Medical records are used to track events and transactions between patients and health care providers. They offer information on diagnoses, procedures, lab tests, and other services. Medical records help us measure and analyze trends in health care use, patient characteristics, and quality of care.
Electronic health records (EHRs) were first introduced in the 1960s, but only became popular in the 2000s1, in part due to the American Recovery and Reinvestment Act and the Affordable Care Act. EHRs can make it easier for providers to enter information about patients. The data from EHRs can then be used for research, like comparing how effective providers are, and seeing how patients respond to treatment. In the U.S., patient privacy is still protected even with the use of EHRs by the Health Insurance Portability and Accountability Act (HIPAA), enforced by the Office for Civil Rights (OCR) of the HHS.
Medical records are usually accurate and detailed because they come from health care providers. The data are automatically collected, including information that patients might not think to add or feel comfortable sharing through other data sources like surveys. Because the information is written down in a specific context, however, it can be misinterpreted if taken out of context. And of course, medical records are (by definition) only available for people who are able to get medical care. For researchers, it can be costly, both in time and in money, to obtain medical records in the United States, especially for large-scale studies. This is why surveys are often relied upon to collect information.
This chart shows the hospital discharges by first-listed diagnosis among children in the United States from 1990–2010. This information is gained from medical records.2
| Diagnosis | All ages | 0–17 | 0–4 | 5–17 | 5–9 | 10–17 |
|---|---|---|---|---|---|---|
| All Diagnoses | 1,165.3 | 337.6 | 585.1 | 238.6 | 167.2 | 283.8 |
| Infectious and parasitic diseases | 42.7 | 16.7 | * | 7.3 | 8.3 | 6.7 |
| Septicemia | 24.5 | 1.8 | 4.4 | * | * | * |
| Cancer, all | 41.6 | * | * | * | * | * |
| Endocrine, nutritional, and metabolic disorders | 59.3 | 18.9 | * | 12.4 | 11.1 | 13.2 |
| Diabetes | 21.2 | 3.9 | * | 5.0 | * | 6.3 |
| Dehydration | 10.9 | 9.1 | 23.3 | 3.3 | 4.7 | 2.5 |
| Anemias | 13.4 | 4.0 | 4.2 | 4.0 | 2.6 | 4.9 |
| Mental disorders | 68.2 | 32.0 | * | 44.0 | 12.6 | 63.8 |
| Alcohol and drug | 14.4 | 1.5 | * | 2.1 | * | 3.4 |
| Nervous system disorders | 33.0 | 15.8< | 28.0 | * | 10.8 | * |
| Circulatory system disorders | 197.3 | * | * | * | * | * |
| Heart disease | 127.9 | * | * | * | * | * |
| Arrhythmias | 26.1 | 0.6 | * | * | * | * |
| Heart failure | 33.8 | * | * | * | * | * |
| Respiratory system disorders | 116.0 | 73.4 | 183.8 | 29.3 | 42.8 | 20.8 |
| Acute bronchitis and bronchiolitis | 5.5 | 15.8 | 54.2 | * | * | * |
| Pneumonia | 38.2 | 21.8 | 53.9 | 9.0 | 14.8 | 5.3 |
| Asthma | 14.9 | 18.5 | 36.2 | 11.4 | 17.9 | 7.2 |
| Digestive system disorders | 114.7 | 29.2 | 38.1 | 25.7 | * | 28.6 |
| Appendicitis | 9.3 | 10.4 | * | 13.5 | * | 14.2 |
| Inflammatory bowel disease | 3.2 | 0.8 | * | 1.1 | * | 1.6 |
| Intestinal obstruction without mention of hernia | 11.3 | 1.8 | * | * | * | * |
| Genitourinary system disorders | 69.6 | 11.2 | 19.1 | 8.0 | 6.1 | 9.1 |
| Kidney disease | 18.3 | 1.3 | * | 1.1 | * | * |
| Urinary tract infection | 17.9 | 2.9 | 7.7 | 1.0 | * | 0.9 |
| Cellulitis and abscess | 22.8 | 10.0 | 21.1 | 5.6 | 6.0 | 5.3 |
| Musculoskeletal system and connective tissues disorders | 72.6 | 5.9 | 3.7 | 6.8 | 4.2 | 8.5 |
| Injuries and poisoning | 64.7 | 24.7 | 25.6 | 24.4 | 14.9 | 30.3 |
| Fracture | 36.1 | 10.6 | 9.8 | 10.9 | 8.0 | 12.7 |
| Certain complications of surgical and medical care | 34.2 | 5.3 | 7.7 | * | * | 4.5 |
1. Office of the National Coordinator for Health Information Technology. 'Office-based Physician Electronic Health Record Adoption,' Health IT Quick-Stat #50. https://www.healthit.gov/data/quickstats/office-based-physician-electronic-health-record-adoption.
2. "Hospital discharges by first-listed diagnosis among children: US, 1990-2010.". Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data.
