What is an electronic health record (EHR)?

Most hospitals and clinics no longer keep paper charts as their main medical record. Instead, they use an electronic health record, or EHR. This is a digital system. It stores your visit notes, test results, imaging, medications, allergies, and diagnoses in one place your care team can pull up during an appointment.

A patient portal is a smaller, separate piece connected to that system. It's the website or app you log into yourself. There, you can see some of what's in your EHR, usually results, upcoming appointments, and messages from your care team. The EHR is the whole filing system. The portal is the one drawer you get to open.

Many patients are surprised, and sometimes frightened, to see a scan or biopsy result appear in their portal before anyone has called to explain it. This isn't necessarily a mistake, and it is not by itself a sign that something is being hidden. Many health systems release results quickly so patients can see their own information sooner. But it also means a number or a word in a report can land in front of you with no context attached, before your care team has had the chance to walk you through what it actually means.

If a result in your portal worries you, call your care team's office. Ask when someone can go over it with you. This is a reasonable, common step. You don't have to sit with an unexplained result alone until your next scheduled visit.

It's common to assume that once something is entered into "the computer," every doctor treating you can see it. That isn't always the case. HealthIT.gov says a complete patient record usually requires combining data from multiple providers over time, and that depends on different EHR systems being able to share data. When they can't, a record created at one hospital may not be visible to a doctor at another practice unless it is requested or sent.

This is one reason an oncologist may ask you to bring copies of prior scans, pathology reports, or notes from another provider. That's true even if you assumed that information had already been shared. It isn't a sign of disorganization on any one side. It's a limitation of how separate EHR systems typically work.

You can ask for your own medical records. Maybe you want a copy for your own records, for a second opinion, or to bring to a new provider. Your care team or the hospital's medical records department, sometimes called "health information management," can tell you how to request it. This is worth asking about early. Gathering records can take time.

An EHR and a patient portal are tools for storing and sharing information. They are not a substitute for a conversation with your care team. A portal message or a posted result can tell you a fact. It usually can't give you the full clinical picture, weigh that result against your history, or tell you what happens next. When something in your portal is unclear or concerning, treat it as a reason to call your care team. If you have severe symptoms, call 911. Don't treat it as a complete answer on its own. That is the safer way to use it.