Health information managers should prepare for the day electronic health records (EHR) are mandatory by making sure their computer and software programs will work to protect the security, quality and authenticity of patient data, Shelley Safian, chair of the Allied Health Department at Herzing College, Winter Park, Fla., said during a February 7, 2008 audio seminar of the American Health Information Management Association.
Although only 7 percent of listeners to the call were completely prepared for EHR, Safian encouraged the rest to continue moving forward and testing their systems. She said that although there are many challenges, moving to EHR is “incredibly beneficial for patient care, continuity of care, transferring a patient to another physician.”
In 2004, President Bush outlined a plan to ensure that most Americans have electronic health records by 2014. In July 2004, the Department of Health and Human Services unveiled a 10-year plan to create a new national health information infrastructure, including an EHR for every American and a new network to link health records nationwide, Safian outlined. Safian noted that when coding from EHR, professionals should remember that the same coding guidelines that apply to paper documents apply to electronic documents.
Better accuracy
One benefit of EHR is increased accuracy compared to paper documentation, Safian said. “Although EHR will not eliminate errors altogether, it will dramatically reduce errors,” she said. For instance, EHR software can be programmed to flag misspelled names, Safian noted. And once a name is entered into the EHR correctly, she noted, it never has to be entered again. By the same token, she said, it’s that much more important to enter the correct information. “Otherwise, it’s going to be wrong a million times,” she said.
The software programs also can remind health information managers and physicians to be more thorough in their documentation, she said, noting that templates can remind providers to input information such as family medical history, information that they may otherwise not complete. To increase authenticity, users should have to sign off on their work and users should be tracked with regard to who has permission to enter data and who has permission to read only, she said. She suggested implementing e-signatures. “You need to make sure that physicians or anybody inputting [data] are able to sign off on it,” she said.
To ensure increased efficiency, EHR software needs to be compatible both internally and with systems at other facilities, Safian said. Because there is no national standard, compatibility “is definitely a concern” of EHR, she said. For example, she said, email attachments from other facilities may not open. And outside laboratories and imaging centers may fax documents that need to be scanned into the system. “You’re going to have to have an internal process to deal with that,” she said.
Time saved
With EHR, there is no delay waiting for dictation or transcription, electronic queries can provide written response more quickly, and documents do not need to be copied when a patient is transferred, Safian said. In addition, more than one nurse or clinician can access the information at one time, avoiding the time wasted where a provider may pull a file, leave it on his or her desk and then go to lunch, making it difficult for others to find or access the file, she said.
Safian acknowledged that while productivity may suffer 25 or 30 percent while the staff is getting used to the computer programs, that slowdown will last for only weeks or months. “Without question you will be able to exceed your pre-EHR levels with regard to effectiveness and efficiency,” she said. She noted that increased efficiency will lead to faster billing, better collections and better cash flow. “Accurate, complete, and fast clinical documentation is key to patient care, as well as reimbursement processes,” she emphasized.
Source: CCH Washington Bureau, Feb. 20, 2008.
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