The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. CDSSs constitute a major topic in artificial intelligence in medicine.
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. This stands in contrast to the more widely used electronic medical record, which is operated by institutions and contains data entered by clinicians to support insurance claims. The intention of a PHR is to provide a complete and accurate summary of an individual's medical history which is accessible online. The health data on a PHR might include patient-reported outcome data, lab results, and data from devices such as wireless electronic weighing scales or from a smartphone.
Oracle Health, formerly Cerner Corporation then Oracle Cerner, is a US-based, multinational provider of health information technology (HIT) platforms and services. As of February 2018, it had 27,000 customers globally and 29,000 employees, with over 13,000 at its headquarters in North Kansas City, Missouri.
Health information exchange (HIE) is the mobilization of health care information electronically across organizations within a region, community or hospital system. Participants in data exchange are called in the aggregate Health Information Networks (HIN). In practice, the term HIE may also refer to the health information organization (HIO) that facilitates the exchange.
Epic Systems Corporation is an American privately held healthcare software company. According to the company, hospitals that use its software held medical records of 78% of patients in the United States and over 3% of patients worldwide in 2022.
Patient portals are healthcare-related online applications that allow patients to interact and communicate with their healthcare providers, such as physicians and hospitals. Typically, portal services are available on the Internet at all hours of the day and night. Some patient portal applications exist as stand-alone web sites and sell their services to healthcare providers. Other portal applications are integrated into the existing website of a healthcare provider. Still others are modules added onto an existing electronic medical record (EMR) system. What all of these services share is the ability of patients to interact with their medical information via the Internet. Currently, the lines between an EMR, a personal health record, and a patient portal are blurring. For example, Intuit Health and Microsoft HealthVault describe themselves as personal health records (PHRs), but they can interface with EMRs and communicate through the Continuity of Care Record standard, displaying patient data on the Internet so it can be viewed through a patient portal.
Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.
The Office of the National Coordinator for Health Information Technology (ONC) is a staff division of the Office of the Secretary, within the U.S. Department of Health and Human Services. ONC leads national health IT efforts. It is charged as the principal federal entity to coordinate nationwide efforts to implement the use of advanced health information technology and the electronic exchange of health information.
DrChrono is an American digital health technology company that provides software and billing services on a platform of web apps and cloud-based apps for doctors and patients. The company makes electronic health records (EHR), practice management software, and medical billing software and provides medical revenue cycle management (RCM) services. The company is based in Sunnyvale, California.
Practice Fusion is a web-based electronic health record (EHR) company based in San Francisco, CA. The company was founded in 2005 by Ryan Howard and acquired by Allscripts in 2018.
Veradigm Inc. is a publicly traded American company that provides physician practices, hospitals, and other healthcare providers with practice management and electronic health record (EHR) technology. Veradigm also provides products for patient engagement and care coordination, as well as financial and analytics technology. The company has more than 180,000 physician users and has products in 2,700 hospitals and 13,000 extended care organizations. The company formally changed its name from Allscripts to Veradigm in January 2023.
Nightingale Informatix Corporation, commonly abbreviated as Nightingale, is a public company headquartered in Markham, Ontario, Canada with offices in Rancho Cordova, California, Cambridge, Ontario, Kansas City, Missouri, Pembroke, Massachusetts, and Wexford, Pennsylvania. Nightingale provides products and services that support physicians, allied healthcare practitioners, hospitals and other healthcare organizations with their clinical and operational requirements. Nightingale provides EHR and Practice Management services, as well as a Patient Portal, Revenue Cycle Management and Medical transcription services to solo physicians, group practices and large clinics across the United States and Canada. The EMR/ EHR by Nightingale is a web-based program and is hosted in a secure ASP environment.
The Health Information Technology for Economic and Clinical Health Act, abbreviated the HITECH Act, was enacted under Title XIII of the American Recovery and Reinvestment Act of 2009. Under the HITECH Act, the United States Department of Health and Human Services resolved to spend $25.9 billion to promote and expand the adoption of health information technology. The Washington Post reported the inclusion of "as much as $36.5 billion in spending to create a nationwide network of electronic health records." At the time it was enacted, it was considered "the most important piece of health care legislation to be passed in the last 20 to 30 years" and the "foundation for health care reform."
A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe, or just scribe. A scribe is trained in health information management and the use of health information technology to support it. A scribe can work on-site or remotely from a HIPAA-secure facility. Medical scribes who work at an off-site location are known as virtual medical scribes.
American Well Corporation, doing business as Amwell, is a telemedicine company based in Boston, Massachusetts, that connects patients with doctors over secure video. Amwell sells its platform as a subscription service to healthcare providers to put their medical professionals online and its proprietary software development kits, APIs, and system integrations enable clients to embed telehealth into existing workflows utilized by providers and patients.
PhysAssist Scribes is a provider of medical scribes to hospitals and medical practices. The company was founded in 1995 in Fort Worth, Texas by Dr. John Geesbreght, an emergency department physician and Dr. Elliott Trotter, also an emergency department physician, who began a model program at Harris Methodist Hospital. Dr. Geesbreght, with approval from Texas Christian University (TCU) administration, recruited four pre-med TCU students to establish what is now PhysAssist Scribes, Inc.
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records. The US Congress included a formula of both incentives and penalties for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the, American Recovery and Reinvestment Act of 2009.
RXNT is an American privately held healthcare software technology company. The company provides ambulatory practices, hospitals, medical billers, and other healthcare professionals with digital health tools. The company was created in 1999, as a standalone e-prescribing system.
$76 million (2014) [1]