The Paperless Office: Fact or Fiction?

What Electronic Health Records Offer, Now and in the Future

Some call it the paperless practice, some the digital practice, and some just simply say, “EHR.” Whatever you call the digital system that is going to manage your records, do not call it unlikely. Many signs point to a very near future of federal and state mandates requiring Electronic Health Records (EHR’s) in the offices of all healthcare providers. Are you ready?

An EHR is a secure, real-time, interoperable point-of-care, patient-centric information resource for clinicians. It can aid in the decision process of providers by delivering access to patient health information using evidence-based decision support. It can automate and streamline workflow, improve communication with staff, and improve response times to make the office more efficient. It can also create alerts and reminders to improve quality of care and also supports the collection of data for billing, quality management, outcomes assessment, and practice management statistics.

Your EHR will not be just any kind of digital note-taking device. It must be a truly interoperable electronic health record, which will manage the whole breadth of patient data with full security and portability. You can see why chiropractors should be able to identify with this program that has what they need for the future.

There are three key areas where electronic health record systems set themselves apart from other kinds of software in the following three ways:

1. functionality,

2. security, and

3. health care integration.

I will describe a few of the key differences below. Hopefully, this information will help you reconsider the kind of software you need, so you can make the right investment in clinic technology.

EHR Functions

Some chiropractors want simple digital records, so they purchase digital note generators. That’s what works for them right now. Other chiropractors, however, know they need the functionality that comes with a true electronic health record system. But, without knowing which functions to identify, they end up buying a digital note generator because it appears simpler and cheaper. They now have digital SOAP notes that are legible, but not the more advanced program they need. Often, they do not discover the difference until later.

So what is the key difference between software functions, like a digital note generator, and an EHR system? It can be summed up in one statement: The latter contains the digital SOAP notes, but digital note generators alone cannot function as EHR’s.

An EHR Manages a Spectrum of Digital Documents

For example, an EHR will contain and manage intake forms, insurance information, scheduling data, EOB’s, X-rays, MRI’s, radiology reports, rehabilitation orders, provider correspondence, etc. The paper chart is out, and the digital chart is in. All of these files will be protected and properly archived. You can see that “electronic health record” is appropriately named, because its purpose is to contain and manage patient records.

Digital note generators are properly named, because that is exactly what they do: They generate digital versions of your paper SOAP notes. While some generators have more features than others, overall, their functions are to digitize your notes from your patient encounters. They are only one part of the electronic health record.

EHR’s Archive for Instant File Recall

This difference between digital note software and EHR software is most obvious in their archiving functions. Nearly all digital note generators save patient encounters to a folder on a local hard drive or an office network. For a SOAP note program, this lack of archiving is expected, because the program was not engineered to focus on management.

Problems can arise, however, if a digital note generator is all a chiropractor happens to use. This lack of archiving often means that multiple patient SOAP notes, along with a few other forms, land in the same folder without much organization. After a few years of care, finding specific information on the patient will be difficult without proper archiving and a separate management program.

Proper systems, on the other hand, archive all patient files in such a way that they are immediately accessible and searchable by multiple parameters. Files are not just saved to a local folder, but managed through the electronic health record. This fits with the EHR purpose of being the storage and retrieval device for all patient documentation. 

A True EHR Is Secure and HIPAA Ready

Due to the way that they save and archive files, proper electronic health records offer full protection of patient data. It does not matter if we are talking about computer crashes, malicious employees, or the errors that can come with electronic file transfer and email communications. They are programmed to meet the requirements encouraged since the coming of the Health Insurance Portability and Accontability Act (HIPAA). Electronic health record software will protect all of the information within the patient file with varying levels of pass codes, encryption, and opportunities for regular off-site data back-up and storage. They are meant to be more durable, permanent, and portable than even properly stored paper records. Good security ensures this.

Electronic Health Records Will Define Healthcare Integration

What is integration? Integration is the ability of your documentation to share information with other internal software programs, external diagnostic devices, and software that increases the portability of records between third party payers and providers.

Electronic health record systems can be judged by the level of integration that they offer. First, the program will make all documents related to patient care activities compatible and functional together, including billings records, schedules, doctor notes, care plans, radiology reports, and exam findings. Second, the record will be accessible from multiple points within the clinic by various departments, and instantly portable via electronic transfer. Third, advanced programs will make sure that data from external diagnostic devices and even functions like patient education media are integrated into the patient’s digital chart. 

Integration Is behind the Mandates

It is the potential cost-savings of this clinic integration that is largely spurring government mandates. It is important to note that all discussions of future mandates mention electronic health records specifically. Other forms of software are not included. We can safely say that digital note-taking devices may be helpful and suitable for the time being for some chiropractors. They will need to integrate with an EHR system, however, to meet coming governmental requirements.

Where to from Here?

If you want to invest in electronic health records, keep this information in mind when looking for an EHR system. It is best to compare apples to apples and look at EHR software side by side. Do not confuse the picture with digital record generators, which should also be compared to each other, oranges to oranges. If you understand the functions, security, and integration offered by EHR, then you are one step closer to meeting future documentation mandates and improving efficiencies for your clinic of the future.

Steven J. Kraus, DC, DIBCN, CCSP, FASA, is the CEO of Future Health, Inc., which provides an integrated chiropractic EHR software specializing in documentation compliance, credibility, and elevating the profession. Dr. Kraus has owned 18 practices and is the Chairman of the Iowa Board of Chiropractic. For more information, contact Dr. Kraus at [email protected].

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