In this Era, Electronic Health record software is a digital computer application that is designed to make an individual record of the hospital which can be easily changed, gather, and manageable by the consulted approved clinicians and staff within one health care organization. This digital system provides the facility of work-flow and enhances the quality of patient care and patient safety. EHRs provide real-time, patient-oriented that is immediately accessible by both patient and medical personnel. EHRs are more powerful and effective than paper in maintaining patients all records. It can be upgraded more than the paper record, and also prevents the accidental loss of the paper record of patients. This system contains the medical and treatment history of the patient.
The EHRs automates and streamlines the clinical work-flow. The EHR can create a complete record of clinical patient encounters, as well as other supporting activities related to the health-care directly or indirectly via-interface including evidence-based decision support, effective management, and outcomes reporting. AMCs are the pioneers in developing EHRs. EHRs are the future of health-care because they provide the important data that informs the clinical decisions, and they help to coordinate between all the health-care providers in the health ecosystem.
History of EHR
The first known medical record was developed by Hippocrates, in the fifth century. He dictates two objectives:
- A medical record should perfectly reflect the course of the disease.
- A medical record should point to the probable cause of the disease.
These goals are still appropriate, but the Electronic Health Record software adds some extra functionality to it, such as interactive flow sheets, interactive alerts to clinicians, all of which can not be done with the paper-based systems. The first EHR prototype is called Problem-oriented Medical record appears 50 years ago. It consists of a database of a patient’s complete clinical history, a problem list with patients medical complaints, an initial plan of care in which a doctor decides what to about the problem, daily progress notes, and a discharge summary that tells about the fullest resolution of a problem emphasizing the remaining concern.
The institute of medicine implemented the study of paper documentation record usage in the mid-1980s and published the results in 1991. The report argued the case for using EHR, as one of seven key recommendations for improving the patient records. And to propose a means of converting paper records into electronic records. By 2004 you need to convert medical records to EHRs records were recognized nationally with the creation of the National Coordinator(NC) of Health Information Technology(IT). After a short time, EHRs were incorporated into the Health Information Technology for Economic and Clinical Health Act (HITCH).
Features of EHrs
EHRs system allows access to proof-based tools that providers make decisions about the patients care. It is built to share the information with the other health care providers and organizations like clinics, laboratories, specialists, pharmacies, Emergency centers, schools, and workplace clinics, so they can get the information from all clinicians involved in the patient’s health care. It should authenticate the users or new entries and settle their ranking of access. It safeguards the patient’s data against the possible threat and data loss with automatic backups of data, and automatic log-outs, secure messaging system. The most effective features of EHRs are given below:
- laboratory results
- History of patients
- Pharmacy gateway
- Enticing user interface
- Role-based preservation
- Better scheduling of patient’s
- Ability to contact other systems
- Anytime access from any device
Benefits of EHRs
Electronic Health Record has many effective benefits. EHRs make the record system simpler for the physician to access a chart digitally, they can be made aware of potency dangerous medication error far sooner. EHRs also share information between different multiple health care providers and also permit the user to learn about critical lab values rapidly. This software saves a lot of time, Management of patient records is much easier through EHRs. A physician can get the overall review of the patient’s condition in just some clicks. EHRs increased the precision of records, electronic records are easier to read than paper written records. Electronic health records have helped the providers to carry the records to other locations using a digital system. Patients, in general, also appreciated this electronic health record system. EHRs provides accurate, up to date and real-time condition and complete the information about patients at the point of care.
Improvement in Care quality
By implementing the electronic health record, a patient’s all health information such as medical history, lab tests, vital signs, diagnosis, and medication history is instantly available to the physician. A physician can review the all medical history of the patient in just some clicks, which is much easier than the paper history of the patient.
Computerization of clinical process
An electronic record system automates the whole care process. This system-based clinical automation starts from the front desk with the computerized entry of patients and moves on to the electronic-based medical checkups, lab orders, E-prescriptions, and submission of insurance claims, follow-ups, and E-payments. It means that switching to electronic health records has opened the doors to a whole new world of clinical automation.
Increases in revenue
Every business has the goal of maximizing its revenue. That’s also often true of health care organizations. EHR provides billing and payment tools to manage income and ensure payment. Claims can automatically be scrubbed of mistakes and coding errors, which could otherwise lead to rejections. This feature increases first-time acceptance rates for insurance claims, helping speed up reimbursements without lost or delayed claims. EHR also allows physicians to document every single aspect of a patient’s visit, which makes it easy to provide evidence about individual claims.
Ease of access
It is not easier to store and access the patient’s health records. If it’s a large clinical practice then it requires a huge hoard to store the patient record files in ranks and the dedicated staff resources to manage the patient’s record and finding them when they are needed. If a patient diagnoses with chronic disease or requires discussion with multiple physicians and visit a lot of health care facilities then these health record becomes highly fragmented. It becomes very difficult for the patient to unitize and carry all the records and also very different for the physician to have all the records at the same place. Through electronic health, record physician can easily overview the history and the recent medical treatments. It is much easier to diagnose as compared to the traditional way of handling the care flow.
Less time consuming for physician/patient
Using Electronic Health Records is time-efficient. In the Paper-based health system, physicians waste many hours in documenting the patient history records and were quoted as the most common reason for physician burnout. Accessing, changing, removing, and storing data in electronic health record saves a lot of time. During a natural disaster, the electronic health record system is proven damaged-free with cloud technology integration, and when the patients are in calamity, the electronic system retrieves all the medical history of the patient.
When new functionality was added to the electronic health record it influences the care process and reduces the operational cost of medical practice. Electronic health records are easy to store and access. Previously the hospital management wastes a lot of time in filling the form and other processes related to health. Using the electronic record decreased the cost of paper printing and management. An electronic record system is very cost-effective in all ways.
Perfect Billing system
Electronic Health records improved the accuracy of the patient medical billing. Data travel immediately between a patient insurance carrier and the physician. EHR perfect billing module shows when the bill is put, then shows that when it is accepted by the patient, when it is being processed and when the payment is paid. This billing module helps in managing financial resources.
Depletion in needless testing
When the physicians do not have access to previous data, they always repeat the testing, which is a big wastage of time and money. This is especially important when the test is unwanted, causing unnecessary soreness for the patient.
Types of EHRs
EHRs are established in different ways. Individuals have their advantages and disadvantages, dependent on a medical practice’s necessities and demands.
Clinician Hosted system
Clinician Hosted system means that all the data of the care ecosystem is hosted on the clinician’s servers.
The clinician is responsible for buying the hardware and software of the Electronic record system, and also responsible for the upkeep of data securely stored on their servers. EHR system hosted by a clinician on the medical work may be effective for larger practice that can cover the expensive costs of the complex software. Servers on the site also boot up an EHR system and make it an authentic source of information.
Remotely Hosted system
A remotely hosted system switches the record of data from the clinician to a third party.
This unit must deal with the maintaining of, backup of data, and security. This kind of system puts the responsibility for maintaining data anywhere else excluding one clinician or medical practice. This turn of responsibility might be fascinating to smaller practices or any other health care provider that wishes to concentrate more on gathering the information and not saving it. This kind of system evacuates some of its headaches then brings away a clinician focus from the patient’s care and comfort.
There are three different types of remote systems.
This system comprises an interconnection with some entity that subsidizes the rate of an EHR. Normally, a clinician forms this interconnection with a hospital, which then manages the data. Remember that a remote system including a subsidizing entity can raise particular copyright affairs, including antitrust and data ownership matters.
A devoted host system means that clinicians save EHRs on a vendor’s servers. And these servers are in a particular area. A clinician cannot handle most facets of data storage with this system.
The most popular EHR remote system is a cloud. Or a computerized system based on an internet connection. A clinician doesn’t need to save data on their servers, but a vendor saves it `in the cloud`. This means the data is always saved away anywhere safe on the internet and it can be approachable through the vendor’s website.
Two types of EHR systems
In recent years, the use of Electronic Health Records has skyrocketed, becoming standard practice for virtually every single health care organization. There are two types of Electronic Health Record software. These two types are defined below:
When the Electronic Health Record is web-based, accessibility is a vital benefit. With the help of a web-based system, u can log in and work easily on your EHR wherever you are, while u have an internet connection also. This is exceptionally important if a key clinician is far from the facility and they need to review a patient’s medical history. Generally using the patient’s portal enables your customers to see the lab results, communicate with their physicians, claim prescription refills, order medications, pay payments, and more. Patients can use these web-based EHR to provide simple information, which greatly decreases the number of forms they need to fill out by hand. The patient’s also received appointment reminders and tests they need to fulfill. This gives both physician and patient an early approach to information.
System Based EHR
System-based Electronic Health records can be installed/configured in a computer system. This system runs in local computing under an office or a building. A patient can login into the EHR from a specific location like an office, and a local building. And can add or remove the medical information from a specific location because the setup is installed in the system and cannot be available everywhere. U have to work with system-based EHR by sitting in a specific office. In this, the patient can’t get the claims prescription refills, and cannot view the lab results by sitting everywhere.