Since 2014, when electronic health records (EHR) were mandated in the Health Insurance Portability and Accountability Act (HIPAA), medical practices across the nation are adopting EHR technology. As to be expected with the advent of new technology, new regulations, and widely variable user needs, the transition to EHR has been bumpy. While not perfect, EHRs are the way of the future and should improve patient care and access to their health information.
What is EHR? How is it different from electronic medical records (EMR)?
EHR and EMR share several characteristics but have different purposes. To break it down, an EMR is a digital version of a patient’s chart. It includes details that allow you to track patient data, schedule preventive health screenings, and track patient progress on specific health parameters such as blood pressure, weight loss, or glucose levels. EMRs typically include:
- Contact information
- Billing and insurance details
- Personal health information (weight, BMI, temperature, allergies, etc.)
- Complete medical history
- Record of appointments
- Physician notes
- Treatment plans
An EHR, on the other hand, contains more details about a patient’s health and medical history to provide a more comprehensive record of their health.
EMR are excellent tools for in-practice records and high-quality patient care, but they aren’t usually built to share information outside of the practice. EHRs are designed to save you time and money when you need to share patient information with other health care providers, insurance companies, and other authorized parties.
A brief history of EHR
Until the 1960s, all medical records were paper. Usually written by hand, bound in folders, and stored on shelves using systems that varied from practice to practice, but often involved the patient’s last name, last few digits of their social, or another numbering system selected by each individual practice. All records had to be retrieved manually. Also, there were no standards or regulations regarding patient confidentiality or sharing records with other health care service providers or other authorized parties.
However, in the mid-1960s, Lockheed developed the first electronic system and started the evolution. By the 1970s, the Department of Veteran’s Affairs had implemented an EHR, and just a decade later, EHRs were more prevalent in hospitals and universities.
In 2004, the need to convert to EHR became a national priority when the Office of the National Coordinator (ONC) of Health Information Technology was created. In 2009, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) was introduced and included motivation for the implementation of EHR in practices across the country. The HITECH Act aimed to standardize EHR and reduce the financial and time burden of storing and exchanging EHR between doctors, hospitals, and other health care providers. In 2014, HIPAA mandated that all medical practices implement EHRs.
The HITECH Act and HIPAA takes a carrot and stick approach offering financial incentives for practices that comply and financial penalties and fines for those that don’t.
Why do we have to use EHR?
There are two ways to look at this question. You could consider all the benefits of using an EHR, both for your practice and your patients. Or, you could take the point of view that we have to implement and use EHR because the government says so and will penalize us if we don’t.
Yes, we have to use EHR to avoid financial penalties and reduced insurance payments. But let’s focus on the positive. Once you find the EHR program that best suits your practice, implement the program, and train yourself and your staff, it should make some of your administrative tasks more manageable.
You can find patient records at the touch of a button. Your office team can code patient records and issue billing to insurance companies and patients at the touch of a button. When you receive a request for patient records, you can use a service like ePaperRoad to automate your responses, saving you time, and reducing your opportunity cost.
Additionally, EHR helps you provide a better service to your patients. You can track and graph vitals like blood pressure, weight, and complete blood count results. This information allows you to identify trends or changes quickly.
What are the elements of a good EHR?
Depending on the scope of your practice, you may need your EHR to have specific features. However, there are a few critical elements that any good EHR should have.
Confidential but searchable
Improved confidentiality and security are two of the founding tenets of EHR. Your EHR should be fully encrypted to protect your patients’ private information. Old fashioned paper records were not secure enough to meet the stringent confidentiality regulations in place today.
Easy to pull up records
However, with the correct login, you and your team should be able to bring up a patient’s records within minutes. This ensures you have all the information you need to schedule an appointment or review their details before you meet with them. Additionally, if you need to retrieve records to fulfill a medical records request, you should be able to either pull patient records with a few clicks or automate your responses with a program like ePaperRoad.
Link with billing
Your EHR should also link up with your billing system. Connecting the details of your appointments and diagnosis with your billing department reduces error and increases the speed that you can send information to insurance companies with requests for payment.
Easy to update notes
The days of scribbling on a notepad while you examine a patient are long gone. Today, you can enter your notes directly into the patient’s EHR, or you have an assistant take notes while you focus your attention on your patient. After all, patients want to feel like you’re paying attention to them, and patient satisfaction is becoming increasingly important.
Intuitive to use
This is an essential aspect of an EHR to test while you’re looking for the right system for your practice. Does it make sense to use? To almost everyone in your practice? The dashboard should be easy to understand, and you and your team shouldn’t have to make a million clicks to get to where you want to be.
What are the common problems with EHRs?
Despite the wide variety of EHR systems available today, few of them are even close to perfect for every practice. Some of the main complaints that we encountered include:
Not clinically focused or not admin friendly
Most EHR programs seem to be designed for either clinicians or the administrative team instead of catering to the needs of both critical functions in a medical practice. When you’re comparing EHR systems, make sure to have members from both the clinical and administrative teams try the programs to find the system that provides the best features for your whole practice.
Doesn’t track billing codes
Your EHR should make billing more manageable, but many programs don’t track billing codes, which can make the billing process more complicated than it needs to be. It can also lead to billing errors.
Doesn’t send patient reminders for scheduled or due appointments
One of the best ways to increase your practice revenue is to make sure that your patients not only schedule their annual exams and screenings but actually attend their appointments. Your EHR should track when patients are due for appointments. If your EHR could send messages to your patients to book or attend an upcoming appointment, it could save your team time.
And finally, EHRs that are far from perfect are also expensive. In addition to an annual fee, you also have to pay licensing fees per user, implementation costs, training costs, and more.
Remember the benefits
Remember, using an EHR is mandatory, so despite the costs and imperfections, you need to find the right program to fit your practice. When you’re frustrated, keep the critical benefits of an EHR in mind:
- Speed and mobility
- Better patient care
- Enhanced confidentiality
Here at ePaperRoad, we want to solve medical practice management problems. Our suite of services is designed by busy physicians for busy physicians. Contact us to learn more about our medical manager software and how we can help you make your medical practice more efficient and profitable.