EMR Systems – From the Vantage Point of Medical Record Sharing and Medical Review

by | Published on Mar 16, 2015 | EHR/EMR

Electronic medical records were introduced primarily to reduce administrative burdens and cut costs and at the same time reduce medical errors and improve the quality of care. Healthcare providers who have not made the transition to EMR system are very likely to face cuts in Medicare and Medicaid reimbursements in 2015. However, according to the Rand Corporation, the non-profit policy think tank, even seven years after its initial analysis of electronic medical records, healthcare spending in the US has grown by $800 billion annually. In its 2013 study, the corporation had found that these electronic systems were not interconnected and were not easy to use either.

The Prospect of Medical Record Sharing

If we consider the possibility of medical record sharing between different provider facilities, it is not always easy. Take the case of the emergency department. Time is crucial here and the information providers can obtain about a particular patient from his/her visits to other medical facilities is helpful if it can be obtained immediately for review via medical record sharing. Though sharing does occur across the same hospital system, it is mostly impossible across different hospital systems. Even hospitals less than two miles away are unable to share patient information electronically.

Seamless sharing of medical information nationwide as envisaged by the government will be possible only if compatible electronic medical record systems are developed and the networking is made efficient. It is a welcome step that some states such as Iowa have created efficient networks such as the Iowa Health Information Network (IHIN). Hospitals and physicians in the network will be able to share important information such as medication history, clinicians’ notes, as well as radiology/lab results electronically. When useful information such as this is shared, it will automatically improve the level of care and help control costs.

EMR from the Viewpoint of Medical Record Review

Providers have to choose an EMR system carefully to ensure that it is efficient and meets the requirements of Meaningful Use. Moreover, in the event of a medical record review that may be necessary for settling personal injury and malpractice claims, accurate medical documentation is very important. A service found not to be medically necessary or inappropriately coded will be denied by auditors and medical reviewers. When it comes to claim settlement cases, lawyers involved review the relevant medical records that are the main evidence. A comprehensive review involves medical records organization and indexing, preparation of medical chronology or sequence of medical encounters, and medical case history and summary. Documentation has to be thorough because that is what helps determine the appropriate medical treatment for the patient and is also the basis of coding and billing determinations.

To steer clear of compliance hassles, providers must ensure active involvement throughout the process of choosing and implementing an EMR system. A reliable system will have appropriate security mechanisms in place and the templates will be customized so that information specific to the provider’s specialty can be included. It should ideally be able to accept narrative statements for more clarity. It is the provider’s responsibility to ensure the accuracy of the records. Since electronic records are associated with special compliance issues, providers should fully understand the capabilities of the software, and be aware of the existence of fields that may self populate. Each record must clearly reflect the patient’s condition at the time of evaluation so that the services provided are understood as medically necessary.

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