Intro to Electronic Health Records - Chapter 1

Key Terms

Term Definition

American Recovery and Reinvestment Act (ARRA)

Elegible Professionals (EPs)

Main goals of MU program:

• Improve quality, safety, and efficiency and reduce health disparities

• Engage patients and their families

• Improve care coordination and population and public health

• Maintain privacy and security of patient health information

MU program was divided into 3 Stages.

EPs were required to demontstrate 10 Objectives and measures

1. Protect EHI created or maintained by CEHRT (Certified Helath Record Technology)

2. Clinical Decision Support to improve performance on high-priority health conditions

3. Computerized provider order entry for meds, lab, and radiology orders

4. Generate and transmit permissible prescription electronically (eRx)

5. Health info. Exchange - EP who transitions pt. To another setting of care or provider refers pt. To another provider of care and provides a summary care record for each transition of care or referral.

6. Use clinically relevant information from CEHRT to identify patient-specific education resources and procide those resources to patient

7. EP who receives pt. Form antoehr setting of care or procider of care or beleives an encounter is relevant performed mediccaiton reconciliation.

8. Patient Electronic Access - provides pt. With ability to view online, download, and transmit their health information within 4 Business days of the information being avalible to EP.

9. Use secure electronic messaging to communicate with pt. On relevant health information

10. Public Health Reporting - EP is in active engagement with a public helath agency to submit electronic public health data from CEHRT, except where prohibited, and in accodancce with applicable law and practice.

Contents of EHR

The Electronic Health Record

History of Health Records

• Used as early as 200 BCE and vitial in many different times during history

Sections of EHR

(Note: Some may overlap w/ eachother)

Clinical Information

• Med list

• Allergies

• Immunization records

• Lab reports

• Oath reports

• Surgical reports

• Hospital records

• Hx and physical assessment findings

• Risk assessment

• Preventive services

• Progress Notes

• Vitials + growth charts

• Imaging test results

Admin. Information

• Pt. demographics

• Name of emergency contacts

• Patient correspondence

• Referral and consultation letters

• Prior authorizations

• Insurance information, copies of insurance cards

• Helath insuracne claims status

• Billing account ledgers

• Superbills/Encounter forms

• Day Sheets

• Appointment Hx

• Dx and procedure orders

Legal Documents

• Health record release forms

• Consent Forms

• HIPAA Forms

• Notice of Privacy Practices (NPP)

• Advance directives (Living will, DNR, Health care power of attorney)

• Disclosure logs

Note: EHR, as a whole, is considered a legal document

Health Record Documentation

• Physicians, PAs, NPs, PT/OT, SW, Specialist, Surgeons, Medical billers Nurses, CCMA, CMAAs may all have documentation responsiblities

• All aspects must be recorded in EMR

• Process of Documentation can include handwritten, dictated, structured data entry, or scanned-in pt. Information

• Who ever created the record is the one who owns it.

• Should be noted that pt. Has legal right to access or view copy of medical information at anytimes and has right to request resticted access, amendments to errors, and obtain list of disclosures.

• Med. practices may charge a fee for coping a health record. However, a provider cannot withhold copies of the health record if a patient has an unpaid balance on their account.

• Exeption to pt’s right to health record is called the Docterine of Professional Discretion. States providers can exercise best judgment when deciding whether to share progress notes and clinal observations with a patient who is being treated for mental or emotional disturbances.

Varity of EHR software is available, but in order for a provider to be considered ameaningful user and avoid penalties from CMS (Centers for Medicare and Medicaid Services), EHT software must meet criteria for structured data established by the ONC. CMS focus for EHR is on interoperability and improving patient access to health information.

Basic Functions of EHR

Fundemental capablities

• Progress notes

• Documentaiton using free test, prediefined clinical templates, or user-defined clinical templates

• Provider review of incoming lab datea and reports

• Pt. correspondence

• Storage of office forms (incidence reports, inventory, petty cash, ROI)

• Images and Report attachment Function

• Electronic Signature Insertion

• Prescription (CPOE) templates that provide dosage, suggest alternatives, list prices, cross-check prescriptions for drug interactions, pt allergies, and avaliblitiy in the fomulary

• Fax + messaging function to transmit presctipons directly from EHT to pts pharmacy

• Reminders for pt care (ex. Due for screening, health mateience test or procedure)

• Vital signs data capture

• Patient portal

• Importation of lab data from outside or in-house lab, usding industry-standard formats

• Automatic flagging of abnormal data and test results

• Intrasoffice messaging and email functions

• Summary and print functions

Pt. Identifiers Within the EHR

• MRN - Medical Record Number, Automatically assigned to a patient and used to locate pts record within EHR. Name + DOB can also be used to locate the record.

• Can verify pt Identity with Name + DOB, can also ask patient to spell first or last name.

Clinical Decision Support

• Allows providers to tailor care of individuals by making sure it adheres to published guidelines for their Dxs

• Ensures pt care complies with established screening recommendation for disease for which they are at risk

• Plan treatment in accordance with evidence-based treatment guidelines. May also help practitioner can make more accurate and timely diagnoses with aid of advice generated by EHR system based on pt’s clinical data

• Gernate pt data reports and summaries

• Complete documentation templates specific to pt’s Dx

• Perform database searches to identify patients who meet specific criteria to ensure they are getting teh recommended care + Screenings

• Daignostic Imaging Utlizaiton Act of 2013; requires use of CDS tools when ordering diagnostic testing and added that providers who wish to receive MU incentive program funding must implement at least one CDS element for patients

Practice Management Software

• Allows electronic management of the business side of the practice

• Includes handling of pt demographics, tracking billing and insurance information, sceduling appointments, and processing paymetns for patient visits

Pt Demographics

• PMS compiles all of a pts demogrpahic inforamtion (socioeconomic info. Such as age, sex, marital status, educaiton, occupation, language, race, eithnicty)

• The pt demographics tool in SCMO stores all of the information on three tabs: Patient, Guarantor, and Insurance

Billing and Insurance Information

• Determines who i slegally responsible (the guarantor) for the pts account

• Adults are usually their own guarantor, a parents or gaurdians are usually a minor’s guarantor

• Important to obtain guarantor’s name, address, and DOB

• Pts health insurance card, if insured, should be reviewed at each visit and scanned inot system if different from previous visit

• Information on Insurance card will include the types of medical insurance, the subscriber (person responsible for paying the premium), insurance carrier, claims submission address and phone number, policy and group numbers, and required copayments.

Pt Identifiers in the PMS

• PMS will have billing number, account number, or guarantor number used or pt billing and sending insurance claims.

• Number will be included in any response from the insurance company to ensure correct account is located for billing purposes or to get additional information needed by the insurance company.

Appointment Scheduling

• Electronic Appointment Scheudling allows quick search of available appointments, easy rescheduling, documentation of cancellations, and quick links to pts clinical record

• Most common appointment is a fixed appointment; the patient is asked to appear at a specific time and date

• Fixed appointment times may range from 10-20 minutes for acutely ill established patients to an hour for new-patient visits.

• Less within last 3 years = established patient, new patient not seen in past 3 years = non-established patient.

Advanced Accounting Procedures

• Accounting procedures performed by practice management software

• Include creation + management of patient statements

• Generation of day sheets

• Completion of insurance claims in HIPAA 5010 Claim Format

• Account ledger is a document that contains a responsible payer’s name (guarantor), pt’s identifying and contact information, services provided, payments made, insurance reimbursements received, account adjustments, and balance owed.

• Day sheet or Day journal is a register of daily business transactions.

• Acts as a system of checks and balances for the office as it prepares to make deposits into the bank

• After pt’s financial information has been documented for the medical office, a cliam must be submitted to a third-party payer if the pt is covered by a health insurance company.

• HIPAA 5010 is a standard electronic format that speeds cliams processing for physicians and suppliers

• Built into these systems is ability to flag errors and discrepancies.

• Can include an error report when information is being uploaded from one system to another or when a prescription is entered for a medication that a pt is allergic to

• Report would require someone to follow-up, find reason for the error, and then correct it.

• PMS may also use a claim scrubber to evaluate data entered for claim submission

• Scrubber looks for missing data or data that doesn’t match and generates a report so that the missing information can be entered or information can be corrected

• Claim payments will not be delayed due to denied claim

• Audits

• Should be done on a regular basis

• Internal audits can help to catch compliance issues before the regulatory agency and allow for correction of issues before a fine can be issued. Can also identify where training may need to occur to correct the issue.

• Discrepancies within and among EHRs, PMS, or other software systems once discovered, should be reported immediately to ensure prompt corrective action.

Advantages of electronic Health Records

Improved Quality and Continuity of Care

• Labs are avalible much quicker

• Makes for a more efficient workflow in all aspects of the medical office

• Allows prompt and accurate communication between medical professionals

In context of Managing Patientes with Chronic Conditions

• Allows specialist to plan and coordinate treatment easier

Disaster Preparedness and Response

• Records are easier to access in the event of an emergency

• EHRs are backed up by a secure web-based system and can be more durable than paper records during disasters and emergency situations

Increased Efficiency

• Allow for many different medical staff to gain the information needed

• Decreases need for paper records - records take up less space, less time spent finding them

Improved Documentation

• Electronic records eliminate need for hand-written documentation - less errors in relation to poor penmanship, less occurrence of incompleted notes

• EHR can link records electronically and allows providers to compare previous test results or vitals

• Reduces data entry errors and ensures a complete, accurate, and legible record

Why it is important to Document Properly

• Facilitates communication between health care professionals

• Avoid delay of reimbursement or denial of claims

• Comply with insurance companies and accreditation companies enforcement of documentation guidelines for healthcare facilites

• Aid work of investigators and regulators during legal issues (incl. Subpoenas of helath records in court cases and state investigations)

• Protect practice in case of a malpractice suit.

• Establish evidence of care

Easier Accessibility at the Point of Care

• Gives Medical Professionals a broad, accurate idea of pts health status

• Decreases delays in initiating care

Better Security

• Having the use of Usernames and Passwords help ensure that only authorized individuals access patient health records - system administrator will determine how much access and user has

• HIPAA requires users to change passwords periodically

• Can track or audit user access and can show what users have viewed or modified a patient record

Reduced Expenses

• Eliminates need for most transciption

• Reuceing need for paper storage facilities

• Reduces duplication of services

• CDS can flag test orders that may be unnecessary for that pt

Improved job Statisfaction

• Once EHR is adopted and fully implemented, most say they’d never go back to paper charting

• 79% of physician users were happy with EHR systems (2019)

Providers

• Many providers feel they are delivering high-quality care after EHR is implemented

• Allows for easier time contacting pts for a drug recall

• Smaller pracitices can deliver better quality at Point of Care]

Staff

• Support staff feel they are better able to manage a busy practice when using an EHR

• Staff spend less time doing tasks such as chasing charts, clarifying prescription orders for pharmacies, preforming billing, coding, and transcriptions during pt appointments.

• Communication with providers requires fewer interruptions during pt appointments

Improved Patient Satisfaction

• 2020 survey - 81% of adults support increaed access to health information for patients and providers

• When using EHRs, pts feel more confident calls and messages will be returned quickly and prescriptions will be filled promptly

• Pts have easy access to their health information with ease of appointment scheduling and getting test results back

• Easier for provider to find information needed when looking at a chart

• A positive effect on interaction between providers and parents during pediatric visits

• EHR systems posed more open-ended questions and allowed for a conversational style that was more pt centered than those who didn’t use EHRs

Disadvantages of EHRs

Lack of Interoperablity

• compatibility between different EHR systems is not yet universal

• If in an incompatable format, information must be hand-keyed into the record or appropriate template must be filled out; more time consuming, can lead to errors, decreases efficiency, increases cost, and can discourage small providers from adoping EHR systems

Cost

• 70% of all interactions between physicians and patients occur in practices that have 4 or less physicians (small pracitices). Like a business they must control cost, weigh benefits of capital investment and decide how staff time will be spent.

Financial Investment

• Cost of EHR implementation can depend on type of system being used.

• medical office must buy the software system or subscribe to an EHR vendor to record and store patient charts

• Hardware may need upgraded to support the software

• Customization of EHR can raise the cost

• Healthcare organizations can expect to spend up to 70,000$ per provider

• Grants and Incentives are available to offset some of the cost of implementing an EHR

• MU legislation offers federal incentives who use EHR systems in meaningful ways

• According to federal law, providers who don’t successfully demonstrate MU of an EHR for medicare patients can get a reimbursement penalty of 1-5%

• Providers should purchase EHR systems listed on the CHPL (Certified Health IT Product List)

Time

• Productivity may be lost while staff members are training instead of doing their normal jobs and company may have to pay for the training sessions

• Converting charts from paper to electronic format is timely and costly and takes staff away from normal jobs and limits amount of patients who can be seen during the transition

• All of a pt’s information must be entered in the EHR before it can be used for that patient

• Process can divert resources from patient care and office support function for weeks or even months

Employee Resisance

• Medical Professionals who have been in the field for a long time may resist the conversion to an EHR

• Some may feel that the RHT is diffucult to use and mmay not be familary with computer techonoogy

• Providers may feel as if they are doing busy work that they used to be able to delegate to staff

• EHRs can change how administrative and medical tasks are carried out in the office

• Job responiblitsie and duties often need to be modified

• Addtional steps and time for proper documentation may distract EHR users from patient care as they learn new technology

Regimentation

• Standardization in computer systems cannot account for idiosyncrasies.

• Some providers complain that EHR systems rely too heavily on check boxes and quantitative data rather than descriptive terms and narrative.

• May believe that need to standardize documentation takes the art out of the science of medicine

Security Gaps

• Security standards are outlined by HIPAA and HITECH (Health Information Technology for Economic and Clinical Health) Act.

• Power outages, virueses, backup procedures, and compputer freezes and crashes pose safety and security concerns for medical offices using EHRs

• System security is important to proving compliance with MU program - providers must prove that standard and compliance programs are in place

Role of Healthcare Professional using the Electronic Health Record

Working Knowledge of medical Terminology and A&P

• Having this knowledge helps with proper documentation and interpret information that's already documented in the pt chart.

Basic Typing and Computer Skills

• Skill is crucial to effective use of EHR

• Eases navigation through the system

Organizaitonal Skills

• Helps organize an office by keeping pt data organized in one place, ensures patients’ care and office workflow are managed effectivly on busy days

Interpersonal Skills

• When learning to work with an EHR, Patience and helpful personality are key to keeping staff moreale high

Duties and Workflow

• Cross-training, flexibility, and multitasking are important in the medical field

• Keeping up with tasks during the learning process may be frustrating and is important to remember patient care is top priority

Administrative

• Admin. Task may include… Reception duties, Appointment scheduling, Electronic chart creation, Inactive chart purging, Gathering and entering patient information, Creaing patient correspondence, Maintaining email communications, providing patient instructions, Coordinating patient care (incl. Patient refferals, treatments, and procedures)

Clinical

• Clincal such as progress notes, laboratory requisitions, prescriptions, and test results, must be documented

Billing and Coding

• Aid in Billing and Coding by…Submission of superbills/encounter forms, Creation of billing statements, Assignment of procedural diagnostic codes, Linking procedural and diagnostic codes for reimbursement, Auditing, Organizing office finance (day sheets, deposit slips, and patient account ledgers), Generating prior authorization forms, Monitoring submission and follow-up claims (insurance claim tracers)

Considerations for Remote/Virutal Training and Support

Consideration needed for providing remote/virtual training

• Equipment needs - does everyone have items such as a camera and a microphone

• Internet Access - Does everyone have reliable internet access

• Learning styles - Account for different learning styles and have content to accommodate for such

• Protection from online intrusion - Users must have online security to protect information that is being shared or accessed.

Coaching and Mentoring

• Many different material that can be used when training people on EHR

• EHR vendor may provide training manuals to explain basics of the system but organization may have a training manual specific to their organization

• All training provided should be documented - incl. Who received training, when it ewas provided, and what the training involved