In case you haven't noticed, I'm a little bit of a technofile.  My computer literally feels like an extension of my brain and managing physical paper... not my strong suit.  For me, using Electronic Health Records or EHR instead of extensive paper files is natural and easy, but this may not be the case for everyone.  As we continue to move into the digital age, however, learning to work with EHR is a must.  Indeed, Medicare will only accept digital claims now, and CMS, the Center for Medicare and Medicaid Services, gives incentives to physicians for adopting EHR and its easy to understand why.  

EHR cuts down on paperwork, makes it easy to share files between physicians and offices, ensures that more complete files and more health history can be accessed by more providers with ease, even cuts down the physical space required to house files which can be a bonus as well.  Electronic Health Records also make it easy to provide documentation to auto accident claims, worker's comp claims and insurance companies when SOAP notes are requested to document specific treatments - gone are the days of leafing through files, whiting out sections and making copies.  You merely select the file, print it out or save it as a PDF file and you can mail or email it away in a matter of minutes.  Truly a timesaver.

How do you create electronic records?  Using a database system such as Clienttracker, Practice Mate or Acu Base is the easiest way.  Instead of writing paper SOAP notes, you can type directly into the SOAP note inside the database system when seeing patients and eliminate the need for paperwork beyond the initial health history at the first visit.  Voila!  EHR in use.

Inherent in EHR, however, are some security risks.  In addition to general HIPPA privacy compliance, you must do your best to protect patient records from electronic discovery to guard against identity theft, and there are some specific recommendations from HIPPA for doing this.  They include:

• Individual User Login - create an individual user login for each staff member who accesses the EHR.  This can be an individual user login for the computer itself, for the EHR system (database), for either or for both depending on what is available to you within your software system.
   
• Encryption - encrypt records whenever possible.
   
• Backup - make sure you are backing up your records!
   
• File Security - be sure you are keeping your backups locked in a locked room or filing cabinet in your office AND that you have a backup copy secured offsite in case of a fire/theft/flood etc. that could damage your records.
   

If these things sound foreign or unmanageable to you, your best option is to hire an IT professional to set these safeguards in place for you.  There are many companies like PC Paramedix who specialize in IT systems and HIPPA compliance specifically and can make sure you are meeting all the required safeguards for EHR in your office.  Most of the recommendations are common sense and are not difficult to put in place.

I find EHR indispensable and a huge time saver, especially when records are requested.  A little investment in time and computer systems up front can make a huge difference in your ease of use down the line.

I hope this missive was helpful and until next time, here's to your practice building and insurance billing success,

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