EMR Adoption, Selection and Implementation Checklist, medical records

Physical Therapy EMR Tips to Smoothen Implementation

by Nitin Chhoda PT, DPT | Dec 1, 2018 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Management

Nitin Chhoda provides a guideline that can be used when making the decision about physical therapy EMR. These tips are important, and if executed correctly, will positively affect the efficiency and productivity of your staff.

Physical therapy EMR systems transition are often interpreted as an uphill battle by clinicians and managers.

Gaining traction with all staff members and ensuring that the product is actually more efficient will be a big challenge at first.

Here are a few tips to help implementation of physical therapy electronic medical records go more smoothly.

Assign a Project Manager or Team Leader

Usually this job is given to the office manager or other administrative executive. No matter who does the job, it is critical that someone is responsible for pulling everything together. They will be responsible for figuring out which physical therapy EMR software is best for your practice and they will need to get buy-in from the entire staff.

They will set up a schedule for implementation and manage expectations so that nobody feels surprised or overwhelmed by the changes. They will also need to assess and inventory your current resources and decide what needs to be purchased.

Include Everyone

Having a point person is very important to implementing your physical therapy EMR. And one of the most important jobs that this staff member will do is manage the expectations of the rest of the staff. One of the hardest parts of transitioning to physical therapy EMR and software is that staff members are set in their ways and do not want to change.

Staff member buy-in should be prioritized by adding meetings or interviews to the schedule and plan. Each staff member’s job should be reviewed, to some degree, and the changes they will need to make should be determined and discussed beforehand.

Asking staff what would make their jobs easier and attempting to find the right physical therapy EMR that incorporates the needed improvements can make the process simpler and smoother.

Invest in Training Programs

Another thing that staff will find difficult is learning on the fly. If you are changing the way things work, you’d better train the staff beforehand. Physical therapy EMR should improve efficiency. While there will always be a bit of a lag at first, the more training given before implementation, the smoother the implementation will go.

Physical Therapy Specific Software

There are a lot of physical therapy EMR systems out there. Many are general and can be adapted to any kind of practice, from a general practitioner to a chiropractor or even a dentist.

But rather than worry about making a system fit your practice, find a system that is made for physical therapy documentation.

Physical therapy EMR and software will make billing, scheduling, and patient management more efficient. If you are just starting out and are looking for an EMR that will be easier to implement, find specific physical therapy EMR software.

Be Flexible

Make a schedule, ensure that the staff are ready, and transition your practice to physical therapy EMR software. But remember that there are always going to be challenges and the adjustment period will never be perfect. Build some flexibility into your schedule and ensure that staff have opportunities to refresh any learning even once the EMR has been implemented.

Electronic Medical Records – What Is It?

by Nitin Chhoda PT, DPT | Nov 18, 2018 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Software

The latest and most convenient way to process your physical therapy documentation is through the use of electronic medical records. Nitin Chhoda defines this system and how it affects the whole process within a physical therapy practice.

Technology has allowed humans to achieve amazing things, even in the past couple of decades. Consider that less than 40 years ago email was a science fiction dream.

Sending messages instantly from anywhere to anywhere else in the world were seemed impossible then. Even electronic medical records are not developed yet.

Today we take that convenience for granted, even though email and the Internet have made it possible for improvements in efficiency that were previously unimaginable.

What is EMR?

EMR stands for electronic medical record, and electronic medical records promise to be the technology of the future for anyone with any kind of medical practice.

An electronic medical record (EMR) is the digital, or paper-free way for medical practices of all kinds to track a patient’s care, medical history, and progress.

From doctors to physical therapists to dentists, anyone who treats a patient must adhere to certain documentation practices like having electronic medical records. However, until recently the only option was to write everything down on physical forms and review the notes before each visit with a patient.

Electronic medical records allow healthcare professionals to review information more quickly and provide better care to their patients. Consider that a clinician may see anywhere between eight and fifteen patients in a single day.

Some may be new patients, others are coming back for check-ups, and others have specific diseases or conditions for which they need regular testing. Without a photographic memory, it is impossible to keep up with all the details that are important to caring for each patient.

That is why an effective and correct implementation of the electronic medical records is very important. In fact, some clinicians find that just remembering the names of all their patients is a huge challenge.

Recalling Important Details

Medical records are critical to the process of recalling those important details, including things like which medications a patient is currently taking and what was discussed at their last visit.

Electronic medical records make reviewing this information quick and easy.

Rather than having to spend time looking for a medical file, electronic medical records make all the information carried around on a tablet or computer shared between the reception desk computer and the clinician’s computer with the click of a button. Files are pulled up instantly and are always legible.

Of course good medical recordkeeping is a continuous job. Clinicians and other healthcare professionals must update records during and after each visit. In fact, electronic medical records can even help a clinician to remember which questions they should be asking and which tests should be performed, based on what information must be entered into the electronic medical records.

EMR and Billing

Then, with automatic or manually triggered processes, a patient can be billed as soon as the appointment is over. All the appropriate filing for Medicare or health insurance company billing can also be handled by electronic medical records systems. And alerts can be arranged so that if bills go unpaid, the clinic staff can re-bill quickly and easily.

If you want to know what electronic medical records are, think about the way you would manage all patient information, billing, and recordkeeping. Imagine a system that integrates all administrative tasks with a system that allows all kinds of medical professionals to be more efficient and better informed when heading into an appointment.

Electronic Health Record Differentiated With EMR

by Nitin Chhoda PT, DPT | Nov 12, 2018 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Management

Nitin Chhoda describes the difference between electronic health record and electronic medical record. He gives examples on how these two terms are intertwined, and how they relate to the whole process of physical therapy practice.

Electronic health record or EHR sounds like it might be the same thing as an electronic medical record. However, these two terms should be used differently, in different settings.

While an EMR is a focused digital record that is only used by a single medical clinic, an electronic health record (EHR) is a digital record that is produced so it can be shared between two clinics.

For example, if a patient is admitted to the emergency room with injuries sustained from a car accident, an electronic medical record is started by the hospital.

Until the hospital discharges the patient, they will continue to update the record with diagnoses made, procedures conducted, and medications that have been given to the patient. Electronic health record implementation is still not present at this time.

Let’s say that the major injury sustained by the patient is a broken leg. When the patient is discharged, they will still be in a cast and will not be able to walk until the broken bones have healed. But once they have healed, it’s time for physical therapy.

EMR to EHR

When the hospital or clinician who has been treating the patient up until this point decides to prescribe physical therapy, they will produce and send an electronic health record to the physical therapist’s clinic.

EHR or electronic health record is a form of communication between medical professionals that summarize the information in a medical record and ensure that the new clinic has all the critical information about each referred patient.

Of course, electronic health record is not entirely mandatory and even transferring patient information from one clinic to another is not required. If the patient did not go to physical therapy right away, but then had trouble reducing pain and limping due to weakness after their injury, they could go to a physical therapist without bringing their official medical history with them.

A patient can request a personal health record (PHR), which is the term for an electronic health record handled by the patient. Or, the patient can have an EHR sent from their previous clinician to the new physical therapist. If they cannot do neither of these things, they can always attempt to describe their injuries to the physical therapist.

While an electronic health record is a useful technological advance which allows for rapid and legible transfer of information, not all medical clinics prefer the electronic system.

Electronic Health Record as a Long-Term

In some ways, the benefits of sharing electronic health record are more long term. In a patient-by-patient situation, clinicians may find it much easier to communicate electronically.

But the broader implications have to do with aggregate data. If clinicians can readily share statistics on the success of certain treatments for particular diseases, they can make more educated and informed decisions when making new treatment plans.

For now, most people who are used to using email and communicating quickly and efficiently, electronic health record seems to be the smartest way to cooperate with other medical clinics. In the future, they may transform the way that clinicians make the most of all available information.

Medical Records and More

by Nitin Chhoda PT, DPT | Nov 6, 2018 | Electronic Medical Records, Physical Therapy Documentation

Medical records provide health information about a patient. Nitin Chhoda discusses the value of having a complete and accurate information of a patient’s health records so that practitioners can decide the best treatment for a patient’s health.

Medical records of every individual contain personal, private information such as their blood type, previous diseases or conditions treated, and any medications being taken currently or in the past.

A medical record, which can also be entered in a physical therapy documentation process, will also include information about allergies as well as details about each visit to the healthcare provider’s clinic.

Like all legal documents, medical records are kept according to laws that usually relate to certification or licensing of a medical professional or medical clinic.

Maintenance of medical records is required by state or federal laws, depending on the specific requirements, and for good reason. Incorrectly maintained medical records could cause serious harm to the patient.

A doctor who neglects to record allergies to medications could be held responsible if a patient is administered that medication in the future because the information is not included in the patient’s medical record.

Medical and Health Records

Medical records can be the folder where all medical information for a single patient is stored as well as the cumulative history that a medical record provides.

A health record is the critical information about a patient contained in a medical record that is sent from one medical provider’s clinic to another.

Medical records can include charts, x-rays, prescription orders for physical therapies or medications, observations, test results, and the date of each previous visit to the medical clinic.

Any important type of note about the patient will also be included, such as pre and post operative notes and operative notes, admission notes, SOAP or progress notes, discharge notes, delivery and postpartum notes, and on-service notes.

Many of these notes are also regulated, so that certain procedures are always followed. The information contained in medical notes can inform the way a future clinician treats the patient.

Medical Records and More

A medical record can also be useful for future clinicians who may not have the opportunity or the context to know to ask certain questions about the patient’s medical history.

Until fairly recently, medical records laws were kept and maintained by health professionals only, and patients had little to no access to their own medical record.

However, today patient’s have more rights and can not only view their own medical record but have the opportunity to comment on some entries that they feel are inaccurate.

The other way that has helped medical care to improve is the use of medical records as educational materials. Medical school students and resident physicians can get the next best thing to first hand experience if they can compare a real medical record, which would be anonymous, to a current problem they are trying to diagnose or treat.

A Form of Communication

Besides being a compilation of all medical information relating to a patient, a medical record is also a form of communication and a way to share knowledge.

Because medical records can be so important and so helpful, there are legal precedents for maintaining medical records correctly. Medical services providers are also required to keep medical records for seven years after the last recorded addition to the record.

Health Information Defined

by Nitin Chhoda PT, DPT | Oct 28, 2018 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Management

Health information sounds like a vague and ambiguous term. It means different things to different people. In this article, Nitin Chhoda ‘breaks it down’ and defines health information in a manner that makes it meaningful for a private practice owner.

Nitin also highlights the implications of health information (and its privacy) for your practice.

As a general term, health information can be any information that relates to health. However, in a medical information management context, health information has a more specific meaning.

Health information refers to medical records, health records, and communication regarding patients that is sent between hospitals, doctor’s offices, health insurance companies, and anyone else in the health care industry, physical therapy management practice included.

Health Information and Technology

As technology improves, health information that must be transferred between clinics, or even between a clinician and nurses in the same practice, is traveling faster.

That means that we now can send sensitive and personal information with a single keystroke.

The technological improvements that are coming to all medical clinics are making communication simpler, faster, and more efficient, but some worry that health information will not be managed as well as before. A paper document is somewhat cumbersome when compared to electronic medical records or electronic health records.

Due to concerns about security and privacy, an entire industry has grown up around health care information management. But the management of health information didn’t start as a technological career – health information management has been around in the United States since the late 1920s. It is now possible to earn a degree or certificate in health information management.

The Skilled Professionals

Naturally, with improvements in technology there has been an increase in the need for skilled health information professionals who are also technologically savvy. In fact, many information health professionals are in favor of moving to entirely electronic systems to manage medical records and health records.

Medical records are used internally, within a single clinic or practice, but often must be accessed by more than one person. Nurses and clinicians, as well as receptionists, may need to know what is going on with a patient so that the proper tests are scheduled and performed.

Having an electronic medical records system allows for quick and easy access for everyone charged with caring for a patient. The same can be said for electronic health records, and many health information managers will say this is an area where electronic records are even more beneficial.

Electronic Health Records

Health records that must be passed from a surgeon to a primary care provider, or from a doctor to a physical therapist, can be more easily, efficiently, and securely transported using electronic health records.

Health information can also refer to the various forms and paperwork that is passed back and forth between a healthcare provider and a health insurance company.

For every insurance claim, healthcare providers must fill out certain paperwork and ensure that there are no mistakes.

This form of health record can cause problems when it is not filled out correctly, as an insurance company can reject a claim even if a small mistake is made.

Health information professionals often encourage healthcare providers to use electronic systems because electronic health records tend to be more accurate and are less likely to be filled out incorrectly than paper records.

HIPAA Regulations Discussed

by Nitin Chhoda PT, DPT | Oct 21, 2018 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Management

HIPAA was designed to protect patient privacy. Every private practice owner should be mindful of guarding patient health information.

Nitin Chhoda explains the link between HIPAA and your electronic medical records system and what you should look for in an EMR vendor.

HIPAA regulations can be seemed complex and overly demanding, especially if you run a small medical clinic or private practice.

However, there are a few very important things to know about HIPAA regulations, especially if you are going to use electronic medical records.

First of all, the regulations are not as stringent for smaller practices. In many ways, HIPAA was designed to focus on the biggest offenders first, but design a roadmap for everyone to eventually follow.

At this point, all medical clinics must follow the HIPAA regulations. When the law was first written and adopted, practices were given a lot of time to transition to the new forms and standards.

Some adjustments were made to accommodate problems that were discovered through the process. Compliance dates were set for 2003 and some as late as 2006. The National Provider Identifiers had to be used starting in 2007 and the smallest plans had a deadline of 2008.

HIPAA Regulations Related to EMR

Some of the most specific parts of HIPAA regulations are about maintaining and sharing medical records, and especially electronic medical records. It is likely that any practice that has been operating for any amount of time will already know about HIPAA regulations pertaining to documentation, and there are many places where you can find out what the standards are.

Most importantly, you should remember that if another medical provider asks for information about a patient or patients, you are only allowed to do so with permission from the patient and under conditions that merit the transfer of electronic health records.

Privacy is a major part of HIPAA regulations, so always err on the safe side when handling patient health information.

The technical safeguards detailed by HIPAA regulations include a few specifics that you must know about if you are operating a medical facility of any kind.

Some of these are obvious, such as the requirement that monitors should not be situated in a way that allows patients to see private information of another patient. A few more are listed below.

Access to hardware, software, and any equipment that contains health information is limited to authorized personnel and should be monitored carefully.
HIPAA regulations of individual practices and covered entities must be documented and submitted to the government so compliance can be verified.
Risk analysis and risk management programs must be in place, to assess how safe private health information is within the clinic and on the computers.

HITECH Act Effects on HIPAA

The HITECH Act was enacted in 2009 as part of the American Recovery and Reinvestment Act. There are a few requirements made that effect HIPAA regulations compliance.

First of all, if a HIPAA covered facility experiences the theft or exposure of private health information of over 500 patients, they must report the breach to the media, the patients, and the Dept of Health and Human Services. There are also regulations about how electronic medical records can be shared and stored.