What’s In Your Electronic Health Record (EHR)?

Remember the days when people used to write on paper with a pen or pencil. Will the pen and pencil someday be in the Smithsonian Museum of History?

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Future Smithsonian Exhibit

I guess my typing class in ninth grade is paying off after all. What’s the point of studying for spelling tests when we have spell check on our computers and at our fingertips? Spellcheck even tries to help guess what we are spelling by presenting suggestions for us to choose from or just changing the word automatically for us. Take the abbreviation “EHR” for example, the computer helps me out every time by reorganizing the letters for me into what it thinks I meant to spell.

Writing activates parts of our brain involved in thinking and memory. It helps one think more thoroughly about the information one’s documenting. Since writing is slower and more tedious, it makes it harder to take notes verbatim. Therefore, one has to actually process the information and summarize it in a way that makes sense to us and forces our brain to engage with the information. A draw back, everyone’s handwriting is different and not everyone’s handwriting is legible to read (the unofficial term for bad handwriting—chicken scratch).

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Unamused chicken. 

This makes the reader have to decipher at times the written word. Hmm…. almost like the computer spell checker does for words it does not recognize.

On the other hand, typing encourages verbatim notes without giving much thought to the information. This mindless transcription can lead to a lack of meaningful understanding of the information. Although typing allows words to be documented more quickly and more legibly, that doesn’t mean what is written is any more understandable. This can be especially noticeable when there is redundancy in text data, incorrect concepts are used, or references are made to data that was accidently or intentionally copied from other sources, i.e. another office visit’s notes.

Now that we can access our medical records electronically through our doctor’s patient portal and they are legible to read, have you ever sat down and read the medical note your provider wrote about you? Putting aside the medical terminology, how did it flow? Computer technology makes it very easy to cut and paste or copy and paste data from one location to another. While this technology is great to help save time, especially if you are a slow typist or very busy, it can have it consequences if not done correctly or quality checked for accuracy. Providers are not only expected to see and care for many patients throughout their day, but they are also required to make sure whatever is done is also documented clearly in the patient’s medical record. As technology makes things easier and faster for us to do our jobs, it also makes it easier and faster, when in a hurry or busy, to make factual errors, or use boilerplate or copious amounts of text of little relevance to the individual patient.

Back to question about reading your medical record. Have you? Being a nurse, I have seen records where a person’s age and sex changes within the same office visit note (date of service) and social histories or physical exam documentations appear to stay the same from one office visit to the next. I have seen words misspelled or spelled correctly, but the wrong word was used in the sentence which can lead to confusion. You know, like when you send a text to someone and the word you typed is changed by your smartphone and now the message you sent to your friend sounds encrypted and you don’t even recognize what you said even though you sent it.

I have also seen records that have diagnoses listed when the note within the visit states they have been ruled out. And by the way, according to CPT® there are specific rules about billing ruled out diagnoses, depending if the service was performed inpatient or outpatient. Yes, many of the mistakes are human errors that are easy to make when using technology such as, copy & paste, spell check, etc. Technology is great, but the human is still necessary (as referenced in our Machine Minded blog).

The bigger concern about inaccurate or not up-to-date information within our charts rears its head when your medical information is needed for emergencies or you need it to qualify for other services. Have you ever tried to get life insurance? You can be denied life insurance or your premiums could be more expensive depending on your medical diagnoses. Also, it seems like identity theft is always in the news nowadays. Guarding your health insurance card is just as important as guarding your credit cards. Someone else’s diagnoses or allergies in your medical record could harm you, especially if you are unconscious or unable to communicate. On the plus side, with the implementation of the EHR, information is more accessible at the patient level. It is no longer a black box of unknowns. This in turn, allows the patient and their provider(s) to work together better as a team to make sure data is accurate. The next time you look at your medical record online, take a moment and read it.

 

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

The Lost Art of Face-to-Face Conversation

Imagine you are in a restaurant and at the next table over you see a family of four. There appears to be a father, mother, and two children. However, no one is talking, laughing, or making eye contact with one another. Instead, they are all looking down at their smart phones. Now imagine you are visiting a healthcare office or hospital and the provider is doing the same thing. This has become a recurring scenario in many health care settings. Doctors, nurses, even therapists interacting with computer screens more than they do with their patients is pretty much the norm. According to a Forbes article, this is known as the “iPatient” phenomenon1.

“i” (iPad, iPhone), has been marketed by Apple® since 1998. Created by Steve Jobs, the “i” in iMac stood for Internet. These days, anything associated with technology, often has either an “i” or an “e” (i.e. eRecords) in front of the word. By putting an “i” or “e” in front of patient, does that take the “human” out of patient and make the “human” more like a “thing”?

Stepping back a second, why are we discussing experiences about less eye contact between patients and healthcare professionals? Oh yes, now I remember, the implementation of the EHR. Technology designed to streamline patient care, produce legible records for other providers caring for patients, and to help health professionals be able to “see” the whole patient (i.e. know what tests have been performed, diagnoses already ruled out, medications tried and determined not to be effective). checklist-2077023_1920It is also supposed to help decrease healthcare costs by reducing redundancy in services by multiple providers and improve healthcare outcomes by allowing the sharing of information across disciplines. All great goals, but are we losing the care in healthcare?

As we grow increasingly reliant on computers to help make decisions, today’s healthcare professionals spend more time in front of the monitor charting and examining tests results and less time meeting the real live person. Remember the days before digital when you could actually hold “data” in your hands? Radiologists used to go over chest films with the medical team. Now a radiologist may be reviewing films at home in the evening alone. Provider rounds are slowly disappearing, along with the time allowed for clinicians to be able to think collectively about what something may mean. Is technology causing us to make decisions faster without giving our human brain time to think and rationalize? Humans are not computers and everything is not according to the textbook or black and white.

Nurse friends of mine that still provide direct patient care in today’s environment state that charting via the “old” paper way actually took less time and gave them more time with the patient. Time with the patient was what they enjoyed and why they became a nurse. E-paperwork was not the care they wanted to provide.  From their perspective, valuable information that they could gather from direct human-to-human contact has suffered. Bedside skills appear to have dropped in inverse proportion to the technology available as evidenced by hospitals having to implement Medical/Surgical Skills Day to ensure that staff remember how to correctly perform basic tasks learned in nursing and medical school.

Based on my own recent office visit, less direct human communication levels started when I walked up to the front desk to check in for my appointment. I was handed an electronic tablet and told to review and sign the documents and make corrections for any data that is wrong. Soon afterwards, my name was called and I headed back to an exam room. My Provider entered the room and went directly over to the computer, pulled up my records (that I just put in) including the reason why I was at the office in the first place. comicNot taking her eyes from the computer, she asked me questions of what brought me there. As I was explaining my symptoms, I noticed that my provider was not even looking my way. She was concentrating on her computer screen and clicking boxes. Yes, being a healthcare professional myself, I understand why she has to do that and yes, I appreciate that it is important that she does it; however, I thought to myself, was my provider even listening to what I was saying.

Back when I was growing up and again later, when I was in nursing school (before computers, as my son would say, “old”), I was taught that if you are not looking at the person that is speaking to you, then you are not listening. Experience has taught me that active listening involves more than the ears. To really understand what a person is telling you, you have to see their facial expressions. It feels like yesterday when I was taught this, but in technology time, it was a lifetime ago. Technology time changes quickly and more frequently. What was here today is gone tomorrow. My Provider did a quick hands on examination, ordered a diagnostic test, and a prescription that was directly sent to the outpatient diagnostic office and pharmacy of my choice according to my healthcare plan. I did not have to do a thing. I was taken completely out of the picture. Almost like I was never even there.

 

What’s your experience?

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

Practice Makes Perfect – But We’re Not There Yet

In my last blog, we looked at the ability to demonstrate meaningful use that includes specific objectives, milestones, and metric requirements to monitor use of health information. We discussed technology, the certified EHR, the tool to help demonstrate meaningful use by having a place to document health care data that can be easily shared across disciplines, thus, allowing healthcare professional to “picture” the entire patient, not just fragments of them. All this aims to demonstrate, through EHR data metrics, that healthcare costs are decreasing (or at least not rising so fast) and healthcare outcomes to the population are improving. It’s all because we are becoming more efficient.

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Any nostalgia for paper charts out there?

Because we can “see” data real-time and it’s not stored in paper charts at some doctor’s office or in boxes in a storage facility. We can show through data that multiple providers are not performing the same diagnostics tests, less medical errors are occurring, and readmissions to hospitals are on the decline. Can the EHR really do this?

It is not as simple as it may sound to put this into practice and be able to get the metrics needed to demonstrate what’s being requested from the healthcare arena, or at least into today’s healthcare setting. Until recently, health care records were paper located at the individual provider’s office. Providers worked in silos, not sharing with others except by fax transmission or postal mail. Even the patients were not provided copies of their information until HIPAA came along and mandated that a patient be allowed to see and have their own information. But even then, the patient had to request it and pay for it. When a patient was referred to see a specialist, one still could not rely on the information getting back to the primary care provider or what did get communicated was just a summary (without all the details).

Even today, the EHR is not a comprehensive record for each patient. Clinical notes and tests ordered by a patient’s various health care providers cannot be viewed from a single record by all providers, nor is there one patient portal for the patient to access their comprehensive medical record. A patient cannot go to Walgreens® and request their pharmacy records from CVS®. As a result, this can provide an incomplete picture of a patient’s health and behavior. Becoming electronic does not prevent health records from being fragmented, which could affect milestones and metric requirements. In addition, the tool itself does not make the data for the measurements; it still takes a human to enter the data into the tool. At least for now (to learn more about that tale visit our Machine Minded blog). However, with little or no standards on data entry, accurate measurements are a challenge. The old saying still holds true, “garbage in is garbage out”.

On the more positive side, while the EHR is not perfect, we are heading in the right direction. It is still much better than paper and it’s a step closer in regards to being able to demonstrate meaningful use. Having a health record available in real-time to providers and patients is far more useful.

 

 

Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

Continuing Down the EHR Path

In my last blog we looked at the Health Insurance Portability and Accountability Act (HIPAA) and how it helped corral security, electronic signatures, coordination of benefits, and unique identifiers such as the national provider identifier (NPI). HIPAA was more than just a method of ensuring the privacy of protected health information (PHI) and who can have access, it helped bring us one-step further in the evolution of the EHR.

So not to bore you with a bunch of history, let’s skip ahead another decade or so to the Health Information Technology for Economic and Clinical Health (HITECH) Act which was enacted as part of the American Recovery and Reinvestment Act of 2009. You may be wondering how did the EHR play a role in HITECH and what was the purpose of this Act? The short answer is that it was to promote the adoption and “meaningful use” of health information technology. Now for the long answer.

This act was passed to show that the federal government firmly believed in the benefits of using the EHR by encouraging the widespread adoption of the EHR and authorizing the Centers for Medicare & Medicaid Services (CMS) to incentivize doctors and hospitals that chose to use a “certified” EHR. doctor tablet

The incentives were intended to drive adoption of the EHR in order to reach the goal of every American having a “secure” EHR (remember HIPAA?).

What were the rewards? Providers who implemented and proved meaningful use of a certified EHR prior to 2015 were eligible for incentives. This meant a practice that had a certified EHR system in place were actually paid more money than a practice continuing to use paper charts (or maybe in reality, it was just to help practices recover some of the added costs with implementation and training of staff).

We’clouds-17602_1920ve all heard the saying, “every cloud has a silver lining”; well, perhaps, every silver lining has a cloud too. After 2015, Medicare was authorized to begin to administer financial penalties to physicians and hospitals that do not use an EHR. These penalties involve reducing the provider’s payments by 1 percent per year for up to five years. Also, as with any technological initiative and operational change, it is important to stay abreast of the latest security updates to keep sensitive information secure. The ability to demonstrate meaningful use that includes specific objectives, milestones, and metrics needs to happen at regular intervals as well. This means the need and expense of employing qualified individuals and updating software become factors. As part of HITECH, there are requirements to monitor:

  1. The electronic exchange and use of health information.
  2. The use of an EHR for each person in the United States.
  3. Privacy and security protections for electronic exchange of individually identifiable health information.
  4. Security methods to ensure appropriate authorization and electronic authentication of health information and technologies or methodologies for rendering health information unusable, unreadable, or indecipherable.
  5. A process for receiving communications concerning recommendations and policy changes under or related to this Act.
  6. The fostering of the public understanding of health information technology.
  7. The use of health information technology in improving the quality of healthcare, reducing medical errors, reducing health disparities, improving public health, increasing prevention and coordination with community resources, and improving the continuity of care among healthcare settings.
  8. Plans for ensuring that populations with unique needs, such as children, are appropriately addressed in the technology design, as appropriate, which may include technology that automates enrollment and retention for eligible individuals.

As discussed in our @Face Value blog, how will the smaller practices and providers meet these challenges? How will hospitals meet these challenges with all their other challenges (i.e. doctor and nurses shortages, patients who cannot pay for services rendered)? What is meaningful use? Come back to the next blog as we continue to peel this onion.

How Did We Get Here? – the “Official”, “Unofficial” Beginnings

 

When did the electronic health record (EHR) evolve? Why did it evolve? How did it all really begin? Are there benefits? So many questions. Where should I begin?

Once upon a time….Isn’t that how stories usually start?

According to The American Health Information Management Association (AHIMA), EHRs have been around in the United States healthcare setting in one form or another since the late 1960’s or early 1970’s.

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Photo Credit: ESO

We have been trying to figure out how to make health data more useable and accessible for quite a while. Homegrown systems were popping up in different places and the technology was rudimentary, but something big was starting from computerized physician order entry systems to the storage of patient data for easier retrieval.

Skipping ahead a few decades, in 1996 the Health Insurance Portability and Accountability Act (HIPAA), brought us one-step further in the evolution of the EHR.  Providers were suddenly trying to figure out whom we could talk to and when we could talk to them. Didn’t healthcare professionals already have a standard in place for that called the ‘Code of Ethics’?  Clinton_signing_documentHIPAA’s main objective is to protect health insurance coverage for workers who change or lose their jobs by making it “more portable” and easier to continue without having to restart time requirements regarding pre-existing conditions.  How does one make data more portable when there are no standards? Prior to HIPAA, healthcare billing was like the Wild West; anything goes. Payers could have their own set of codes.

HIPAA established administrative simplification standards for healthcare systems and was a driving force behind the security and privacy regulations of the electronic transmission of healthcare and financial data. In addition, it mandated standards for code sets used for encoding data elements such as tables of terms, medical concepts, medical diagnosis procedure, and drug codes. ICD-10-CM is an example of a code set, for more information on such code set, check out our Code Words blog. HIPAA also helped corral security, electronic signatures, coordination of benefits, and unique identifiers such as the national provider identifier (NPI). It was more than just a method of ensuring the privacy of protected health information (PHI) and who can have access, it was actually the “official”, beginning of the EHR.

Stayed tuned to see how the EHR plays a role in the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009. The Act to promote the adoption and meaningful use of health information technology.

Whose Record is it Anyway?

 

Welcome to Health-e Records. I’m Ruthanne Romero, RN, MSN, HCAFA, CPC, a registered nurse at Health Integrity with a specialty in Healthcare Informatics and Health/Public Policy. In the past, medical records were treated like sacred documents that only your medical provider could read or access. During an office visit, you’d try to glance over discretely to try and see what was being written about you, turning your eyes quickly so you would not be caught when the provider looked your way.  Thanks to Electronic Health Records (EHR), those days are gone. Your medical record is exactly that; it’s yours. Since it is yours, knowing what is in it is essential.

In addition, as information becomes more portable, and accessibility to that information becomes the norm, the need for protection and uses of the data become a factor. While there are plenty of benefits around the implementation of the electronic health record, there are also potential consequences of which to be mindful. It’s important to be aware of the legislation around both the reasons for the implementation of the EHR and the impact when the rules and regulations are not followed.

Each month I’ll be bringing you my thoughts on aspects of the EHR (not HER like spell check wants) ranging from consumer basics to the importance of the medical record.  We’ll cover the benefits of an EHR, facts & fictions, things to look out for, and a lot more. The best way to care for your health going forward is to know your medical history.”

All of my blog posts will be posted here so check back often!

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