Physical Therapy Management & Physical Therapy Documentation

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.

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.

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: Defined

by Nitin Chhoda PT, DPT | Jul 8, 2018 | Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

Medical management in today’s world is not as simple as it was decades ago. Many practitioners believe they need to extend their education in order to properly manage their clinic. Nitin Chhoda defines medical management practice in the 21st century.

Clinicians and other healthcare practice management professionals spend a lot of time getting a thorough education. Unfortunately, their medical knowledge is not supplemented with quite enough business and medical management study.

Private Practice Trends

Some clinicians opt to get an additional degree in business or medical management so they can comfortably run a private practice. However, that is the exception and not the rule.

There has been a recent trend in private practices where clinicians are finding themselves in financial trouble due to mismanagement of expenses, billing, and health insurance companies refusing to pay for the provided care.

In some ways, the problems of private practice physicians in medical management are not their own fault at all. Insurance companies change their policies frequently, and what was billable one week may not be billable the next.

Additional Education

In response, new degrees and a new career path have been forged so clinicians or their staff can be educated about dealing with the particular challenges of running a medical practice. A medical manager is also often called the healthcare administrator, health services manager, or healthcare executive.

For those interested in medical management careers, you must complete at least a bachelor’s degree in business or a related field, and a master’s degree is highly recommended. The Bureau of Labor Statistics estimates that medical management is growing more rapidly than many other fields due to projections of an increase in demand for medical services over the next decade.

Medical management combines strategy, information management, and leadership for building and managing a successful health care practice.

Components

One of the major components of being able to manage a medical practice is having an understanding of the laws and requirements that health care providers must adhere to, such as HIPAA and the HITECH Act.

Clinicians are usually concerned with being able to do their job and take care of their patients as best they can.

What a medical management professional can bring to a private practice should include everything else, from understanding how to implement an EMR and EHR system to reporting to government agencies and ensuring that the practice is eligible for tax breaks and HITECH Act incentives.

The health care industry is changing rapidly and clinicians who run a private practice are starting to pay for inattention to administrative and management duties which they do not really have the time to handle.

There are medical management systems that attempt to streamline the way that medical clinics handle administrative tasks, such as billing, scheduling, and health insurance filing.

In fact, most EMR systems are equipped to handle medical management tasks as well as medical records. EMR and EHR systems will include scheduling and billing organization and reminders so that the clinic can be more efficient.

They can also ensure that the proper paperwork is filed for Medicare, Medicaid, and health insurance companies. Claims are often rejected due to illegibility or errors in the paperwork, and EMRs attempt to do away with those kinds of mistakes and rejections.