Key capabilities of an electronic health record system
This is a review of the report to the U.S. Department of Health and Human Services, Key capabilities of an electronic health record system. 
Background and Purpose
In this report to the U.S. Department of Health and Human Services, the Institute of Medicine clarifies the key capabilities of an Electronic Health Record (EHR) system. A functional model of these capabilities is necessary for achievement of nationwide strategies to promote widespread adoption of EHR systems and interoperability across multiple organizations and providers. A common set of functional capabilities informs software development and assists decision making during acquisition of an EHR.
Identification of core EHR functions was driven by the need to fulfill the following key criteria: improve patient safety; support effective care delivery; manage chronic illness; improve process efficiency; and determine implementation feasibility.
|Core Function||Beneficial Examples|
|Health information and data||Display of patient demographics, medical history, current medications, allergies, problem list, diagnoses and care narratives for provision of efficient care delivery|
|Results management||Display of previous laboratory test results, radiology reports accessible by the provider at the point of care|
|Order entry/management||Computerized ordering for medication, laboratory tests, and procedures enables consistent, complete care delivery, reduction in duplicative orders, reduced lag time in execution of orders and improved communications between ancillary service providers|
|Decision support||Provide knowledge-based guidance to deliver enhanced clinical performance. Examples include reduction in adverse events, improved drug selection and dosing, increased preventive interventions, and computer-assisted diagnosis and treatment management|
|Electronic communication and connectivity||Secure, effective exchange of information among care team members and other care partners (e.g., laboratory, pharmacy) allows for continuity and completeness of care (especially for chronic conditions), improves patient safety and quality of care and enables public health surveillance|
|Patient support||Provision of patient education and facilitation of home monitoring by patients encourages self-care|
|Administrative processes||Scheduling; billing & claims processing; eligibility, referrals and authorizations management can all serve to eliminate delays, confusion and miscommunication in care administration processes|
|Reporting & population health management||Facilitation and automation of reporting key internal quality indicators as well as mandated reporting requirements increases the safety and quality of care and for patients and populations - automation of these reporting tasks can increase data accuracy and reduce data collection burdens|
This set of core functions should assist providers and vendors in efforts to implement EHR systems. Addressing each of the functional areas and the underlying criteria should help to build a comprehensive foundation for clinical information systems allowing providers to improve delivery of care and enable patients to become active participants in their care plans.
Providers with a safety-net role face multiple barriers to EHR adoption such as lack of funding and leadership support as well as policy constraints. This report is useful for building a case for the need for EHR implementation and achieving leadership buy-in.
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- <Tang, P. C. (2003). Key capabilities of an electronic health record system. Institute of Medicine: Committee on Data Standards for Patient Safety• Board on Health Care Services, Washington, DC.