Information Contained in Electronic Health Record

May 4, 2022

Electronic health record (EHR) comprises of patient’s medical history, diagnoses, medications, treatment plans, allergies, immunization dates, laboratory results, and radiology images. EHR may also include administrative data, such as demographics and insurance information. EHRs are stored in digital format and can be easily shared across different health care organizations and providers like clinics, laboratories, medical imaging facilities, and pharmacies. These records contain all the clinical data involved in patient care which makes patient-centric information readily available to authorized users.

The following are key components within EHR that can be used in clinical trials:

Medical history and allergy

Includes the details of past and present illness, medications, allergies, surgeries, and immunizations. This information can be used to streamline and identify potential clinical trial participants. EHR-based screening and recruitment minimizes the time, effort, and cost involved in enrolling participants.

Clinical Evaluation and data collection

Includes clinical observation, assessment, treatment plan, and follow-up details. Data collection helps in evaluating the participant’s response to the study intervention and identifying the clinical needs of individual participants and the outcome of the clinical research, such as adverse events, and hospitalization.

Laboratory and radiology results

Includes the specimen collection details, laboratory, and radiology results. Test results stored as part of EHR reduce duplication of unnecessary and costly tests and procedures. Instantly sharing laboratory results and radiology images ensures real-time data is readily available to clinical investigators and study personnel to assess and make the right decisions.

The use of EHR in clinical trials provides opportunities to improve data accuracy and promote clinical trial efficiency. It facilitates a secure and seamless flow of clinical information and leverages digital progress in clinical research.

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