Electronic Medical Records – What Is It?

Electronic Medical Records – What Is It?

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.

electronic medical recordsTechnology 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.

electronic medical records definitionRecalling 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

Electronic Health Record Differentiated With EMR

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 recordElectronic 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.

electronic health record differentiatedWhile 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

Medical Records and More

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 recordsMedical 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.

medical records regulationsMany 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.

 

HIPAA Regulations Discussed

HIPAA Regulations Discussed

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 discussedHIPAA 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.

HIPAA regulationsThe 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.

Electronic Medical Records Adoption Checklist

Electronic Medical Records Adoption Checklist

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.

electronic medical records checklistWhen 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.

electronic medical records adoptionSwitching 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

EMR Adoption Priorities Checklist for Office Managers

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.

EMR adoption prioritiesThe 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

electronic medical records adoption checklistEMR 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.