Introduction to electronic health records
Before technology became as prevalent as today, patient records were handwritten and stored manually in filing cabinets. While this method was once necessary, new changes have impacted managing health records.
Because of these changes and the role that health records play in patient treatment and care, it is more important now than ever to ensure that healthcare workers have an in-depth understanding of record management. To help practitioners achieve this knowledge, we've written a detailed guide that breaks down the essential aspects of managing health records.
What are personal health records?
Health records are documents related to a patient's experience within the healthcare industry. Management care relates to how these documents are created, shared, and destroyed. Several intersecting protocols and regulations govern these processes; every healthcare professional must abide by them.
Correct health records management is important for various reasons. First, a study completed by Johns Hopkins University found that medical errors are the third leading cause of death in the United States. Poor health records management can lead to missing information, false diagnoses, and ineffective communication, all entirely avoidable situations (McMains, 2016).
Secondly, the information in health records is often confidential and, as such, needs to be treated with privacy. Not only is there personal and identifiable information within these records, but they also usually include a patient's medical history, medications, and treatments. Patients want to feel comfortable trusting you with often highly personal health information when they come into your care. You are responsible for ensuring that these records are kept safe and secure.
Now that you understand the importance of effective health records management, it's time to examine what healthcare practitioners can do to ensure the security of their electronic medical records themselves.
What should be included in a patient's medical records?
The information that makes up a medical record helps inform practitioners of their patient's medical condition. When medical records are accurate, they can facilitate better decision-making, treatment options, and overall improved clinical outcomes. While the specific information within a medical record will depend on a variety of factors, we have drawn up a list of some of the things they typically include:
- Patient identifiers: This includes information directly related to the patient's identity, including name, date of birth, address, and phone number. Patients are often assigned unique patient IDs to help make data processing easier.
- Demographics: The patient's age, gender, and ethnicity are recorded so the patient can be found and matched across several different databases. Other demographics, including education, nationality, and income, can also be recorded.
- Diagnosis: The patient's diagnosis is one of the most critical information in a medical record. When a patient is being treated or seen by a new provider, having access to this information allows the provider to quickly understand the patient's symptoms, condition, medication, and treatment plan.
- Medications: Recording the patient's medication allows providers to make more accurate decisions regarding treatment plans, particularly if the patient has recently been transferred to a different department or facility.
- Procedures: Any procedures the patient has undergone, including surgery, laboratory, radiology, and pathology. A diagnosis or treatment plan for a patient should be backed up by evidence, and results from the above procedures can serve as evidence.
- Vital signs: One of the most fundamental elements in evaluating a patient's health is that providers can use vital signs to assess their patient's condition quickly and accurately. These may include weight, height, blood pressure, glucose levels, temperature, body mass index, pulse rate, and respiratory rate.
- Family and social history: Health records don't always include this information. However, it can paint a bigger picture of the patient's health condition and is often used for research. For example, this may include the health condition of immediate family members, family diseases, occupation status, and community support.
What shouldn't be included in a patient's medical records?
Just as key pieces of information should be included in a medical record, some things are best to leave out. Remember that the purpose of a medical record is to improve communication and clinical outcomes, so if the information you are considering does neither of these, it is best to exclude it. For the most efficient and accurate medical records, you should keep in mind the following:
- Subjective opinions: While professional views can sometimes be necessary when evaluating a patient, they must be kept to a minimum. Medical records are used as resources to guide providers and ensure patients receive the best possible treatment. Overly subjective or opinionated statements can cause various issues and are generally unhelpful to providers and patients.
- Assumptions: This may seem obvious, but you would be surprised how often assumptions are included in medical records. Concluding will occasionally be guided by some level of inference, but evidence should nonetheless support these. A patient who comes into a clinic with specific presenting symptoms should still have tests completed to determine the cause.
- Financial or health insurance information: Medical records should only contain information pertinent to a patient's clinical treatment. Financial and insurance information is highly confidential to the patient, so it shouldn't be included in the medical record.
If you are concerned about whether or not to include something in a patient's medical record, take a minute to consider how relevant it is to the patient's treatment and care. If it isn't clinically crucial to a patient's health, then it is most likely irrelevant, and you should leave it out.
One more thing we'd like to mention about the contents of a medical record is the varying diagnoses, medications, and opinions of different healthcare providers. Not every practitioner will reach the same conclusion; seeing a medical record with differing diagnoses and recommendations is common.
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What is an electronic health record software?
At the beginning of this guide, we briefly mentioned that although medical records used to be handwritten and stored manually, technological advancements have led to new ways of creating and storing documents, particularly electronic health records (EHR).
EHRs are designed to assist healthcare providers in managing their medical records. At its most simple, an EHR is a digitized version of a patient's medical chart. However, EHRs have been designed to go beyond simply storing patient information. They utilize technology that allows authorized users to access and transfer data at any time, from anywhere.
The systems are updated in real time, facilitating more effective communication between providers and ensuring patients receive the highest quality of care possible. Although the primary purpose of an EHR is to store and organize health records, it has a broader role in elevating a practice's workflow and improving both the quality of care and clinical outcomes for patients.
With EHRs, practitioners can leave behind the arduous task of handwriting medical records and combing through filing cabinets. EHRs streamline the clinical documentation process, making accessing, transferring, and sharing records with other caregivers significantly easier. EHRs have become incredibly popular, and understanding their role in the healthcare industry is critical to achieving effective health records management.
Advantages of using EHR
I know we just discussed the benefits of using cloud-based technology for your EHR, but now it's time to consider the widespread advantages of using EHR as a whole. If you are interested in optimizing your health records management (and you should be) and improving outcomes for practitioners and patients, EHR is undoubtedly the way to go.
Accuracy
Maintaining accurate health records is critical to ensuring patients receive the necessary care. EHR facilitates more precise health records by reducing the number of errors, including spelling and grammar mistakes, missed information, and illegibility. Additionally, most EHR systems will automatically alert users to any identified mistakes, helping to make sure that these are fixed as soon as possible.
Improved quality of care
Attempting to improve the quality of care should always be the leading reason behind introducing any new system into healthcare practice, an improvement facilitated by EHR. Physicians have access to their patients' records 24/7, which are updated in real-time. Access to medications, medical history, symptoms, and allergies helps ensure that physicians are properly informed and can make appropriate treatment decisions.
Communication
Communication has been an area of healthcare that frequently poses difficulties for patients and physicians. We understand that practitioners lead hectic lives, and finding the time to communicate effectively with their patients and each other can be difficult. Nevertheless, poor communication can lead to mismanaged continuity of care and harmful treatment decisions.
Fortunately, EHR presents an easy way to improve communication, allowing physicians 24/7 access to important records regardless of where they are.
Saving time
We mentioned that a lack of time is one of the biggest barriers to effective communication for practitioners. It is a well-known fact that typing notes is significantly faster than handwriting notes, and with the right EHR system, practitioners can streamline the process of writing paper medical records themselves.
EHR also makes viewing, sharing, and transferring health records much easier, saving practitioners time to see and treat patients in need instead of waiting.
Patient involvement
As the healthcare industry moves to a model of consumer-based care, it is becoming increasingly important to listen to the needs of patients. Many patients have cited the importance of a transparent treatment process, and the providers are responsible for granting them this transparency. EHRs often come integrated with patient portals that provide clients with immediate access to their health records, allowing them to stay informed of their treatment plans and progress.
Reduced costs
A further benefit of implementing EHR into your practice is the financial savings you will have. Not only does EHR eliminate the need to pay for manual data entry, but reduced errors will lead to faster reimbursement, and the saved time can contribute to increased revenue. Although delivering high-quality healthcare is always the top priority, it is important to remember that every healthcare practice is a business, and effectively managing finances is necessary to keep operating.
Disadvantages of using EHR
As you can see, implementing an EHR into a healthcare practice has many benefits. However, it would be remiss of us not to mention that certain disadvantages often prevent providers from utilizing its full features.
Change
Perhaps the most impactful disadvantage of implementing any new system is the time it takes to adjust to the change. Even the most intuitive, user-friendly EHR will require increased effort for providers to use the system effectively. However, many EHR systems have training programs that educate practitioners on effective use, allowing them to become experts quickly.
Compliance
Every practitioner knows the risks of storing data online, and EHR is no different. Although the EHR system you have in place should have robust security measures designed to protect patient data, there will always be at least some risk of data jeopardization or leakage. In saying that, there are specific regulations (that we'll talk about shortly) that can protect data more securely than any manual storage options.
Additionally, although managing compliance for online systems can be complex, there are advanced protocols that can ensure the security of EHR data. As such, although EHR has definite risks, the advantages far outweigh these.
Who uses an EHR?
As EHR technology continuously improves, clinicians and other healthcare professionals are adopting it widely. The National Center for Health Statistics reported that in 2019, 89.9% of in-office physicians in the United States were using an EHR system (Centers for Disease Control and Prevention, 2023).
Although these numbers indicate how valuable and popular EHR is becoming, there is still a somewhat common misconception regarding what type of healthcare professionals can use EHR. Regardless of the healthcare field you work in, how big your practice is, or the services you offer, it is guaranteed that EHR will help elevate your efficiency and organization.
Thankfully, we are beginning to see increases in the numbers of different professions utilizing EHR, including:
- General practitioners
- Nursing
- Psychology
- Psychiatry
- Physiotherapy
- Counseling
- Mental health therapy
- Occupational therapy
- Chiropractor
- Psychotherapy
- Physical therapy
- Aged care
- Nutrition
The difference between EMR and EHR
When people are initially introduced to EHR, they frequently confuse it with EMR. While both systems have similar roles in managing the storage of different types of patient data, they also have some key differences. Before diving into these, let's first examine the similarities.
Both systems are designed to store and relay patient information electronically. By using efficient processes, they help healthcare businesses save time and resources. We have created a small list of differences that identifies how each is distinguished.
EHR features
Some features of an EHR include:
- Interoperability: EHRs are built to share patient data seamlessly among healthcare providers and institutions, enabling a comprehensive and updated overview of a patient's health journey. This feature supports continuity of care across various healthcare settings.
- Real-time data updating: EHR systems are designed to provide real-time updates and access to patient records. This ensures that the most current medical information is available to all authorized healthcare providers.
- Comprehensive patient management: EHRs integrate a wide range of data, including diagnostics, treatment plans, and patient outcomes, facilitating a holistic approach to patient care and management.
- Patient access: Many EHR systems include patient portals that allow patients to access their own medical records, schedule appointments, and communicate with their healthcare providers, enhancing patient engagement and self-management.
- Decision support systems: Embedded clinical decision support systems help clinicians make better treatment decisions by providing diagnostic and treatment recommendations based on patient data and clinical guidelines.
EMR features
As for an EMR, some features of it include:
- Digital record keeping: EMRs provide a digital alternative to paper records, organizing patient data such as treatment histories, diagnostics, and medications specific to a single practice.
- Limited sharing capability: Unlike EHRs, EMRs are generally not designed to be shared outside the practice in which they are generated. This ensures data privacy within a single healthcare setting but may limit collaboration.
- Data security and compliance: EMRs ensure that patient data is stored securely and in compliance with local privacy and data protection regulations, which is critical within a single healthcare practice.
- Customization: EMRs can be customized to suit a practice's specific needs and workflows, enhancing operational efficiency and aligning with the healthcare provider’s procedures and services.
- Patient tracking: EMRs are effective for tracking patient visits, managing treatment histories, and monitoring patient health over time within a single practice, aiding in consistent and informed patient care.
By distinguishing the features of EHRs and EMRs, healthcare providers can better understand each system's capabilities and limitations. This knowledge is crucial for optimizing their use in various clinical settings, ensuring that patient care is effective and efficient.
Whether integrating broad healthcare networks through EHRs or managing patient data within a single practice using EMRs, understanding these tools enhances the delivery of medical services and supports superior health outcomes. With the right application, both EHRs and EMRs are indispensable assets in the modern healthcare landscape.
What is cloud technology?
EHR systems typically offer two different types of technology. First, there are server-based EHRs, meaning the software and data you upload are stored on local servers (at the healthcare clinic).
Alternatively, this is the much more popular option; you can use cloud-based EHRs, which store patient data and information on off-site servers. Cloud technology allows information to be accessed, shared, and edited from anywhere worldwide, provided you are an authorized user.
Additionally, because the software is accessed via the Internet, it doesn't require any additional hardware and is typically maintained by an external provider. Cloud-based EHRs are also updated in real-time, helping ensure that practitioners can access the most up-to-date clinical data and make informed decisions regarding the various treatment plans of their patients.
Benefits of cloud-based EHRs over server-based EHRs
Although your practice may have its preference for which type of server you choose, there are various advantages of cloud-based technology that we feel would be remiss.
Installation
The installation process is one of the most daunting aspects of introducing any new system into a healthcare practice. Luckily, cloud-based systems make the installation process extremely simple. Because the system runs on the web, no additional hardware or software needs to be installed in your practice.
Costs
Although a new system will inevitably incur costs for your practice, cloud-based EHRs are generally much more affordable than server-based EHRs. Cloud EHR typically requires a monthly or annual subscription fee that is part of the SaaS (software as a service) arrangement. This arrangement also means that the external provider is responsible for any maintenance, updates, or changes to the system, allowing your practice to avoid additional costs.
On the other hand, server-based EHRs can cost upwards of $30,000 for installation, which doesn't consider the additional maintenance and upgrade costs associated with new hardware and software.
Accessibility
EHRs have revolutionized how healthcare providers communicate with each other, allowing them to stay updated and informed about their patient's current medical conditions. This type of communication works best with cloud-based systems, as they enable authorized users to log in and access information from anywhere in the world, provided they have a secure internet connection.
What should you look for in an EHR system?
Whether you are starting a new business, looking into EHRs for the first time, or the system you already have isn't working effectively, we can help you make the right decision for your business. The EHR industry is booming, and it can be pretty daunting scoping the market for a solution.
To help you, we've collated a list of the key features you should be on the lookout for, regardless of the size of your business or what type of healthcare you work in:
- Compatibility: The EHR system you choose should be compatible with your clinic's electronic devices and software already in place. Most EHRs work with mobile devices, computers, laptops, and tablets, with the additional ability to utilize AI technology and speech recognition software and further boost the quality of care.
- Interoperability: Your healthcare practice likely already has pre-existing software, and it is important that the EHR system you use can integrate with this. One of the primary purposes of EHRs is to improve communication between other healthcare providers, so you should look into whether your system can easily share data with different practices.
- Workflow: EHRs have been designed to go beyond simply creating and storing data, and the best systems will have features that cater to different areas of patient care. Look into the various tools and resources the EHR offers and whether these can be customized to suit your business needs.
- Billing and coding resources: Patient health records are frequently used during the billing and coding processes, so having specific resources that help this within your EHR is always helpful. Accurate health records contribute to faster billing and reimbursement, helping to ensure that your practice receives payments for the services they deliver.
- Staff engagement: We mentioned that one disadvantage of introducing EHR into healthcare practice is the time it takes practitioners to learn the new system. When researching the different options, you should consider how intuitive the system is and whether practitioners with minimal technology experience can use it to its full advantage.
- Extra features: Many EHR systems are integrated with various healthcare features designed to improve practices' organization and productivity, including appointment scheduling, patient portals, online payments, and clinical note templates. With these tools, your practice can streamline various tasks, saving time and resources.
Guidelines for implementing EHR into your practice
So, now that you know what EHR is and the different features to look for, it's time to look at the implementation process. This will differ for every healthcare practice, depending on the system you are installing and what type of software you already have. Nevertheless, we have created a brief guide that proposes some critical steps to help make implementation as seamless as possible.
- Plan: Although apparent, constructing a detailed plan is the often overlooked first step. It would be best if you could form a proposed timeline for how long the implementation process will take and what needs to be done before the system is up and running.
- Budget: Managing the financial side of a business is dull but necessary. You should have a realistic budget before you scope the market for a suitable EHR.
- Installation: Once you have selected your EHR, you need to find a suitable time and date for the installation. This process can take a long time (primarily if you use a server-based system), and you don't want to reschedule appointments or other important meetings.
- Data integration: After the EHR has been installed, the patient data you already have must be integrated into the system. This process can be complicated, especially if your records are hard-copy, as they need to be scanned and processed. However, once it has been integrated into the new system, your documents will be organized, cleansed, and verified, allowing you to elevate your data management.
- Staff training: The final step in the installation is training your staff (both clinical and administrative) on how to use the EHR system. To be effective, staff must feel confident navigating the database to manage their health records. Implementing a training program as soon as the system has been installed is the best way to make switching to a new system as seamless as possible.
Compliance
Health records often contain PHI (protected health information), meaning that specific rules and regulations dictate how the data can be created, stored, and shared. Health records management becomes significantly more complicated when you factor in the different compliance protocols, and understanding how these impact your work is essential.
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) is a collection of federal laws that dictate how PHI can be created, stored, shared, and destroyed. HIPAA has five main guidelines: privacy, security, transaction, identifiers, and enforcement, each with its regulations.
The specific policies required by HIPAA change frequently, so your practice must know the most recent rules. Although this is by no means a comprehensive list, the following are some of the most important policies that affect health records management:
- Medical records security and storage: A healthcare provider needs to be able to identify and protect against possible security threats by implementing systems designed to monitor access to data. There should be enforced restrictions on who can access information, and all staff members need to be trained on security regulations.
- Medical records access and release: HIPAA dictates that patients should always have access to their medical records, and only they can authorize access for anyone else. Unauthorized access is a violation of HIPAA and can result in hefty fines.
- Data destruction: Besides regulations around how health records are created and stored, there are certain rules surrounding destruction. Although the specific method used to destroy records will depend on how they were made, this may involve shredding paper documents with burning or pulverization until they are illegible. Electronic records must have overwriting software or magnetic tools to destroy the hard drive.
- Retention timelines: There are also specific laws concerning the length of time medical records need to be kept. Each locale differs, but you must research and implement these protocols into your practice.
Encryption
Suppose you implement an EHR into your practice or use another system to manage your health records. In that case, you need to be aware of the compliance regulations that specifically apply to data stored electronically. HIPAA dictates that all electronic PHI must undergo data encryption, one of the most secure ways of protecting against unauthorized access.
Encryption works by translating data into code form that requires a password or other form of authorized access to be readable. This means that even if a hacker or someone without authorization managed to locate and access patient records, they would still be unable to read them.
In addition to the data being encrypted while stored on the server, HIPAA dictates that any information being transferred or shared between systems must also be encrypted. If you are in the process of selecting an EHR for your business, you must evaluate whether its encryption technology and other compliance protocols are sufficient.
Compliance is an inherent aspect of working within the healthcare industry that can be highly stressful for practitioners and patients. Because health records contain confidential information, they must be protected in the right way.
Additionally, the consequences are severe when a practitioner or practice breaches HIPAA. The consequences of a breach will vary depending on what tier it falls into and whether it was accidental or intentional.
Key strategies to help you effectively manage your health records
Now that we have covered what health records are, how to use EHR effectively, and the relevant compliance protocols, we have almost reached the end of our guide. Before we conclude, however, we wanted to provide you with a brief selection of our top strategies to improve how your health records are currently managed.
Although different practices will have preferences for managing their data, these suggestions should help you stay compliant, organized, and efficient:
- Encourage physicians to check their patient records during non-busy times
- Verify identification information with patients before finalizing the patient record
- Complete regular audits of the health records management to ensure your practice stays compliant
- Archive (but don't necessarily delete) the health records of inactive patients
- Utilize the full features of EHR, including the systems that they are integrated with
- Encourage patients to play an active role in managing their health by accessing their records
Current and future trends in electronic medical records management
The management of health records has always been crucial in healthcare, but technology and resources are changing how these processes function. The most notable change is the widespread adoption of EHR systems.
Many professionals believe EHRs revolutionize healthcare delivery, but what changes are we seeing? Here are three key trends:
1. Alleviating practitioner burden
The healthcare industry is demanding, with practitioners sometimes working 24-hour shifts. Beyond direct patient care, administrative tasks significantly increase workload. This can lead to 60-hour weeks, limited work-life balance, and burnout.
Fortunately, EHRs and health record management systems streamline time-consuming hospital processes, which can cause some practitioners stress. While not a cure-all, embracing efficient systems can significantly reduce pressure.
2. Empowering patients
EHRs and effective health record management are crucial for shifting healthcare towards a patient-centered model. Patients are increasingly involved in managing their health, making transparency and access to information paramount.
The widespread use of EHRs has led to a significant increase in patient engagement. This active participation fosters stronger patient-provider relationships, improved communication, and better treatment plans and outcomes. The global EHR market size is projected to reach USD 47.25 billion by 2027 (Valuates Reports, 2021), reflecting the immense potential of these systems to revolutionize healthcare delivery.
3. Data-driven decisions for better care
EHRs create a wealth of patient data. Advanced analytics tools can leverage this data to identify trends, predict potential health risks, and personalize treatment plans. This allows healthcare providers to make more informed decisions, improving patient care.
Key takeaways
Health records management is crucial for improving healthcare delivery. Electronic health records play a key role by enhancing diagnostic accuracy, streamlining communication, and fostering patient engagement. Here's a streamlined recap:
Effective health records management is essential for precise medical assessments and developing effective treatment plans. EHRs boost these efforts by improving record accuracy, increasing patient involvement, and enabling better communication, all while reducing costs and saving time.
Factors such as compatibility, interoperability, workflow integration, and user-friendly features are crucial when choosing an EHR system. Security is also paramount; HIPAA compliance and data encryption are essential to protect sensitive patient information. Cloud-based EHR systems offer affordability and accessibility, making them a preferred choice for many practices.
Adopting these strategies simplifies administrative processes and shifts healthcare towards a more patient-centered model.
By implementing these takeaways and staying informed about the latest trends in health records management, you can ensure your practice delivers the best possible health care ever to your patients.
References
Centers for Disease Control and Prevention. (2023, November 4). Electronic medical records/Electronic health records (EMRs/EHRs). https://cdc.gov/nchs/fastats/electronic-medical-records.htm
McMains, V. (2016, May 3). Johns Hopkins study suggests medical errors are the third-leading cause of death in the U.S. The Hub. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/
Valuates Reports. (2021). Electronic health records (EHR) market to reach USD 47.25 Billion by 2027 at a CAGR of 7.14%. PR Newswire. https://www.prnewswire.com/in/news-releases/electronic-health-records-ehr-market-to-reach-usd-47-25-billion-by-2027-at-a-cagr-of-7-14-valuates-reports-861829251.html
