Capabilities of electronic health record systems
Features of the electronic health record
The EHR system can perform a multitude of tasks, saving time and money in the provider’s office. The following are some of the features of a typical EHR system.
- Specialty software. Patient data are captured and processed into a system that is specialty specific, so that the terminology and patient care treatments are compatible with the provider’s specialty. However, additional features can allow the provider to include terminology from other specialties.
- Appointment scheduler. The appointment scheduler allows the staff to track and schedule appointments, matrix the schedule, and account for recurring time blocks. The appointments can be merged into specific types with default times so that lengthy procedures are not scheduled in short appointment blocks. The scheduler features also allow various search parameters; if a patient calls because he or she cannot remember the appointment time, a search can be initiated using the date, provider’s name, patient’s name, or other search keywords.
- Appointment reminder and confirmation. The system can be programmed to initiate automatic reminder or confirmation calls to patients. The staff can record the reminders, and patients are prompted to choose options, such as “Press one” to confirm or reschedule appointments.
- Prescription writer. The EHR system can produce electronic prescriptions, which can be printed and given to patients or automatically submitted to a pharmacy. Lists can be created with the provider’s most common drug choices and dosages. A patient allergies function can block the prescription of drugs the patient cannot take, and the system can generate a patient information sheet on new prescriptions.
- Medical billing system. The EHR billing system can manage all of the practice’s billing and accounting systems. The system also can interface with clearinghouses for electronic claims submission and tracking. Reports can be generated that provide accurate details of the financial state of the practice at certain intervals or whenever requested.
- Charge capture. The charge capture functions can store lists of billing codes (e.g., International Classification of Diseases [ICD] and Current Procedural Terminology [CPT]) in addition to charges associated with procedures, supplies, and laboratory tests. Evaluation and Management (E/M) codes are used during office visits to obtain the highest possible reimbursement; these help the provider maximize profits while remaining in compliance with the law. Alerts can let the user know when a certain charge does not match a diagnosis code; for instance, a blood glucose done for a sore throat. In such cases, the software alerts the user and helps prevent errors that can lead to denial of insurance claims.
- Eligibility verification. EHR billing systems can perform online verification of insurance eligibility and can capture demographic data.
- Referral management. Current and referring providers can be coordinated and automated, allowing the provider to share patient information with another provider. This reduces the patient’s physical effort of transporting copies of records back and forth to referring providers, eliminates the costs of such copies, and is faster and more efficient than copying and mailing patient records.
- Laboratory order integration. The laboratory order integration feature allows the user to interact with outside laboratories and to 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 e-mail and uploaded directly into the patient’s record.
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.
The EHR usually has a scheduling system that can be changed to manage the needs of the provider and office staff.
Nonverbal communication with the patient when using the electronic health record
Although many patients are covered under a type of insurance that requires them to choose a primary care provider (PCP) and to have a referral to a specialist, remember that the patient has the option of changing that PCP or specialist. The patient may decide to change providers simply because he or she does not feel comfortable with that particular provider.
Because the change process is relatively easy, the provider wants to keep his or her patients (in most cases), because losing patients means loss of income. If the care begins to seem impersonal, patients may feel a strong desire to change providers. Remember, patients are consumers of healthcare services, and they expect quality healthcare.
When using the EHR, the medical assistant must make sure his or her nonverbal communication sends the right message to the patient.
If the medical assistant constantly looks at the electronic device, the patient feels largely alienated from the information exchange process. Make eye contact with the patient while asking questions, looking at the screen only when needed to enter information.
Do not insinuate by physical action that the EHR is a “hidden entity”; for example, do not necessarily shield the device from the patient’s view when entering information. Although patients may not understand anything they see on the screen, they will feel more at ease if their information is not hidden from them.
Also, modify your stance so that the patient feels like a part of the information process. Just as sitting in a chair across from a supervisor’s desk can be intimidating, the patient may feel the same emotions sitting across from a medical assistant entering information into the EHR. Take an open stance; sit next to or at an angle to the patient to support the impression that those in the healthcare facility and the patient are partners in the healthcare plan.
The medical assistant must make eye contact with the patient when using an EHR.
Remember that patients have the right to make decisions in most aspects of their healthcare plans; therefore offer choices wherever possible. Never expect patients to make quick decisions about their care. They may want to consult family members or give some thought to important medical decisions.
Providers often assume that patients will automatically follow their instructions or orders; however, some patients prefer some time to think. Always follow up and make note of any wait time the patient requests, notify the provider, and enter that information into the EHR. Make sure timely communication is done with the patient and that any additional orders that need to be put in place are completed.
The many features of the EHR allow the medical assistant to be efficient and highly competent if he or she is willing to make an extra effort to master the EHR system.
Also make sure patients understand all instructions given to them regarding test procedures or preparation for procedures.
The customer service aspect of patient care is even more important when the facility uses an EHR system.
Transfer, destruction, and retention of electronic health records
In most medical offices, records are classified in three ways:
- Active, which are the records of patients currently receiving treatment.
- Inactive, which generally are the records of patients whom the provider has not seen for 6 months or longer.
- Closed, which are the records of patients who have died, moved away, or otherwise terminated their relationship with the provider.
An EHR system can be set up to automatically move the inactive records to another server so that processing time will not be slowed down, but the records are still readily accessible if the patient returns to the healthcare facility. Closed EHRs are also separated from the active records and are typically stored elsewhere. They may be placed on CDs, computer hard drives, or maintained in inactive cloud space by the EHR vendor.
Retention and destruction
Providers have an obligation to retain patient records, whether they are paper or electronic, that may reasonably be of value to a patient, according to the American Medical Association (AMA) Council on Ethical and Judicial Affairs. Currently, no nationwide standard rule exists for establishing a records retention schedule.
Medical considerations are the primary basis for deciding how long to retain health records. For example, operative notes and chemotherapy records should always be part of the patient’s health record. The laws regarding the retention of health records vary from state to state, and many governmental programs have their own guidelines for specific records retention. When no rules specify the retention of health records, the best course is to keep the records for 10 years. However, for minors, the facility should keep the records until the minor reaches the age of majority plus the statute of limitations.
If a particular record no longer needs to be kept for medical reasons, the provider should check the state law for any requirement that records be kept for a minimum time (most states do not have such a provision). The time is measured from the last professional contact with the patient. In all cases, health records should be kept for at least the period of the statute of limitations for medical malpractice claims, which may be 3 years or longer, depending on state law. In the case of a minor, the statute of limitations may not apply until the patient reaches the age of majority.
The records of any patient covered by Medicare or Medicaid must be kept at least 10 years. The HIPAA privacy rule does not include requirements for the retention of health records. However, the privacy rule does require that appropriate administrative, technical, and physical safeguards be applied so that the privacy of health records is maintained.
Some providers refuse to destroy or discard old records. Storage is less of an issue with EHRs as they take up much less physical space. Always refer to state laws when discarding health records.
Before old records are discarded, patients should be given an opportunity to claim a copy of the records or have them sent to another provider. The medical facility should keep a master list of all records that have been destroyed.
Releasing health record information
The healthcare facility must be extremely careful when releasing any type of medical information.
Requests for medical information should be made in writing. Electronic signatures may be accepted as long as they are obtained with proper process controls. HIPAA has designated that very specific information must be included on the Release of Information form, including specifically who the information is being released to, what specific information is to be released, and an expiration date for the release.
Accepting a faxed request for medical information or a faxed release of information from a patient is unwise. Even requests from the patient’s attorney or third-party payers must be cleared by the patient for them to obtain information.
Health information exchanges
The demand for electronic health information exchange (HIE) from one healthcare facility to another, together with nationwide efforts to improve the efficiency and quality of healthcare, is creating a demand for HIEs. As more and more providers move to EHRs it only makes sense to have a system in place that will facilitate the exchange of that information electronically to improve the timeliness of that exchange. Patient care can be improved because all providers will have access to the information needed to treat the patient.
The ONC states, “There are currently three forms of HIE":
- Directed Exchange —ability to send and receive secure information electronically between care providers to support coordinated care
- Query-Based Exchange—ability for providers to find and/or request information on a patient from other providers, often used for unplanned care
- Consumer-Mediated Exchange —ability for patient to aggregate and control the use of their health information among providers”
The implementation of HIE varies from state to state. There is some federal funding for the implementation of HIE that is being administered by the ONC.