adds no value to the interaction. Until then providers can still instruct the EHR to create “progress notes” to satisfy whatever coding level they believe is appropriate for a visit. If on the other hand, the provider wants to view the data in a more efficient manner a view can be constructed at any time since the data is coded and remains unchanged in the underlying database.

Instead of always reading the transcribed reports of radiologists, if the institution has an electronic image archive, the primary care or other specialist can look at the actual image on the screen to explain to the patient or double check for themselves.

Advantages of Electronic Health Record

One of the most powerful reasons to evolve to the electronic record is security. The roof leak or flood scenario could put a paper-based organization out of business. Paper records can be physically stolen and there is no backup available. Paper records can be photocopied and there is no way to detect the act. Anyone with access to the file room technically has access to stealing, altering or copying any record from the shelves. Electronic records can never be stolen or damaged if backups are properly done. Everyone who accesses a record for whatever reason can be audited for review by a appropriate security official or by the patient themselves in some systems. No copies or alterations are possible without leaving an audit trail. We can give certain people full access to a particular record for audit or other reasons and they do not inherit access to any other record. Currently it is against any medical records organization rules to physically take records out of the building. There are many good reasons to have this rule. It is routinely broken in some organizations by well-meaning providers who can’t get all the work done during the day and need to finish documenting at home. With an electronic system, it is unnecessary. A particular chart can be securely viewed anywhere in the world with proper security precautions that have already been established and tested in the banking world. In the same vein a chart can go with the patient to the cardiologist and be back for the primary care visit even if the appointments are minutes apart because the chart never actually goes anywhere. Paradoxically, the chart can go more places because it doesn’t actually go anyplace!

One of the markers of a high quality product is reduced variability in the final product or service. With paper records it is so inefficient to tell exactly what kind of care is going on that only with a huge budget is serious quality control possible. By careful design of templates and data dictionary and automatic 100% auditing of important aspects of care, the virtual record makes consistency and high quality attainable goals.

Reminders in a paper system are of two kinds. The chart surrogate is the most common. Keeping the chart as a marker for a sick patient or an important result does work, but the chart is unavailable for other unrelated care in other locations. The other reminder occurs when providers create a “shadow chart” by keeping a separate note book of patient names, medical record numbers, multiple contact numbers, an abbreviated problem list and the actual reminder. Then they can manually review the list at intervals to see whose results has not come back. Even so, chart pulls are required to check on details and document results taken over the phone. The frequent, tragic and needless failure to diagnose cancer and other serious illness because of failure of the reminder function should embolden providers to try anything else because of the manifest failure of paper systems or at least the tremendous additional labor involved if they are properly done.

From time to time in looking at paper charts providers will come across an article photocopied and stapled or bound into the record. This may have been from the patient or a student and would likely have some tangential relevance to their conditions. Instead of being the exception, an intelligent virtual record could have routine protocols, care paths, guidelines and evidence based advice just a click away.

Link-outs are possible in a virtual record connected to the Internet. Even if the record is stored on a single computer and inaccessible from the internet, a link to a library of full-text references could add measurably to the care of the patient.

Reminders, embedded Intelligence and Link-outs are a feature of Electronic Health Records called Clinical Decision Support which is not available in paper records. Features such as evidence based order sets, evidence based templates for progress notes are another form of clinical decision support not as easily provided in the paper record.

The busy provider rarely has time to notice the random photocopied article in the occasional chart. To enhance a patient oriented education, they could jot down the reference and look up and study the article. But the reference could be tangential or exceptional and not helpful for most other patients. What if the provider could leave a bookmark in the chart of a patient - not visible to other providers or auditors or to the patient, but kept in a special place that the provider could reference from home or elsewhere during a continuing education activity? What if providers could actually list their information needs without making that knowledge known to anyone else? What if they could audit themselves and design an education program specifically for their weaknesses and in the light of their learning style and strengths in other areas? Or better yet what if their information needs were anonymously feed to specialist in the appropriate area to have a suggested program designed for them and feed back anonymously? Why not give them CME credit for actually looking up and learning information in the course of their daily practice? The current answer to these questions is that it is impractical or impossible. With a virtual record it becomes possibly to seamlessly transition from patient care to professional education.

Many electronic systems currently have extensive patient education modules. It is a small step to create mass customization for each patient’s problem list.

Extending the ability for patents to read and contribute to their record is available in many EHR systems. When patients are finally incorporated into their care the concept of problem orientation will be the only reasonable way for them to look at the chart. Patients are expert at what bothers them, but clueless about ICD9 and CPT codes that payers require.

The ability of a system to be organized truly in a problem oriented way will separate the pack of contending vendors. The data will be stored in a fully coded technically correct manner, but the various views will be enabled depending on the needs of the user.

It is very expensive to audit paper records. If you can’t read a contributor’s handwriting it is impossible to audit the care they are giving, appropriateness of their reimbursement coding or in some cases even know who they are! Electronic records can audit themselves. Audit could become enmeshed in the continuing education that a provider designs for themselves. Some of the reasons for auditing will disappear. Use of appropriate E&M templates will ensure that appropriate codes are being submitted as a matter of course. In the future, as the more complicated systems come into use, the knowledge of coding will become so arcane that no human could do it in real-time anyway. No “education” will be needed because the need for the skill will go away!

Demand management is the managing of demand for health care. As any provider will tell you, if you don’t have the diagnosis after taking a careful history only a few strikingly unexpected physical exam findings will help. The physical exam only confirms your suspicions in most cases. If history taking could be automated and monitored over the web in real-time by nurses backed up by physicians, the demand for actual face-to-face appointments would decrease. Much of health care could be accomplished over the web with brief confirmatory visits in some cases.

When actual visits or phone conversations are deemed necessary, access management comes into play. Locating resources to match patients’ needs is best done by cell phones augmented by portable networked information appliances. In the current model physicians are called and have to be brought up to date or up to the minute on a patient’s status. If the physician had a summary of the patient’s status they can contribute immediately or preemptively to the care of the patient and avoid the need for an actual phone conversation and the “bringing up to date” function. Virtual records like EHRs can take health care to the next level of value for patients and providers.

Role of Patients in Evolution to Electronic Health Records

The thrust of electronic commerce or e-commerce is to become intertwined in the daily routine of users. Whether it is banking services expanding into full financial services or bookstores selling items with no relation to books, e-commerce seeks to enmesh itself, add value and become transparent to the user.

E-commerce has to first create the need for itself. It must do something so much better than the bricks and mortar alternative that people chose to migrate their activities to the virtual sector and abandon their old ways. In all sectors this is difficult. In the health sector we have a few things pushing us to the electronic realm. Bricks and mortar and face-to-face are expensive compared with web access anytime and anyplace. If we design systems that look and feel like the providers workspace and create value for patients to exploit, the public will assign electronic healthcare “need” status. It may be by financially competing so intensely with bricks and mortar that a face-to-face encounter will become an extraordinary and expensive event. People have shown they must have value to change established patterns. An inferior service at a lower cost will not likely prevail, especially in a robust economy where people can well afford the current cost of face-to-face care. A service that cost the same or less out of pocket, but is easier to use, quicker to get to, automatically follows up on treatment plans, educates you and connects you more closely to your provider will drive traditional healthcare services out of the market. It is likely that a bricks and clicks strategy or a symbiosis of existing physical entities will prevail. In that model, most of the care could occur virtually using EHRs. When a physical visit is needed, the established physical entities like clinics and hospitals will be needed. If a large percentage of care occurs without a visit or phone call by interactive history taking guided by a mid-level provider or nurse, a practice can take more capitated lives. They will still need to see patients but they become more efficient by avoiding unnecessary visits.

When patients use the service as a matter of course, provider organizations can extend into health related areas. Discounted exercise equipment linked to the web for feedback into your personal exercise program, grocery buying with reminders for healthy foods and feedback about total calories, disease specific extensions of care beyond traditional medical care into life enhancements chosen by the provider are all made possible by a virtual practice. Providers still have the ethical responsibility to put their patients’ welfare above profit. Endorsements and web-site links have to be chosen with this in mind, as always. It may be controversial, but this evolution can be done in a way to preserve the best of the healer-patient relationship. Ultimately it will start when we give ourselves permission to re-define healthcare in a broader way and it will thrive when we immerse our patients in mass customized health promotion messages.

Clinical Data Repository

Any EHR must be built on a repository of clinical data. Some have designed the repository into the EHR itself. EpicCare is an example of that kind. Other EHRs keep some of the data themselves, such as the clinical notes the system generates itself, but links to a repository of lab and other results. A Clinical Data Repository (CDR) is characterized by having patient identified real-time clinical operations data in a normalized form that is coded with a data dictionary. It is optimized for individual patient centered queries and not research queries across multiple patients, although theoretically those queries could be run. The CDR is the source of results for providers seeing patients. The lab and imaging results go directly into the CDR for immediate availability for in and out patient care. The portion of the CDR for clinical images is called a Picture Archiving and Communicating System or PACS. Interfaces are built, usually using the HL-7 or ASTM standards to existing legacy and reference lab systems. Different codes from feeder systems are standardized into a common lexicon so that results can be compared between systems if a patient’s insurance (and therefore reference labs) changes. Some pure CDRs have gone into the EHR market by improving their user interface and adding EHR-like functionality and decision support tools. Ultimately it may be hard to decide between the two kinds of systems. In a large enterprise a better choice will usually be a CDR due to the need for robust large scale data manipulation. In a small enterprise a pure EHR will frequently be the best choice for economic reasons. The CDR can contain outcome measures and is the enabling technology for population based care and research. In a pinch, limited research queries can be run during idle time in the evening and weekends on a pure CDR database without creating a research data warehouse.


Practice partner and Logician are two products that have paralleled each other’s development with Practice partner targeting small to mid sized practices and Logician targeting mid to large organizations. Now that both have developed web based products or delivery mechanisms, they compete in the same niche. Patient profile is an system created by an attending physician and a resident programmer in Microsoft access for local use in a clinic. It is shown to demonstrate some generic qualities of EHRs.

Figure 1:  Example of Use of Tabs in Practice Partner

The tab metaphor is a very powerful one for designers of EHRs. The security of a paper metaphor is too strong to be resisted, so many EHRs that have progressed passed the cascading menus of DOS programs use this appearance. With most programs, there is more than one way to accomplish a task. IN Practice Partner (Figure 1) ,the large buttons on top expose the same functionality as the tabs in the foreground. The chart summary is top left followed by progress notes since they have the summary of most recent events. The main past history which changes only slowly is Past/Social/Family history. The next section is consults, discharge summaries and letters followed by messages and flowcharts. The problem list occupies the predominant position on the right side of the screen. The health maintenance area is conveniently located below problems and above the Rx pad. For detailed data the vital signs, lab data and images are next followed by x-ray, ekg, pathology and special studies. The design is very flexible and most tabs can be rearranged or omitted.

Logician Internet uses the typical web page format with hierarchical information on the left and details in the right frame (see Figure 2). Information starts from most general at the top left:

  • Chart Room
  • Desktop
  • Demographics
  • Chart Summary
  • Previous Notes
  • Chart Notes

The Logician Internet web technology is improved by being implemented in Java on the local machine to avoid variable network delays in screen refreshes and enables a complex and detailed program. This creates the need to synchronize the local database with the reference database and also between different users of the chart.

Figure 2:  Display of Information in Logician Electronic Health Record

Profile has functionality for prescription writing which goes beyond it’s CDR function (See Figure 3). In this screen you can see behind the pop-up to see lists of Allergies, Active Medication and Discontinued Medications all together for easy reference. In the background are the other typical tabs of the EHR chart sections. The pop-up gives the impression of a written Rx which is called an affordance. That is it affords the opportunity to enter prescription information. The central drop down has a list of all medication available. The list is available on the web and can be updated on a weekly basis. Below the drop down is the free text Sig: area followed by the amount dispensed, the type of preparation and number of refills, the start date, the prescribing doctor, some free text notes and a link to a problem from the problem list. On the right you notice the formulary area which would indicate the formulary status and alternate suggested drugs. By having a list of medications a provider can check off which ones to refill and make a repetitive task easier.

Figure 3:  Functionality for Prescription Writing in Profile Electronic Health Record

Regional Health Information Organizations

The Regional Health Information Organizations are organized to facilitate exchange of information among health care providers.  George Mason University is proposing to organize one such organization to serve providers of care in wider Washington DC metropolitan area.  The goal will be to allow designated providers access to the patient’s complete record independent of where the patient has received services.    The organization will enable large and small health care providers to effectively communicate to each other about the care of their common patient. 

A test ordered by the primary care physician will be readily available to the specialist and vice versa.

In addition to improving patient safety and quality of care, the integrated data is expected to reduce overall cost of care, enhance health services research, enable detection of public health outbreaks, and improve patient’s access to health information. 

Principles of Operation

The Regional Health Information Organization (RHIO) will be based on the following operation principles:

1.       Voluntary.  Health care organizations voluntarily choose to participate in RHIO.

2.       Public notification. Participating health care providers will prominently display a sign informing their patients of the organization’s participation in RHIO.

3.       No centralized database.  No data is maintained by RHIO.  The organization maintains communication protocols and maps of data structures, which will enable transfer of data from one participating organization to another.  RHIO does not require a uniform data structure among all participating organizations. 

4.       On demand transfer of data.  At point of care and on demand, RHIO will enable a provider of care who has client’s permission to gain access to all data on the client in participating organizations.  Each participating organization will process the request for transfer of the data on demand.

5.       Algorithm based record identifier.  RHIO will not use any unique identifier for matching the patient’s records across several providers.  Instead, clients will be matched based on automated algorithms.  Details of the procedure are provided elsewhere.

6.       HIPAA compliant.  George Mason University’s Institutional Review Board will supervise the data safety issues related to the proposed organization.  No data will be transferred without authentication of the provider and verification that the patient has signed a consent form.  Participating organizations will maintain the signed consent forms of the patients.    

7.       Data mining & research Health care researchers will be allowed to have access to the data after removing patient, provider and organization’s unique identifiers. 

8.       Personal records.  Patients will be allowed to review their records and suggest changes to participating organization. 

9.       Online health education.  Patients will have access to confidential health information tailored to their needs. 

10.    Public health monitoring.  RHIO will allow public health agencies to use the data to monitor outbreak of diseases. 

11.    CMS review organizations.  RHIO will work with Center for Medicare and Medicaid Services peer-review organizations to provide assistance in analysis of improvement trends.

12.    Free EMR to small and safety net clinics.  RHIO will provide the Veteran Administration’s Vista Electronic Medical Record free of charge to all participating clinical groups of less than 12 clinicians.  In addition, RHIO will provide free training and maintenance services for these clinics if the State supports the University in accomplishing these goals. 


It seems odd to think of all the changes in the rest of our lives brought about by the internet and then to go and sit in the waiting room of a doctors office and read old People magazines and fill out paper forms. Ultimately healthcare will be as different as airline reservations and banking have become, or more. We are seeing, in some places, truly modern information enhanced practices with EHRs spring up and thrive. The ruts of the past are deep, but the need for advanced practices is too strong to resist. Existing practices are gradually enhancing their appeal by adding virtual elements. So the first competition will be avant-guard providers reaching out over the web and taking patients away from plain waiting rooms. Patients who see value in this and respond by putting up with the inevitable bumps in the road will be able to shape the future of healthcare.


Lærum H, Ellingsen G, Faxvaag A.  Doctors' use of electronic medical records systems in hospitals: cross sectional survey.  BMJ 2001;323:1344-1348 ( 8 December )

Mitchell E, Sullivan F.   A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97 BMJ, Feb 2001; 322: 279 - 282.

Majeed A, Lusignan SD, Teasdale S.   Ten ways to improve information technology in the NHS • Commentary: improve the quality of the consultation • Commentary: Clinical focus might make it work BMJ, Jan 2003; 326: 202 - 206.

Mandl KD, Szolovits P, Kohane IS, Markwell D, MacDonald R.  Public standards and patients' control: how to keep electronic medical records accessible but private • Commentary: Open approaches to electronic patient records • Commentary: A patient's viewpoint BMJ, Feb 2001; 322: 283 - 287.


The following additional resources are available to help you think through this lecture:


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Prepare to present one of the articles in the reading set.

This page was created by Farrokh Alemi, Ph.D.  Last revised on 10/22/2011.  This page is part of the course on Electronic Commerce and Online Market for Health Services.  This is the session on Online Medical Records.