When the movement to digitize medical records began, the new terminology was not very clear, and electronic medical records (EMR) and electronic health records (EHR) were often referred to as EHR/EMR, so it is no wonder that people were confused about the terminology.
Adding to the confusion, the two terms were often used interchangeably by people who did not know the difference or who thought it would be easier to use only one term. With the introduction of electronic systems and the addition of personal health records (PHRs), it is time for all of us to clarify what these various records are and how they are used.
Electronic Medical Records – Patient Records on a Computer
The simplest way to describe electronic medical records is that they are electronic medical records or digital medical records. EMR refers to the records or charts of individual patients, including notes on diagnoses and treatments, maintained by each facility.
When you consider how easy it is to access information in digital form, the benefits of EMRs over paper records become very clear.
Practices can easily send reminders for routine and preventive checkups. EMRs also allow doctors to view a patient’s medical history and track changes over time, which is very difficult when all the information is on different pages in a folder full of different reports. These combined benefits empower healthcare providers to deliver quality care overall.
Electronic Health Records – Patients Networking Service Providers
Traditionally, specialists have been very limited in their access to information from general practitioners and vice versa. Similarly, specialists at different facilities could not easily review a patient’s medical history from another healthcare provider.
This could mean that highly relevant information is missing in medical decisions, such as when a cardiac patient suffers a stroke or a diabetic patient is involved in a car accident. Having full access to a person’s medications, medical history, and expected condition can be extremely helpful in diagnosis and treatment.
Laboratories, hospitals, and specialists can all access this much-needed information.
If a patient relocates to another city or state, new doctors and other health care providers can access the patient’s medical history through the electronic medical record, so important information isn’t lost every time a doctor changes.
Personal Health Records – Patient Involvement in Their Own Care
The same type of information found in electronic health records is also included in personal health records, but they are designed to be managed by the patient, who can access and enter their own records. Personal health records include diagnoses and medications, but also store family medical history and immunization records.
PHRs allow patients to update and access their information from the comfort of their own home. PHRs can be linked to EHRs, eliminating the need for patients to add all of the information themselves, resulting in a more complete record.
EMR/EHR Caveats
Electronic health records (EHRs) and electronic medical records (EMRs) often come with software that will “advise” you on coding. This consulting software is touted as helping you take your CPT to the next level if you document more, leading to increased revenue. Fully documenting can turn a level 3 visit into a level 4 or even level 5 visit.
Level 4 and 5 claims are easily spotted and challenged. Don’t think that automated code advisors with electronic medical record software have solved these problems.
Somewhere in the software documentation, there will be a disclaimer explaining that the code consultant only determines and provides advice on the appropriateness of coding, and that responsibility for the actual coding remains with the physician. Also look at the diagnosis. The level of service provided must also correspond to the diagnosis being treated.
The level of care requirements may all be well documented, but are the diagnoses being treated commensurate with the level of service? Increasingly, payers are using computer-based models to compare CPT codes to diagnosis codes and identify patterns of what may be considered overpayment for listed diagnoses. For example, it would be difficult to justify an ear infection in an otherwise healthy patient with stage 5 E/M, even if the stage 5 was fully documented per documentation standards.
MedEx MBS offers a full range of healthcare revenue cycle management (RCM) services for healthcare providers of all sizes. Our innovative medical billing and practice management systems are proven to increase revenue and reduce stress for your customers. request a demo to discuss how we can help you achieve your business goals.