Medical assistants play an active role in managing health records, requiring familiarity with two advanced recordkeeping systems, electronic medical records (EMR) and electronic health records (EHR). What’s the difference between them, and how do they help medical assistants do their jobs? Let’s find out.
The History of Health Records
In the 1960s, medical records were kept on paper. Lab reports, progress notes, and doctors’ orders were all handwritten and bound together in binders labeled by patient name, Social Security number, or other identifiers. It was common for private institutions to create their own labeling systems.
Records were filed in drawers or racks for accessibility, but as the number of patients and volume of information increased, storing and retrieving files became a costly, laborious, space consuming process. Archiving records long-term requires expansive, climate controlled facilities.
It could take hours for a medical assistant to search for and deliver a single file and days or weeks to gather a complete record from different sources. Referrals required copying and mailing thick files at significant expense, or later, faxing hundreds of pages of data for a single case. By the late 1970s, it was obvious a new way to manage records was needed.
The Institute of Medicine, now the National Academy of Medicine, commissioned a study of paper medical records in the early 1980s looking for ways to improve data storage and sharing efficiency. Key recommendations included the use of electronic medical records (EMR) and the development of an electronic health records (EHR) system.
Engineers began implementing these measures in government-run health facilities almost immediately, but the technology proved challenging. Delays were common, and private institutions resisted changes due to cost. The capital investment required to purchase and maintain both hardware and software was enormous.
But by the late 1980s, change was inevitable. The cost of storing the growing volumes of documentation was becoming equally cost-prohibitive, and EMR/EHR was the natural solution.
EMR vs. EHR
EMR and EHR are both digital versions of a patient’s health record. The terms are often used interchangeably, but there’s a clear difference.
An electronic medical record is equivalent to a patient’s chart. Created for a single clinician, it’s efficient to use and convenient to store but contains only the information a paper file would hold.
- Demographic data
- Allergy list
- Medication profile
- Vital signs
- Progress notes
- Care plans
- Lab and test results ordered by the same practice
- Administrative and billing data
Patients have a different EMR in each office they visit, and access is limited to the doctor or patient and can’t be shared without consent. Its uses are limited.
Electronic health records contain data from multiple sources. EHR systems are specifically designed to share information among participating providers, so each benefits from seeing a complete clinical picture. Patients can still control who accesses their files, but doctors have the information they need at their fingertips to make the best medical decisions.
The benefits of digital recordkeeping far outweigh the risks, however, there are a few drawbacks. Large quantities of medical data stored on a single server are vulnerable to hacking. Today’s identity thieves are less inclined to target individuals when they can glean volumes of information in a single hack.
Who patients are is critical in medicine, so records contain significant personal data. The good news is that fewer databases are as secure as an insurers’ or medical facilities’, making any potential breach difficult to achieve.
Another concern is that some EHR systems remain off-limits to all but participating providers. EHR managers want to vet practices before giving them access to information and ensure they have the necessary security infrastructure to safeguard sensitive data. But spats between competing health systems result in unnecessary exclusions, something professionals suggest will improve as the health care system changes and technology advances.
EHR systems are also vulnerable to power disruptions, however most facilities have contingency plans, from off-grid power generation during natural disasters to cloud-based data backups.
It’s one of the many reasons power is always restored to health care facilities first.
The Benefits of Electronic Health Records
Electronic medical and health records have many benefits. Here are some of them.
Cut Paperwork Costs
Cost estimates of medical data handling may exceed billions annually. Offices once hired five staff members to manage documentation for one provider.
Sharing medical records is faster and easier when they’re stored digitally. With a few keystrokes, a medical assistant can update information, request test results from a referring physician, and transmit prescriptions to a pharmacy. Data is efficiently organized and simple to find.
Speed the Delivery of Care
Timely medical care depends on accessible data. EHR allows an ER physician in California to see an unconscious patient’s allergy list from a collaborating provider on the East Coast within minutes.
Hospitals, laboratories, and imaging services can send diagnostic test results with the push of a button. Patients no longer have to wait for treatment because it takes printed records a week to arrive by mail. Fewer files are lost, and there’s less paperwork to juggle.
Prevent Duplicate Treatments
A substantial percentage of all diagnostics were once redundant, having been ordered by consulting physicians who were unaware of prior tests. Today, results are immediately uploaded to the patient’s EHR, and the doctor is notified, curbing billions in wasteful spending.
Reduce Medical Mistakes
Many medical errors can be attributable to miscommunication. Each time data changes hands, information may be altered or lost. Misplaced records, missing results, and illegible handwriting are all issues EHR addresses.
Improve Patient Outcomes
Many Americans have chronic health conditions requiring routine preventive care. Before the advent of EHR, doctors depended on elaborate systems to track when services were due. Now, a medical assistant can run a report showing how many patients haven’t been in for their annual flu shot, allowing practices to reach out proactively.
Electronic health records put nearly unlimited information at the doctor’s disposal. Data is better organized and can be cross-referenced to identify patients’ vulnerabilities to disease. Diabetes and hypertension combined, for example, carry a higher risk of coronary artery disease. A quick search of the database can identify patients with both, so physicians can recommend targeted interventions that improve long-term health outcomes.
Emergency follow-up care is also easier because of EHR. In the past, hospitals didn’t always notify patients’ physicians when they were seen for severe symptoms. Today, EHR cues a practice to contact vulnerable patients for a follow-up visit.
Bolster Public Health Surveillance
COVID-19 underscores the need for increased public health surveillance. Electronic health records contain the diagnostic codes the CDC and WHO use to track community disease rates in real time.
Paper tracking would make large-scale pandemic management nearly impossible, but easily accessible digital data can be converted quickly enough to guide immediate resource management.
HIPAA and Electronic Health Records
HIPAA is an acronym for Health Insurance Portability and Accountability Act. Signed in 1996 by President Clinton, it’s a federal statute with several key purposes impacting medical assistants, including these.
- Modernizing the flow of medical information
- Regulating how personally identifiable data is maintained by health care facilities and insurers
It took years of data conversion to prepare for the digital era, but deadlines for compliance have passed, and most providers are now onboard. Gone are the days of swimming in paperwork. EMR and EHR systems free up medical assistants for more important tasks, like spending time with their patients.
HIPAA also improves patient confidentiality by limiting access to sensitive health data. Staff members may access only the details they need to provide care.
A paper record, once opened, could reveal far more than necessary. Coding specialists looking for a single diagnosis, for example, could easily access information unrelated to their task.
Controlling who can open records is simpler with electronic systems. Entry is password protected, and information is secured by role. Algorithms can tell whether it’s a social worker or dietary aide requesting information. Restricted data are siloed.
HIPAA is also a double-edged sword, however, creating additional responsibility for health care staff. Employers are mandated to train their teams annually and as needed with any substantive changes to the rules, but ultimately, medical assistants are responsible for safeguarding records. Just as they would have secured paper charts before leaving a room, so should they guard their computer screens from prying eyes and log out before leaving a terminal.
HIPAA violations may result in significant financial penalties for institutions and job loss for employees, so staff must be vigilant. Major hospitals and insurers have been fined millions for failure to protect data. EHR security depends on the knowledge and commitment of the people using it.
Electronic medical records were the first leap forward in recordkeeping technology since doctors wrote their first notes. EHR expanded on the promise of better information sharing with high-speed access to a wealth of information. With the volume of medical data expected to skyrocket in the coming decade, our digital transformation was not a moment too soon.
Did learning about the differences between EHR and EMR interest you? Ready for an exciting new career in the medical assisting field?
The Medical Assistant program at Hunter Business School prepares competent, entry-level medical assistants in the cognitive (knowledge), psychomotor (skills), and affective (behavior) learning domains required for professional practice.
The Medical Assistant program provides hands-on experience in a real medical setting where you can foster professional relationships with actual patients. Medical Assistant students spend 160 hours in an externship in a professional medical environment where they are supervised and taught in order to gain valuable on-the-job training.