2.1 An electronic health record (EHR) is a digital version of a patient’s paper chart.

EHRs are real-time,

patient-centered records that make information available instantly and securely to authorized users. While
an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond
standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s
care. EHRs are a vital part of health IT and can:

▪Definition: patient specific repository of electronically maintained information about an individual’s

health status and healthcare, stored electronically such that it can serve the multiple legitimate uses and
users of the record (the physicians)1 . ▪ Healthcare Information and Management Systems Society
(HIMSS) definition: longitudinal electronic record of patient health information generated by one or
more encounters in any care delivery setting (so it is a record that includes the patient’s information
from birth to death not only for a one hospital nor one health care condition) ▪ Electronic Health Record
System: includes the active tools that are used to manage the information. Electronic health record and
electronic health system are the same ▪ Interoperability standards to exchange info outside a single
healthcare delivery system ▪ Supports other care-related activates directly or indirectly (evidence-based
decision, support, quality management and outcomes reporting) ❖ Computer-based Patient Record
(CPR) ▪ Electronic health records is interchangeable with computer-based patient record ▪
Comprehensive lifetime record ▪ Attributes identified by the Institute of Medicine (IOM) provide the
basis for today’s understanding of the EHR. 1. Results reporting 2. Data repository 3. Decision support 4.
Clinical messaging and communications e.g. e-mail 5. Documentation 6. Order entry 1 another
definition: a computerized lifelong care record for an individual than incorporate data from all sources
that provide treatment for the individual

❖ Electronic order entry can improve health care at several levels (computerized physician order entry
“CPOE”): • Reduce errors and costs. E.g. it will decrease the medication error due to eligible hand
writing • Deliver decision support at the point where clinical decisions are being made. E.g. if the patient
have allergy to a medication, if the physician ordered that medication a pup up alert will appear on the
system to alert the physician and may also give suggestions of another alternative medication the
physician may use

o Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates,
allergies, radiology images, and laboratory and test results
o Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
o Automate and streamline provider workflow

One of the key features of an EHR is that health information can be created and managed by authorized
providers in a digital format capable of being shared with other providers across more than one health care
organization. EHRs are built to share information with other health care providers and organizations – such
as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and
workplace clinics – so they contain information from all clinicians involved in a patient’s care.

With EHRs, your organization can help build a healthier future for our nation.

For more information on EHR systems, see the following resources.

o Benefits of Electronic Health Records

o How to Implement EHRs
o What are the advantages of electronic health records?
o What information does an electronic health record (EHR) contain?
o EMR vs EHR – What is the Difference?

2.2 Electronic medical record (EMR) systems, defined as "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,"
[1] have the potential to provide substantial benefits to physicians, clinic practices,
and health care organizations. These systems can facilitate workflow and improve the
quality of patient care and patient safety. Despite these benefits, widespread adoption
of EMRs in the United States is low; a recent survey indicated that only 4 percent of
ambulatory physicians reported having an extensive, fully functional electronic
records system and 13 percent reported having a basic system. [2]

▪ A general term describing computer-based patient record systems. It is

sometimes extended to include other functions like order entry for medications
and tests, amongst other common functions. ▪ EMR (Electronic Medical Record) –
the set of databases (lab, pharmacy, radiology, clinical notes, etc.) that contains
the health information for patients within a given institution or organization

Among the most significant barriers to adoption are:

 High capital cost and insufficient return on investment for small practices and
safety net providers.
 Underestimation of the organizational capabilities and change management
required.
 Failure to redesign clinical process and workflow to incorporate the technology
systems.
 Concern that systems will become obsolete.
 Lack of skilled resources for implementation and support.
 Concern that current market systems are potentially not meeting the needs of
rural health centers or federally qualified health centers (FQHC).
 Concern regarding negative unintended consequences of technology.

Recognizing the role that EMRs can play in transforming health care, in 2003, the
Institute of Medicine issued a group of eight key functions for safety, quality, and care
efficiency that EMRs should support.

 Physician access to patient information, such as diagnoses, allergies, lab

results, and medications.
 Access to new and past test results among providers in multiple care settings.
 Computerized provider order entry.
 Computerized decision-support systems to prevent drug interactions and
improve compliance with best practices.
 Secure electronic communication among providers and patients.
 Patient access to health records, disease management tools, and health
information resources.
 Computerized administration processes, such as scheduling systems.
 Standards-based electronic data storage and reporting for patient safety and
disease surveillance efforts.

2.3 what is the electronic medical record is not a simple replacement of

the paper record
While the terms "electronic health record" (EHR) and "electronic medical
record" (EMR) are often used interchangeably, there is a subtle
distinction between the two.
 An electronic medical record (EMR) is a digital version of a patient's
medical chart within a specific healthcare organization, such as a
hospital or a clinic. It typically contains the patient's medical and
treatment history within that particular setting. EMRs focus primarily on
clinical data and are designed to support healthcare providers in
diagnosing and treating patients within their own practice.
 On the other hand, an electronic health record (EHR) is a more
comprehensive and inclusive electronic record of a patient's health
information. It goes beyond the confines of a single healthcare
organization and encompasses a broader range of data from various
sources, including multiple healthcare providers and settings. EHRs are
designed to facilitate the sharing and exchange of patient information
across different healthcare systems, enabling a more holistic view of the
patient's health.
 So, the key difference is that while an EMR is limited to a specific
healthcare organization, an EHR is designed to integrate and aggregate
information from multiple sources to provide a more complete and
interoperable view of a patient's health.
 It's important to note that the transition from paper records to
electronic records, whether it's an EMR or an EHR, involves more than
just a simple replacement of physical documents. It requires the
implementation of new technologies, the establishment of data
 standards, and changes in workflows and processes within healthcare
organizations. The ultimate goal is to improve the quality of patient
care, enhance communication and coordination among healthcare
providers, and streamline administrative tasks.
2.4 The what is the personal health record
A personal health record (PHR) is a health information management tool that
allows individuals to document, store, and manage their own health
information in an electronic format. It is typically patient-controlled and can
be accessed and updated by the individual, empowering them to take an
active role in managing their health.
A PHR contains comprehensive health information, including medical history,
allergies, medications, immunizations, laboratory results, and any other
relevant health data. It may also include information such as family medical
history, lifestyle factors, and personal health goals.
There are two main types of PHRs:
1. Standalone PHR: This type of PHR is maintained by the individual and is
not directly connected to any healthcare provider's system. Standalone
PHRs can be in various formats, such as software applications or online
platforms, and individuals manually enter their health information into
the system. They have full control over their records and decide who can
access their information.
2. Tethered PHR: A tethered PHR is typically linked to a specific healthcare
organization's electronic health record (EHR) system. It allows patients
to view their health information from that healthcare provider, such as
test results, appointments, and treatment summaries. The data in a
tethered PHR is usually populated from the provider's EHR system, and
patients have limited control over the content.
PHRs offer several benefits to individuals. They provide a centralized location
to store and manage health information, allowing easy access to important
data when needed, such as during healthcare appointments or emergencies.
PHRs can also facilitate communication and collaboration between patients
and healthcare providers, as individuals can share their records and provide a
more comprehensive view of their health history.
Furthermore, PHRs can help individuals track and monitor their health over
time, set health goals, and make informed decisions about their care. Some
PHR systems also offer features such as medication reminders, wellness tips,
and integration with wearable devices to capture health data.
It's important to note that privacy and security are critical considerations when
using PHRs. Individuals should choose reputable and secure platforms, use
strong passwords, and understand the privacy policies and data sharing
practices of the PHR system they are using.
Overall, personal health records empower individuals to actively participate in
managing their health by providing them with easy access to their health
information and promoting better communication and collaboration with
healthcare providers
2.5 information management in an electronic environment

Information management in an electronic environment refers to the

systematic organization, storage, retrieval, and utilization of information in
digital form. It involves the effective handling and control of electronic
information assets within an organization or system.
In an electronic environment, information management encompasses various
processes, including:
1. Data Capture and Input: This involves capturing and entering data into
electronic systems, such as through electronic forms, scanning paper
documents, or automated data feeds from other systems.
2. Storage and Organization: Electronic information is stored in databases,
servers, or cloud-based storage systems. It requires organizing the
information in a logical and structured manner, such as using folders,
directories, or metadata to facilitate easy retrieval.
3. Retrieval and Search: With electronic information, search capabilities are
essential to locate specific data quickly. Information management
systems provide search functionalities based on keywords, filters, or
advanced querying techniques.
4. Security and Access Control: Managing access to electronic information
is crucial to protect sensitive data from unauthorized access,
modification, or loss. This involves implementing security measures like
user authentication, role-based access control, encryption, and backup
procedures.
5. Version Control and Document Management: In an electronic
environment, managing different versions of documents or files is
 important to track changes and ensure the availability of the most up-
to-date information. Version control systems allow users to collaborate,
track revisions, and revert to previous versions if needed.
6. Metadata Management: Metadata provides additional information
about electronic documents or files, such as creation date, author,
keywords, or file format. Effective metadata management enhances
searchability and supports information organization and categorization.
7. Data Retention and Disposal: Electronic information management
includes defining policies and practices for retaining information for
legal, regulatory, or business purposes. It also involves securely
disposing of data that is no longer needed or has reached its retention
period.
8. Integration and Interoperability: In complex electronic environments,
information management involves integrating various systems and
ensuring interoperability between different applications or databases.
This enables seamless exchange of information between systems and
facilitates data sharing and collaboration.
9. Compliance and Governance: Information management in an electronic
environment requires adherence to legal, regulatory, and industry-
specific standards for data privacy, security, and confidentiality. It
involves establishing policies, procedures, and controls to ensure
compliance and mitigate risks.
Efficient information management in an electronic environment enables
organizations to access, utilize, and protect their digital assets effectively. It
supports decision-making, collaboration, and knowledge sharing while
ensuring data integrity, security, and compliance with relevant regulations.

2.6 data quality issues

Data quality issues refer to problems and deficiencies that affect the accuracy,
reliability, completeness, consistency, and timeliness of data. These issues can
arise at various stages of the data lifecycle, including data collection, entry,
storage, processing, and reporting. Data quality issues can have significant
implications for decision-making, analysis, and overall business operations.
Some common data quality issues include:
1. Inaccurate Data: Inaccurate data contains errors, mistakes, or
inconsistencies that do not reflect the true or correct values. This can be
 due to human errors during data entry, system glitches, or technical
issues.
2. Incomplete Data: Incomplete data lacks certain necessary information or
fields, making it difficult to obtain a comprehensive understanding of
the subject matter. Missing data can occur due to oversight, non-
response, or system limitations.
3. Inconsistent Data: Inconsistent data exhibits discrepancies or
contradictions across different sources or within the same dataset.
Inconsistencies can arise from data entry errors, different data
definitions or formats, or data integration issues when combining data
from multiple systems.
4. Duplicate Data: Duplicate data occurs when multiple copies of the same
data exist within a dataset or across different systems. Duplicates can
lead to data redundancy, consume storage resources unnecessarily, and
cause confusion during data analysis.
5. Outdated or Stale Data: Outdated data refers to information that is no
longer current or relevant. Stale data can result from delays in data
updates or lack of synchronization with real-time events, leading to
decision-making based on obsolete information.
6. Data Integrity Issues: Data integrity issues involve the overall reliability,
consistency, and validity of data. It encompasses problems such as data
corruption, data loss, or unauthorized modifications that compromise
the integrity of the data.
7. Lack of Data Standardization: Data standardization ensures consistency
and uniformity across data elements, formats, and definitions. The
absence of standardization can result in data discrepancies, difficulty in
data integration, and challenges in data analysis and reporting.
8. Data Bias: Data bias refers to systematic errors or prejudices in the data
that skew the representation or analysis of certain groups or variables.
Bias can arise from sampling methods, data collection processes, or
inherent biases present in the data sources.
9. Poor Data Governance: Poor data governance practices, such as
inadequate data documentation, lack of data policies, or insufficient
data quality controls, can contribute to data quality issues. Without
proper governance, data may not be managed effectively or consistently
across the organization.
Addressing data quality issues requires proactive measures, including data
validation, data cleansing, data profiling, and implementing data quality
management processes. Organizations should establish data quality standards,
employ data quality tools and techniques, and promote a data-driven culture
to ensure high-quality data for decision-making and operational excellence.

1. computer-based patient record systems. It is sometimes extended to include other functions like
order entry for medications and tests , amongst other common functions. Definition of?

A. Electronic medical record B. Electronic heath record C. Medical informatics D. Health and technology
system

2. All are Barriers of EHR in Saudi Arabia except one:

A. Legal and regulatory barriers B. Human Barriers C. Professional barriers D. Ethical barriers

3. Chose the right Component of EMR :

A. Decision support B. Quality reporting C. Coding D. Billing

4. Offices, the hospital, and the emergency room should all be linked together, which of the following is
the main barrier that prevent such linkage ?

A. Ethical barriers B. technical barriers C. Organizational barriers D. Regulatory barriers

5. Which one is a Functional Component of EMR System ?

A. Clinician order entry B. patient decision support C. Quality reporting D Documentation

6. a repository of electronically maintained information about an individual's Health status and health
care, stored such that it can serve the multiple legitimate uses and users of the record. Define which of
the following?

A. Electronic medical record B. Electronic heath record C. Medical informatics D. Health and technology
system