What is an electronic health or medical record?
How are medical procedures and diagnoses coded? What is the value of electronic health records? What is a health information exchange? How has ransomware affected the security of electronic health records? This blog article tackles these questions and shows why electronic health records are the future of medicine.
In the past, physicians would have shared information by printing out medical records and faxing them over to other physicians’ offices. Much of the handwriting and printouts may have been illegible, leaving physicians to interpret previous treatments, vaccinations, and patients’ health histories.
With the advent of the electronic health record, physicians no longer have to interpret cryptic messages in other health care providers’ health record notes.
Using electronic health records also cuts down on all the time and personnel necessary to track down and share patient histories between health care professionals.
What Is an Electronic Health Record (EHR)?
An electronic health record (EHR) (or electronic medical record (EMR) if it is used to replace paper charts in a single facility) is a systematic collection of patients’ electronically stored health information in a digital format. Electronic health records can be shared by all providers in a patient’s care including physicians, medical offices, and health care professionals.
Some of the valuable information recorded in electronic health records includes medical histories, medications, allergies, immunization statuses, laboratory test results, radiology images, vital signs, patient statistics (age and weight), and all insurance billing information.
How Are Electronic Health Records (EHR) Coded?
There are three different types of medical coding systems that the average medical assistant or medical coding specialist will use in day-to-day tasks. They include ICD-10 (International Statistical Classification of Diseases and Related Health Problems), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System).
ICD-10 Coding – The use of ICD-10 helps standardize medical coding internationally. The International Classification of Diseases (ICD) is used to record diagnoses. ICD consists of alphanumeric codes that follow an international standard, making sure that diagnoses are interpreted the same way by every medical professional around the world.
CPT Coding – Current Procedural Terminology (CPT) coding is a US standard for coding medical procedures maintained by the American Medical Association (AMA). ICD-10 focuses on diagnoses, while the CPT identifies the services provided. CPT is used by insurance companies to determine how much physicians will be paid for their services.
HCPCS – Healthcare Common Procedure Coding System is a set of health care procedure codes based on the AMA’s CPT system. HCPCS is a medical billing process used by the Centers for Medicare and Medicaid Services (CMS). This coding system was created to standardize the coding of specific items and services proved by health care professionals and billed to Medicare and Medicaid.
The HIPAA Act of 1996 made the use of HCPCS coding mandatory for processing insurance claims through Medicare and Medicaid. It includes circumstances and procedures not included in the CPT and is used by hospitals for non-Medicare and Medicaid cases, as well.
Benefits of Electronic Health Records (EHR)
There are many benefits to adopting electronic health records. Electronic health records offer greater collaboration, patient historical tracking, the ability to properly monitor patients, and less errors and duplicate testing. They save time and resources, assist research, and are more secure than paper files that are sent in the mail.
Greater Collaboration – An electronic health record can be accessed, created, managed, and consulted by authorized providers and staff from multiple health care organizations. A pharmacist is able to access meds from multiple physicians to identify any negative interactions from prescribed medications. A psychiatrist has access to the primary care physician’s notes, and in an emergency, a hospital will have access to the patient’s complete health history.
With electronic health records, a patient is also able to access and respond to physicians with the use of communication tools including text messaging and emailing. An electronic health record system offers a greater collaboration among health care professionals and their patients.
Historical Tracking – Physicians have valuable access to their patients’ records across their entire life, offering explanations for different conditions or treatments that have been tested. Many patients move from one physician to the next, and each is able to access the notes of the previous physician in electronic format.
Properly Monitor the Patient – Have patients been vaccinated against chickenpox, or did they have it at an early age and are not susceptible to shingles? By using electronic health records, the health care community can properly monitor a patient and understand when screenings are necessary or when preventative care should be administered.
Less Errors and Duplicate Testing – With the help of electronic health records, physicians do not make as many errors in medications prescribed and treatments offered as they might otherwise do. If a patient reports an allergy to one physician, all physicians who access that patient’s medical records will know about the allergy and not prescribe medication or use materials that will cause an adverse reaction.
Electronic health records also reduce the amount of duplicate tests that are performed due to lack of insight into another physician’s treatments and medical records.
Save Time and Resources – Many physicians used to have medical assistants dedicated to managing incoming and outgoing files for past and current patients. Time and resources were wasted by the inefficiency of the old filing processes used by physicians. Having electronic health records and a universal coding system saves valuable time for physicians to help more patients.
Better Research – With the entirety of a patient’s history, treatments, and other health care information searchable in electronic format, a provider or facility can now perform medical research professionally in an easier way to compile data and identify trends in the global population. Major illnesses and the treatments for those illnesses can be identified quicker and with a greater data set with the help of electronic health records.
More Security – Keeping a patient’s personal information in a secure environment makes it harder for people to steal chart notes than if they were still on paper, when someone’s protected health information would be vulnerable to interception through the mail. New ransomware concerns have to be reviewed, and strong encryption is needed to stop hackers from stealing patients’ personal and confidential health records.
What Is a Health Information Exchange?
A health information exchange is a technical and social framework that enables information to move electronically between organizations. Through the health information exchange, patient information is accessible by computer, tablet, or smartphone.
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