Table 4.
Operational Definitions of Basic and Fully Functional Electronic Health Record Systems
| 2008 Health Tracking Physician Survey | 2008 National Ambulatory Medical Care | ||||
|---|---|---|---|---|---|
| Survey Item | Basic System | Fully Function al System | Survey Item | Basic System | Fully Function al System |
| Is information technology available in YOUR PRACTICE for the following activities? | Does your practice have a computerized system for the following? | ||||
| Patient Information | |||||
| Patient demographic information | X | X | |||
| Demographic information including patient problem list | X | X | |||
| Access to patient notes, medication lists, or problem lists | X | X | Clinical notes | X | X |
| Notes including medical history and follow-up notes | X | ||||
| Order-Entry Management | |||||
| Write prescriptions | X | X | Orders for prescription | X | X |
| Transmitting prescriptions to pharmacy | X | Prescription sent electronically to pharmacy | X | ||
| Order laboratory, radiology, or other diagnostic tests | X | Orders for tests | X | ||
| Test orders sent electronically | X | ||||
| Results Management | |||||
| View results of laboratory, radiology, or other diagnostic test | X | X | Viewing laboratory results | X | X |
| Exchange clinical data and images with other physicians | X | Viewing imaging results | X | X | |
| Exchange clinical data and images with hospitals and laboratories | X | Images electronically returned | X | ||
| Decision Support | |||||
| Obtain information on potential patient drug interactions with other drugs, allergies, and/or patient conditions | X | Warning of drug interactions or contraindications provided | X | ||
| Obtain information about treatment alternatives or recommended guidelines | X | Out-of-range test levels highlighted | X | ||
| Obtain up-to-date decision support for diagnostic and treatment recommendations based on data about your patients and practice guideline | X | Reminders regarding guideline-based interventions or screening tests | X | ||
| Generate reminders for clinicians about preventive services | X | ||||
| Generate reminders for clinicians about other needed patient follow-up | X | ||||
| Adoption level; % of Physicians(95% CI) | 22.29 (21.01–23.63) | 7.84 (7.03–8.73) | Adoption level: % of Physicians(95% CI) | 11.16 (9.04–13.69) | 4.56 (3.09–6.68) |