Electronic health records explained

What is an EHR?

The EHR meaning goes beyond digital recordkeeping: it is about connecting information to support a person’s care over time. Each diagnosis, test result and treatment adds to a clinical history that authorized professionals can draw on across healthcare settings. This gives them the context to make informed decisions and maintain continuity as the patient moves between services.

Although the content varies, an EHR typically includes:

• A patient’s medical history and diagnoses
• Medications, allergies and immunizations
• Laboratory results and medical images
• Treatment and care plans
• Clinical notes, referrals and discharge information
• Appointments, insurance and billing details

Together, these elements provide a shared basis for clinical decisions, coordination and follow-up, while sound information governance protects patient privacy and supports regulatory compliance. The key difference with an electronic medical record (EMR) is scope: an EHR is designed to support care across organizational boundaries.

EHR and EMR systems: the key differences

An electronic medical record, or EMR, is the digital equivalent of a patient’s paper chart, generally maintained by a single provider or healthcare organization. It supports clinical and administrative work within that setting, from documenting diagnoses and treatments to managing prescriptions and follow-up care.

An electronic health record, or EHR, has a broader reach. When systems are interoperable, information can follow the patient between primary care providers, specialists, hospitals, laboratories and other services. This gives professionals a more complete clinical picture, improves coordination and reduces the need to recreate information at each stage of the patient journey.

For healthcare organizations, this distinction matters because it affects what they need from their EHR system; supporting internal workflows is different from exchanging information that other providers can securely access, interpret and use.

What is EHR software?

EHR software is the technology used to create, manage and use electronic health records. It gives healthcare professionals, administrative teams and patients the tools to work with the information in those records, while supporting secure exchange between providers. Its configuration depends on the setting: inpatient systems must accommodate complex hospital workflows and coordination across departments, whereas outpatient – or ambulatory – systems serve individual practices, clinics and other non-hospital services.

Whatever the environment, core features include:

• Patient records: tools to capture, organize, update and retrieve structured patient information
• Orders and prescriptions: electronic ordering of tests, medications and treatments, with easy access to test results and reports
• Decision support: alerts, prompts and evidence-based recommendations that help healthcare professionals make informed decisions at the point of care
• Information exchange: secure sharing of information with laboratories, pharmacies and other authorized providers and systems
• Privacy and security: identity management, access controls and audit trails that protect sensitive information and record how it is used
• Billing and payments: functions for coding, claims processing, invoicing and payment management
• Patient access: portals or applications for viewing health information, managing appointments and communicating with care providers

In practice, these features must work together, support daily workflows and meet the organization’s clinical, operational and regulatory requirements.

Benefits of electronic health records

EHR systems address a persistent problem in healthcare: fragmented information. When patient histories and test results are scattered across systems, professionals lose time, decisions are delayed and work is duplicated. EHRs help reduce these inefficiencies by making reliable, up-to-date information available when and where it is needed.

At the point of care, a fuller view of diagnoses, medications, allergies and previous results helps healthcare professionals identify risks, avoid unnecessary investigations and make informed decisions. Treatment can reflect the patient’s wider clinical history, rather than a single encounter.

Across the organization, shared information improves coordination between teams. Connecting documentation, appointments, prescriptions and billing reduces manual processing and opportunities for human error. More efficient workflows can lower costs and free up resources, while access controls and audit trails strengthen EHR privacy and accountability.

For patients, this can mean less repetition of their health history, fewer delays caused by missing information and care that is better tailored to their needs. Secure access to records also helps them understand their treatment and participate in decisions about their care.

More engaged patients

EHRs give patients a practical way to stay involved between appointments. Through patient portals, they can review test results, check medications and treatment plans, prepare questions for consultations and flag errors or omissions in their records. They can also share access with family members or caregivers who support their care.

For people managing long-term or complex conditions, these tools can help them track progress and follow through on treatment. Providers benefit too: patients arrive better prepared, discussions can focus on specific concerns, and care instructions remain available after the consultation.

Access alone, however, does not ensure patient engagement. Information must be clear, explained in context and designed for people with different language needs, levels of health literacy and access to technology. Healthcare organizations must also manage identity, consent and caregiver permissions carefully to protect EHR privacy. The true measure of success is whether patients can use this information to ask informed questions, make decisions with their care team and manage treatments between visits.

EHR systems: usability and workflows

Professionals also need information they can readily use. For those working with EHRs every day, that means being able to find, understand and act on it quickly and easily. If entering notes, reviewing results or ordering tests requires too many steps, productivity falls, data quality suffers and the risk of error increases. Effective EHR software reduces this friction, allowing health professionals to focus on care.

Usability must be considered across the organization. Clinicians need to document treatment and retrieve relevant information quickly, while administrative teams rely on the system to coordinate services, manage appointments and complete other essential tasks. The EHR interface must make these tasks straightforward, with clear navigation and consistent processes.

Introducing an EHR system is also an opportunity to improve workflows. Simply moving existing processes into a digital environment can carry over unnecessary steps and delays, so testing realistic clinical and administrative scenarios helps organizations find ways to simplify work and make information flow more smoothly between teams. Training and ongoing support then help staff use the system confidently as their work evolves.

Making EHR systems work

Achieving electronic health record benefits takes careful planning and effort. Organizations need to manage the disruption of introducing a new system, then commit the resources needed to keep it secure, reliable and useful.

During implementation, priorities include:

• Funding and capacity: EHR software, hardware and integration require substantial investment, while migration and training draw on staff time alongside normal duties.
• Reliable migration: Existing records must be transferred without losing information or carrying unresolved errors into the new system.
• Staff readiness: Teams need role-specific training and workflows that allow them to use the system confidently without disrupting care.

Once the system is in use, the aim is to keep it working effectively:

• Data quality and exchange: Records must remain accurate and current, and information must retain its meaning as it moves between systems and providers.
• Security and privacy: Access controls, monitoring and clear governance are needed to protect sensitive information and maintain EHR privacy.
• Service reliability: Infrastructure, backups, maintenance and ongoing support must keep information available when it is needed.

While many of these challenges can be managed internally, exchanging patient information across providers calls for a shared approach to recording, interpreting and protecting data. International Standards help establish that common foundation.

Standards for connected care

For an electronic health record to support connected care, the systems behind it need to interpret information consistently. A laboratory result sent to a hospital, for example, must retain its structure, meaning and context – and remain protected throughout its journey. International Standards help make this possible, so that information shared between systems remains understandable, usable and secure.

Within ISO, the technical committee on health informatics (ISO/TC 215) leads this work. Its broad portfolio includes the ISO 13606 series for exchanging EHR information, alongside standards covering architecture, terminology, data quality, interoperability, security and EHR privacy. Together, these standards provide a common foundation for sharing and protecting health information, so reliable data is available where and when it is needed.

• ISO 13606-1:2019Electronic health record communication — Part 1: Reference model
• ISO 13131:2021Telehealth services — Quality planning guidelines

The path to EHR adoption

A successful EHR transition starts with reliable technology and a clear understanding of the organization’s needs: how care is delivered, how information moves and where existing workflows create delays or uncertainty. These needs guide the choice of EHR software, from functionality and usability to interoperability and the ability to scale.

Once the software has been selected, organizations need a clear plan for the transition, with defined timelines, budgets and responsibilities. In particular, it should set out how data migration and workflow changes will be managed to maintain continuity of care. Planning these elements together helps healthcare providers anticipate pressure points and stay in control throughout implementation.

Staff and patients also need support through the change. Involving staff early, tailoring training to their roles and acting on their input helps the new EHR system fit into daily practice. Patients, too, need to understand what is changing, how to use the system and how their EHR privacy will be protected. A clear explanation of the benefits of electronic health records can build trust and encourage engagement, while continued feedback from both groups helps organizations assess whether the rollout is delivering the intended improvements.

Care you can count on

Every new consultation should be a step forward. For patients, that means less time reconstructing their medical history and greater confidence that the person treating them understands it. For health professionals, it means a clearer starting point for the clinical decisions ahead.

That’s an ambition worth building an EHR system around. As healthcare becomes more digital, success will be measured by how well information serves people: helping professionals exercise their judgement, giving patients a voice and making continuity of care an everyday expectation. Each of these advances brings us closer to the future we want for healthcare: connected, informed and centred on the patient.