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Electronic Health Records

Guidance for electronic health records in Medicare.

Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 26, 2012

An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports   The EHR automates access to information and has the potential to streamline the clinician's workflow.  The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.

EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians.  The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.  

For example, the EHR can improve patient care by:

  • Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
  • Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
  • Reducing medical error by improving the accuracy and clarity of medical records.

For information about the Medicare & Medicaid EHR Incentive Programs, please see the link in the "Related Links Inside CMS" section below.

For industry resources on EHR, please see the links in the "Related Links Outside CMS" section below.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.