Electronic Health Records
What is EHR?
An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:
Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
Automate and streamline provider workflow
Increase organization and accuracy of patient information
Support key market changes in payer requirements and consumer expectations
One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.
EHRs and the ability to exchange health information electronically can help you provide higher quality and safer care for patients while creating tangible enhancements for your organization.
Beginning January 1, 2022, all practitioners must have the capability to issue and receive e-prescriptions to a pharmacy selected by the patient. All prescriptions, excluding eyeglass and contact lenses, must be issued as an e-prescription.
Health IT offers resources to the entire health system to support the adoption of health information technology and the promotion of nationwide health information exchange to improve health care.
Health IT Playbook: a source for clinicians and practice administrators who are adopting, optimizing, upgrading, or changing an EHR system. The tools you’ll find here are intended to make your EHR experience more efficient, less burdensome, and more effective: https://www.healthit.gov/playbook/electronic-health-records/
Regional Extension Centers (REC)
RECs provide on-the-ground technical assistance for individual and small provider practices, medical practices lacking resources to implement and maintain EHRs. RECs to provide education, outreach, and technical assistance to help providers in their geographic service areas to select, successfully implement and meaningfully use certified Electronic Health Record technology to improve the quality and value of health care.
California Health Information Partnership Services Organization (CalHIPSO): assisting providers in all counties excluding Los Angeles.
HITEC-LA: assisting providers in LA County
Certified EHR Technologies
The Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program provides assurance to purchasers and other users that a system meets the technological capability, functionality, and security requirements adopted by the US Department of Health and Human Services.
Search the Certified Health IT Product List for Health IT modules that have been tested and certified under this program.
21st Century Cures Act Final Rule
The new rules hold the promise of increased clinical collaboration between doctors, allowing for informed and better health care decision-making. Providers must comply with the new rules by April 5, 2021. The Cures Act Final Rule pertains exclusively to electronic health information and the access and exchange of that electronic data.
Considerations to make when preparing for the new changes:
Make sure your health IT vendor is prepared to support these requirements of the Cures Act rules.
Confirm that your vendor is working on certification under the 21st Century Cures 2015 update certification criteria and maintenance of certification requirements. Ensure your vendor is planning to offer supporting USCDI data elements and interoperability improvements in the C-CDA workflows.
Verify that your vendor is planning to meet the requirements for API-based certification criteria and will be prepared to support your practice before the regulatory deadline of December 2022.
Check if your IT vendor has educational resources on the rules.
Review your practice privacy and security policy to ensure operations are outlined for patient information access requests.
Review the information-blocking exceptions to exercise these options when appropriate.
Develop a process of communicating the steps of how patients will request access to EHI.
Consider developing a policy for incoming reports from other health care providers. Consider workflows for lab and test results needing physician review prior to access.
Establish timeliness for the data being made available for access, exchange and use.
Learn more by reading this Q&A by the AOA.