Medical Record vs Electronic Health Record

Medical Record vs Electronic Health Record

An electronic medical record (EMR) / Electronic Health Records (EHR) is a digital version of a paper chart that contains all of a patient's medical history from one practice. An EMR/EHR is mostly used by providers for diagnosis and treatment.

With the relatively recent healthcare models of pay-for-performance, patient centered medical home model and accountable care organizations there are new reasons to embrace technology in order to aggregate and report results in order to receive reimbursement. It is much easier to retrieve and track patient data using an EHR and patient registries than to use labor intensive paper chart reviews. EHRs are much better organized than paper charts, allowing for faster retrieval of lab or x-ray results. It is also likely that an EHR will have an electronic problem summary list that outlines a patient’s major illnesses, surgeries, allergies and medications. How many times does a physician open a large paper chart, only to have loose lab results fall out? How many times does a physician re-order a test because the results or the chart is missing? 

Understanding that technology is important. Physicians should understand what are the current regulations in place for Electronic Medical/Health Records.

Currently , providers are instructed that electronic health records are to be handled the same as written medical records. The Board of Medical Profession and States are in the process of developing Rules and Regulations for the handling of electronic health records.

Until said Administrative Laws, Code of Federal Regulation , and State Laws have been developed and approved providers MUST be in compliance with CURRENT LAW.

FAILURE to comply with CURRENT regulations will result in FANANCIAL PENALTIES and/or SANCTIONS !!!

Physicians and Providers should be asking questions when contracting  with an EMR/EHR  vendor:

·       How long do you maintain records for?

·       How do I obtain copies/files for my record?

·       In the event of a Data Breach, who is responsible ?

·       In the event that a vendor goes out of business -  how do I get my records?

Remember that Providers ARE the TRUE CUSTODIAN of the Medical Record / Electronic Health Record.

Understand the Law and requirements of the Health Record and AVOID COSTLY PENALTIES !!!

For more details , contact:

SILBEN Healthcare Services, INC.

Paul G. Silverio-Benet

Phone: 305-975-1171

Email:  sbhealthcaremgmnt@gmail.com