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5 Crucial Components your PT EMR Needs

What exactly should your EMR have? Find out in this blog post.

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5 Crucial Components of EMR Your PT Practice Needs

A modern physical therapy practice requires digital solutions that streamline daily operations and provide the peace of mind that patients’ sensitive health information is well protected. Electronic medical systems, often referred to as EMR systems, are the preferred physical therapy solution to maintain effective patient care and compliance. With so many types of EMR systems on the market today, it can be difficult to pinpoint which solution is right for you. When you’re in the market for software, the key is to identify the five crucial components of EMR every solution needs — whether you’re at the helm of a large-scale, multi-practice operation or the owner of a local physical therapy clinic. Here are the five components of EMR to be on the lookout for when eyeing EMR systems.

History of Electronic Health Records

Though the aspect of electronic health records (EHR) has existed since the 1970s, they remained largely unregulated until the U.S. federal government passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996. This act created national standards to protect patient privacy and limit the amount of Protected Health Information (HPI) disclosed by healthcare & medical professionals. According to HIPAA guidelines, PHI historically consists of all medical records and other individually identifiable personal health information. Examples of PHI in physical therapy include:

  • Patient medical history
  • Patient insurance details
  • Patient plans of care (POC)
  • Patient laboratory and test results
  • Patient demographic data, such as age, marital status, etc.
  • Identifiable patient information, such as name, address, and contact information

The evolution of technology has required updates to original HIPAA legislation, namely the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. Subtitle D of the HITECH act addressed security and privacy concerns surrounding the electronic transmission of health records by strengthening HIPAA criminal and civil enforcement and was expanded to cover outside entities, subcontractors, and business associates via the HIPAA Omnibus Rule in 2013.

What is an EMR (Electronic Medical Record)?

An electronic medical record (EMR) is a collection of digital health records containing standard medical and clinical data connected to a single healthcare provider's practice. EMRs can be viewed as the digital version of information typically on a patient’s paper chart, such as medical history, allergies, lab results, diagnosis, and immunization records. These details are privately used by a practitioner for ongoing patient diagnosis and treatment. Thorough documentation of these various EMR components on behalf of physical therapists helps ensure proper care over the entire course of the patient-doctor relationship.

Types of EMR Systems: Cloud-Based or Server-Based?

Cloud-based EMR systems, also commonly referred to as web-based EMR systems, do not require internal server hardware. Rather than being stored internally, cloud-based systems store EMRs in a virtual location that offers enhanced security through high-level encryption and allows professionals to access data from anywhere at any time.

Server-based EMR systems, on the other hand, rely on an in-house server system to store electronic medical records. Because record storage is run entirely internally, clinics who utilize server-based EMR systems will need to have staff to operate that system and to consider the use of firewall protection, recovery plans, and backup options to protect record accessibility and patient privacy.

Benefits of Electronic Medical Record Systems

Electronic medical record systems contain a limitless amount of valuable patient health information that can be used to form patient plans of care (POC), establish home exercise programs (HEPs), and maintain patient and provider communication. The benefits of EMR systems are endless; however, there are four key benefits that can be of assistance to physical therapy practices, in particular.

1. Support Compliance: EMR systems are equipped with multiple layers of physical and digital security, such as high-level data encryption and access controls, that enable practices to remain HIPAA compliant. Likewise, built-in tools like 8-minute rule checking and payment cap tracking help stay in accordance with Medicare and other insurances.

2. Better Organization: The ability to keep data organized is a crucial feature for any EMR. Charts should be neatly organized with documentation as well as external documents. Within a patient's chart, notes/documents should be organized so that they can be easily filtered for recall; whether it's for a patient's record request or for internal use such as a chart-review.

3. Immediate Access: Forget allocating a chunk of time each morning to gathering patients' notes and documentation. EMR systems dramatically speed up the document pulling processing, from intake paperwork and insurance cards to the most recent POC that requires physician signing.

4. Paperless (and Eco-Friendly): At a time when more consumers crave eco-friendly solutions, EMR systems help physical therapy practices eliminate the need for any sort of paper records. Paperless solutions gather all patient electronic information in one digital space that providers can access with one click.

5 Key Components of EMR Systems

Now that you’re more aware of how an EMR software differs from an EHR software and how this type of system can benefit your practice, it’s time to dive into the information you really need; how to pick the EMR solution that’s right for you. As a general rule of thumb, always look for these five components of EMR systems to guarantee a solution that will streamline your business.

1. Compliance Warnings and Tools
Compliance is a primary objective for all physical therapy providers, second only to a positive patient experience. An EMR system must have built-in compliance warnings and tools, so your practice is never faced with a surprise. In particular, seek an EMR solution with HIPAA PHI protection, Medicare’s progress note and recertification requirements, and comprehensive billing and scrubbing tools to maintain changes to coding and more.

2. Customizable Documentation/EMR Templates
In today's world, your documentation has to be customizable. Customizable templates are one of the most important keys to fast documentation. Almost every practice expresses a desire to write notes quickly without sacrificing quality. Systems that can be customized allow clinics and therapists to have the content they want, in the order they want, presented in the order desired.

3. Secure Electronic Communication for Providers and Staff
Secure electronic communication is crucial to making sure providers and support staff can collaborate internally in an effective, efficient, and compliant way.  Historically, communication between providers and staff has been carried out verbally. However, demanding patient schedules and an increase in a team-driven approach to patient care,  have created a need for a new approach to internal communication. To ensure compliance, save time, and relay the necessary information to all parties, all electronic communication should be built into your clinic's EMR rather than an external software or, worse, delivered through unsecured e-mail.

4. Patient Access to the Practice Digitally (Patient Portal)
Now more than ever, patients expect on-demand access to their personal health information and the ability to schedule their own appointments. A patient portal is one of the most crucial components of EMR systems for patients to register online and even complete initial intake forms. Not to mention, EMR patient portals can offer patients access to home exercise programs (HEPs), which providers can customize with pictures and videos of 1000s of exercises.

5. Advanced Documentation Tools
Last but certainly not least, every EMR system requires advanced documentation features. Advanced EMR software will include features like the ability to copy data from previous notes entirely or selectively or  the ability to view data, such as flowsheets, in different formats. Integrated patient outcomes are also a core feature to look for in any EMR system to help you document patient experiences and continually improve the quality of care you offer at your practice. Your chosen solution needs to be more than just a basic word-processor while remaining intuitive & easy-to-use day-in and day-out.

The Bottom Line

A compliant, efficient EMR system can revolutionize how your physical therapy practice communicates and cares for patients. Have the peace of mind that your patients' medical information is safe and secure when you switch to a reliable EMR and practice management system like MWTherapy. Learn how to make your practice more protected, proficient, and productive when you book a demo to try MWTherapy today.

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