Electronic Health Record (EHR)

The term EHR (electronic health record) has always been used interchangeably with EMR (electronic medical record). What is an EHR? It refers to a patient care medical record that is recorded in digital format. These computerized systems actually coordinate the storage and retrieval of individual records. Networking allows us to access EHRs from any global location. Thus, from one location one can have access to a variety of medical information. There are many types of medical information in an EHR.Here are the important ones,Health “power of attorney”Laboratory test resultsRadiology images Demographic details of the patientBilling recordsRecord of side-effects of medicineMedical historyAppointment recordsList of allergiesMedicationImmunization statusRecommendation for medical conditionsEndoscopy / laparoscopyLiving will detailsAmong the advantages of implementing an EHR is the fact that it leads to minimal medical errors. Moreover a handwritten medical record is rarely legible. When compared to the paper based records EHRs are so very convenient because they take up almost no space and can be accessed from distant locations also. Digitization of medical records also facilitates the collection of data for research and clinical studies.It is indeed a great challenge to implement an HER system because all the old records which are now in different formats will have to be digitized. Simply scanning old records is not sufficient but have to be brought into the electronic record system. Another challenge is synchronization of data that originate from two different locations. Other issues relate to privacy and other legal barriers.

Health Level 7 and Medical Coding

What is Health Level 7 (HL7) and its function? Well, in the health care sector we know standards are very important. The American National standards Institute (ANSI) has accredited many Standards Developing Organizations and HL7 is one of such international community of healthcare subject experts and IT scientists who create standards for the exchange, management and integration of the EHR (Electronic Health Record). HL7 was founded in 1987 and is a not-for-profit volunteer organization that promotes the increased use of standard within and between the health organizations. As a result of such implementation everyone gets benefited and it increases the effectiveness of the total health care. Besides being involved in the development of international healthcare standards it also defines standards for administrative data.HL7 has more than 2,400 members that represent approximately 500 corporate members, including 90 percent of the information systems vendors that serve healthcare. The HL7 is headquartered in Ann Arbor, Michigan, U.S. Here is its home page, http://www.hl7.org/ Actually the term “level seven” refers to the highest level of the International Standardization Organization (ISO) communications model for Open Systems Interconnection (OSI) - the application level. Historically there was no proper integration / communication between a health care management information system and the electronic medical records. When using the process of coding of medical records for claiming, to government and commercial insurers, it is mandatory that all information must be referenced or copied into from a physician authored document. How does the HL7 help in better medical coding? Today’s XML documents are compliant with Health Level Seven’s (HL7) clinical document architecture (CDA) and provides the missing link between healthcare information management (HIM) and the electronic medical record (EMR). Besides improving the processes of medical coding and abstracting, it provides for great accuracy during the insurance claims process thereby enabling quick reimbursement.The list of sponsors for HL7 is very impressive and to name just a few, it includes names like, Microsoft, Philips, Siemens GlaxoSmithKline, Pfizer, the US department of defense and the FDA (Food and Drug Administration).

Medical Transcription Services and Specialties

Today medical transcription has almost become a popular term among the health professionals and services are available for all medical specialties. What is Medical transcription? It is the extensive procedure of transcribing voice-recorded reports done by doctors and healthcare professionals into text formats for various uses including for research and reimbursements. A medical transcriptionist’s job primarily involves converting significant, confidential, and up-to-date data into written text. This text is printed and included in the patients’ records, archived and retained as an EMR (electronic medical record).Transcriptionists can today work either from inside the hospital premises, from their homes or from any other distant global location. Electronic storing of medical records is preferred by modern medical institutions because of the huge volume of patient data being accumulated. Also it makes it very easy to incorporate all details including the medicine, diseases details and other diagnostic information. Maintaining of this type of records is primarily to facilitate the patient’s healthcare and also to use it as a general use data bank while still maintaining confidentiality of patient data.What is the actual MT process comprised of? It generally includes,Tying of documents Active listening Information formatting Editing/proofreading Checks for compliance with medico-legal policies and proceduresMedical transcription services are offered specifically for all the different medical specialists. Today we have experienced medical transcriptionists who do specializations in transcription of different branches of medicine. Thus there has evolved various specialty medical transcriptions like radiology transcription, pediatrics transcription, cardiology transcription and so forth.Though all medical transcription professionals have to be familiar with transcribing all branches of medicine, a speciality transcriptionist, (some one specialized in transcribing for a particular branch of medicine) often gets preferred by the respective specialist. Further specialty in each branch is also done. Thus if we take a specialty transcription professional he will be an expert in transcription of all pediatric specialty areas such as allergy immunology, anesthesiology, endocrinology, cardiology infectious diseases, neurology, nephrology, orthopedics, sports medicine and general academic pediatrics.There is a recent increased trend in the usage and dependence of voice recognition software for specialty transcription. However the technology for it is yet not perfect and if the documents are not well looked into and edited by humans, it can give irrelevant and absurd transcripts. One can expect the regular manual transcription to be around for some time into the future and the fear of voice recognition software based transcription totally replacing the human element is not valid. The demand for health services and medical transcription is on the rise as the number of aging population is fast growing and the law requires transcription documentation of medical bills for the insurance benefits on worker’s compensations.

Medical Billing/Coding Services: A Boon for Doctors

There are many small clinics and specialist doctors who have a very good practice but have very little spare time to spend and be involved in organizing their office papers and execute the entire medical coding /claims / billing. It is important that someone has to successfully look into all aspects of medical billing/coding so that there are no errors. Neglecting this area of operations can be dangerous and prove to be costly. The physician can be free himself from all hassles by just outsourcing the entire process to a reliable medical billing service company. It will leave him with plenty of time to concentrate on his core work of treating the patients and other related office operations.There are some basic requirements today that have to be followed. It is of foremost importance that all patient data and related information /papers are filed and organized properly. There has to be some employee or office staff who will carefully organize every single piece of paper and information that may contain patient information/ demographics scans etc. Even loosing a small piece of information / bill could mean loss of money for both the doctor and the patient. It may sound exaggerated but money lost because of these missing bits of paper usually run into thousands of dollars annually.A good Billing service company will help to,Train your staff perfectlyInstall billing softwareKeep all claims organizedReduce claim timeIncrease earningsWith a good EMR (Electronic Medical record) in place the doctor has to just enter the basic information into the computer using the online billing software and the rest will be handled by the billing company. What are the advantages of using a web based medical billing software?Can retrieve patient records in an instant.Can check old bills/ claims anytimeAll records are stored with high securityNo lost dataQuick claim processing possibleCan be integrated with any office automation software used in the clinicRecords accessible 24 hrs a dayCan integrate patient scheduling alsoDictation for transcription possibleClearing house service availableReduced rejection of claimsThus it is indeed a boon for the “one man show” type physicians /specialist to outsource their entire medical coding / billing to an online professional company.

What is a Medical Billing System?

An efficient medical billing system is of prime importance for the smooth functioning of any medical service provider. A comprehensive medical billing system will in turn secure speedy reimbursements for clients. Most major medical billing companies today do have a medical billing system that features a set of advanced medical billing programs. The system has to be fully integrated and completely automated to perform time intensive administrative tasks such as code capture, medical billing and account receivables. Medical billing systems handle simple to sophisticated processing requirements with the highest degree of efficiency and accuracy. It has several powerful features and is customizable with its highly flexible and configurable design, for meeting all aspects of medical practices. It works with an EMR (electronic medical record) to bring together all patient demographic and financial information of your practice. The system also supports on-demand invoicing, batch claims processing and interactive electronic claims submission and remission. The common features of a medical billing system is that it,Provides easy access to all patient demographic and financial informationFully customizable ledger screensWeb-enabled capabilitiesFull visibility and control of transaction posting and charge balance managementCharges, payments, and adjustments can be made from the single platformStreamlines the payment posting Has a follow-up processHas specialized A/R work lists and real-time aging informationManages backs-up and secures data with the norms specified by the HIPAA standards in force.How is the medical billing system useful to the clients /patients? Well first this way the patients will be assured of accurate statements and claims besides providing security to all patient financial information. It is also the cause for reduction in miscommunications, demographic and billing errors.

The Patient relation Management Solution was designed for bariatric and metabolic surgical practices. Whether your bariatric program is small, medium or large, PRM provides a comprehensive approach to tracking the patient flow from the initial contact to surgery and post follow-up care.

Patient relation Management software is neither a Practice Management System nor an  Electronic Medical Record software. It is a specifically  focused diseased state driven software to qualify a patient for treatment; simplify the process for scheduling a patient; tracking the patient flow; and reporting on the progress of treatment. Some of the potential benefits that will enable providers of bariatric and metabolic surgery devices and services are; efficient collection and reporting of accurate and long term data on the affects of surgery; communication of disease state reports through e-mail and other avenues to both referring and primary care physician; data collection that is a requirement of Center of Excellence eligibility.

Patient relation Management, LLC was launched in 2007 by a team of visionaries who realized that the healthcare industry needed IT solutions that leveraged the latest technology, addressed the increasing complexity of managing a bariatric program and generated real, tangible benefits to bariatric practices of all sizes. Working with healthcare advisors and physicians, the PRM development team spent many years turning the vision into reality. The result of the vision is Patient Relationship Management – a disease state driven software for bariatric and metabolic surgery. The goal of the disease state driven software is to work in tandem and leverage Practice Management Systems and Electronic Medical Record software capabilities of maintaining one electronic record per patient for all disease states. A real solution that streamlines operations, increases patient flow, and improves patient satisfaction.

LOCAL INSTALLATION

The Patient relation Management Solution is available in the ASP Model or a stand-alone model. With the ASP Model, the system is supported and maintained at a secured datacenter so you don’t need a dedicated IT staff and do not incur server/network infrastructure cost. With the Stand-Alone Model, you install, support, and maintain servers and data at your place of business. The Patient relation Management Solution provides bariatric practices with easy to use features including enter once data entry and a robust reporting mechanism. PRM starts where Practice Management System and Electronic Medical Record software stops and improves bariatric programs efficiency and virtually eliminates patient completing paperwork with a pen.

The synergy that PRM can provide to your bariatric program can be very lucrative and productive to your entire business model.

Source

www.PatientRelationship.net

Despite the fact that electronic medical record programs and services are in demand, many have remained skeptical about them. But an article on the American Academy of Family Practice has shown that it may be a feasible option. The piece addresses all queries and hesitations on the efficiency of the service and the systems themselves.

First, the battle is between using the usual paper and file based medical records and using an electronic medical record software method that turns everything digital. Many may wonder, if it isn’t broken why fix it? But with the rising patient numbers, any product that would lessen the health care professionals’ time handling papers and increase patient visits is a good thing.

The promise of technology with an electronic medical record service is the capacity to quickly and easily obtain patient records from virtually anywhere and quickly and accurately make correct diagnosis.

Skepticism involved questions on the software’s accuracy with records, operational costs, and difficulty of use. Some are skeptical about giving their patients’ private history under the care of an electronic medical record company. We list the issues raised here:

- A doctor can still be efficient even without these electronic record keeping products.

- The price may be too high.

- It might not be HIPPA regulated.

- It might be too difficult to understand and would only waste very important time.

- What will become of the physical records if the transition to computerized form happens?

- There are so many electronic record service providers to choose from.

Electronic medical record programs will at first have a high cost to them without doubt. Money is recovered via the increase in patient care, reductions in paperwork and associated costs for equipment, supplies and staffing and in centralizing information and data and health records. Compare it with medical transcription, which costs as high as $25,000 and you’ll notice the difference.

HIPPA compliance concerns are also not a setback, as electronic medical record packages all meet HIPPA standards. As regards ease of operation, while it could take time to learn, it’s really not difficult to master, given a very user-friendly interface. Customer hotlines are even available at all times for all concerns and queries.

Using an electronic medical record service has also been proven to tack on some minutes to each patient consultation and even allows real-time updating. Some opt to store their records for a year first, before turning over to electronic records firms.

Regarding the specific program that the physician should use, it really depends on the purpose. Shopping around and reading articles and reviews about the programs in the market first will allow you to bag the most appropriate suite.

The American Academy of Family Practice, or AAFP, is an association that stands for over 94,000 family practice doctores. As a perk, the association developed a website dedicated to the connection between computing and technology and health care. Another website with a selection of tutorials and tools on information technology is CHIT, or the Center for Health Information Technology. One very useful tool is standard specific for good electronic medical record (EMR) software and EMR systems.

Health care professionals are now starting to see how health care gains from information technology. EMR systems presently flood the market. Cost is important, but capabilities and specifications are even more so.

The AAFP listed these criteria to look for in excellent EMR systems:

- Data details, including patients’ medical histories, vital information, lab data, allergy and medication lists, hospitalization records, etc.

- Handling of codes, issue or family-oriented, and other structures and organization.

- User interface should be simple to use and user-friendly.

- Options for web-based or native accessibility and provision for remote access by many users.

- Management capabilities that function with financial and scheduling systems.

- External or internal email.

- Compliant with HIPPA, confidentiality, and privacy requirements.

- Good support system, like help screens and ongoing technical support.

- Security.

An EMR system must encompass many of the required features. Other factors also require examination:

- Does it manage records?

- How does it handle case management?

- Can it handle administrative functions?

- Is it capable of scheduling and reminders?

- Are there educational add-ons that come with the EMR software?

- What size of practice does it serve?

- Factoring in hardware and software, setup, user licenses, and support, what’s the overall cost?

- Are there other criteria that your practice needs?

Simply know your practice’s needs to find the right EMR software. Find out which EMR software is perfect for you by using the demos provided by the various EMR companies.

Advantages

Corresponds intuitively to the physician’s usual method of working. Dictation remains the most intuitive and least time-consuming means of data entry.

Physicians can dictate anytime, anywhere using PDA, Dictaphone or telephone at their convenience.

Providers need not change the way they practice just to accommodate an EMR. EMR can interact with transcription service so that transcriptions can be attached directly into the patient’s electronic medical record, if such a facility is provided by the EMR vendor.

Provides expressive power to describe patient’s condition and other health related events

Disadvantages

Details of the exam can easily be forgotten and omitted while dictating, if dictation is not captured immediately at the point of care

It cannot be queried for generating reports unless transcribed in pre-formatted templates

Transcribed reports are not immediately accessible. Physicians would normally have to wait for 12 to 24 hours for charts to be delivered, unless few vendors supporting 2-4 hours short turn around time.

Transcription provides for more efficient use of doctor’s time.

Although average transcribed report costs $2 to $4, it can reduce the doctor’s time spent on data entry. Considering the value of doctor’s time, transcription is not a costly proposition.

EMR should give the freedom to the physician to decide to use either Point %26 Click or Medical Transcription. For a physician, the EMR that fits into his practice workflow would be invaluable. A competent EMR must have a template driven charting feature and the ability to interact with a transcription service at the same time. Both are indispensable features of Electronic Medical Record Software, as doctors are not unanimous on point and click charting or transcription. Such an EMR will be both efficient and cost effective.

The trends in transcription itself are changing with Medical Transcription service providers aiming to adopt new technologies. These technologies will evolve to increase efficiency %26 accuracy, decrease turnaround time and support data capture. While many of these technologies like such as digital dictation and electronic signature exist today, several technologies are still on the horizon.

Your medical practice can greatly gain from the appropriate kind of electronic medical record software. Electronic medical records software is quickly taking the place of paper documents these days.

Electronic Medical Record Software Advantages:

- The efficiency of your practice improves. This is because the data is easier to maintain.

- Time consuming and long paperwork that add to your overhead expenses will be eliminated.

- No paperwork represents less space required to save and store your documents.

- When you use EMR software, data is easily accessible.

- Users are provided with password access so the data is secured and confidentiality is maintained. There’s less danger of unauthorized users gaining access to data as opposed to paperwork documentation. History of who accessed and edited data is also on hand.

- Data is backed up 3-4 times each day and a duplicate of it is also saved in an off-site facility.

- Physicians can go into patient records fast so they can be better cared for.

- Electronic prescriptions lessen mistakes that pharmacists may make because of the illegible handwriting of the physician.

- Electronic medical record software also means huge savings on the cost of transcription.

- You may be provided with a discount on your malpractice insurance if you have reliable EMR software installed.

- Time is saved by allowing multiple user access to records.

- Remote access to the data is given.

- You can improve your practice’s administration by analying the trends.

- They can be easily integrated with other databases and systems and are also easy to use and install.

EMR software is truly a worthwhile investment as it improves efficiency in administration to provide enhanced patient care. This depends on your selection of vendor, though. Find an established vendor with an excellent track record. Your provider must be able to give adequate support and good customer service and must be able to conduct on-site or web-based training. As long as it complies with HL7 or HIPAA requirements, you can go for either the cheaper web-based service or a full scale software package.

You should be sure that the product is just how you want it. Know all the fees associated with the EMR software. Know if upgrades are free or at least, discounted. For better integration, buy a medical practice management software from the same firm, or find a product that can do both.