One of the hottest topics right now in the world of Health Information Management and even the news in general is the medical industry’s transition to an electronic format for managing patient’s health records. The electronic health record, or EHR, allows healthcare providers to record patient information in a variety of electronic formats instead of on paper. The transition to an electronic health record is challenging but brings many benefits to healthcare providers, including:
- Reducing the burdens of managing paper: One of the most immediately obvious benefits to using an electronic record is the reduction in the amount of paper that must be produced and handled in order to maintain a patient’s medical record. Paper records require many times more storage space than electronic records. Paper records must be protected from possible physical damages. A single fire or flood can wipe out a decade of paper records that cannot be replaced. Paper records must be filed and re-filed, shuffled and re-shuffled in completing the tasks of a healthcare provider’s day to day operations.
- Improved patient safety and quality of care: Electronic health records can have alerts built into them that let the clinician know when the patient has allergies to certain medications being considered for treatment or when these medications are contraindicated for use in conjunction with other medications the patient is taking. Electronic records also provide information about current, clinical best practices that can aid in clinical decision, often resulting in fewer tests and procedures and better outcomes of care.
- Increased security: Electronic formats for record maintenance provide better control over who has access to the information in the patient’s record. Access to patient information can be based on usernames and passwords or levels of authority. With a paper record, anyone who has the record in their hands can access any part of the record. With electronic records access can be restricted to allow the user to see only the portions of the record necessary to do their jobs.
Medical coders are part of the larger health information management team and any change that improves the workings of the HIM dept as a whole will have benefits for the coder even if it’s just in the form of a happier department manager, supervisor or co-workers. However, the benefit of an EHR that is likely to have the greatest impact on medical coders is interoperability.
- Interoperability: Interoperability is the ability for authorized users to access patient information from any approved location, at any time, and includes the ability for multiple users to access the same record at the same time. This capability has an impact on medical coders in light of both productivity and working conditions. Coders sometimes fall behind in their productivity because they have to wait to code records that have been removed from HIM by someone else who needs access to the information in the record. EHRs will mean coders can have all necessary access at anytime to all information they need to do their work. The interoperability of EHRs also advances the feasibility of remote coding. Coders will continue to assign ICD-9 codes, ICD-10 codes and CPT codes as they have in the past, but they will more frequently being doing these tasks from the comfort of their own home. This arrangement has benefits for both the coder and the healthcare provider in terms of flexibility in both work space and work flow.
As a future medical coder, how do you feel about the possibility of working with an EHR?