Electronic Medical Records Lesson 1-5

Introduction to Electronic Health Records (Chapter 1)

A patient's medical record is a complete physical collection of an individual's healthcare information.

Paper records are few and far between and most medical records are found within an electronic health record, or EHR.

An health record is a combination of all the health information and document of a single individual. Keeping accurate and up to date records is essential for quality patient care.

L02-002 Clinical Information

The medical record is the primary source for a patient's clinical information.

Including:

-medical history

-progress/clinic notes

-medication lists

-allergies

-vital signs

-immunizations

-lab results

-imaging results

This information is primarily obtained during a visit with a physician or provider.

L02-003 Legal Document

The entire health record is a legal document, it also used in court proceedings for malpractice lawsuits.

There are also legal forms within the document including:

• consent forms

• medical records releases

• advance directives

• do not resuscitate (DNR) orders.

L01-004 Administrative Information

Information used by the front office staff and billing staff to maintain appointments and bill insurance companies appropriately.

This type of information includes:

• patient demographics

• insurance info

• prior authorizations

• referral letters, and so on.

L02-005 (Q1) Who documents in the Medical Record?

Anyone in the office who is involved in patient care will document in the chart, includes receptionists, administrative and clinical medical assistants, nurses, medical coders/billers, and providers (physicians, physician assistants, and nurse practitioners). Each party documents in a specific area of the chart, but there may be overlap between areas of documentation.

L02-006 (Q2) Who owns the Medical Records?

The medical records is considered the property of whoever created it, which may vary by location.

The one who creates and maintain the medical record is the owner of the medical record.

Patients control the information in their record and can gain access to any of their medical records by signing a release form. They can also request amendments.

The doctrine of professional discretion allows providers to use their best judgement regarding sharing medical records when dealing with patients with emotional or mental disturbances.

L02-007 Meaningful use (MU)

A payment incentive program for physicians who implement and use their EHR in a meaningful way to improve quality, safety, and efficiency; reduce health disparities; engage patients and family; improve care coordination and population; and maintain privacy and security of patient health information (PHI).

L02-008 The Four Buckets of Meaningful Use

• Adopt & Use CEHRT

• Utilize EHR functionality

• Upgrade to certified system

• Capture Data

• Very important

• Data captured today affects reimbursement tomorrow

• Move Data

(Interoperable between disparate system)

• Coordination of care

• Transition of care

• Report Data

• Report clinical data to CMS

-Required and expected

-Must also report to other registries

Stage 1 meaningful use:

Adopt & Use CEHRT and Capture Data

(Move Data and Report Data both a Stage 1 Test)

Stage 2 meaningful use:

Fall into four buckets very strong

L02-009 EHR Software:

Basic Functions of EHR

Includes:

progress notes, trending vital; signs, documentation with free text or templates, provider review of labs and reports, storage of forms (incident reports or release of information), electronic signatures, prescription templates with cross checks for allergies and interactions, patient portals, laboratory data, flagging of abnormal results, intraoffice messaging and email, fax and messaging functions, and maintenance or screening reminders for patients.

L02-010 Clinical Decision Support (CDS)

Allows providers to tailor care of a patient by making sure it adheres to guidelines for the specific diagnosis/diseases.

Some of the features of the CDS are to ensure that care complies with established screening recommendations for a patient's specific disease with reminders for preventative testing (that is colonoscopy, mammogram, immunization, or pap smear).

Treatment can be planned using evidence-based medicine using the patient's clinical data, generating patient data reports and summaries, documenting with templates specific to the patient's diagnosis, and performing database searches to identify patients that meet certain criteria to ensure they're receiving the appropriate care and screening.

The main limitation to the CDS tools is the provider taking advantage of it appropriately. If data isn't entered correctly, the function of CDS may be less effective.

L02-011 Practice management software (PMS)

DEMOGRAPHICS: Age, sex, marital status, language, race, contact information.

BILLING AND INSURANCE: Insurance cards should be reviewed at every patient visit and scanned into the system.

APPOINTMENT SCHEDULING: Each patient is scheduled to appear at the clinic on a specific day and time. There are time intervals for appointment slots, based on whenever the patient is new or established. An established patient has been seen by a provider in the office within three years and a new patient has either never been seen or it has been more than three years.

ADVANCE ACCOUNTING PROCEDURES: An account ledger is a document that contains the guarantor (responsible payer), patient's identifying and contact information, services provider, payments made, insurance reimbursement, account adjustments, and balance owed. After this is receives, a claim is submitted to a third-party payer, which is typically the insurance company.

L02-012 Advantages of EHR include:

Include: continuity of care, increased efficiency, easier access, reduced expenses, improved job satisfaction for providers, and improved patient satisfaction.

L02-013 Continuity of care (1)

One of the most important ways the EHR can improve quality of care.

Each specialist and the primary care provider having access to all of this information is important for providing quality and accurate patient care.

As many EHR s are internet-based, they can be accessed despite computers or a medical facility being destroyed by a disaster, leading to more accurate continuation of care.

L02-014 EHRs provide increased efficiency (2)

EHRs provide increased efficiency as patient information is readily available to any user.

Improved documentation with the use of preset templates, drop-down menus, and trying eliminates illegible handwritten notes, which in turn, eliminates errors.

Records, such as lab results and vital signs, can be linked and compared.

Proper documentation is important to facilitate communication among providers.

L02-015 Easier to Access (3)

Interconnecting EHRs decreases delays in initiation of care.

EHRs provide better security as they're protected by a username and password, with the password changing periodically. Each user has a different level of access. The system can be audited to determine what each user has viewed or modified to protect patients from inappropriate access to their medical record.

L02-016 Reduce expenses (4)

EHRs allow for reduced expenses - transcription fees and storage facilities for paper charts are no longer needed, and duplicate tests aren't being performed.

Improved job satisfaction - occurs as providers are more confident in the delivery of high-quality care and the support staff is more comfortable with day-to-day operations, such as phone calls, medication refills, and results of testing.

Improved patient satisfaction - occurs as patients feel that their phone messages and refills are handled better with EHR.

L02-017 Disadvantages of EHRs include:

Lack of interoperability

Cost can increase

Time consuming and costly effort

Employees resist

Regimentation

Security gaps

L02-018 Lack of interoperability

Health records for a patient may not be shareable among hospitals, primary care, and specially medical practices.

This can decrease efficiency, because it may involve more paperwork or more data being keyed into each EHR.

L02-019 Cost can increase

Due to high start-up cost and the need to purchase the software and potentially update hardware to support the new system.

L02-020 Time consuming and costly effort

Required to convert paper charts into the electronic format.

L02-021 Employees resist

Due to unfamiliarity with computer technology, including office staff and providers close to retirement, and providers can feel that they have more work and are less able to delegate tasks.

L02-022 Regimentation

More standardized documentation of progress notes, using templates and check boxes, can obscure the provider's reasoning or the narrative of the patient's story.

L02-023 Security gaps

Such as power outages, viruses, backup procedures, and computer freezes cause safety concerns for protection of EHRs.

L02-024 Professional Use of the EHR

Patient care is the primary goal when using the EHR. It is important to understand medical terminology and anatomy and physiology when deciphering through the EHR to interpret information presented in the chart.

Basic typing and computer skills, organization skills, and interpersonal skills are all attitudes needed to excel at using the EHR.

L02-025 Three items that might be found in a patient medical record:

Operative Reports