Electronic health records

Electronic records

Paper health records are far less efficient than electronic ones: only one person can use a paper chart at a time, misfiling is common, and sharing data across departments or gathering it for research is difficult.

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, letting clinicians track data over time, flag patients due for preventive screenings, and monitor quality of care within that 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.”

Federal regulations now push all electronic records toward the EHR standard rather than the more limited EMR. Because EHRs can be accessed across organizations, they support continuity of care, reduce duplicate testing, and let information move with the patient - to the specialist, the hospital, another state, or across the country - including to 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 federal criteria for demonstrating that certified EHR technology is used to improve care, now administered as CMS’s Promoting Interoperability program. 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. For example, a patient’s name paired with a diagnosis is PHI, while a de-identified count of flu cases in a region is not, since it can’t be traced back to an individual. HIPAA requires that all PHI held in the following systems be safeguarded:

• EHRs
• EMRs
• Patient portals

Telehealth and virtual visits

Telehealth is the use of telecommunications technology to provide health care, health information, and education at a distance; telemedicine is the older, narrower term for remote clinical services that has been phased out in favor of the broader term “telehealth.” Telehealth is delivered through several methods, and patients often join a video visit through the patient portal:

• Live video (synchronous) - a real-time visit between patient and provider
• Audio-only - telephone visits, used where payers and state law allow them
• Store-and-forward (asynchronous) - images or records, such as a photo of a skin lesion, sent for a provider to review later
• Remote patient monitoring - home devices send readings such as blood pressure, blood glucose, or weight
• Mobile health (mHealth) - apps on a phone or tablet that patients use to track their health between visits

The medical assistant plays a key role in preparing and supporting a virtual visit:

• Send the visit link and instructions, and help the patient test the connection
• Verify the patient’s identity with two identifiers
• Confirm where the patient is located at the time of the visit, since a provider generally must be licensed in the state where the patient is located
• Make sure the patient can talk privately
• Collect the reason for the visit, the medication list, and any readings taken at home
• Document that the visit took place by video or by telephone

Beyond storing patient information, the EHR performs tasks that help providers and medical assistants catch errors and work more efficiently. For example, alerts can let the user know when a certain charge does not match a diagnosis code - for instance, a blood glucose test billed for a sore throat visit. In such cases, the software flags the mismatch and helps prevent errors that can lead to a denial of insurance claims.

The EHR also supports eligibility verification, referral management, and laboratory order integration; a later chapter, Capabilities of electronic health record systems, covers these in detail.