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The “In Case You Missed It” CLE Recap: Navigating Electronic Medical Records

By Debi Binkley, Bose McKinney & Evans LLP

On February 27, 2013, Ms. Carolyn Murry, MBA, RHIT of Indiana University Purdue University Indianapolis presented an engaging and informative seminar on the highly evolving and developing topic of Navigating Electronic Medical Records. Ms. Murry provided an overview on how we have gone…

From this:

To this:

The EMR Concept has been around since the late 1960s; however, the evolution of the electronic health record (EHR) has been and remains an ongoing process.

An electronic health record (EHR) is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

An electronic medical record (EMR) is an electronic record of health-related information on an individual that can be created, managed and consulted by authorized clinicians and staff within one healthcare organization. It can also refer to a hospital achieving a paperless environment with a document imaging system or a physician office EHR system. EHR and EMR are often used interchangeably; however, the appropriate term is EHR. The EHR is not just about automating the paper chart, but about using information to improve the quality of health care.

The many advantages and benefits of the EHR, include:

  • Availability at the point of care
  • Bar code technology
  • Better information and accessibility
  • Improved quality of care with improved healthcare outcomes
  • Enhanced patient safety
  • Maintenance of patient confidentiality and exchange of data securely
  • Increased productivity
  • Efficiency and savings

 

BUT there are challenges, including textual and contextual data, mobile professionals, equipment, training, maintenance, risk of privacy and security breaches, identity theft, audit functions, workflows and process changes. It is a system of systems made up of various systems.

The Veterans Administration manages the largest medical system in the United States, providing care to over 8 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes throughout the continental U.S., Alaska, and Hawaii on a single electronic healthcare information network. The VA’s VistA CPRS (Comprehensive Patient Record System) is an enterprise-wide information system built around an EHR used throughout the VA medical system. It consists of nearly 160 integrated software modules for clinical care, financial functions, and infrastructure. Over 60% of all physicians trained in the U.S. rotate through the VA on clinical electives, making VistA the most familiar and widely used EHR in the U.S. As such, the VA system is a model for the uniform national standards regarding EHRs, which are developing.

As the EHR continues to evolve, it is important to be aware that we may have a hybrid record consisting of both a paper record and an EHR. Hospital and physician records may not yet be fully integrated. Therefore, be sure when you are requesting health care information that you ask for both the hospital and the doctor’s records.

In 2004, President George Bush referenced the importance of every American having an electronic health record by 2014. That time is nearly here. The government currently has in place several Health Information Technology initiatives designed to encourage those who create and manage health-related information to convert from a paper record to an EHR. $20.8B in Medicare/Medicaid incentives are being paid to adopt EHRs. Standards for electronic exchange of administrative and financial information are being established as we speak. Mandated electronic submission of healthcare claims for Medicare and/or Medicaid reimbursement is forthcoming or there will be penalties. Many changes are coming.

The ultimate goal is to have the Nationwide Health Information Network (NHIN).

Whether your professional legal practice touches health care issues or not, each of us needs to personally be aware of these important changes as patients in our own personal lives. Indiana currently has the Indiana Health Information Exchange.

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