What is an EHR System and How to Select Best EHR for your needs?

The development of EHRs was fueled by a combination of factors, including advances in technology, growing concern over medical errors, and the need for more efficient and effective healthcare systems. The US government played a significant role in promoting the adoption of EHRs through legislation such as the Health Information Technology for Economic and Clinical Health (HITECH) Act, which provided financial incentives to healthcare providers who adopted EHRs.

The early EHR systems were often proprietary and lacked interoperability, making it difficult for healthcare providers to share patient information across different systems. However, in recent years, there has been a push towards open standards and interoperability, with initiatives like the Fast Healthcare Interoperability Resources (FHIR) standard, which has been adopted by many EHR vendors.

What is an Electronic Health Record (EHR)?

An Electronic Health Record (EHR) is a digital record of a patient's health history maintained by authorized clinicians and staff across multiple health care organizations over time and includes “all of the key administrative clinical data relevant to that person’s care under each care provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports" and is vital to providers making better decisions and providing better care.

EHR (Electronic Health Record) system is an enabling technology for healthcare professionals and is designed to improve and safety of patient care by providing healthcare professionals with timely access to accurate and comprehensive patient information, streamlining workflows, enabling care coordination, and providing decision support tools. This can lead to better outcomes for patients, including improved health status, reduced complications, and increased satisfaction with their care. It also include solutions like interoperability which enable better workflows and reduced ambiguity, and allows data transfer amongst EHRs and multiple health care stakeholders.

Additionally, patients can access their EHR system  through a patient portal, which enables them to view their health information and communicate with their healthcare providers.

The use of EHR Systems is becoming increasingly widespread as the healthcare industry moves towards a more patient-centered approach. EHR Systems play a crucial role in ensuring that patients receive the best possible care and outcomes.

What you should know about EHR?

1. Patient Management: A comprehensive view of a patient's health history, including medical history, medications, allergies, and lab results allow healthcare providers to manage and update patient information in real-time.

2. Clinical Documentation: A range of tools provided to document patient encounters, including progress notes, medical histories, and diagnoses helps healthcare providers maintain complete and accurate records of patient care.

3. Decision Support: EHRs provide decision support tools to help healthcare providers make more informed decisions about a patient's care. These may include alerts for drug interactions, reminders for preventive care, and clinical guidelines based on the patient's health history.

4. Interoperability: EHRs are designed to be interoperable, meaning they can share patient information across authorized providers belonging to more than one healthcare organization and systems. This can help improve care coordination and reduce medical errors.

5. Security and Privacy: EHRs are designed to be secure and to protect patient information from unauthorized access. They use a range of security measures, such as user authentication and data encryption, to protect patient information.

Other features that are often included in EHRs may include e-prescribing, patient portals, clinical quality measures, and reporting tools.

Advantages of EHR

There are several advantages of using an Electronic Health Record (EHR) system, including:

1. Improved Patient Care: They provide healthcare providers with immediate access to a patient's complete health record, including medical history, current medications, allergies, and lab results. This helps healthcare providers make more informed decisions about a patient's care, resulting in improved patient outcomes.

2. Increased Efficiency: They eliminate the need for paper-based medical records, which can be time-consuming to manage and may lead to errors. EHRs streamline the process of documenting and managing patient information, making healthcare delivery more efficient.

3. Improved Communication and Care Coordination: Healthcare providers can easily share patient information with other providers involved in a patient's care. This helps improve care coordination and can help reduce medical errors.

4. Decision Support: Included  decision support tools, such as alerts for drug interactions, reminders for preventive care, and clinical guidelines based on the patient's health history can help healthcare providers make more informed decisions about a patient's care.

5. Patient Access: Patients get access to their own health information, allowing them to be more engaged in their own care and to better understand their health conditions.

6. Cost Savings: EHRs can help reduce costs associated with managing paper-based medical records and can help reduce the incidence of medical errors, which can be costly to correct.

How to select the 'best' EHR for your needs?

Modern EHRs have transformed significantly from simple text entry to comprehensive medical practice systems with a multitude of functionality. Shortlisting, selecting and implementing the 'best fit' EHR has become a daunting process. This post includes 23 criteria, some of which belong to the 'essential' category while the others belong to 'nice to have' category.

1)     Flexible Charting with specialty specific customizable templates

Chosen EHR must offer out of the box specialty specific set of templates for your specialty which are further customizable by the practice with little or no support from the EHR vendor. Once customized fully, EHR templates provide valuable insight besides streamlining patient encounters and an intelligent way to track and manage daily tasks to help providers work smarter. It must expedite clinical encounters by supporting flexible and personalized charting styles including voice recognition, handwriting recognition, etc.

2)     Simple, Intuitive and Attractive User Interface

Flexible charting works best in conjunction with advanced user experience design (UX). Medical practice software must have a visually appealing graphical user interface to satisfy aesthetic needs and create some joy when using the software on daily basis. Information and workflows are presented in logical and practical ways which are the main ingredients of an intuitive user interface. 

3)     Integrated PM/EMR to optimize Billing and Revenue Cycle Management

Time has passed where many different software developers applied their special knowledge to one topic (e.g. Billing, RCM, EMR, Scheduling etc.) and created an awesome application that did just one thing. As the market consolidates and medical practice software becomes more mature, the buyers expect an all-in-one package without the hassle of dealing with different providers, different software packages and installations. Modern medical practice software is expected to deliver excellent functionality in all four categories:

• Practice Management,
• Electronic Medical Record,
• Patient Engagement, and
• Knowledge Management.

An integrated EHR is built on a single database, thus eliminating the headache of creating and maintaining APIs (Application Programming Interface) between different software packages. For instance, the scheduling module links the patient details with the date and time of an appointment; the task management module sends out reminders; the charting module provides the codes for RCM (Revenue Cycle Management), and so forth.

4)     E-Prescribing Capabilities

E-Prescribing is a prescriber's ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care - is an important element in improving the quality of patient care.

There is now consensus that e-prescribing provides a better and safer way of prescribing medication than paper-based prescription. In addition, The American Journal of Pharmacy Benefits found that e-prescribing was “associated with significant prescriber and patient behavior change”. Increased primary, secondary, and tertiary fill rates indicated improved patient adherence. Electronic medication management represents an excellent example of how computer software can make use of large connected datasets (e.g. drug formulary, drug-drug interaction, pediatric dosing). The optimal e-Prescribing software will take many factors into consideration to ensure prescription of the safest drug. However, ongoing work needs to be done to address problems with alerts, developing protocols, and adding new medications.

5)     MACRA Certification

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created the Quality Payment Program that is changing the way how Medicare rewards clinicians. The conventional fee-for-service reimbursement model is slowly being replaced by the concept of value-based care. Clinicians have two tracks to choose from: Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). The decision is based on their practice size, specialty, location, or patient population.

A recent article published in Family Practice Medicine (published by the American Academy of Family Physicians) reminded primary care physician that engagement with the QPP needs to be started in 2018. To obtain the full benefit, a 2015 Edition ONC Certified Health IT Product is strongly recommended. Successful participation could earn a positive payment adjustment of 5 percent in 2020. On the other hand, not engaging with the program will risk a negative payment adjustment of up to -5 percent in 2020.

6)     Clinical Decision Support

Clinical decision support is no longer a “nice-to-have” feature. The paradigm, "The Right Information at the Right Time, in the Right Place, in the Right Way to the Right Person", first described by Gerhard Fischer, University of Colorado Boulder, has become one of the hottest features of modern EHRs. Powerful and very affordable computer technology, paired with nearly unlimited storage space and almost universal access to large data repositories, have paved the way to the delivery of large amounts of primary and secondary information. Ironically, the amount of information is not too little anymore. It is too much! Information overflow and alert fatigue have become new buzz words. Well-crafted medical practice software is becoming more and more sophisticated to deliver the “5 Rights”. The right Amount of information should be added as the sixth “Right”. Naturally, this should depend on the user’s personal preference. Eventually, new technologies like supervised and unsupervised machine learning and AI will revolutionize how medicine is practiced. For now, the best EHRs find the right balance between information need and delivery to ensure patient safety, value-based healthcare, and high practice efficiency and efficacy.

7)     Demonstrated Interoperability capabilities

For 2019, the CMS emphasizes that 25% of the MIPS final score is based on promoting interoperability. This ensures the sharing of health care data between health care providers and patients.

8)     Mobile Integration of all core pieces

Cloud computing and powerful mobile devices have given users of modern EHRs unprecedented freedom of mobile access to EHR data. It is paramount that software vendors must adhere to privacy, safety and cybersecurity standards to prevent hacker or ransomware attacks. Physicians appreciate the increased comfort of mobile e-prescribing or submitting refill-orders, to name only two benefits. Software design for multiple platforms gives the user a choice whether he or she wants to use Windows, Mac, iPhone/iPad or Android. Some software is delivered via web browser which should therefore support Microsoft Edge, Internet Explorer, Google Chrome, Safari, or Firefox. 

9)     Patient Portal with secure messaging

The CMS has incorporated the patient portal as a measure of promoting interoperability. The patient portal is seen as an important component of a successful patient engagement strategy. For the tech-interested patient HIPAA compliant messaging provides a convenient and safe way to connect with providers and practice staff. Even though many patients, especially elderly patients, are still more likely to use the phone to speak directly with staff, the acceptance and usage of the patient portal will increase.

The functionality that is provided via patient portal is already impressive:

• Request or schedule appointments
• View test and lab results
• View summaries of recent doctor visits
• Make payments online
• Request prescriptions and refills
• Communicate with staff

10)  Comprehensive task management

Effective task management deals with all aspects of a task. The Task Life Cycle (see graph below) describes the different states of a task. A performant PM/EHR system is configured in a way that it automatically creates and executes tasks, e.g. send out appointment reminders one or two days before the scheduled appointment.

Intelligent task management monitors the state of each task and either gives the user regular updates or keeps to-do lists up-to-date and sends out reminders or even warnings, if appropriate. Another important functionality is automatic synchronization of physician calendar and integrated patient self-scheduling system.

11)  Flexible and configurable Workflow Management

Effective workflow management provides the infrastructure for handling a defined sequence of tasks. Medical practice software applies a date/time stamp to every single user action. Equipped with detailed time/task analysis, every practice can now identify areas that are labor and/or time intensive. It reveals how patients travel through the system and how information is gathered and processed.

Modern medical practice software can help to optimize and restructure workflows. Typically, completion of one task or user action triggers a response by the system.  For instance, as soon as the patient has filled out the electronic intake form, the system updates the task list of the nurse indicating that this patient is ready to be examined. At the same time, the doctor receives notification that the same patient is due for another test, e.g. oral glucose challenge. As soon as the doctor signs the order for the test, the nurse receives the notification on his/her screen. As per pre-defined protocol, the system will highlight the necessary steps on how to perform this test. Smart workflow management helps the practice to become safer, more efficient, and more effective.  

12. Interface to Lab of Choice

Modern medical practice software provides a lot of functionality for managing lab results. The computerized physician order entry (CPOE) is one of them. It helps to reduce errors and improves efficiency by sending out lab requests automatically. Most software products connect directly with the laboratory that is affiliated with the EHR vendor. However, the mandate is to be able to choose any laboratory interface that is commonly available. Medical practice software needs to remain open in terms of the interface to the lab of choice. In addition, a feature-rich interface sends out lab requests, receives the results, receives lab specific information about reference values, and obtains instructions on how to correctly obtain blood or other specimens. Most systems can share information with other healthcare providers.

If your EHR vendor cannot connect with the lab of your choice or asks you to spend extra dollars, do your homework and find the vendor that does!

13. Cloud-based PM/EHR software

Cloud technology has matured over the last decade. Advances in computer power, virtualization, and high-speed connectivity make it a feasible and reliable choice; especially for small practices. Cloud software is easier and cheaper to implement, maintain and update than local client/server installations. It enables easy access from nearly any device from nearly anywhere. If you need more in-depth information about this topic, RevenueXL has published an overview article.

Moving patient data into the “cloud” is safer than ever. Encryption technology makes it secure. Contrary to some people’s belief, cloud-computing is still based on solid computer hardware embedded in a secure network located on earth! To ensure this high standard of safety, mobile EHR software requires a password protected login, encrypted data transfer, and two-factor authentication for logins. Cloud-based EHR software increases patient privacy and makes practice management more flexible and more efficient.

14. Telemedicine

Modern computer and communication terminology can sometimes be confusing. Terms like telehealth and telemedicine describe similar things but are not synonymous. According to The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services, telemedicine refers specifically to remote clinical services, whereas telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. The AAFP describes telemedicine as a telecommunications infrastructure between a patient (at an originating or spoke site) and a physician or other practitioner licensed to practice medicine (at a distant or hub site).

In a most recent article about promising IT trends, Becker’s Hospital Review cited a survey conducted by Reaction Data. The survey found that 29% of healthcare executives believed that telemedicine will have the biggest impact on healthcare in the future. The Deloitte 2018 Surveys of US Health Care Consumers and Physicians found that most physicians recognize the benefits of virtual care technologies but only 14% have telemedicine implemented today and only 18% are planning to use it in the near future.

Many states in the U.S. have not implemented regulations around reimbursement, special purpose license, and telemedicine licenses to practice across state lines yet. In January 2018, the Federation of State Medical Boards published an overview of telemedicine policies by state. So far, 28 states require both private insurance companies and Medicaid to reimburse telemedicine services to the same extent as face-to-face consultations.

15. Document Management

The paperless office was announced in the early eighties. Surprisingly, the opposite happened because of improved scanner and printer technology. With the introduction of comprehensive EHR software the trend is now in favor of electronic document storage systems. The old productivity rule “touch a document only once”, i.e. for scanning, should help to increase efficiency and improve access to the documents.

Medical practice software provides functionalities of a modern document management system. Ideally, the system should not only perform optical character recognition (OCR) to enable full text search but also automatically recognize the patient’s name and the date of the document to facilitate correct electronic filing. In the future, natural language processing (NLP) and handwriting recognition might even further help to make text information accessible and readable by computer systems.

16. Automated Coding Assistance

Automatic generation of evaluation and management (E/M) codes helps to efficiently analyze information collected during patient charting. It also includes ICD codes with rapid code lookup and an up-to-date code set. Automated coding assistance helps to eliminate errors and omissions. It has the potential to enhance overall productivity and to reduce coding time. Computer-assisted coding quickly becomes a great asset with regards to billing and practice management. Application of correct codes maximizes the billing potential of every practice (SoftwareAdvice).

17. Medical Speech Recognition

Commercially successful speech recognition technologies have been in use for almost 2 decades. For many specialties, the introduction of medical dictionaries helped to speed up the dictation and transcription process. Other specialties (e.g. Cardiology - author’s personal experience) have had difficulties because of an extended training period and frequent use of abbreviations that were commonly used to describe ECG or echocardiography findings. Although the introduction of machine learning and AI have improved the rate of recognition significantly, it is recommended to experiment with speech recognition before purchasing it.

18.  Handwriting Recognition

Handwriting recognition represents another technology that has the potential to significantly improve practice workflows. Intake forms, doctor’s notes, and handwritten letters are still encountered in daily medical practice. Scanning technology imports the document as an image but reading the content of the fields of an intake form is not standard yet.

The author of this article conducted a simple test to check Google’s ability to recognize handwriting. The following image was uploaded to Google Drive and then opened with Google Docs which automatically performs the handwriting recognition. The first two sentences were written by a doctor, and the second two sentences by his assistant.

The results were as follows: Patreut says that he can not left his right prot any more. The petrut's main complaint was pain in his left hand. Patient says that he cannot lift his right foot anymore. The patient's main complaint was pain in his left hand. Based on this simple test the recommendation is not to let doctors do any handwriting anymore.  However, for people with good handwriting the rate of recognition can be up to 100%!

19. Online Payments

Patient portals are becoming more and more popular because they offer convenient patient-provider communication by using standard internet technology. In addition to the functionalities listed in the first article of this series (→link), the online payment provides an easy and convenient way of settling the doctor’s or the lab’s bill. Standard payment portals process credit card or debit card information to offer the functionality that most patients are nowadays acquainted with.

20. Text Reminders

As part of the task management system, text reminders help to keep patients up-to-date with pertinent information. Studies have shown that sending out text reminders reduces the number of no-shows (McLean 2016). Text reminders can also be used to improve patient compliance with their treatment.

21. HIPAA Compliant Faxes

Most recently, CMS Administrator Seema Verma called for an end to physician fax machines by 2020. The transmission of protected health information (ePHI) by fax is not always secure and protected. Many EHRs incorporate integrated fax solutions that transmit ePHI and other important documents by email using encryption and the recipient's fax number.

22. HIPAA Compliant Virtual Document eSignature

E-signature is an electronic method to confirm the identity of the creator of the document. Digital signatures are considered the same as handwritten signatures. The Electronic Signatures in Global and National Commerce (ESIGN) Act in 2000, made electronic signatures legal in every state and U.S. territory where federal law applies. As this U.S. Guide to Electronic Signatures (by Adobe Sign) explains, there are two primary types of electronic signatures available: e-signature and digital signature. The latter provides authenticity and integrity that can be held up in a court system.

23. Choice of Medical Clearinghouse Interface

As with the choice of the lab interface the choice of medical clearinghouse interface should lie in the hands of the customer. Some EHR systems go even further by connecting with multiple clearinghouses, enabling a choice for which clearinghouse they send a specific set of claims to.

To find more info on how to choose the best clearinghouse, follow this link: Choosing the Best Healthcare Clearinghouse for your Medical Practice.