Electronics Systems Used by Medical Billers and Coders

By Karen Smiley

You need to distinguish between two types of electronic ­systems — Electronic Medical Records (EMR) and Electronic Health Record (EHR). An EMR is just a digital version of a paper chart. It is not accessible by adjunct providers and can’t be transferred electronically. These records must be printed out to be sent, just like making copies of the paper chart.

The future of medicine is the EHR. Use of the electronic records is intended to do away with the paper chart and make protecting and sharing information easier for providers. If a physician has access to the hospital’s records, he or she can receive test results, pathology reports, and other information needed to treat the patient immediately.

EHRs are also considered to be more secure. They’re password protected and can be programmed so that even those who have access to the records don’t have access to the entire record, but only to those parts necessary to do their jobs.

The front office, for example, may need full access to patient demographics and insurance information, but it may not need access to test results. Similarly, the nurse caring for the patient needs full access to health information but probably doesn’t need to know the patient’s Social Security number or address.

Not surprisingly, electronic records offer many advantages. Many types of record systems come with expansion modules that target specialties. These templates present mandatory data fields that must be completed before the record can be closed. This function eliminates the risk of missing information necessary for correct coding and billing (in addition to providing quality patient care).

Privacy is a major concern when a practice implements an EHR system. For that reason, privacy protocol must be followed. Paper charts may violate an individual patient’s privacy, but with EHRs, one data breach can violate hundreds of patients’ privacy.

Data loss is another potential issue with electronic records. A computer or server crash can erase several years’ worth of data if the server isn’t backed up daily. The use of cloud computing further complicates the issue. Primarily, cloud storage takes the PHI (personal health information) completely out of the provider’s hands, making encryption essential.