What Is EHR Software? And Must-Have Features for Interoperability
Electronic health records (EHR), can be thought of as digital versions of traditional paper patient charts. The goal is for EHR software to use standardized formats so that patient data can be shared between healthcare providers. Standardized formats increase the transportability and interoperability of digital health records for patients and providers.
EHRs provide an interactive repository of the patient’s data including: medical history, diagnoses, treatment plans, medications, test results, immunization records, radiology images and allergies. But what is EHR software without proper interoperability? When interoperability works well, EHR software allows users the ability to track treatment progress for patients across multiple healthcare providers and specialists. This enables a holistic view of patient care and provides all stakeholders a unified view of a patient’s longitudinal health record.
When diagnosing patient health concerns and coding a patient chart, clinicians may focus on just one or two diseases based on the face to face encounter. Risk adjustment models require a more comprehensive view of the patient’s disease burden and they benefit from coding decision support at the point of care. EHR vendors don’t build sophisticated risk adjustment logic into their electronic health record systems. They build patient data input, storage and retrieval systems, but most have not introduced the AI tools required to manage risk adjustment models.
An EHR overview will reveal EHR vendors never provide all the “built in” digital health record features required to make the user experience complete. Even the largest company in the world, Apple, understood that software native to the iPhone would never be able to fulfill the potential of the device, hence the growth of the App Store. Likewise, your EHR will always be the software used to record the major portion of an encounter, but applications (apps) built to augment basic EHR functionality will increasingly become part of your workflow. The 21st Century Cures Act, mandates that EHRs share previously siloed data. 21st Century Cures leverages new technologies related to interoperability that will play a major role in the adoption of novel EHR apps.
Any introduction to electronic health records will reveal standards such as FHIR (Fast Healthcare Interoperability Resources) APIs and SMART (Substitutable Medical Applications, Reusable Technologies) are essential for building upon a legacy EHR system. Those technologies help third party developers create standardized, easy to implement, software that will make the interaction with EHRs more inviting. FHIR and SMART enable developers to create apps that can be used in multiple EHRs. Those apps that adapt to native EHR workflows in the same way App Store software downloaded to a cell phone integrates with the native operating system.
Accurate and complete diagnosis code selection impacts patients and providers. We are beginning a new era of medical record interoperability and patients will demand that their disease profile is accurate and complete. The digital health record has become more portable and patients now rely on the accuracy of the codes in their integrated electronic health records more than ever. Sharing data electronically is quickly becoming the de facto standard because it is faster and less cumbersome than print and fax. Speed and convenience means that records will be exchanged at a faster cadence than ever before, making accuracy more important than ever.
Provider compensation is becoming increasingly linked to risk adjustment models. Risk adjustment models are used by many Medicaid plans, all Exchange (Obama Care) plans and of course the Medicare Advantage program. This year CMS introduced the Primary Care First Model which will also incorporate risk adjustment principles. Current participants in risk adjustment models are often bogged down by requests from payers for medical records as those payers perform retrospective risk adjustment analyses….yes that means more faxing and printing. Our industry needs to take a more prospective approach, retrospective analysis has a place in risk adjustment workflows, but only as a last resort, because it causes more work on the back end. Coding accurately at the point of care, getting it right the first time, is the most efficient and precise workflow.
When conducting an electronic health record overview, and while evaluating your EHR system, work with your vendor to be sure that the system is incorporating all the leading standards, including FHIR and SMART, then add an app that can help your practice begin to adopt prospective risk adjustment workflows.
The goal of any EHR system is to create a comprehensive, accurate healthcare history for a patient. Now healthcare constituents are demanding that the patient’s personal medical record be exchanged (with patient permission) between practitioners and practices in a gapless, easy to read format. We’re some distance from that goal, but by implementing the latest interoperability standards, such as FHIR and SMART, we are creating the common language for data exchange and the use of third party apps in what were previously closed systems.
Do you want to learn more about ForeSee Medicals approach to dealing with the challenges of HCC risk adjustment? Our risk adjustment software can help you capture every appropriate HCC code, and get the reimbursements you deserve.
Blog by: The ForeSee Medical Team