Electronic Medical Records Software

A comprehensive look at Electronic Medical Records Software and the benefits of Electronic Medical Records. Common abbreviations and trends when considering an EMR software solution.

What is Electronic Medical Record Software?
Electronic medical records software – also referred to as EMR – is a computerized or digital medical record created by a health care provider like a hospital or doctor’s office.

This electronic format allows the medical records to be easily created, stored, queried, and shared by the health care organization. EMR software allows providers and their staff to enter patient records electronically versus maintaining records and charts on paper. The electronic data is typically stored on a secure server for access either from a local or remote PC, laptop, or tablet. This data can include patient diagnosis and treatment, physician notes, digital copies of x-rays, lab results, prescriptions, or insurance information, demographics, etc.

Electronic medical records software is also commonly referred to as EHR – Electronic Health Record software. They are also commonly referred to as computerized medical records or digital medical records.

Many EMR software applications can interface with electronic medical billing software to send diagnosis and procedure codes for generating and submitting medical claims.

Good electronic medical records software allows the users to search, locate, and access patient files quickly. Simply pull up the patient by name or number and view the associated files. In situations where the patient may be admitted to a hospital, the electronic medical record software allows this information to be transmitted to the health care facility instantly. This can reduce duplicate treatments and tests, saving valuable time and cost.

Abbreviations Common with Electronic Medical Record Software
Before we get much deeper into electronic medical records software, lets introduce the acronyms commonly used when discussing the topic. We won’t get into a detailed explanation of all of these as most are self-explanatory::

  • CDO – Care Delivery Organization
  • EMR – Electronic Medical Records
  • EHR – Electronic Health Records
  • HL7 – Health Level 7
  • NAHIT – National Alliance for Health Information Technology
  • NHIN – National Health Information Network
  • CPOE – Computerized Provider Order Entry
  • CDR – Clinical Data Repository
  • CCR – Continuity of Care Record
  • CDSS – Clinical Decision Support System
  • CMV – Controlled Medical Vocabulary
  • CRS – Care Record Summary
  • NHIN – National Health Information Network
  • eRx – Electronic Prescribing
  • HITECH – Health Information Technology for Economic and Clinical Health
  • PHR – Personal Health Record

EMR and EHR – What’s the Difference?
Most people use EMR and EHR interchangeably, but there are differences. An EMR is the patient’s medical history created, managed, and stored at a single location by the provider involved in the patients care. The EHR is a comprehensive collection of the patients medical records created and stored at several locations – or typically created and gathered across more than one health care provider.

Electronic Health Records (EHR) differs from EMR in that it is more comprehensive and includes the patient’s health history obtained from other EHR or EMR’s. The EHR contains clinical lab data from several sources such as medical care providers or labs. The EHR record would also contain referrals and consultations with other providers. It would typically reside with the practice providing the patient’s primary care. The EHR is also helpful in measuring quality of care and pay for performance incentives.

The EMR is more of a stand alone record of a one time diagnosis or treatment, typically by a specialist. An EMR may be more suitable for a specialist who only need patient history pertaining to their specialty.

The Need
The majority of medical records are still maintained on handwritten paper typically maintained in a large file storage cabinets. You’ve probably noticed them in the back of your doctor’s office when you sign in. One of the challenges with traditional paper medical records can be difficult to read due to poor legibility. This can contribute to medical errors. Use of pre-printed forms, standard abbreviations, and standards for penmanship are attempts to improve the legibility of paper medical records.

In the United States, most states require that medical records be maintained for a minimum of seven years. This can add up to a substantial amount of storage space. When patient records are required in different locations, copying, faxing, and transportation costs are significant compared to transfer of computerized medical records.

There are probably hundreds of electronic medical records software providers. If you are in the market for a system, the offerings can be overwhelming. Many software providers offer customized systems for just about any specialty or size of practice. They also range in price from free to hundreds of thousands of dollars.

Configuration and Features
The electronic medical records software can be deployed in a variety of ways beginning with a stand-alone system or a complete EMR that offers integrated medical records, scheduling, and billing features or modules. It’s common to see a practice implement a stand-alone EMR system if they already have a billing and/or scheduling or practice management system they have invested in and don’t want to replace it. They may also have require unique features or uses that the integrated system cannot provide.

There are advantages to installing an integrated system with EMR, billing, and scheduling modules. It allows the practice to have a centralized system to meet their clinical, financial, and administrative needs. Having separate systems from different vendors has the disadvantage in that they can typically not easily share information and it requires maintaining two or more software systems – licenses, updates, back-up, etc.

Government Incentive
Because of the electronic medical records benefits, insurance companies and federal and state governments are strongly encouraging the use of electronic medical records software. As part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, Congress recently included incentives for adopting and penalties for not adopting electronic medical records software. Under the HITECH Act, an incentive of up to $44K per physician under Medicare or up to $65K over 6 years under Medicaid. Penalties are decreased Medicare and Medicaid reimbursements to doctors who fail to use EMR’s by 2015.

Web Based or Client-Server
Web based electronic medical records systems – sometimes called SaaS (Software as a Service) or cloud based are becoming increasingly popular. As cloud computing gains acceptance and understanding in general, many see the benefits for the health care uses also. Issues such as HIPAA compliance and data security, data backup, and reliability of a local server make a cloud based EMR a reasonable alternative. The web-based EMR reduces considerably the upfront cost, hosting, and maintenance requirements associated with a traditional client-server EMR system.

Tablets and Mobile Devices
The use of mobile devices such as tablets and smartphones has also worked its way into the healthcare industry. Healthcare providers try to increase efficiency and increase mobility, these tools are becoming key to this effort. The use of iPads, tablet PC’s and Android tablets allow a flexibility and use not afforded by traditional desktop systems. The attraction of these devices is that they allow the doctor to have access to the patient data, enter treatment and diagnosis information, request lab information, and issue prescriptions at the point of care when meeting with the patient. Many EMR systems are adopting the capability of Apple iOS and Android devices in their systems. You can expect to see mobile access as a feature in most all EMR systems.

Of course HIPAA compliance is a major consideration when using mobile devices to access the EMR system. Its important to make sure the mobile device when used with the electronic medical records software is HIPAA compliant so patient data and the integrity of the EMR system is not compromised – especially in the event the mobile device gets lost or stolen.

HL7 – Health Level 7 – What Is It?
Health Level 7 (HL7) is an industry standard protocol for data transfer between health care applications and defines the format for exchanging data between medical applications. This information is sent as a collection of messages.

Healthcare providers, hospitals, clinics, etc. typically have different sometimes non-compatible computer systems which include information necessary for billing and maintaining patient records. Since these systems are not compatible, HL7 provides flexible standards and guidelines that allow the different healthcare systems to accept data and communicate with each other.

You may have seen the abbreviation CPOE used in association with medical EMR software. This stands for Computer Based Provider Order Entry and allows the provider to order laboratory tests, procedures, and medications directly into the patient record. This information is then transmitted electronically to the appropriate destination. This would be a lab, another provider, pharmacy, etc.

CPOE reduces handwriting and transcription errors, decreases delays in completing orders, allows order entry at the point-of-care or off-site location, enables error-checking for incorrect doses or tests or duplication, and simplifies the posting of charges. COPE is also known as Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry.

There’s also the Personal Health Record (PHR) which is defined as electronic health information collected on a patient, taken from multiple sources, that is created, gathered, and maintained by the individual – or patient. This differs from the EMR or EHR which is collected and maintained by the health care provider or organization. The protection and integrity of the PHR is solely the responsibility of the patient.

Two good examples of PHR’s are Google Health and Microsoft HealthVault.

Electronic Medical Records Software and Data Security
One of the big concerns when implementing an EMR system is data security, protecting patient information, and HIPAA compliance. There is sometimes the perception that electronic records are not a secure as traditional paper records – probably because it may be hard to detect if an EMR system has been compromised or accessed by unauthorized persons. But these same concerns would apply to paper records also. EMR systems are actually more secure than paper records.

The EMR software allow access only to those with a legitimate need to know. It also offers password and encryption features as well as audit capability to determine exactly who accessed the system and when. Access to the electronic medical records software is through individual passwords which are given different levels of access depending on their position. A good example is a receptionist does not need to access patient medical records, were a nurse or medical assistant does.

The regular backup of EMR system data provides protection against loss of data due to fire or natural disaster. The data can be regularly backed up to a secure off-site service or electronic data repository as frequently as desired. This kind of protection was not available for paper medical records.

Economic Considerations
Of course one of the major reasons for implementing electronic medical records software is to reduce administrative costs and improve the quality of patient care. We’ve all heard stories of the sometimes scary costs of implementing EMR systems which can sometimes overwhelm the budget of a small practice.

But with increased competition, the use of cloud based EMR systems, and the economic benefits of having many systems already implemented, costs are beginning to come down. The federal government stimulus program has also offered incentives and cost relief making it more feasible for small practices to implement EMR.

Electronic medical records software costs vary considerably depending on the type of system implemented (client-server or web based), modules or options, and size of practice. Systems located in house will require software licenses, servers, training, and support for maintaining the software and hardware. They also have to be backed up offsite on a regular basis. Typical annual support and maintenance costs are in the 15 to 20% range of the initial installation costs.

A SaaS (also referred to as Cloud or Web based) will typically have significantly lower up front costs and frequently includes necessary implementation and training. However monthly subscription costs are typically higher and may require a contract term. These fees cover costs incurred by the provider such as licenses, software upgrades, server maintenance, backups, etc.

Another consideration is the significant cost of integrating the EMR system with the existing scheduling and/or billing software. This can be as much as the cost of installing an integrated EMR and practice management system and can also be a disruption to the billing and administrative functions of the practice.

If you’re considering the purchase of an electronic medical records software, check out the EMR Software Reviews and the highest user rated EMR software pages provided with the help of Software Advice. Their expertise is determining the best software based on a user’s needs by providing free and un-biased recommendations. This can save you a lot of time and effort by narrowing down the best software solution based on your needs and budget.

Electronic Medical Records Benefits
Electronic medical records benefits are intended to both save cost and improve patient care. The many advantages of implementing electronic medical records are given and discussed.

Medical EMR Software and Billing Services
Many billing services feel threatened by the implementation of electronic medical records software. This page discusses the impacts and considerations of medical EMR software along with some of the misunderstandings and opportunities for the billing service.