EMR Adoption, Selection and Implementation Checklist, medical records

Electronic Medical Records Adoption Checklist

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

Electronic medical records help simplify physical therapy documentation and billing, and serve to ease the life of the private practice owner.

Before you make a transition, Nitin Chhoda provides a checklist and series of questions to identify the system to use, and how to maximize its effectiveness for your practice.

When thinking about adopting an electronic medical records system, there are many things to consider.

The 4 Ws are: Who, What, Why, and When.

Who will come up with a plan for implementation, hold meetings to get buy-in from all staff, and make sure that there is support for everyone using the new system?

What type of software will you select and which brand is best for your practice? Why will your practice benefit from electronic medical records? And when will implementation be completed?

Who Helps Make the Transition Smooth?

The first thing to decide is who will be responsible for defining goals and identifying the requirements of your electronic medical records system? Determining the best implementation plan will probably require a project manager, who will be responsible for the nuts and bolts.

The project manager should work with a clinician or other practitioner who can ensure that the decisions being made will actually benefit the people who will be working with the electronic medical records new program.

For a small practice this may be one and the same person, but it is more likely that a committee or team will be able to accomplish things more smoothly. Because everyone on this team probably has other responsibilities, each will only be able to dedicate a little bit of time. By spreading out the job of getting buy-in and engaging all staff in the electronic medical records process, everyone benefits.

Why Make the Switch?

Answering this question is critical to adopting the right electronic medical records program. Are you hoping that the clinic will be better able to re-schedule after cancellations? Are you interested in making everyone more efficient when it comes to accessing electronic medical records? And do you want reporting options because you want to know where the inefficiencies in your practice can be found?

By answering these types of questions, you will be able to come up with a list of requirements for the electronic medical records program you finally select. This will aid greatly in answering the next question.

What Program Do We Choose?

The project manager will be responsible for determining what electronic medical records program will be the best program, but there are many variables that will help him or her make that determination.

They must consider how the program will be used, on what platforms, and whether or not different programs offer the things your practice needs.

When Do We Finally Switch?

The timing of your switch may change, but by giving yourself some deadlines you can ensure that goals are met on a schedule.

Switching over should be relatively smooth, and even though many people are reluctant to learn the new electronic medical records system, you will find that once they get used to it, they will be happier.

Becoming a more efficient staff member and seeing your clinic work more smoothly is encouraging and exciting. Having the control and power to measure your efficiency can really change the way you do business.

Electronic medical records training and adoption can be a very exciting process, and the more you plan and prepare, the smoother the transition will happen.

EMR Adoption Priorities Checklist for Office Managers

by Nitin Chhoda PT, DPT | Sep 9, 2018 | Electronic Medical Records, Physical Therapy Documentation

The responsibilities of an office manager in a physical therapy practice are significant. In order to function effectively as a manager, EMR technology plays an important role. Nitin Chhoda outlines the goals and skills necessary to improve efficiency as an office manager.

The job of the office manager in the electronic medical records adoption process requires a holistic approach and the willingness to do a lot of negotiating.

At first, there will be resistance to any new idea, especially if it requires that everyone change their habits.

We get set in our ways, and that is only human. But we are also very good at learning new tricks and getting set in new ways if we have the right attitude.

It is the office manager’s job to help foster a positive attitude. Of course, the office manager must also seriously dedicate him- or herself to the technicalities of implementing a new EMR system.

This will include a resource audit to determine what hardware you have and need, as well as a list of requirements for the new system. Below is one path that office managers can take through the process of EMR adoption.

Goals, Enthusiasm, and Skills for EMR Adoption

First of all, determine what your goals are. These will include individual goals of clinicians or staff as well as business goals for improving efficiency and reporting. These goals should be prioritized and they should be reasonable. In other words, you should be able to measure your success and goals should be achievable.

Once you have a set of goals, you can start to look for EMR solutions that can and will help you achieve those goals. EMR and EHR systems can vary depending on the designers, programmers, and goals of the system. Finding the system that will work for you will be one of the most important decisions you make.
The next step will require that you can think through the changes to come. What will the clinic need to change in order to adopt an EMR solution?

If you want to achieve certain goals, some staff may have to sacrifice comfort temporarily. But if you can see those changes coming, it will be easier to prepare for them.

And being able to see what is coming will help you to get the rest of the clinic on board. Building some enthusiasm and managing the expectations of your staff in EMR software adoption process will be critical to making it smooth. Everyone who will be affected should be briefed, asked for feedback, and told what they can expect. The end result should be commitments from all involved that they are ready and willing to make the switch.
There will then be a period when you must assess the skills necessary for EMR adoption and efficient use. The skills needed may not align with the skills of current staff, so training may need to be organized.

Resources and Planning

EMR adoption might require an upgrade to the current equipment. If so, you should identify those upgrades now and take care of those changes before implementation.

But once you understand the goals, skills, and resources available and needed for EMR adoption, you will be ready to come up with a plan.

Training, switching over, and implementation will take some time, but if you make a plan, you can follow it to completion.

HITECH Act Explained

by Nitin Chhoda PT, DPT | Jul 22, 2018 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

HITECT Act was created aside from the pre-existing HIPAA laws to strictly implement the patients’ security of information. Nitin Chhoda explains the difference between the two, and how they are connected to each other.

HITECH Act Protections for Patients

HITECH Act or the Health Information Technology for Economic and Clinical Health Act expands on the already existing HIPAA regulations protecting patient health information.

The result is that healthcare practice management providers must take certain steps when privacy issues arise.

If sensitive and personal health information has been stolen or possibly viewed, HIPAA covered hospitals or medical facilities must notify their patients within 60 days.

Within the HITECH Act, the term breach is used to mean

“unauthorized acquisition, access, use or disclosure of protected health information which compromises the security or privacy of such information, except where an unauthorized person to whom such information is disclosed would not reasonably have been able to retain such information.”

A breach of patient health information not only requires the medical clinic to report to the patients, but also to a major media outlet and to the Secretary of the Dept of Health and Human Services.

The HITECH Act even outlines what must be included in the notice, including the date of the breach as well as the date of discovery of the breach along with a description of what happened. Other information that must be included:

Steps that patients can take to avoid potential harm.
Description of what was stolen or viewed.
Description of what is being done by the medical clinic to minimize damage, investigate what happened, and avoid a similar incident in the future.
Contact information so patients can call, email, review, or write to the company for more information or if they have questions.

While some of the information in the HITECH Act may be familiar because it relates to pre-existing regulations from HIPAA, the major difference will be enforcement.

HIPAA is thought to provide these protections, but it is also considered to be very poorly enforced.

The HITECH Act puts enforcement as a top priority and includes hefty fines for what has been termed “willful neglect”, a very imprecise term that will be defined by cases in the future.

Additionally, the HITECH Act puts more pressure on “business associates” of healthcare providers. HIPAA allows these business associates to have access to information via contracts.

But now they will be held responsible for breaches in a more comprehensive way. Providers of EMR or EHR systems are considered business associates and will have to consider HIPAA security and privacy rules when designing EHR or EMR systems.

Incentives for Healthcare Providers

The HITECH Act isn’t all focused on procedure, however, and as it is part of the American Recovery and Reinvestment Act (ARRA), there are also some incentives for healthcare providers.

Most of the incentives focus on promoting the use of electronic medical records and electronic health records. Because electronic records cut down on long term costs, but require an initial investment that many clinics don’t want to make, ARRA and the HITECH Act offer financial benefits if you make the switch.

HITECH Act : Economic Stimulus for EMR Adoption

by Nitin Chhoda PT, DPT | Jul 15, 2018 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

Nitin Chhoda reveals a few ways that the HITECH Act can help a private practice switch to an electronic medical records system using a limited budget. He also shares the requirements needed so that the practice can qualify with the HITECH Act incentives.

While the HITECH Act may help improve the safety and security of electronic medical records keeping systems, the aspects that clinicians and healthcare providers are excited about is the incentives.

The HITECH Act provides financial encouragement to clinicians, hospitals, and medical practitioners for the “meaningful use” of electronic medical records. A total of $19 billion has been allocated for incentives.

Financial Benefits

There are some great financial benefits to switching to electronic medical records anyway, but the HITECH Act makes things even easier. Physicians could qualify for as much as $44,000 for electronic health record implementation and use over the five years that the Act is funded.

The incentives only apply to the Medicare and Medicaid programs, but they can only get incentives through one program at a time. This means that they can also accrue incentives through one program and then when that runs out, they can accrue the same amount through the other program.

The incentives were also meant to encourage providers to adopt EMR systems for HITECH Act as soon as possible. One deadline was for 2012, and next year the incentives will be lower than they are this year.

And after 2015, medical practices will start to incur penalties if they have not switched to an EMR, starting with a 1% Medicare fee reduction. After 2017, that fee reduction is increased to 3%, an after 2019 the fee reduction will be increased to 5%.

Regional Extension Centers

In addition to financial incentives for adoption of EMR, the HITECH Act also funded 70 regional extension centers that can provide administrative help and guidance for health care providers attempting to make the switch to EMR.

Specifically, these regional extension centers will help “providers select the highest-value option, defined as that which offers the most favorable cost of ownership and operation, including both the initial acquisition of technology, cost and implementation, and ongoing maintenance and predictable needed upgrades over time.”

However, there is no requirement that health care providers use the regional extension centers unless they need help implementing an EMR.

Qualifying for HITECT Act Incentives

The most important requirements for qualifying for HITECH Act incentives for EMR adoption are the proper selection of an EMR system and understanding “meaningful use”.

There are a total of 25 meaningful use criteria, and health care providers must demonstrate 20 out of those 25. Fifteen criteria are pre-determined by the HITECH Act, and out of the final ten, you must choose five. The criteria are measured in three stages over five years.

The first stage of HITECH Act requires that you use a certified EMR system and document set percentages of criteria electronically.

You will also be required to use the reminders and warnings systems that certified EMR systems have, share patient information, and report public health information and quality measures.

The second state of HITECH Act requires that you also send and receive lab results and other information using the EMR.

The third stage of HITECH Act requires that you also enroll patients using public health records, access patient data, improve population health, and report on national high priority conditions. Other criteria may be added in the future.

Medical Management Streamlined with EMR

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

Streamlining medical management is now possible with the use of EMR. Nitin Chhoda enumerates the benefits of EMR including the efficiency of billing, scheduling and managing productivity reports.

Clinicians, practitioners, and other private practice owners that use medical management are being forced to take certain steps toward efficiency.

The financial pressures of an increasingly hostile and uncooperative health insurance industry, combined with the fact that more and more patients are unable to pay their bills, has put clinicians in an uncomfortable bind.

How can you provide the best medical care possible if you are restricted by financial considerations? The transition may be a bit rough, but it looks as though private practices are going to get some major help by adopting electronic medical records.

Electronic medical records cut down on administrative costs, making it just a bit less expensive to run the clinic. But more importantly, they can streamline medical management and help the practice to run more efficiently.

Billing and Scheduling: Efficiency Traps

It turns out that much of an clinic’s efficiency is decreased because of errors and delays in billing and scheduling. The ways that EMRs can streamline the billing aspects of medical management may be obvious to some.

A billing system that tracks unpaid bills and sets reminders for the medical management personnel responsible for billing will increase the likelihood that bills will not be forgotten.

This is true for patients as well as health insurance companies. Most medical management and health insurance companies have very particular requirements for the filing of claims. These forms can be time intensive and frustrating to complete. EMRs that are designed to streamline medical management will include options for filing the appropriate paperwork and will include reminders so the paperwork is filed in the required timeframe.

Increased efficiency in scheduling is less obvious at first, but the benefits are certainly easy to understand. When a patient cancels an appointment, that time slot is easily lost and left empty. Scheduling components of EMR programs will ensure that all empty slots are filled when possible. They also allow for re-scheduling with a few clicks of the mouse.

Reporting and Medical Management

On the other hand, medical management professionals will tell you that one of the biggest challenges to improving efficiency is the lack of useful data.

On paper, it is overwhelming to attempt to compile reports that detail how many appointments have been missed, how many bills are left unpaid or the collection percentage, and productivity as measured by the number of patients scheduled for each medical professional.

EMRs offer reporting tools and instruments for medical management systems that make evaluation of the practice quick and efficient. Imagine if you could print a referrals report with a few clicks or figure out how many visits each patient typically schedules.

More Productive and Efficient

Medical management can be more productive and more efficient if these kinds of figures can be analyzed. Without EMR and reporting capabilities, this kind of analysis is overwhelmingly challenging and presents time barriers that are insurmountable.

Rather than relying on the business to continue as usual, medical management professionals and EMR systems learn what is working at your practice and what is not working. Once you know how things are actually going, you can take action to change it for the better.

Medical Coding As A Modern Necessity

by Nitin Chhoda PT, DPT | Jun 24, 2018 | Electronic Medical Records, Medical Billing, Physical Therapy Billing

Nitin Chhoda provides reasons why medical coding is necessary and the role it has in a private practice setting. By defining what medical coding is and what codes are involved, it helps simplify the process for practice owners and staff.

What is medical coding?

Medical coding is an important step between the treatment of a patient and medical billing for the procedures, tests, and services. Clinicians will talk to patients, administer or order tests, and write down notes about each visit.

Those notes may describe what the patient needed, and in turn a medical coding staff member will translate each billable item into the assigned medical code.

Every doctor, medical clinic, and hospital must record a patient visit and include any procedures and tests performed. No matter whether the patient, their health insurance company, or another party is paying the bill, medical coding will take place to document how the bill should be drawn up.

What are the codes that are used?

There are a few kinds of necessary codes that medical coding staff members handle. The first is ICD-9 codes, or the International Classification of Diseases codes.

The number 9 refers to the version of this form of classification, and in 2013 a new version will be introduced, ICD-10. CPT codes, or current procedural terminology codes provide a list of alphanumeric codes used by medical coding professionals in the United States.

HCPCS codes, or Healthcare Common Procedure Coding System codes, are used for Medicare and other insurance programs. All codes were developed in an attempt to streamline and standardize the way medical procedures and tests are described and billed.

Why is this necessary?

The most interesting thing about medical coding is that it comes from an interest in standardization. The fact is that most medical procedures can be described in a single way – medical tests and processes have been developed over time, and while that development continues, clinicians are taught a right way to do things fairly consistently.

Medical coding allows a medical facility to bill for anything using a standardized system.

If one hospital performs a surgery and describes it differently from another hospital, even though the procedure is essentially the same, a health insurance company is going to have a hard time determining whether or not they truly are the same procedure.

Rather than spending the time guessing about the appropriate amount that should be billed, medical coding allows everyone to agree in advance that a certain code can be billed at a certain rate.

Does that really work?

The sad thing is that this attempt at a system works in some ways and fails in other ways. The first problem is that health insurance companies change their billing requirements constantly.

Even if a certain medical code is used for a certain test, the billable amount for that test may have changed. Laws attempt to keep things flexible and reasonable, but everyone is still trying not to spend any more money than they absolutely have to.

On the other hand, medical coding has made it possible for trends in diseases and public health and safety problems to be tracked at local and national and even international levels. This kind of information and the data collected through medical coding can help to improve medical care.