Electronic Medical Records

Advantages of EHR

1. Continuity of care 2. Increased efficiency 3. Easier to access 4. Reduced expenses

Why document properly?

1. To facilitate communication among healthcare providers. 2. To avoid delay of reimbursement or denial of claims because medical necessity of services provided has not been proved. 3. To comply with insurance companies' and accreditation companies' enforcement of documentation guidelines for healthcare facilities. 4. To aid the work of investigators and regulators when legal issues arise, including subpoenas of health records in court cases and state investigations. 5. To protect the practice in case a malpractice suit is brought. 6. To establish evidence of care.

Health Record

A combination of all the health information and documents of a single individual.

Medical Record

A complete physical collection of an individual's healthcare information.

Chief Complaint

A patient's main reason for seeking care.

Authentication

A record that traces a user's electronic footsteps by recording activity and transactions, including unsuccessful attempts to view unauthorized screens, with the EHR system.

Password

A sequence of characters and sometimes spaces used to prevent unauthorized access to or disclosure of patient information contained in secure electronic files.

Anaphylaxis

A severe form of an allergy where massive swelling occurs in the airway, leading to respiratory failure.

Radio Button

A specialized type of button on a software interface that toggles on (round button visible) and off (blank circle). Radio buttons tell the user that only one response is appropriate because two radio buttons can't be depressed at the same time.

Check Box

A specialized type of button that toggles on (checked) and off (unchecked). Check boxes are often used when more than one response might be appropriate (as in "check all that apply"), but sometimes they should be interpreted to mean yes or no (as in a check box next to the caption "OK to mail?")

Off-Label Indication

A use for a prescription drug other than that for which the US Food and Drug Administration (FDA) has approved it.

Secondary Use

A use of health information that is not directly related to patient care. Such uses include statistical analysis, research, quality and safety assurance processes, public health monitoring, payment, provider certification or accreditation, and marketing and other business activities.

What are the three groups that health records are categorized by?

Active, inactive, and closed.

Demographics

Age, sex, martial status, race, contact information.

Signature Pads

Allow for electronic signatures to verify that patients have received proper documentation of policies and procedures.

Find Patient Tool

Allows for entry of the first few letters of a last name to display matching names to locate a patient more easily than scrolling through lists of names.

Practice Management Software (PMS)

Allows for the electronic management of the business side of the practice, such as patient demographics, scheduling appointments, tracking billing and insurance, and processing payments.

Clinical Decision Support (CDS)

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

Doctrine of Professional Discretion

Allows providers to use their best judgement regarding sharing medical records when dealing with patients with emotional or mental disturbances.

Retention Period

Amount of time closed patient records must be kept; varies by state.

Advanced Accounting Procedures

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

Electronic Medical Record (EMR)

An electronic patient record created by a medical practice or hospital.

Confidentiality

An individual's right to have all his or her information kept private.

Electronic Health Record

An interconnected aggregate of all the patient's health records from multiple providers and healthcare facilities.

Review of Systems (ROS)

An inventory of the organ systems to pinpoint unusual findings.

E-Visits

An up-and-coming way of evaluating or managing services provided by a medical provider over a secure web-based or electronic-based communication network for a single patient encounter.

Protected Health Information

Any identifiable health information that may include demographic information, diagnoses, or billing information that's stored, maintained, or transmitted electronically.

Covered Entities

Any medical provider, health plan, or healthcare clearinghouse that transmits health information electronically.

Business Associates

Are any person or entity that performs functions or activities that involve the use or disclosure of PHI. A contract is written from the covered entities for the business associates that outlines the privacy and security requirements of the PHI.

Patient Letters

Are commonly produced in the medical office. Examples: lab results or a welcome letter for new patients. Sometimes unpleasant correspondence needs to be drafted, such as letters to request payment of delinquent accounts or to terminate patient/provider relationships.

Consumer Reporting Agencies

Are used by potential lenders to check your payment history before providing a loan. Life, health, disability, and long-term care insurance rely on consumer agencies to find out about health and prescription drug history.

Increased Effiency

As patient information is readily available to any user. Time that may have been spent looking through paper records and filing papers can now be spent on other office tasks. Improved documentation with the use of preset templates, drop-down menus, and typing eliminates illegible handwritten notes, which in turn, eliminates errors.

What is the difference between an electronic health record and an electronic medical record?

As the concept of the EHR evolved over time, a distinction was sometimes made between the terms EHR and electronic medical record (EMR). The EMR was said to be an electronic patient record created and maintained by a medical practice or hospital, whereas the EHR was said to be an interconnected aggregate of all the patient's health records, culled from multiple providers and healthcare facilities.

Current Procedural Terminology (CPT)

Codes designate numerical codes for office visits and procedures.

Incident Reports

Communicate situations to the risk manager, such as falls, needle sticks, and medication errors.

Chronic Conditions

Conditions that are persistent and recurrent; examples include asthma, diabetes, and congestive heart failure.

Acute Conditions

Conditions that occur suddenly and may be severe, but are over brief periods; examples include a common cold, influenza, or joint sprains.

Encryption Technology

Converts data to an unreadable code during transmission to keep the data secure.

Objective Data

Data that is observed, measured, or collected by the provider.

Progress Notes

Descriptions of the patient's encounter.

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 whether the patient is new or established.

Fax Machine

Encodes documents to be sent over telephone lines.

Electronic Appointment Books

Essential for time management, allows several user to access the calendar at one time to book more than one patient simultaneously.

HIPAA Privacy Rule

Establishes standards for the use and disclosure of individually identifiable health information, promotes patients' understanding of their privacy rights, and helps patients control ways in which their health information is used and disclosed. This applies to all health information in any form, such as conversation, paper, or electronic.

Laws

Formal enforceable rules and policies based on community standards of conduct.

Buttons

Found throughout the SCMO, clickable when in full color, provides access to another part of the program.

History of Present Illness (HPI)

Gives further details regarding the conditions including onset, duration, location, quality, severity context, associated symptoms, and modifying factors.

Disclousure

Giving access to, releasing, or transferring information to a person or entity.

Technical Safeguards

Grant users the minimum amount of access necessary to perform their job duties.

Established Patient

Has been seen by a provider in the office within three years.

New Patient

Has either never been seen or it has been more than three years.

Coding and Billing

Have services rendered must be reimbursed.

What are the basic functions of EHR?

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

Administrative Information

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

Unstructured Entry

Informed is typed directly into the field of a database.

Billing and Insurance

Insurance cards should be reviewed at every patient visit and scanned into the system.

Interoperability

Interact with, or "talk to," one another.

Account Ledger

Is a document that contains a responsible payer's name (guarantor), patient's identifying and contact information, services provided, payment made, insurance reimbursements, and balance owed. A day sheet, or day journal. is a register of daily business transactions.

Meaningful Use (MU)

Is 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.

Protected Health Information (PHI)

Is any identifiable health information that may include demographic information, diagnosis, or billing information that's stored, maintained, or transmitted electronically. If PHI is released for any reason other than healthcare operations, this must be documented and kept in a log for six years.

Info Panel

Is found on the left of the screen and changes based on which module is being used.

Continuity of Care

Is one of the most important ways the EHR can improve quality of care. As many EHRs 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.

Legal Document

Is the entire health record, since federal law requires documentation, but it's also used in court proceedings for malpractice lawsuits. There are also legal forms within the document, including consent forms, medical record releases, advance directives, and do not resuscitate (DNR) orders.

The International Classification of Diseases, 10th Edition (ICD-10)

Is used to designate alpha numerical codes for patients' diagnosis.

Clinical Care

Is where all patient care can be viewed and documented. Documentation must occur within a patient encounter. Any clinical imaging, labs, or forms can be uploaded with the form repository.

Administrative Safeguards

Means that covered entities must adopt processes that prevent, detect, contain, and correct security violations.

Minimum Necessary Standard

Means that only the minimum amount of information should be included when a covered entity makes an allowed disclosure to accomplish the task.

Anonymity

Means that the patient's information wouldn't be attached to specific testing, therefore the testing couldn't be traced back to the patient.

Front Ofice

Module in SCMO that uses the calendar as the default and allows appointments to be created, deleted, or edited; schedules to be blocked for meetings; and patient letters, emails, and calls to be made.

Lack of Interoperabilty

Not all EHR systems are compatible with one another, but they may be compatible with pharmacies, hospitals, or laboratory networks. This means that health records for a patient may not be shareable among hospitals, primary care, and specialty medical practices.

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, all of which are handled appropriately.

Improved Patient Satisfaction

Occurs when patients feel that their phone messages and refills are handled better with EHR. Most patients like having a patient portal where they can access their health information.

Consumer Reporting Agencies

Organizations used by potential lenders to check your payment history before providing a loan.

Active Patient

Patient who has been seen by a provider in the clinic within three years.

Closed Patient

Patients who have terminated their relationship because they have moved away, have been discharged from the practice, or have died.

Clinical Information

Primary source, inlcluding medical history, progress/clinic notes, medication lists, allergies, vital signs, immunizations, lab results, and imaging results. This information is primarily obtained during a visit with a physician or provider.

Physical Safeguards

Protect the facility where the EHR is housed. This can include locks, security guards, badges, and video monitoring. Equiptment, such as computers, should also be protected, and this can be done with a password.

Assessment Data

Provider's summation of the diagnosis or impression of the ailment.

Ethics

Rules and standards of conduct that govern professional behavior and arise from our shared understanding of morality.

Double-Booking

Scheduling two patients at the same appointment time with the same provider.

Structured Entry

Selecting from a preexisting database with drop-down menus.

Access Trail

Shows which patient records have been accessed and which functions have occurred within the patient record.

Speech Recognition Software

Software that allows a provider to convert speech into text as he or she speaks into a microphone.

Practice Management Software

Software that allows for electronic management of the business side of a medical or healthcare practice.

SimChart for Medical Office (SCMO)

Software that is housed in a central location and can be accessed through the internet, allowing it to be accessed in a variety of locations.

Field

Space allocated on a form for specific numeric or text data.

Safeguards

Steps put in place to avert security breaches. These fall into three areas: administrative, physical, and technical.

Purging

The act of separating active records from closed records.

Privacy

The patient's right to control how his or her healthcare information is used and shared with others.

Authorization

The process of determining whether the person attempting to access a given network or EHR system has authorization. User authentication can include password entry or use of bio metric data (such as digital fingerprint or voice signature) or a smart card (a data-laden microchip).

Reduced Expenses

Transcription fees and storage facilities for paper charts are no longer needed, and duplicate tests aren't being performed.

Patient Portal

Used within EHR to allow patients to contact the clinic and potentially make their own appointments.

Front Office

Uses calendars as the default for this page. Appointments can be created, deleted, or edited. Schedules can be blocked for meetings or lunch hours. Patient letters, emails, and phone calls can be created.

Structured Data Entry

Uses drop-down menus, default settings, templates, default settings, templates, and check boxes to enter patient information. Structured data provides more consistent documentation and is easier to share among computer systems. It's important to become familiar with both types of data entry.

Electronic Transcription

Using structured data entry (drop-down menus and automatic sentence builders) eliminates the need for handwritten notes, which tend to be riddled with errors. These structured data entry tools allow the provider or other documenter to select from precontstructed options (templates) or choices within a record of document.

Default Settings

When dialog boxes are opened the options are already preselected, much like in a word processor document with fonts and margins.

How to avoid duplicate charts?

• Always ask if the patient has been seen by the practice before. • Always search for the patient before creating a new chart. • Ask established patients if they've had a name change. • Always set up the EHR with the name listed on the insurance card, as a claim can be denied if the name doesn't match precisely.

Common Telephone Etiquette

• Answering the phone by the third ring. • Avoiding personal calls on office telephone lines. • Smiling before answering the phone. • Answering with a professional and pleasant greeting. • Speaking slowly and clearly • Documenting the conversation. • Asking if the patient has additional questions at the end of the conversation.

Well-organized clinical documentation facilitates healthcare delivery in the following ways:

• Promoting patient safety—making diagnosis and treatment more efficient and likely to be effective. • Reducing medical errors—conveying critical information to other healthcare providers. • Providing risk management—recording all communications between the practicioner and patient. • Providing evidence of care delivery for third-party payer reimbursement. • Allowing related items, such as history, progress notes, and patient letters, to be linked and easily accessed.

What causes double-booking?

• The practice expects a certain number of no-show appointments. • The practice expects certain patients to arrive early and others to arrive late, staggering the schedule. • The double-booked patients are being seen for different reasons with different clinic rooms needed. • Patients with urgent medical problems need to be accommodated.