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Benefits to Implementing an Electronic Medical Record

Posted on January 14, 2018 by CPC Exam Medical Coding Updates

One of the most cumbersome tasks in a medical office is the maintenance and storage of paper medical records. This statement rings true in all medical practices rather it be dental, family medicine, specialty practices, or a chiropractic office. But what most practice managers and physicians may not realize is that maintaining a paper medical record is also one of the most costly administrative and clerical tasks in the office.

For years, medical offices have struggled with medical record documentation, as well as filing and retention of literally volumes of paper records. They have been stored in costly medical record storage cabinets and when the volumes of records outgrow the office space, they are purged and sent to off-site storage.

A major benefit of an electronic health record is that record maintenance and storage problems go away. All medical histories, medication lists, chart notes, labs, x-rays, reports, letters, and any other form held in a paper record is either documented directly into the EMR or scanned.

Having patient records available at a few clicks of a mouse or touch screen, can be invaluable. Once a medical practice is trained and comfortable using their EMR, physicians and other care-providers save time, and record documentation is greatly improved. Templates can be setup to mimic individual practice standards, or standard templates can be utilized for the entire practice. For example, a template is setup for sore throat, fever, and congestion. At intake when patient complaints are “ticked” in the EMR, a template pops-up requiring only the fields to be completed that pertain to the specific illness. Obviously, if the complaint is a fall or bee sting, the template would be quite different, but only protocol pertaining to the complaint would be visible.

Perhaps the most attractive benefit of adopting an EMR is the overall cost savings it generates. The EMR virtually eliminates the cost of reams and reams of paper, the off-site printing of forms such as encounters or super bills, in-house printing of schedules, and the zillion copies of insurance cards and scripts. Some practices even decrease their payroll costs by implementing an EMR. Without the paper record there is no backend record maintenance, no finding, filing, or re-filing charts, which equates to less labor requirements.

There are many advantages of the EMR over paper medical records, although currently it is estimated that 70% of medical offices have not yet converted to an EMR. With the financial incentives being offered by the Medicare Program and the addition of the Stimulus Package signed into law by President Obama, the percentage of medical offices adopting an electronic record will rapidly increase in the near future.

Any medical office that has not yet begun thinking about electronic implementation should very seriously start researching EMRs to best fit their practice. Eventually penalties will be assessed to offices not in compliance with electronic health record technology.

Harry E. Selent is President of medicalcharting.com and medicalbillingsoftware.com. Harry is passionate about helping single and small practice doctors implement cost effective electronic medical record software.

Some Ways to Keep Your Electronic Medical Records Plan Moving Ahead

Posted on January 7, 2018 by CPC Exam Medical Coding Updates

The most common question I get writing this column is: ‘Why is it taking so long to implement electronic medical records?’ Our initial 18-mo project turned out in about three years, instead. Though this seems a bit cautious to some colleagues, people in IT and project management industries commended our careful approach to the situation. It’s well-known that Internet Technology system implementations (such as EMR) fail up to 50 percent of the time. A solid plan must be in place, taking into account any unforeseeable circumstances which could change the time frame. For example, our journey included two new associates, two hurricanes, and a departure of an associate.

Your electronic medical records vendor should be able to refer someone to guide you through implementation. However, this person can be either a person with EMR experience or someone who knows about the system itself, though not so much about roll-out at a medical office. I strongly recommend taking on the services of a certified PM (Project Manager). One important thing a PM can do is turn your project into a dynamic process which can take a series of setbacks or delays. The standard calendar can’t really do much to ensure this sort of follow-through.

We first implemented a Project Manager to plan the location for our new office. Our employees could use what was learned from the process, which includes how to use mind-mapping software. We have used these techniques for all major projects at our practice since then, including implementation of the electronic medical records (EMR).

For meetings and other minor projects I recommend Getting Things Done by David Allen.

The primary advantage of using a work breakdown structure is that any glitches that pop up don’t completely ruin your goal to successfully implement the EMR system. Of course, at a small practice there is more schedule flexibility. A hard deadline should most certainly be set, as part of the plan for EMR roll-out. However, with a proper plan structure your plan can roll on with the punches instead of simply rolling over.

When we finally arrived a a place when staff had training, we posted the hard deadline to go live. There was a simulation date on a Saturday which occurred two days before launch; both dates were mandatory to attend.

Although theoretically we could have pushed the launch date back, these dates helped to keep us working together and exposed risks that were faced. Now we’re about 5 months into our roll-out. The stress levels have begun to settle a bit, and we’re now tweaking our templates and getting ready for the next wave of patients to introduce to electronic medical records.

Peter J. Polack, M.D., F.A.C.S., is founder of emedikon, a medical practice management consulting firm and president of Protodrone, a software development company specializing in medical practice applications. He is managing partner of Ocala Eye, a large multi-specialty ophthalmology practice. Find more useful articles and podcasts at http://www.medicalpracticetrends.com

Electronic Medical Record Keeping Helps Medical Providers Provide Quality Care

Posted on December 28, 2017 by CPC Exam Medical Coding Updates

Medical records are extremely important to the running of any sort of health facility, such as hospitals, doctor offices, or nursing homes. They keep track of the health history of a patient, any new diagnoses, any treatment plan that has been prescribed, medications that a patient takes or has taken in the past, allergies that a patient has, etc. All of this used to be documented on paper. When I was working in a nursing home in 2004, all of our records were paper based. We needed to document everything that we did with our patients.

If we checked on our patient at all, even if we didn’t actively do anything in their room, we needed to document this. This ensures that we aren’t ignoring the needs of our patients. Since patients need to be checked on very regularly, a lot of space can be taken up using paper records. Especially since in most states, physical records need to be a kept for a minimum of seven years. It is also more difficult for healthcare professionals in different locations to read paper records of a certain patient. A lot of copying and faxing is required to accomplish this.

Electronic Medical Records (EMR) allows the healthcare professional to be more organized and allows them to more easily keep up to date about their patient. If there is something in particular that they need to find out about their patient, it is more readily available with EMR technology. They no longer need to sift through useless information in order to read the one piece of information that they need.

In most hospitals, a computer is placed in every patient’s room so that medical errors are reduced. Every time a medication is given or a treatment done, the patient’s name-band needs to be scanned so that it is ensured that they are receiving the right medication with the right dose at the right time by the right route. Having a computer right next to you when you check all of these decreases medical errors in the hospital system. EMR also ensures patient confidentiality. Only the people directly involved with the care of a patient can read that patient’s medical record.

Log ins are password protected so unless a healthcare provider gives someone their password, they can’t get in to check on the status of a patient. EMR is a very good system that is readily becoming more widespread throughout our medical system.

Prime Clinical Systems (http://www.primeclinical.com/) designs and installs EMR systems that are easy to use and easily customized to the individual EMR requirements of individual medical practices and professionals.

Electronic File Cabinet For Medical Records

Posted on December 17, 2017 by CPC Exam Medical Coding Updates

Choosing an electronic file cabinet for medical records has become popular over the last several years. Having paper files for patients in medical offices can take up a lot of space; especially if your medical practice expands with more patients. Plus, the time to retrieve patients files on a daily basis can be very time consuming when there are many other duties and responsibilities that need to be done. Health professionals will definitely want to research for a great document management software program to fit their needs.

There are many advantages of having a good electronic file cabinet. You will have the opportunity to import, store, find, and edit your documents right at your fingertips. Any paperwork you have, you will be able to scan them and, in turn, will go into an electronic in box. At that point, your document management system will allow you to file it in its proper place. It will be organized, stored and if you need to retrieve it, you will have easy accessibility to do that. You will be able to store all types of paperwork together no matter what format or file type.

So, if you have scanned copies, typed letters, drawings, emails and other documentation, they can be stored together in a patients file. When it comes to finding a particular file or piece of paper, you will be able to retrieve it quickly within seconds saving you much time. Editing will be quite easy as well. If you need to forward medical records onto another facility and there is some confidential information on there, you will be able to block parts of the document. You will be able to add or change information to any paperwork as well.

As you can see, there are many benefits to using this type of software program for more organized filing; especially medical records. This will ensure patients files are not misplaced or misfiled. Plus, you will be able to control security access of who is authorized to the files and what information they are allowed to have access to.

Take the time to research a few companies that have document management software systems. You will be able to find one that will be suitable for your business needs at an affordable price. Remember, you will save on money in the years to come with just less paper to purchase, file cabinets and storage space. Many medical professionals are using the electronic file cabinet to keep track of their patients in an organized and safe manner.

To learn more about electronic file cabinet, please visit our website.

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NJ Electronic Medical Record Mandate

Posted on December 5, 2017 by CPC Exam Medical Coding Updates

The New Jersey Health Information Exchange Project was presented on behalf in the community of New Jersey. Along with this a grant procedure was also submitted. The grant program and also the project had been aimed at facilitating greater adoption of healthcare details norms as stipulated by HIPAA. It pays specific emphasis to the understanding and adoption of ‘meaningful use’ of patient details in healthcare settings. This initiative is commonly called the New Jersey EMR Mandate.

Now, the New Jersey EMR Mandate is also referred to as the New Jersey Well being Data Technology Extension Center or the NJ-HITEC. This initiative can also be aimed at providing healthcare professionals the significantly needed suggestions after selecting facts technology systems for upgrading their operations towards the electronic format, i.e. storage of patient well being records within the electronic format (EMR).

The NJ-HITEC mandate is aimed at the electronic upgrade of practically 6,000 healthcare providers towards EMR platform from the first, 2 years. To gain this goal, the NJ-HITEC is planning to jobs in collaboration community colleges to make certain greater outreach towards the physicians.

NJ-HITEC is a lot more focused upon doctors who are serving the urban and rural populations deemed much more prone to developing healthcare problems. The mandate seeks to achieve out to the primary-care physicians serving these groups to make sure that at least 85% of all paper-using physicians adopt EMR technologies.

New Jersey has a history of taking the lead in enterprising the adoption of healthcare technologies like EMR. The Region HIE Cooperative Agreement Process is one more assistance obtainable in New Jersey through the American Recovery and Reinvestment Act (2009).

This system represents nearly 15 many years of jobs dedicated at facilitating health facts technologies. The state of New Jersey enacted Well being Information Electronic Details Interchange Act or the HINT Act in 1999 that was officially the very first system inside the US aimed at doing an additional transparent regulatory framework for making electronic submission of healthcare facts standardized. A Commission on Rationalizing Health Care Resources had earlier issued its report in 2008 that produced the roadmap for improving delivery of healthcare services.

New Jersey has also been at the forefront of creation of a lot more community-based Well being Data Exchanges that are aimed improving the health popularity from the state’s residents through better-coordinated healthcare centers. These community-based Well being Information Exchanges or HIEs can also be looked upon as the building blocks for making a more coordinated health-information pattern from the land of New Jersey and eventually throughout the nation. This really is basically mainly because community-based initiatives make sure participation from hospitals, long-term care providers and physicians besides other entities handling patient information.

Despite these noteworthy features, NJ-HITEC acknowledges that outpatient healthcare providers inside nation have not been quite enthusiastic about adopting information technology and thus, greater advice in this regard is needed.

Boone Gomez administers edocscan.com. For more information on NJ Emr Mandate and electronic medical records , visit http://www.edocsan.com

EMR: Electronic Medical Records

Posted on December 1, 2017 by CPC Exam Medical Coding Updates

Prior to the advent of this system, the only method available with the medical practitioners was the preservation of records on paper. The paper work posed some very serious challenges. The records preserved in the paper format were almost unable to browse if the title of a certain required file was not present since all the other information regarding a case was in a file that can be found if its title was known. The records preserved in the paper formats also needed a lot of paper and even more space to preserve these records. The musty record rooms and molds growing therein often tampered or sometimes mutilated the papers. A patient’s file could only contain a limited years of his medical history as preservation of each patients life-long span would need tens or may be hundreds of files. The study of these records, often, needed a visit to the record-room or a special instruction to the staff member to fetch these. The transportation of these records as often required, in case the patient is to be shifted at some other hospital or health care facility was not only pretty expensive, rather it also involved hours of process amidst the hectic daily routine. There would often be a separate diary for the doctor of his/her assistant to give appointments.

The electronic medical records (EMR) has not only resolved all these problems, thanks to technology. Now even life-long long records of all the patients can be saved in a laptop. Not only this but these records can also be viewed from any place in the world using internet. There is an absolute safety as the back-up copy of the software can be used to retrieve the data, even in case if the software is deleted or tampered with. The law requires all the medical facility

EMR, an abbreviation for Electronic medical records, is a a system that is employed by a lot of hospitals, healthcare units, and medical practitioners practicing independently. This system allows the medical treatment providers to maintain a digital computerized records of the patients.

Prior to the advent of this system, the only method available with the medical practitioners was the preservation of records on paper. The paper work posed some very serious challenges.

health,emr,medical records,software

Electronic Medical Records ? A Vital Need

Posted on November 30, 2017 by CPC Exam Medical Coding Updates

Electronic Medical Records prove to be a lot more useful than paper-based records. EMR offers the medical practitioners a far more economical and user-friendly alternative to the decades old paper-based documentation. Medical practitioners or healthcare units using this system do not have to hire a special person to organize their records. The huge space that the papers and files cover made it another gigantic task to accomplish as it asked for a huge space for maintaining the hard-copies. Doctors throughout the world are stereotyped as having an illegible hand-writing. This though may not be a problem for the other doctors, sometimes it may cost dearly in sensitive issue relevant to health if the doctor’s report is not legible. This is also possible that the authoring doctor, himself, cannot read his hand-written report some years later. Not only can this hinder the case study of a patient in future for further medical purposes, it may also have an adverse impact on the course of law if the record is sought by the courts. With Electronic Medical Records, this issue diminishes due. The exchange of hard copies is pretty cumbersome. But the same can simply be emailed within seconds if the Electronic Medical Records is being in use. Certain reports are needed to be kept, both, by the hospital/doctor and the patients. In some cases, when the patient alone has some needed records , but lost by him/her ; it becomes another ordeal to impart treatment. With EMR, a doctor can simply scan the records of the patients, when seen by him, and attached to the profile of the patient. He can even study these records later on.

Yet, there are vast number of hospitals and medical practitioners who still use the paper-based record-keeping and prefer it. The reasons for this vary. Some doctors do it to avoid the ordeal of entering the data into computer by typing or hiring a person for the data-entry is also not economical. The Electronic Medical Records is relatively expensive to install. The outlay cost deters many doctors from using it. Even in a country like US, the number of doctors, preferring the hard copy records outnumber those using Electronic Medical Records

Despite of the relative modernity and long-term economical alternative, to choose or otherwise, is dependant the medical heath provider. It remains only to be a matter of choice. This may be the only field on earth where most professionals are technology-shy. We hope to fix the problem one day. More information can be found at http://www.healthtec-software.com/electronic-medical-records.htm

Electronic Medical Records

Electronic Medical Records May Save Lives

Posted on November 9, 2017 by CPC Exam Medical Coding Updates

Electronic medical records may dramatically improve the diagnosis, management and care of patients, according to a Kaiser Permanente study from the September 2007 issue of the Journal of the American Geriatrics Society. This study reports that electronic medical records improve the quality of health care overall and may result in quicker diagnosis and response time to critical needs.

Electronic medical records can also enable the study of data from an entire population in ways not previously possible: allowing conditions to be analyzed to determine what treatments work and what do not, finding patterns of care that are more effective, and defining the cost-effectiveness of various techniques and approaches for optimal care. By being able to track larger amounts of data than ever before, medical teams can track vital medical data without the need for costly and cumbersome voluntary studies. Lives might be saved by following and analyzing diagnosis and treatment across a large group of patients and new solutions could be discovered through new found research data. These are the positive influences that electronic medical records may supply on the research side, but every day solutions are also provided.

The safety alerts, built into many electronic medical record systems, may draw attention to life-threatening situations. Imagine a patient seen by two separate doctors. These doctors each prescribe separate medication that could harmfully interact, medication that is somehow not noted or brought to the second doctor’s attention. This could have a potentially fatal consequence. With a electronic medical record systems, doctors are alerted instantly to any potentially dangerous medical interactions or conditions of a patient. According to a “Safety in Prescribing” study in Archives of Internal Medicine, safety alerts that appear in electronic medical records reduce potentially dangerous interactions of co-prescriptions.

“This study shows that safety alerts in electronic medical records are a powerful tool to help clinicians make decisions about what drugs they should prescribe for their patients,” says Adrianne Feldstein, MD, MS, lead author of the study and an investigator at Kaiser Permanente’s Center for Health Research. “We compared the effects of two interventions in outpatient clinical settings – safety alerts in electronic medical records versus safety alerts plus clinician education courses. We found that adding clinician education to electronic medical records safety alerts did not reduce the rates of co-prescribing medications that interact any more than electronic medical records safety alerts alone. The reason is unclear, but it may be that the ‘just in time’ information provided by safety alerts is more useful to clinicians than education courses.”

Electronic medical records may help save lives, especially when they are properly implemented and understood. For more information about a reliable electronic medical record system, contact e-MDs, a leader in electronic medical record software provision. e-MDs offers a host of affordable solutions for physicians and facilities looking to modernize or enhance their services with the latest EMR technology. e-MDs is committed to providing operational solutions and delivering the clinical tools needed to succeed in today’s medical field.

Brigette Botkin. Electronic Medical Records– e-MDs powerful software can help manage your electronic medical records

What Is Electronic Medical Record?

Posted on October 30, 2017 by CPC Exam Medical Coding Updates

An electronic medical record, or EMR, is typically a digital legal medical record created in an establishment that delivers health care, such as a hospital, a clinic, or a medical office. Electronic medical records are likely to be a part of local stand-alone health information systems that permit storage, recovery and management of documents.

Documentations on paper form need a considerable room for storage space in contrast with digital records. In the United States, most states require tangible records be retained for a minimum period of seven years. The costs of media for storage, such as paper and film, information per unit is dramatically different from that of media storage for electronic files. When paper documents are stored in various locations, gathering them to a single place for evaluation by health care personnel is time-consuming and complex, while the procedure can be simplified with digital records.

This is especially true in the case of individual-centered records and documents, which are impractical to retain if not digital, thus it is difficult to be centralized or federated. When paper-based records are needed in multiple locations, copying, faxing and transporting expenditures are considerably higher in comparison with duplication and transfer of electronic records.

A research approximates electronic medical records increase efficiency by about six percent per year, and the cost per month of electronic medical records is offset by the cost of only a few unneeded examinations or admissions.

Handwritten paper medical records can be voided due to poor legibility of the glyphs and symbols written by hand, which can contribute also to medical errors. Pre-printed forms, the standardization of used abbreviations, and standards for penmanship were pushed upon to further improve reliability of paper medical records. electronic medical records help with these standardizations. Digitization of forms facilitates the collation of data for clinical studies.

On the other hand, electronic medical records can be continuously updated. The capability of exchanging records and documents between different electronic medical records systems would make coordination of health care delivery in non-affiliated health care facilities possible. Furthermore, data from electronic medical records can be used anonymously for statistical reporting in issues quality development and improvement, resource management and public health surveillance for communicable disease.

Learn more about our services at www.MedicalBilling4U.com

Aspects Considered In Electronic Medical Record

Posted on October 30, 2017 by CPC Exam Medical Coding Updates

Even if electronic medical records systems wit computerized provider order entry, or CPOE, have existed for more than thirty years, less than ten percent of all hospitals in the United States, as of the year 2006, have fully incorporated electronic medical records into their systems.

In the year 2008, about thirty eight percent of office-based physicians accounted fully or partially using electronic medical records systems for their work processes. However, the same research found that only roughly twenty percent of all physicians reported using a system depicted as functional in minimal value and engaging in orders for prescriptions and examinations, viewing laboratory or imaging results, and clinical notes.

Electronic medical records, like their paper-based counterparts, must be kept in unaltered state and authenticated be their creators. Under data encryption and protection regulations, responsibility for patient records and documents, disregarding the forms they are kept in, is always on the creator and the custodian of the documents.

The tangible medical records are the property of the medical provider or institution that sets them up. This involves films and tracings from diagnostic imaging procedures, such as x-ray, CT scans, PET, MRI imaging, ultrasound, and other. The patient, however, has the right to have access at the original documents of electronic medical records, and obtain copies under law.

Most national and international sets of standards accept the use of electronic signatures. Applicable to electronic medical records, an electronic signature authenticates a digital scribe by indentifying the signer with the signed file or document. When the signer creates a mark in a unique manner, that becomes can be attributed to the signer.

Using electronic medical records in reading or editing a patients records or documents is not only possible through a health care workstation, but it depends on the type of machine and health care settings. It may also be possible through using mobile devices that are capable of understanding and translating human handwriting. Electronic medical records can include ease of access to personal health records, which makes individual notes from electronic medical records readily available for patients who needs the records for documentation.