Medical Record, Health Record, Health Information and Its Differences

Medical Record, Health Record, Health Information and Its Differences

Nitin Chhoda differentiates between the terms ‘medical records’, ‘health record’ and ‘health information’. The importance of HIPAA laws to protect patient privacy, and how this relates to EMR security is also discussed.

medical record information

With the advent of electronic medical record, a specialized vocabulary has arisen and it’s confusing to many. The terms are often lumped and used to indicate the same type of document.

While one type can encompass information contained in another, they’re distinctly different.

Therapists would do well to differentiate the three, as one contains sensitive information that can create a breach of privacy and security.

Medical Record, Health Record and Health Information

A patient’s medical record includes a wide variety of information that’s been compiled over an extended period of time by multiple healthcare professionals. It includes prescriptions, therapies, x-rays and tests, along with illnesses, surgeries and notes from any number of healthcare providers.

In contrast, a health record compared to medical record is compiled and maintained by a single healthcare provider. A health record is a comprehensive document that details the treatments provided by a single healthcare professional and are kept by the individual therapist.

Health information is personally identifiable data that’s protected by law to ensure privacy. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) set forth national standards for healthcare providers and institutions of all types for the collection, handling and maintenance of client health information.


HIPAA limits the types of medical record information that can be collected, the way it can be shared, and with whom. There are also restrictions on how much client’s medical record data therapists can use in their marketing endeavors.

Patients must be provided with a copy of their own medical records when they request them in writing. HIPAA also makes provisions for the sharing of client data or medical record among healthcare providers to coordinate care. Generally, client information can’t be sold.

Exceptions for the dissemination of medical record data are made when the data is used for research, public health reasons, or in the event of a company merger. It’s also permissible if the president declares a disaster or emergency, or if a public health emergency is declared by the Secretary of Health and Human Services.

EMR Transition

medical record definedWith the transition to electronic medical records, patients and many clinicians have expressed trepidation about the ability to maintain sufficient confidentiality and privacy of healthcare and medical record.

Those doubts and misgivings have prevented healthcare facilities and professionals in all fields to delay the transition to an EMR.

With the deadline of 2014 looming large on the horizon for EMR implementation, the question has been taken out of the hands of therapists. The question facing professionals now is which EMR they should choose.

EMR Security

Security is a primary consideration. Previous generations of providers could simply secure patient information within the office under lock and key. Electronic records require more stringent methods of protection to ensure individual health information and medical record isn’t leaked, stolen or hacked.

Therapists can opt for an on-site server-based system or a web-based solution. Those who select a server-based system are responsible for maintaining a sufficient level of security. With a web-based system provided by a vendor, HIPAA-compliant security is handled by the EMR provider.

Records management and the steps necessary to keep sensitive information secure will play an increasing role in the everyday operation of physical therapy practices for years to come. It’s imperative for therapists to understand the importance of securing medical information and the difference between medical records, health records and health information to avoid the inadvertent release of sensitive and protected data.

HIPAA Regulations 101

HIPAA Regulations 101

HIPAA laws are designed to protect unauthorized access to a patient’s personal and medical information.

Nitin Chhoda elaborates on HIPAA regulations and how to comply with them to avoid fines and penalties in your practice, and the role that your electronic medical records (EMR) system plays in the process.

HIPAA complianceHIPAA or known as the Health Insurance Portability and Accountability Act of 1996 is something with which every therapist must be closely acquainted.

The act sets forth the rules regulating patient privacy and security, and the way personal health records are collected, maintained, used and shared.

Therapists are in possession of sensitive client data each day and clinic owners must take steps to safeguard the security of those documents. Practice owners that aren’t in compliance with HIPAA regulations will find themselves facing harsh and costly fines, along with civil and criminal penalties.

HIPAA Regulations

The HIPAA privacy rule protects patients by prohibiting the release or sharing of individually identifiable health information. It applies to all forms of communication, including oral, paper or electronic.

Protected data includes a patient’s past, present and future medical condition. It includes demographic information such as name, address, date of birth and insurer information. There are exclusions under HIPAA, but therapists must be absolutely sure they’re not violating the law. The parameters are quite narrow concerning the release of client data.

There are unique circumstances in which a patient’s data can be divulged. For example, if the president declares a state of emergency or the Secretary of Health and Human Services declares a public health emergency. The client’s own health information can be released to them if they make the request in writing. HIPAA also makes provision for the release of information to parents and legal guardians of minors.

The usage of unidentifiable information is more liberal. It can be disseminated when used for public health reasons and research. Data can also be included in a wide range of marketing efforts, as long as no data leads back to a specific client, including names, addresses, social security and insurer data.

State Laws and Disclosures

HIPAA regulationsTherapists must also be cognizant of state laws of disclosure, always keeping in mind that HIPAA rules supersede state requirements.

Typically, states can divulge information to prevent payment fraud or abuse, for state reporting on healthcare costs and regulation of controlled substances.

As more clinicians implement electronic medical records, the question of documentation security will continue to grow and evolve to meet the changing needs of electronic medical record systems.

Physical therapy documentation software ensures practice owners are HIPAA-compliant, while providing superior security and safeguards. User login information and verification are required for authorized personnel.

The Connection between your EMR Provider and HIPAA

In an effort to comply with HIPAA requirements, consider the use of an EMR system. With a web-based system, records are maintained in the cloud instead of on local computers, laptops and tablets, where they’re safe from fires, floods and other natural disasters.

Server-based systems are kept and maintained on-site. Therapists run the risk of having equipment stolen that contains personally identifiable patient information. Identity theft and disgruntled employees also place records in danger.

Complying with HIPAA guidelines isn’t optional, it’s the law. It’s one that can cost practices dearly if patient information isn’t adequately protected and is inadvertently made available to unauthorized third parties.

Recent penalties for infractions ranging up to $1 million amply demonstrate this. It highlights the need for clinicians to ensure staff members are trained in privacy regulations and procedures. Even innocent mistakes could lead to penalties that can cripple a private practice.

EMR Adoption, Selection and Implementation Checklist

EMR Adoption, Selection and Implementation Checklist

If you are switching from one EMR system to another, you need to consider several factors including portability, integration and security.

Nitin Chhoda provides a detailed checklist to help you make the transition to an EMR system that will help you prepare for the future, streamline and automate your practice.

EMR systemThe selection of electronic medical records system is one of the most important decisions a practice owner will make over the next two years. It will affect every aspect of the clinic, from communicating with patients to submitting reimbursement claims.

With hundreds of available EMR options available, selecting a documentation software system can be an exhausting and confusing process without a well-thought action plan and clear expectations of what the system will accomplish. Look for the following features in an EMR.

  • Evaluation – Decide what the EMR is expected to accomplish within the clinic.
  • Teamwork – Form a team to evaluate the different EMRs and report back to the final decision makers.
  • Specialization – Choose a documentation system specifically designed for physical therapy practices.
  • Privacy and security – To maintain HIPAA compliance, therapists must ensure their EMR meets stringent requirements to safeguard personal health information. Practice owners that fail to do so will find themselves faced with costly fines, along with civil and criminal charges.
  • Customization – Physical therapy practices have unique need and an EMR should allow clinicians to create custom documents and templates.
  • Web-based – Select a web-based system that stores information in the cloud to eliminate the dangers of fires, floods, natural disasters and identify theft.
  • Workflow integration – Some therapists are attached to their existing systems and don’t want to give them up.

Choose an EMR that integrates any existing office software and offers the ability to remove old systems easily should they no longer be wanted or needed.

  • Portability – iPad compatibility is essential for portability throughout the office, at home and other venues where the clinic offers services.
  • Electronic billing – An EMR equipped with electronic billing reduces the turnaround time on reimbursement claims and allows for the quick submission of documentation and resolution of denials.
  • Communication – Interacting with clients can be automated to deliver appointment and billing reminders. Communications can be sent via email, phone, and text and voice messaging.
  • Patient portal – Clients can schedule an appointment, view test results, complete health histories and provide insurance information with a patient portal. Therapists can easily verify insurer information and contact patients if there’s a problem.
  • Prescriptions – The ability to submit medication orders to a wide variety of pharmacies saves time for therapists and patients.
  • Interconnectivity – Tests, x-rays and lab work from outside facilities can all be ordered from the office with an EMR. Therapists should ensure their EMR is compatible with other facilities in the area. Results can easily be returned to the office electronically and posted through a patient portal where clients can view them.

  • Importation capabilities – EMRs are designed to eliminate voluminous paper files, but the information contained within existing documents must find its way into the documentation software. It’s essential that the EMR offer the ability to import notes, documents and test results for a complete electronic solution.
  • Online training – Staff must be trained in the use of an EMR, but training provided by vendors often results in an overload for staff. Online training can be accessed multiple times and whenever it’s needed to reduce the learning curve and assist staff in retaining more information.
  • EMR adoption checklistCustomer service – Choose an EMR that provides automatic updates, 24/7 support, regular back-ups, and the ability to upgrade and add new modules as needed.

The idea of implementing an EMR can be a scary thought and has led many professionals to delay the process.

An electronic documentation system must be in place by 2014 and therapists need to initiate the search for a suitable EMR as soon as possible to ensure sufficient learning and shake down time before the deadline.

Medical Coding and Its Trends

Medical Coding and Its Trends

Medical coding can be done by a skilled professional or by a trained physical therapy billing staff. It is important that who ever is assigned this task is knowledgeable and detail oriented because it affects the billing and revenue cycle for the practice.

Nitin Chhoda shares the latest trends in medical coding and the role of ICD-10 codes to the medical practices.

medical coding

Incorrect medical coding costs small practices thousands in revenues each year. Medical coding can be a tricky process and requires the expertise of a trained professional, even with an EMR.

Physical therapy billing software will significantly reduce the number of errors and denials, but with upcoming changes in billing codes, clinic owners may want to consider hiring a certified medical coder.

Medical Coding and Billing

Medical coding is a complex and demanding environment requiring someone with special knowledge and expertise, and who is detail oriented. Some practices combine their billing and coding departments under the guidance of a single person.

A good physical therapy documentation system will include billing and coding functionalities that makes a coder’s job easier, but then clinicians must decide if they’re going to hire a certified medical coder or train one themselves.

Even with a top of the line EMR, nothing can replace the expertise that comes with an experienced and certified medical coder. They undergo extensive education and training, build upon their expertise with on-going re-certification courses, and are fully able to navigate changes and updates in the coding system as they occur.

They command more money for their medical coding services, but trying to train a new coder is time consuming and can cost the practice thousands of dollars while they learn.

The Coding Process

The introduction of EMRs adds another level of difficulty to the billing and medical coding process.

An EMR greatly facilitates the job of a professional coder, allowing them to maintain a constant rate of concurrent billing and coding procedures, reducing the ebb and flow of payments that can severely interrupt a practice’s financial health.

A factor that will radically affect the billing and medical  coding process is the switch from ICD-9 to ICD-10 codes in October 2013 that will introduce 100,000 new codes into the existing system of 13,600.

medical coding trendsCorrect coding is difficult enough – the on-going educational requirements for professional coders will make it easy for them to handle the many changes and updates.

The medical coding changes will affect every medical provider in the country and represents the first comprehensive update since 1977.

The coding changes take into account new diseases that have been discovered, a better understanding of old ailments, new medications and vaccines, and the effectiveness of those medications in treatment.

With mutating viruses and diseases that can be communicated among species, the coding change is long overdue. Global travel and journeys to under-developed countries sets the perfect stage for pandemics.

Switching to ICD-10 Codes

The switch to ICD-10 codes will help all practices provide medical coding that more accurately reflect treatments and procedures. The result is better patient care, quicker reimbursements and fewer denials.

The future is bright for professional medical coders. Their extensive medical coding training is a distinct advantage for practice owners who benefit from their expertise. Better medical coding means better and faster reimbursements, fewer denials, mistakes and errors, and issues can be dealt with quickly and efficiently. EMRs will help medical coders accomplish those goals in an expeditious manner.

EMRs will soon be a fact for every physical therapy practice. Clinic owners who implement an EMR system with correct medical coding will be ahead of the game when the coding changes take effect. Professional coders will play a major role in ensuring that clinicians are compensated for their time and services.

Medical Billing Mistakes to Avoid

Medical Billing Mistakes to Avoid

In this article, Nitin Chhoda reveals the common mistakes in medical billing and coding that can quickly impact the cash flow of a private practice.

Some of the mistakes such as illegible handwriting, use of language and incorrect details can be avoided by using an automated physical therapy documentation system.

medical billing mistakesMedical billing and coding errors, mistakes, oversights and insufficient coding represent the most costly problems that physical therapy practices face, resulting in the loss of thousands of dollars in revenue each year.

The busier the clinic, the more likely it is that the problem will occur. An EMR will help eliminate denials and late payments, but practice owners must make medical billing and coding a priority.

Insurance providers are scrutinizing reimbursement claims more closely than ever before, making it imperative that the person responsible for billing and coding be trained and knowledgeable in the specialized language of the profession and familiar with EMR practices.

Sometimes it’s the simplest codes that create denials and a professional medical billing coder can make a tremendous difference in the revenues collected.


The little things in medical billing and coding can wreak real havoc on revenues and result in denials. Identifying a male client as female, dates that don’t match, using outdated codes and not coding for a multiple diagnosis are just some of the ways therapists slow down their cash flow and generate denials. Illegible handwriting is always a problem and if the writing can’t be read, it can be deemed unbillable. Utilizing an EMR will eliminate such problems.

medical billingLanguage

Coders rely on therapists for the information needed to correctly code claims. The language and terms taught and learned in school aren’t necessarily those used in a real world practice.

It’s important for the therapist to include notes to ensure coders have enough information to bill at the highest acceptable level. Therapists should also impress upon medical billing coders the need to look at the explanation of procedures.


Physical therapists offer a wide range of services and products, but in a busy practice, some may go unnoticed when it’s time for billing. Failure to bill for ancillary services such as, medications and supplies dispensed in the office, along with x-rays and lab work that was performed, are just some of the ways that therapists rob themselves of essential income. Clinicians need to make a conscious effort to ensure that each service, appliance and aid is documented for medical billing purposes.


If the service, treatment or procedure isn’t documented, it can’t be billed. Coders can only work with the information provided, even with a technologically advanced EMR. Relying on the coder to “know” that a specific service was provided is pure folly. Document everything in detail and be clear about the type of service offered, including referrals and consultations. It may take a few extra seconds, but the extra time will pay off in greater revenues even in your medical billing.

Up- and down-coding

Medical billing for services at a higher level than documentation supports is embarrassing in the extreme. Many clinicians choose to down-code, hoping to avoid the specter of an audit, and only succeed in cheating themselves of valuable reimbursements.

Insurance Providers

Insurance providers aren’t infallible and it’s up to the practice owner to carefully oversee the explanation of benefits to catch medical billing mistakes when they occur. There’s a tendency to think once the reimbursement claim has been submitted, that’s the end of the process.

In truth, it’s simply the beginning. Insurance companies can lose or misplace claims, or never receive them at all. Therapists who don’t conduct regular audits on the state of their claims stand to lose significant amounts of money.

In the new economy, it’s essential that physical therapists code correctly to ensure they’re reimbursed for their time, services and supplies. Every precaution must be taken to provide clear and concise documentation. The implementation of a correct medical billing EMR will greatly reduce the number of errors, mistakes and denials for the financial health of any clinic.

In Touch EMR vs. OptimisPT Physical Therapy Software

In Touch EMR vs. OptimisPT Physical Therapy Software

When deciding on the right systems for your clinic, many physical therapy practice owners come down to a decision between two great choices.  In this article, we compare In Touch EMR’s integrated scheduling, documentation, and billing suite with OptimisPT Physical Therapy documentation software and OptimisPT Physical Therapy scheduling software.

Compliance, Security, and Federal Regulatory Standards

When deciding on EMR technology, security and compliance is the name of the game.  While OptimisPT physical therapy software uses high-quality security protocols and takes standard back-ups for data protection, In Touch EMR has the most secure server management and data backup procedures on the market.  In Touch EMR is also the first and currently only vendor in the rehabilitation space to be on the certified Health IT Product List, which is a division of the Federal office of the National Coordinator for Health Information Technology (a part of the Department of Health and Human Services).

In Touch EMR’s compliance and security protocols are vastly superior to other rehabilitation EMR/EHR software providers currently on the market, and in the event of an audit you’re going to want that kind of safety and security on your side.

To learn more about the Office of the National Coordinator, click here.

If you’d like to get more technical, click here to view the testing requirements and specs for ONC Certification and Health IT product listing.

Winner: In Touch EMR for superior compliance and security. Bonus to In Touch EMR for also being their own PQRS registry, which makes life a little easier for everyone.

The Creator Factor

For many practice owners, knowing that the higher-ups of a company they do business with understand the industry from a provider’s perspective is key.  Here’s how In Touch EMR and OptimisPT measure up.

In Touch EMR was founded by Nitin Chhoda PT, DPT.  He and is wife are both physical therapists.  Nitin serves as the company’s CEO and is actively involved in daily operations.

OptimisPT was developed by OptimisCorp, a for-profit company that owns several clinics.  OptimisCorp itself is owned by physical therapists.

Winner: We have to call this one a tie – both companies get a five star rating here for being ultimately therapist owned.


With the pleasantries out of the way, let’s discuss another crucial factor also at the heart of the decision making process: money.

OptimisPT pricing for web-based physical therapy EMR software is dependent upon a base price plus volume of visits.  For $200 monthly, you get 235 checked in and documented visits.  Beyond the purchased 235 visits, you pay $0.85 per additional visit with scaling based on volume.  The main situation in which we imagine this is advantageous is if you have a very high number of providers, most or all of whom have schedules that may change from high to extremely low and back again.  This set up may find you with a financial advantage in bursts, but can become confusing from a fiscal perspective and also doesn’t look to include any add-ons or bells and whistles.

In Touch EMR’s pricing is $49 per month per provider with price breaks based on volume (simply put: bringing on a higher number of providers at once will get you a better deal).  This also includes extra features such as marketing integration, email appointment reminders, and faxing directly through the system.  The structure is simple, inexpensive, and makes it easy to anticipate your bill.

Winner: In Touch EMR – less expensive and easier to understand.

Flexibility, Integration, and Support

OptimisPT and In Touch EMR both perform at the head of the class when it comes to flexibility with your bill.  Both allow for increases and decreases according to clinical need, however OptimisPT’s methods may lead to higher bills than anticipated due to volume.

On the documentation and development side of things, In Touch EMR takes the lead as their documentation platform is intuitive and template based, only mandating that Medicare-required questions be answered and allowing users to decide what questions are applicable to their patient-base.  Creation of custom templates for notes leads to faster documentation and a streamlined internal process.  When it’s easier to document, providers are more likely to finalize notes quickly and clinics get paid faster.  Additionally, In Touch EMR seeks out user requests for new features and add-ons and has an in house team of developers to carry them out.

For Integration, In Touch EMR and OptimisPT both integrate scheduling, billing, and documentation.  In Touch EMR also boasts an outsourced billing service, In Touch Billing, for those clinics looking to have billing done by an outside source while continuing to work with a company they trust.

In Touch EMR gets the victory in the Support area as they not only have live chat, email, and phone support, but also designate an Account Manager to each clinic who is the direct contact in charge of the clinic’s support and overall satisfaction.  It’s an interesting and unique approach to handling customer service that gives clinics a “go-to” support representative that gets to know them and their clinical needs.

Winner: In Touch EMR.  While OptimisPT Physical Therapy Software offers flex-billing and integration, In Touch EMR has a both of these plus a superior support structure, customizable documentation, and actively looks to user feedback for new features and enhancements.

Final Results

When comparing OptimisPT Physical Therapy Software and In Touch EMR side by side, it’s hard to come up with anything bad to say about either product.  Both are affordable products created by people who understand the world of physical therapy.

In the end, In Touch EMR comes away victorious as their security and compliance measures are unbeatable, their pricing works out to be easier and cheaper in almost every scenario, their support lends itself to one-on-one relationships between clinic and software vendor, and their flexibility in documentation and development gives clinicians every tool needed to document quickly while remaining compliant.