When you visit a health-care provider, important medical information, such as test results, prescriptions, and recommended treatments, become part of your medical record. Because many different doctors, nurses, and other providers may care for a person with cancer, they create several medical records at each location. Some providers use electronic health records (EHRs) in an effort to improve quality of care by having your complete medical history in a single, easy-to-find location.

What is an electronic health record?

An EHR is a computer-based record of a person's complete medical history that can be shared electronically between health-care providers. Unlike a paper record, doctors can quickly access a patient's medical record from anywhere, at anytime, via a secure Internet connection.

Benefits of an electronic health record

EHRs are part of a larger effort led by the U.S. Department of Health and Human Services to computerize health information. In 2004, President George W. Bush announced that he wanted most Americans to have an EHR by 2014. EHR supporters believe the records can improve patient health care by:

Preventing medical errors. Because EHRs are computerized, they may help reduce medical errors caused by handwriting that is difficult to read. EHRs may also notify doctors when a prescribed medication may interact harmfully with another medication a patient is taking, or when a patient has an allergy.

Reducing health-care costs. EHRs may save patients and health-care providers money in multiple ways, including preventing duplication of expensive imaging and laboratory tests and eliminating costly paperwork.

Reducing delays in treatments.

Reducing office wait times. EHRs may improve office efficiency by eliminating the need for patients to fill out health forms each time they see a new doctor. EHRs may also reduce the need to search through numerous paper files for patient information.

Improving communication between doctor and patient. When doctors have quick and complete access to a patient's information, patients may get more timely responses to questions. EHRs may also shorten the time a patient has to wait for a telephone call to be returned or a prescription to be refilled. Some EHRs also provide detailed post-visit summaries and instructions for patients.

Ensuring continuity of care. EHRs may help ensure people with complex diseases, such as cancer, are receiving the care they need. For example, treatment schedules can be tracked closely in EHRs and long-term treatment side effects may be avoided, detected early, or managed if doctors have all of the information they need about a patient's diagnosis and treatment.

Privacy and electronic health records

Medical information and records are protected under the federal Health Insurance Portability and Accountability Act (HIPAA). With some exceptions, this act states that medical information a doctor collects cannot be shared unless a patient gives permission for the information to be released. HIPAA also gives you the right to see or obtain a copy of your health records, even though they are owned by your doctor.

Personal health records

Not every health-care provider uses EHRs, and some health-care providers aren't able to share EHRs because they have different data systems. Right now, organizations are working on creating technology standards that would allow information in different EHR systems to be shared more easily. In the meantime, personal health records (PHRs) are becoming important tools for patients to keep a detailed record of medical care.

Unlike an EHR, which is owned and updated by health-care providers as required by law, you are responsible for collecting and maintaining the information in your personal health record. A PHR does not replace a doctor's legally required medical records. Creating a PHR is voluntary, not mandatory.

Follow the steps below to create a PHR:

Collect personal health information. Anytime you see a new doctor, you may give them access to part or all of your PHR, which could include:

• Personal information, such as name, birth date, address, and phone numbers
  
  
• Health insurance and pharmacy information
  
  
• Health conditions or diseases
  
  
• Dates and types of treatment received for a health condition or disease
  
  
• Any side effects or late effects of a treatment
  
  
• Screening and/or laboratory test results
  
  
• Allergies (such as latex, drugs, etc.)
  
  
• Hospitalizations and surgeries
  
  
• Medications you're currently taking or have taken, and the dose of each one
  
  
• Immunization dates
  
  
• Family medical history (visit https://familyhistory.hhs.gov/ to create one)

Choose a PHR format. You can create a paper-based PHR by filing health-care information in a folder, or you can scan that information into your computer. Some people use software on their computers that is designed to help manage personal health information. There are also Web-based PHRs that allow people to keep information online so that it can be accessed at any time from any device that connects to the Internet. If you use a Web-based PHR service, make sure you fully understand the vendor's privacy and security rules because not every vendor is required to follow HIPAA regulations.

Use resources. The American Health Information Management Association developed www.myPHR.com, a website that provides step-by-step instructions on how to create a PHR, a searchable list of available PHR tools and services, and health forms that you can download to your computer. The Cancer.Net Feature: Keeping a Personal Medical Record lists more tips and resources for organizing your personal health information.

ASCO and EHR activities

Cancer may result in a person having numerous tests and treatments. In addition, cancer survivors need a detailed long-term plan for follow-up care that may involve multiple doctors at multiple locations. Ensuring that health-care providers have your complete medical history that is available anytime is critical to your ongoing good health. The American Society of Clinical Oncology (ASCO) established a series of initiatives to speed the adoption of EHRs by oncologists (doctors who specialize in treating cancer).

ASCO developed the EHR Workgroup, which provides resources to help oncologists choose and use an EHR and guidance on a variety of EHR issues. Learn more about ASCO's EHR resources. ASCO is also working with EHR vendors to ensure that their products meet the complex requirements of people with cancer.

More Information

Organizing Your Cancer Care

Medical Forms

Additional Resources

Agency for Healthcare Research and Quality: Electronic Medical/Health Records

Department of Health and Human Services: Health Information Technology

The White House: Transforming Health Care: The President's Health Information Technology Plan