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HIT Terminology: What is an EMR or EHR?

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health it terminologyIn 2004 the Office of the National Coordinator for Health Information Technology (ONC) was created to promote health IT adoption and lay the foundation for an infrastructure that would grow with the changing landscape of healthcare and digital records. From the beginning the most basic of terms needed to be defined and adopted to create a consistent language that would support the whole system including public policies, private development, and outreach and educational initiatives. The ONC contracted the National Alliance for Health Information Technology (NAHIT), an organization of industry leaders with a goal to build a common ground for the implementation of health information technology. Declaring its mission "accomplished", the National Alliance for Health Information Technology ceased operation in September 2009.

The National Alliance for Health Information Technology (NAHIT) created key health IT definitions which were released in a report in April of 2008 and accepted by the ONC. The Executive Summary of the report tells us why defined terms are needed.

"The ambiguity of meaning created by not having a shared understanding of what these key terms signify becomes an obstacle to progress in health IT adoption when questions about a term's definition and application complicate important policy expectations or directives, contractual matters, and product features. Differences in how a term is used can cause confusion and misunderstanding about what is being purchased, considered in proposed legislation, or included in current applicable policies and regulations."

The contract to NAHIT was to reach consensus on definitions for the terms EMR, EHR, PHR, HIE and RHIO. HIO was added to the definitions once it was determined that HIE had a process and an entity meaning.

The definitions, when put into practice, will result in a number of benefits including:

  • Health IT concepts expressed in a language that individuals comprehend.
  • Standard terms for policy makers to use when drafting and evaluating policies.
  • Important reference points for health IT initiatives.
  • More effective contracting between health IT vendors and their customers.

The following definitions have been adopted:

Electronic Medical Record (EMR) – An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Electronic Health Record (EHR) – An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

Personal Health Record (PHR) – An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Health Information Exchange (HIE) – The electronic movement of health-related information among organizations according to nationally recognized standards. (verb)

Health Information Organization (HIO) – An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. (noun)

Regional Health Information Organization (RHIO) – A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

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Last updated: June 21, 2013




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