Electronic health records

Electronic records

Paper health records have been shown to be much less efficient than an EHR. In most cases, only one person at a time can use the paper record. It is fairly common for information to be filed in the incorrect record. The entire record also can be misfiled. Gathering data for research and quality control is more challenging. Data is difficult to share in facilities with multiple departments or locations. The paper-based record is good for the documentation of patient care, but it is not nearly as useful in other capacities.

With an EHR, multiple users can access the record at the same time. There are fewer errors because handwritten notes do not have to be interpreted. Most EHR’s link the clinical information needed for billing purposes. An EHR also includes practice management capabilities that allow for patient scheduling and the generation of reports needed for research and quality control.

It is important for the medical assistant to be aware of the differences between the practice management software and the EHR. You may use both during your day as a medical assistant. The EHR contains a record of patient interactions and health history. The practice management software allows the facility to operate the business side by maintaining schedules and financial information for revenue cycle management for reimbursement.

EHR versus EMR

The acronyms EHR and EMR may cause some confusion. These acronyms have been used interchangeably for many years.

Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

• Track data over time
• Easily identify which patients are due for preventive screenings or checkups
• Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations
• Monitor and improve overall quality of care within the practice

But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.

Electronic health records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”

EMR is being used less and less as the federal regulations regarding electronic records have been established. There is a significant push toward having all electronic records meet the definition of an EHR. There are many advantages to having an electronic record system that can be accessed from more than one healthcare organization. The continuity of patient care is much more easily established when all providers have access to the same records regardless of what organization they are working for. There should be less running of duplicate tests and procedures, which will help reduce the cost of providing healthcare.

The information moves with the patient—to the specialist, the hospital, the nursing home, the next state or even across the country. EHRs are designed to be accessed by all people involved in the patients care—including the patients themselves.

Patient portal

Another way for patients to access their healthcare information is through a patient portal. Patient portals allow patients to access their actual EHRs. At any time, a patient can view progress notes, laboratory results, medications, or immunizations. Many portals also include the following information:

• Communication between the patient and the provider
• Completion of forms online
• Requests for prescription refills
• Scheduling of appointments

By establishing effective patient portals, healthcare facilities can meet some of the meaningful use requirements. The security of electronic records is a big part of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA uses the term protected health information (PHI), which is any information about health status, the provision of healthcare, or payment for healthcare that can be linked to an individual patient. HIPAA requires that all PHI be safeguarded. This applies to the following:

• EHRs
• EMRs
• PHI
• Patient portals

The electronic health record (EHR) can perform numerous tasks, in addition to displaying personal information about the patient. This allows the provider and medical assistants to interact with patients and provide better service.

Alerts can let the user know when a certain charge does not match a diagnosis code—for instance, a blood glucose test done for a sore throat. In such cases, the software alerts the user and helps prevent errors that can lead to a denial of insurance claims.

• Eligibility verification: EHR billing systems can perform online verification of insurance eligibility and capture demographic data.
• Referral management: In the case of a referral or consultation, sharing information with another provider can be done electronically. The patient does not have to obtain copies of the record and then take them to the new provider. This also eliminates the cost of making copies and is faster and more efficient than copying and mailing patients’ records.
• Laboratory order integration: The laboratory order integration feature allows the user to interact with outside laboratories. The EHR can receive and post laboratory results to patients’ records. Tests can be ordered from the provider’s laptop, tablet, or smartphone. Results can be transmitted by fax, scan, or email and uploaded directly into the patient’s record.