Sloan Swarten was hired as a medical assistant at the Southwest Family Medical Clinic in Tempe, Arizona, in October. Dr. Adkins and Dr. Brooks opened the practice 2 years ago. The clinic is fully electronic; no paper records are used at all. Sloan is more interested in the clinical aspect of medical assisting, but because she waited 6 months after finishing school to start looking for work, she had a difficult time finding a job. She accepted the position in medical records at Southwest, known to be a sizeable, busy practice, in the hope that she could soon transfer to the clinical side. Her supervisor, Jennifer Sanchez, stressed that the only available position was in the medical records department, but she also said she would consider moving Sloan to the clinical side after a few months if she performed well and if it proved to be a beneficial move for the clinic.

Sloan does not particularly like the medical records department, and she spends her breaks and lunch periods with the clinical medical assistants. She often remarks that she really would like to work on the clinical side. Sloan is computer literate, but she did not take the administrative classes at school very seriously, because she planned to do clinical work. Her probation period is 6 weeks, and she has decided to make the best of the medical records job until she is transferred. Sloan works with Alex, who supervises the electronic medical records aspect of the clinic. Since most of her previous experience was working with paper records, Alex had to learn the entire program when Southwest opened, and she has enjoyed becoming an expert, or superuser, on the system. Alex likes to learn new things and is able to find solutions to records issues quickly and efficiently. Sloan and Alex get along well, although Alex is concerned that Sloan doesn’t really want to learn the electronic systems.

While studying this chapter, think about the following questions:

• Do you believe Sloan will make it to the clinical side of the office?

• Why is the medical records department one of the most important areas of the physician’s office?

• From the information given in this scenario, what mistakes has Sloan already made, if any?

• Why is it important to know both administrative and clinical skills in the physician’s office?

With technology advancing at such a rapid pace, it is no surprise that the number of offices using an electronic medical record (EMR) system is growing steadily. Some physicians may not budge and will never change to electronic health records. However, because more and more hospitals are using electronic records, physicians, medical assistants, and other healthcare professionals must learn to communicate electronically about patients and to originate information by electronic means. For those who have worked in the healthcare industry for some time, this may present a challenge; however, today’s medical students are being trained in the use of the EMR as a standard practice. In the not too distant future, the EMR will be the standard, and paper medical records will be much less common.

Executive Order to Promote Interoperability of EMR Systems

On August 22, 2006, President George W. Bush issued an Executive Order designed to promote the interoperability of health records and the overall quality and efficiency of healthcare. He set a goal of establishing electronic health records for most Americans by 2014. The order took effect on January 1, 2007. It listed five requirements:

1. The agencies involved will implement interoperable systems as their current systems are upgraded (e.g., Centers for Medicare and Medicaid Services [CMS]).

2. Providers (e.g., a regional Veterans Affairs Hospital) and payers with whom the agencies do business also will implement interoperable systems as their current systems are upgraded. In other words, a hospital that receives federal funding, such as Medicare, must adopt electronic health record systems.

3. The prices paid by health insurance issuers will be available both to beneficiaries and enrollees in the health plan.

4. The agencies and providers will participate in the development of information about the overall cost of healthcare services and treatments.

5. The agencies and providers will develop and identify, for beneficiaries, enrollees, and providers, approaches that encourage the provision and receipt of high-quality, efficient healthcare.

An interoperable system sounds complicated; however, it simply is a system that is able to work with another system. For example, a physician could use his office EMR system to access the EMR system of a hospital to check the hospital’s records on his patients. Although the language of the presidential order is complex and the technologic features such systems require are overwhelming to most medical assistants, keep the end goal in mind—providing high-quality, efficient care to patients.

The EMR is becoming the healthcare facility’s most important business and legal record. The legal requirements are more intricate than those for a paper medical record. Just as a paper medical record is considered a legal record in court, so is the EMR.

Technologic Terms in Health Information

Some confusion has arisen regarding the acronyms EMR and EHR. The National Alliance for Health Information Technology (NAHIT) identified 18 to 63 definitions for the five main terms that relate to the electronic medical record. To alleviate the confusion, NAHIT has established definitions for EMR and EHR that are easy to understand. The electronic health record (EHR) is an electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization. The electronic medical record (EMR) is an electronic record of health-related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization.

A personal health record (PHR) is defined by the NAHIT as an electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual. Few PHRs currently exist, and most Americans do not know what a PHR is or how it can be of value to them.

The Health Insurance Portability and Accountability Act (HIPAA) uses the term protected health information (PHI), which is any information about health status, the provision of healthcare, or payment for healthcare that can be linked to an individual patient.

For the purposes of this chapter, EMR refers to the electronic system the physician uses in the ambulatory setting, because it is used within a single healthcare organization. To help yourself understand the difference between the EMR and the EHR, consider this scenario: If the Southwest Family Medical Clinic uses an EMR, their records are in electronic form, but the records are available electronically only inside the office or to staff members who log on to the system remotely. If the clinic were using an EHR, the physicians and staff would be able to see not only records generated in their clinic, but also records on their patients created at multiple other healthcare facilities, such as the local hospital, a regional imaging facility, or a freestanding laboratory. The clinic would have an interoperable access to the records created at other facilities. Healthcare professionals envision that the EHR eventually will provide a patient’s medical records from birth to death.

In “Defining Key Health Information Technology Terms,” a report published in 2008, NAHIT acknowledged the need to define three additional vital terms: health information exchange, health information organization, and regional health information organization. Health information exchange is the electronic movement of health-related information among organizations according to nationally recognized standards. Health information organization is an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. A regional health information organization is a health organization that brings together healthcare stakeholders in a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community. The report stated that as multiple groups grappled with how to achieve the president’s vision, these terms emerged to characterize some of the key building blocks of the envisioned health technologic infrastructure: electronic medical records and/or electronic health records for healthcare professionals; personal health records for individuals and healthcare consumers, and electronic health information exchange to enable efficient communication among these various records.

American Recovery and Reinvestment Act (ARRA)

The American Recovery and Reinvestment Act of 2009 (ARRA), commonly known as the Economic Stimulus Package, was passed to promote economic recovery. This legislation was signed into law by President Barack Obama on February 17, 2009. The health information technology aspects of the bill provide slightly more than $31 billion for healthcare infrastructure and EHR investment. The sections of the ARRA that pertain to healthcare are collectively known as the Health Information Technology for Economic and Clinical Health Act, or HITECH Act.

HITECH Act and Meaningful Use

The HITECH Act provides financial incentives for the meaningful use of certified EHR technology to achieve health and efficiency goals. It was incorporated into the ARRA to promote the adoption and meaningful use of health information technology. Remember, HIPAA was created in large part to simplify administrative processes using electronic devices. Meaningful use, defined simply, means that providers must show that they are using EHR technology in ways that can be measured significantly in quality and quantity. If providers meet the meaningful use requirements, they will qualify for incentive payments. Three main components of meaningful use can be identified, including:

• Use of certified EHR in a meaningful manner, such as e-prescribing

• Use of certified EHR technology for electronic exchange of health information to improve the quality of health care

• Use of certified EHR technology to submit clinical quality reports, procedure and diagnosis codes, surveys, and other measures

Criteria for meaningful use will be implemented in three stages:

• Stage 1 (2011 and 2012): Sets the baseline for electronic data capture and information sharing

• Stage 2 (expected to be implemented in 2013): Continues to expand on the baseline

• Stage 3 (expected to be implemented in 2015): Continues to expand on the baseline and will be further developed through future rule making

In Subtitle D of the HITECH Act, privacy and security concerns related to the electronic submission of health information are addressed. Several provisions strengthen the civil and criminal penalties of the HIPAA rules, most of which became effective in February, 2009. More of the provisions will become effective over the next few years, subject to future lawmaking.

Included in the February, 2009, modifications of HIPAA were:

• Establishment of categories of violations that reflect increasing levels of culpability

• Requirements that penalties be determined based on the nature and extent of the violation and the nature and extent of the harm resulting from the violation

• Establishment of tiers of increasing penalty amounts that determine the range of and authority to impose civil monetary penalties (Table 15-1)

TABLE 15-1

Categories of HIPAA Violations and Associated Penalties

CATEGORY: SECTION 1176(A)(1)	EACH VIOLATION	ALL SUCH VIOLATIONS OF AN IDENTICAL PROVISION IN A CALENDAR YEAR
(A) Did not know	$100 to $50,000	$1.5 million
(B) Reasonable cause	$1,000 to $50,000	$1.5 million
(C) (i) Willful neglect—corrected	$10,000 to $50,000	$1.5 million
(C) (ii) Willful neglect—not corrected	$50,000	$1.5 million

As indicated in Table 15-1, minimum and maximum penalty amounts are established and can be assessed by the Department of Health and Human Services (DHHS), depending on the nature of the violation. The DHHS determines the penalties on a case-by-case basis and may provide or continue to provide a waiver for violations that arise from a reasonable cause and are not willful neglect incidents that are not corrected in a timely manner. The DHHS will also consider whether the covered entity has provided reasonable diligence in its attempts to bring the facility into compliance with the law. Physicians can expect reductions in the amounts they are paid from Medicare and Medicaid if they are not in compliance by 2015. Remember, the computer system in the medical office must be more than a tool for data recall to be considered an EMR system; the physician must use the system for tasks, at a minimum, such as e-prescribing and computerized physician/provider order entry (CPOE).

Advantages and Disadvantages of the EMR

According to a 2010 mail survey of 10,301 physicians done by the Centers for Disease Control and Prevention (CDC), 50.7% of physicians in office-based practices use full or partial EMR systems. The use of EMR systems in physicians’ offices increased steadily from 2001 through 2010. The primary reason physicians have not yet adopted an EMR system is the expense. Other reasons include:

• Inability to find an EMR system that meets the practice’s needs

• Uncertainty about a return on investment

• Physician resistance

• Loss of productivity or down time for installation and learning curve

The EMR has several advantages over a paper medical record. Most experts agree that the EMR can reduce medical errors by keeping prescriptions, allergies, and other information organized; it also can reduce costs by preventing duplicate tests. Staffing needs also may be reduced, because fewer personnel are needed to manage an EMR system. Because a computer keyboard is used to enter information into the record, the record is not nearly as likely to be illegible. Typed copy certainly is easier to read than handwriting, even if the record is several years old. EMR systems require individual user names and passwords, which secure the system from unauthorized users.

Compared to walls and file cabinets full of paper medical records, the EMR requires less storage space. One or two external hard drives with a terabyte of disk space each conceivably could hold all the medical records of all patients throughout the life of a physician’s practice. This would eliminate the need to purge inactive files, and the resulting space requirement for the external hard drive may be no bigger than a large shoebox. The files may be duplicated regularly and placed off site as a backup.

Information can be accessed in a variety of locations, and more than one person can see the record at any given time. The patient database usually allows various types of statistical information to be recalled, which is a valuable tool. Patient information is available quickly in an emergency, even when the patient is not in his or her hometown. The physician and medical assistants can access progress notes, test results, and any other information about the patient, including patient education and appointment no-shows. The physician and medical assistants can access patient information using a smart phone or personal digital assistant (PDA).

Once the physician and staff become familiar with the system, they may find that they are able to see more patients in the course of a day than when paper records were used. All these advantages lead to cost savings and more efficient patient care.

However, the EMR system is not without disadvantages. Studies show that lack of capital is the most significant obstacle to adoption of the system; another stumbling block is the reluctance of employees in physicians’ offices to make such substantial changes and to learn a new computer system. Employees may not be the only individuals resistant to a changeover to electronic records; patients often are fearful that their private health information will be available to unauthorized individuals, and they often assume that their records will be posted on the Internet. The startup costs of conversion to an EMR system usually are quite high, although most physicians realize that the system eventually will be worth the cost. “The Financial and Nonfinancial Costs of Implementing Electronic Health Records in Primary Care Practices,” an article in the online journal Health Affairs, suggests that the startup cost for a five-physician practice is approximately $162,000, with $85,500 going toward maintenance costs during the first year (Fleming et al., 2011). The study also suggested that the implementation team would need an average of 611 hours to prepare for the implementation, and end-users, such as the physicians, medical assistants, and other staff members, would need about 134 hours of training to use the system. Both the physician and staff require extensive training in the EMR system and must be receptive to even more training to use the system to its full capacity. Training is time-consuming and takes the physician and staff away from treating patients for certain periods. Because not all computer systems are user friendly, care must be taken to choose a system that has technologic support, both live and online, that is available during the hours the healthcare facility is operating. Space for the equipment can be an issue, although usually less space is required than for a paper record system. Because healthcare facilities use different sets of abbreviations and terms, issues can arise with interaction of the office system with other systems. Finally, security and confidentiality are major concerns of both the healthcare professionals and the patients.

Successful Conversion to an EMR System