Ch. 1 I An Overview of Prime Suite's Practice Management and Electronic Health Record Software

Interoperability

Many different functions can take place and information can be shared between computer systems, or within applications of the same computer system, which is not possible with a manual or paper record system.

Practice management is also known as....

1. R-ADT: (Registration, Admission, Discharge, Transfer) 2. Billing systems

Why Adopt Electronic Health Record Applications?

1. Return on investment of electronic record systems 2. Eventually EHR can save money versus paper records 3. Impact of initial implementation on providers and staff 4. Sharing of health information is a widespread concern 5. Electronic health records facilitate the sharing of health information 6. EHR is gaining in popularity

Initial cost of EMR/EHR implementation is high for healthcare facilities

1. Service providers and software companies pay for research and development of products, which is reflected in overall cost 2. Allocation of human resources: Planning for implementation and Training on software 3. Hardware and equipment is costly

Use of the Help Feature

1. Use of Help text or Help functions is standard in most software applications 2. Prime Suite Help text

Routing Slip (encounter form or Superbill)

A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed. Also known as a Superbill or encounter form.

Encounter form (Superbill or routing slip)

A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed. Also known as a routing slip or Superbill.

Superbill (encounter form or routing slip)

A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed. Also known as a routing slip or encounter form.

Master Patient Index (MPI)/Patient List

A permanent listing of all patients who have received care in a hospital (inpatient or outpatient). In physicians' offices often referred to as a Master Patient List or Patient List. May also be known as a Master Person List or Master Person Index.

Clearinghouse

A service that processes data into a standardized billing format and checks for inconsistencies or other errors in the data.

PM and EHR using a single database

Advantages: 1. Allows provider to concentrate on patient care 2. Improves the quality of documentation 3. Provides opportunities for sharing documentation with other providers if appropriate and necessary 4. Results in better coordination of care for the patient

Point of care (POC)

Documentation, dictation, ordering of tests and procedures that occur at the same time the patient is being seen.

Electronic claims submission

Submitting insurance claims via wire to a clearinghouse or directly to the insurance carrier.

Care provider

Term used to refer to a physician, physician's assistant, dentist, psychologist, nurse practitioner, or midwife.

What is insurance?

The term insurance refers to health coverage in the forms of any type of commercial insurance, Medicare, Medicaid, TRICARE, CHAMPVA, or Worker's Compensation.

The main applications of practice management software include:

1. Entering each patient seen into a master list 2. Scheduling appointments 3. Assigning ICD-10-CM/PCS diagnosis and CPT procedure codes 4. Completing a billing claim form for each visit 5. Sending the insurance claims to insurance carriers

The Flow of Information from Registration through Processing of the Claim

1. Appointment scheduling 2. Checking-in or registering 3. Rooming by a healthcare professional 4. Encounter with the care provider 5. Check-out 6. Billing procedures

Electronic Health Record Applications

1. Clinical information is collected through EHR functionality 2. An application is software that has a special purpose, such as electronic health records 3. Prime Suite's E H R applications, or functionalities

Practice management software

1. Computer programs that carry out functions in a medical office 2. Used for administrative tasks, such as filing claims and revenue management 3. Data is gathered on patients from the time of appointment scheduling through the time the bill for each visit is paid 4. Also referred to as PM software

What is a healthcare facility?

1. Hospital, physician's practice, or dental practice 2. Outpatient diagnostic center, rehabilitation, or psychological services 3. Hospice, home and long-term care, or ambulatory surgery center

Electronic health records and electronic medical records

1. Includes the clinical documentation of patient care 2. Clinical data includes information such as the chief complaint, vital signs, physical examinations, and patient histories 3. Also referred to as EHR (for electronic health record) or EMR (for electronic medical record)

Master Patient Index, also known as Patient List

1. Permanent listing of all patients who have received care in a hospital, both inpatient and outpatient, or physician's offices 2. Master Patient Index is abbreviated as MPI 3. May also be known as Master Person List or Master Person Index

Each patient is only entered into a hospital or physician office database once

1. Prevents duplication of records 2. Must ensure patient is not already listed before adding to the database 3. Database is referred to as a Master Patient Index or Patient List

Current Procedural Terminology (CPT)

Coding system used to convert narrative procedures and services into numeric form. CPT is used to code procedures and services in a physician's office; in a hospital setting, it is used for outpatient coding (emergency room, outpatient diagnostic testing, or ambulatory surgery, for example).

Electronic health record (EHR)

Comprehensive record of all health records for a patient, which is able to be shared electronically with other health providers as necessary.

Demographic (identifying) data

Data that identify the patient. Consists of name, date of birth, sex, race, and Social Security number (may vary by facility policy).

Application

Software that has a special purpose, such as word processing or spreadsheet, or for a particular industry such as practice management or electronic health record software.

Speech recognition technology

Software that recognizes the words being said by the person dictating, and converts the speech to text. Speech recognition technology "learns" the dictator's voice as corrections are made by an editor, while voice recognition does not.

Practice management (PM)

Software used in physicians' offices to gather data on every patient and perform administrative functions from the time an appointment is made through the time the bill for each visit is paid.

International Classification of Diseases, 10th revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS)

The classification system used to convert narrative diagnoses and procedures into numeric codes. Effective October 1, 2015, replaced ICD-9-CM.

Electronic medical record (EMR)

The legal patient record that is created within any healthcare facility (hospital, nursing home, ambulatory surgery facility, physician's office, etc.). The EMR is the data source for the electronic health record (EHR).

How is the length of a visit decided?

The length of a patient's office visit is based on the reason for the visit. Some visits may be more comprehensive than others, therefore they require more time.