Over the past 5 years the use of electronic health records (EHRs) by physicians in the U.S. has gone from less than 20% to as high as 70%, making them the most common method of storing medical information in the United States today. EHRs mimic the paper record by allowing provides to store basic background information about patients and to create patient visit and procedure notes. They have numerous value-added features, including the ability to use decision support tools that guide a physician to make medication choices that are safe for the patient. They also remind the provider of when certain tests and other interventions are due such as cholesterol level lab tests and immunizations. Some EHRs even help the doctor with deciding what might be wrong with the patient (i.e., diagnostic decision support) and what tests to order that will help confirm the diagnosis, or what therapies or interventions (e.g., surgery) to recommend. One of the most popular features of EHRs is their ability to allow healthcare providers to access information from remote locations, to never lose a medical record, and to them instant access to medical references such as electronic text books and other resources. A key aspect of EHRs is their ability to gather information needed for the doctor to receive payment for services provided to the patient. Complex billing rules surrounding U.S. healthcare have created a situation where it is nearly impossible for a physician to successfully create a claim populated with the correct billing information without help from a computer application of a medical billing professional. For this reason an understanding of how EHRs and billing tools called practice management applications work together to help physicians get paid is an important element for a successful career in HIT.
Michael Stearns, MD, CPC
For additional information see the following articles and information resources:
- Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360:1477-1479.
- DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359:50-60.
- American Academy of Family Physicians: EHR Product Select and Implement
- American College of Physicians: Electronic Health Records
- American Academy of Pediatrics: Child Health Informatics Center
The information contained in this article represents the opinions of its author: Michael Stearns, MD
©Michael Stearns, all rights reserved