When the movement to make medical records digital-first started up, the new terms weren’t very clear, and electronic medical records (EMR) and electronic health records (EHR) were often denoted as EHR/EMR, so it’s no wonder folks were confused about the terms.
Adding to the confusion, the two terms were often used interchangeably by people who either didn’t know the difference or thought it was simpler to just use one term. Since the electronic systems are now in place, and personal health records (PHRs) have been added to the mix, it’s time that we all get clear on what these different records are and how they are used.
Electronic Medical Records—Patient Charts on the Computer
The simplest way to describe electronic medical records is that they are medical records that are electronic, or digital. EMR refers to the individual patient records, or charts, including notes used for diagnosis and treatment that are kept by each facility.
Clearly, data management is much easier and more efficient with the use of computers, so the advantage of EMR over paper charts becomes very clear when we consider how much more accessible information is when it is digital.
Medical offices are easily able to send reminders about routine visits and preventive screenings. EMR also allows doctors to see a patient’s history and track changes over time, which is very difficult when the information is all on different pages in a folder full of various reports. These benefits combine to assist healthcare providers in delivering higher quality care overall.
Electronic Health Records—Connecting the Patient’s Care Providers
Traditionally, medical specialists had very limited access to information from primary care providers and vice versa. Likewise, specialists in different facilities had no way to easily refer to the patient’s history with another provider.
This could mean very relevant information was missing from medical decisions, such as when a heart patient has a stroke, or a diabetic is in a car accident. Having full access to that person’s medication, history, and the expected condition is very helpful for diagnosis and treatment.
That’s where electronic health records come into the picture. EHRs allow all providers who are authorized for a patient’s care to access the records from other care providers. Laboratories, hospitals, and specialists all have access to this much-needed information.
If the patient moves to another city or state, their new clinicians and other providers have access to their history through EHR, so vital information is not lost every time a doctor changes.
Personal Health Records—Engaging the Patient in Their Own Care
The same kind of information that is in EHRs is in PHRs, but these are designed to be managed by patients, giving them access and input into their records. PHRs include diagnoses and medications, but also keep a record of family medical histories and immunizations. Another useful feature is that they contain the contact information for the patient’s providers.
PHRs allow patients to update and access their information from the comfort of home, and they can also be set up to receive and record data from home monitoring devices. PHRs can be linked to EHRs so that patients are not responsible for adding all the information themselves, making for a much more complete record.
Warning About EMR/EHR
Electronic Health Records (EHR) and Electronic Medical Records (EMR) often come with software to “advise” you about coding. This advisory software is promoted as increasing your revenue by advising you that if you document more, you can increase your CPT to a higher level. If you document completely, your level 3 visit can become a 4, or even a 5.
In reality, the services provided must be appropriate for the diagnosis given. Level 4 and 5 billings will readily be identified and should be expected to be challenged. Don’t assume that your automated code advisor with your electronic medical records software will have eliminated these challenges. If the diagnosis does not fit, the CPT code is declared excessive.
Somewhere in the documentation of your software is a disclaimer that explains that their code advisor is simple advising, the determination of the appropriateness of coding, and the responsibility-liability-for the actual coding remains the physicians’ responsibility. Watch the diagnosis as well.
The level of services provided must also be commensurate with the diagnosis under treatment. While all the requirements of a level of care may be fully and completed documented, does the diagnosis under treatment warrant the level of service? Increasingly payers are using computerized models to compare CPT codes with the diagnosis codes and identify patterns of what they allege to be excessive services for the diagnosis listed. For Example, an ear infection in an otherwise healthy patient would be difficult to justify level 5 E/M, even if the level 5 were fully documented according to the documentation standards.
Medcare MSO provides a full suite of medical revenue cycle management (RCM) services to providers of all sizes. Our innovative system for medical billing and practice management has proven to increase revenue and reduce stress for our clients. Call us today at 800-640-6409or request a demo to discuss how we can help you achieve your business goals.
