MEDICAL RECORDS AUTOMATION

Automating Medical Records Using Electronic Health Records Information Systems Shara Heusinger American InterContinental University

MEDICAL RECORDS AUTOMATION

Automating Medical Records Using Electronic Health Records Information Systems Medical Records and Health Information Technicians perform many manual tasks that can be improved upon by using Electronic Health Records (EHR). Those manual tasks may include assembling patients health information, coding patient health records and verifying accuracy and reliability of those patient records. Currently patients medical records are assembled manually using manila folders and color coded labels. Each patient folder contains medical history, medical questionnaires, handwritten notes, prescription history, diagnostic test performed, lab results, diagnosis, and treatment plan. Traditional paper charts are becoming more and more expensive to store as the healthcare providers patient base, and chart sizes continue to rapidly increase. Many older inactive charts may be moved to an offsite location to create additional space for more current files. Another problem with paper charts is that they tend to be error prone and slow to locate and retrieve. A study reported that about 27 percent of patients were treated by physicians without having the patients charts available at the time of treatment. Missing records require the doctor to see the patient without access to medical history and relies on information from the current visit to be added to the chart at a later time (Kofax). Cost saving Electronic Health Records (EHR) would be the most cost saving and beneficial technology to implement. In addition to controlling costs, EHR systems lead to better patient care and increased patient privacy. Concerns about privacy and liabilities of traditional paper files led to the enactment of the Health Information Portability and Accountability Act, more commonly known as HIPAA, in 1986. HIPAA requires that patients have access to their medical records and requires that providers strictly control and track access by anyone else. The

MEDICAL RECORDS AUTOMATION

HIPAA security guidelines would be expensive and very difficult to comply with using the standard paper charting system. Electronic Health Records contain medical history, symptoms, examination results, diagnosis, prescription history, treatment plans, diagnostic test and their results and any other healthcare providers information. All of the information contained in the EHR would be digitally stored in a large database and shared by hospitals, pharmacies, physicians, & medical testing facilities. The EHR would be easily accessed by authorized parties and updated using a small computer terminal in each exam room, lab or pharmacy. Using EHR technology would greatly benefit the patient also by eliminating the need to remember medical history, medications they are currently taking, and the dosage instructions. Serious drug interactions or allergies would be avoided because of inaccurate or omitted information. (Keston, 2009). By sharing a patients EMR with pharmacies, pharmacists can double check patient information to help catch omissions and catch dangerous drug interactions. Physicians would also be able to see the history from the pharmacy and keep track of medications that other healthcare providers may have prescribed and their dosing instructions. Another benefit of implementing an EHR system would be the merging of medical data with image data referred to as Picture Archiving and Communications Systems (PACS). Doctors would have immediate access to X-rays, CT scans, or any other image based test results. Access to PACS as part of the electronic medical record would aid other healthcare providers by eliminating the need for patients to provide copies of tradition image based test results and medical history. Medical records staff reduction is a cost saving result of the electronic medical records. Staff would not be needed to pull or file patients paper based charts. Coding time for

MEDICAL RECORDS AUTOMATION

procedures and supplies would also be reduced as well as speed up the billing process whether the procedure is to be paid by the patient, filed with insurance, Medicare or Medicaid. Reduced bill times result in increased cash flow. The EHR software allows for customized templates to be built to the needs and desires of each physician. Using the templates will initially increase the work on the front end, but will reduce the learning curve and reduce the stress and cost of training. Involving members from every department concerned with a patients record will further streamline operations and increase profitability. Standardized forms and all other information would be scanned using high page per minute scanners. Each document is enhanced, indexed by patient & record type and stored in a document management repository. The health information technician enters the patient name or identification number in the scanner and begins scanning each document generated by the doctor. Using automated database lookup technology, the remainder of the patients information is automatically populated for the remainder of the indexing fields. Further cross referencing with the Current Procedure Terminology (CPT) database will decrease the need for medical coders. Every item on the doctors template will be cross referenced with the CPT database depending on a patients payment option. The correct CPT code is applied and a cost is associated with the procedure for either electronic filing with insurance, Medicare, Medicaid or patient payment. Automating coding procedures reduces the potential for errors and will increase the acceptance of claims by insurance companys electronic filing systems. By reducing the number of claims that are rejected by the insurance companies, there would be a reduction in staff needed to correct errors in medical coding. The payment will be received faster when claims are not rejected and waiting to be corrected, thus increasing the organizations cash flow.

MEDICAL RECORDS AUTOMATION

There are many reasons to automate medical records procedures by using electronic health records. Many of those reasons are for the benefit of the medical organization such as reducing costs, ease of access, higher security & complete patient information. Having an electronic medical record also benefits the patient and patients family by not having to remember important medical history like patient and family medical history, current medications, and surgeries. Electronic Health Records are the future of health care procedures and ultimately will benefit everyone involved in a patients care by increasing efficiency, reducing costs, and enhancing patient security.

MEDICAL RECORDS AUTOMATION

References

The Oregon Clinic Leverages Kofax Intelligent Capture & Exchange to Automate the Processing of Medical Records [Case Study Article]. Retrieved from http://www.kofax.com/case-studies/the-oregon-clinic-leverages-kofax-intelligentcapture-and-exchange-to-automate-the-processing-of-medical-records/ Keston, G.(2009). Electronic medical records: trends. Faulkner Information Services, volume number. doi:00011351 Keston, G.(2009). Developing the standard electronic health record. Faulkner Information Services, volume number. doi:00011305 United States Department of Labor Bureau of Labor Statistics, Occupational Outlook Handbook, 2010-11 Edition, Medical Records and Health Information Technicians [Data File], Retrieved from http://www.bls.gov/oco/ocoS103.htm Butler, E. S. & Lathram, C. J. (2005), Electronic medical records: the future is now. American Academy of Medical Administrators.

Lastname, C. (2009) Title of the source you got info or quote from. The Journal of Education, 22(3), 12-24.