Computers Week 4: EMR Documentation

Course Information

• Course: Computers
• Week: 4

Study Tips

• Do not try to write every word down
• Tables and charts should be copied directly from the book

EMR Documentation Style

• EMRs can be used by doctors to access records from any location remotely via their iPhones
• EMRs include dictation which supports MP3, WAV, etc.
• EMRs include progress notes, SOAP progress notes, etc.
• EMRs have external sources such as hospitals, lab results, X-rays, fax, emails, and letters
• EMRs include digital templates for forms, EPSDT forms, growth charts, and design your own templates
• EMRs use handwriting with tablet PCs
• EMRs use Microsoft Documents (DOC, XLS, TXT) Format
• EMRs include network formats like Windows NT or Novell

Terminology

• EMR (electronic medical records) was the original name, but EHR (electronic health records) was adopted in 2003 since it describes fully the nature of the program
• 2009 HITECH Act provides incentives for using EHR
• Medicare providers using EHR can receive up to $44,000 over five years
• Medicaid providers using EHR can receive up to $63,750 over five years

Meaningful Use Criteria

• Criteria for how EHRs are used to allow for incentives
• Criteria include:
  • Improve quality, safety, and efficiency
  • Engage patients and families
  • Improve care coordination
  • Improve public and population health
  • Ensure privacy and security for PHI (personal health information)
• Examples of criteria include E-Prescribing, exchange of health info to improve healthcare, and submission of information on clinical quality

Certified EHR Criteria

• Certified EHRs have:
  • Patient demographics
  • Clinical health information
  • Clinical decision support
  • Support physician order entry
  • Capture queries relevant to health care quality
  • Exchange electronic health info
  • Information integration from other sources

Functions of an EHR

• EHRs can document progress notes, timestamps (on documentation), prescriptions, patient education info, digital photos of patient & condition, recording of vital signs and diagnostic tests, lab results, imaging studies, and graphs of data, graphs of height, weight, and blood pressure, letters, consultation reports, electronic data transmission, telephone calls, and search capability for patients with specific conditions, ages or locations

Test Your Memory

• Meaningful use descriptions & criteria
• Criteria for a certified EHR, including patient demographics, clinical health info (medical history), clinical decision support, support for physician order entry, capture & query info for health care quality, and exchange of electronic health information
• This information is a list of requirements to be eligible for incentives

EHR Systems

• EHR systems allow providers to view patient records across organizations
• Medical assistants can access patient records quickly using phones when a phone call is received, which includes methods for accessing secure info, like with a PDA or pocket PC
• Physicians can use portable electronic tablets to enter patient data in examination rooms

Cost Savings with EHR Systems

• EHRs can contribute to cost savings in many areas:
  • Reduced transcription costs
  • Reduced chart pull, storage, & re-filing costs
  • Improved & accurate reimbursement coding
  • Reduced medical errors

Cost Savings with EHR - Continued

• Time savings with centralized chart management, condition-specific queries, and shortcuts • Enhanced communication with clinicians, labs, and health plans (easy access, tracking electronic messages, automated formulary checks, order/receipt of lab tests, links to registries/databases)

Test Your Memory - Cost Savings with EHR

• List many cost savings associated with an EHR (don't look)
• Includes reductions in transcription costs, chart-pull costs, coding accuracy increases, reduced medical errors, better disease management, and quality of care
• It also mentions integrated scheduling, automated coding, and claim management benefits
• Additional savings include time-saving features, easier centralized chart management, shortcuts for lookups, enhanced communication with others, and access to patient info from anywhere

Signatures

• Old-style signatures are written
• Electronic signatures are digitized electronic images.
• EHRs also use token-based systems for signatures. Methods include using a code for secure access.
• Digital signatures are most secure using encryption.

Comparison of Paper Medical Records & EHRs

• Lists of pros & cons (paper vs. electronic for each process)
• Examples of each process include scheduling appointments, verifying insurance, sending reminders, checking the patient's health info electronically or by phone, preparing a new patient chart for the day, preparing established patients for their visit, order tests or prescriptions immediately, providing the patient with literature/info, conducting a physical exam, and communicating w/ specialists to make referrals

Review Terminology for Computers

• EMR originally meant electronic medical records
• EHR means electronic health records, adopted by the Institute of Medicine in 2003 for a more precise description
• The 2009 HITECH Act incentivized the use of EHR systems

Review Meaningful Use

• Criteria for EHR use
• Criteria include: quality, safety, efficiency, patient/family engagement, care coordination, public/population health, & privacy/security of PHI

Review Certified EHR Criteria

• EHRs need certification
• Certified EHRs must have patient demographics, clinical info(medical history), clinical decision support, physician order entry, relevant health information, and exchange/integration from other sources

Review Functions of an EHR

• Processes that can occur in an EHR (like progress notes, timestamps, prescriptions, patient education, digital photos of patient/condition, vital signs & diagnostics, lab results, imaging, graphs, letters, consultation reports, electronic transmissions, telephone calls, and patient searching capabilities)

Review Cost Savings with EHR Systems

• Cost savings associated with EHR Systems (like reductions in transcription costs, chart pull, storage, & re-filing)
• Improved coding accuracy, better access to patient data, & enhanced patient education/disease management

Review Cost Savings with EHR-continued

• Time saved with centralized chart management, condition-specific queries, and shortcuts
• Enhanced communication with clinicians, labs, health plans, easy access, tracking/messages, checks, orders/receipt, & public health registry/database links

Implementing and EHR System

• Steps for implementing an EHR system: assess practice readiness (processes & training), create a release plan, select/upgrade an EHR, conduct training, achieve meaningful use, and continue process improvements