Personal Health Records – Integration with Electronic Medical Records

Defining the Terminology

There's a lot of terminology being thrown around as part of health care reform concerning personal health records, electronic health records and electronic medical records.  Of course, there is also stimulus money for health care practitioners being tied to the adoption of electronic health records or electronic medical records.  Let's define the terms so that everyone knows what we are talking about.

For sake of simplicity, personal health records are completed by a patient usually as a desktop or online solution.  A personal health record is similar to the case history form that a new patient fills out which includes the symptoms, medications, allergies, insurance coverage, other physicians, review of systems, pain scale, diagnosed conditions, surgeries, hospitalizations and family medical history.  A comprehensive personal health record allows the patient to maintain and update their records as his or her conditions change. It usually includes more information than you would normally get from a clipboard new patient case history.

Electronic health records or electronic medical records are completed by the doctor.  They represent the objective findings or exam findings, the doctor's assessment and diagnosis and a treatment plan with treatment goals.  Until recently, the personal health records were represented by a series of papers on a clipboard that was handed to the patient at the first visit.  The electronic medical records were represented by travel cards in the chiropractic office.   The use of computers and cell phones are totally changing how information is gathered and disseminated.    

This article addresses how personal health records can augment a chiropractor’s practice.

Effective Business Model

A few years ago, my uncle became sick and was admitted to the hospital with a diagnosis of Valley fever.  He kept telling the doctors that he was on heart medication but they did not continue the medication while he was being treated for Valley fever.  During the course of his hospital stay, he suffered a major heart attack and died.  Had the doctor listened to his patient, the death could have been avoided.  If my uncle had been admitted with a complete personal health record, perhaps the doctor would have been more attentive.  We’ll never know.

ICER-2-GO software prints an emergency medical record ID card for a person's wallet, refrigerator or glove box. Using the instructions on the ID card, emergency responders have instant access to critical medical information that can save a person's life. Imagine that your grandmother suddenly becomes unconscious while shopping. In her purse, there is an emergency medical ID card. Using his cell phone, the EMT brings up your grandmother's medical record and realizes that she has diabetes and that she had a heart attack two years ago. Can you see how information like this would be critical in an emergency situation? When she is transported to the hospital, emergency room attendant has access to her complete medical history. Wouldn't you want this type of information available for your family members and for your patients? You can even test how it works by following the instructions on this card from your computer or from your browser-based cell phone. A complete emergency medical record will appear in your screen. This wealth of information can literally save a life.Since almost everyone has access to a computer, it would make sense that we would use a computer to communicate information about an individual's health care.  In an ideal world, the patient would complete a personal health record.  This wealth of information would be shared with all of the patient's healthcare providers.  When the patient has been evaluated by the doctor, the doctor would send information back to the patient that would become part of the patient's personal health record.  Not only would the patient receive information about their condition, they would also receive information like patient instructions, exercises that they could do to improve their condition and recommendations from the doctor about continued care.  This type of business model puts the patient in the center of their health care and keeps families informed so that they can participate fully.  Unfortunately, we rarely see this type of communication in the healthcare industry.

Avoiding Medical Mistakes

With all of the various treatments and medications available to patients nowadays, it is becoming increasingly important that patients are aware and take responsibility for their own health care.  The main purpose of integration between the personal health record and the electronic medical record is to avoid medical mistakes.  One of the most costly and deadly medical mistakes concerns the use of pharmaceuticals.  I went to the local drug store one day to pick up a prescription.  When I looked at the bottle, I did not recognize the name of the medication.  When I asked the pharmacist, he rudely assured me that my doctor had prescribed this medication.  Not trusting his answer, I questioned him further;  I asked to see a copy of the doctor's orders.  As it turns out, the pharmacist had made a mistake that I recognized because I maintain a personal health record and know firsthand why I take any medication since I certainly do not like pills and only take medication if absolutely necessary.  The pharmacist had filled the prescription with the wrong medication, one that could have significantly affected my blood pressure.  I caught it because I was informed.  Completing a personal health record helps a patient stay organized and current on their health care.

Comprehensive Medical History

When chiropractors use the evaluation and management codes to bill for the initial visit, 99201-99205, a portion of that code references the medical history that has been gathered from the patient.  A personal health record with a complete review of the systems and a family history can meet most of those requirements without a doctor's involvement except to review the history.  In addition, the doctor is alerted to any back surgeries that might contraindicate chiropractic care.

A personal health record with a complete review of the systems and a family history can meet most of those requirements without a doctor's involvement except to review the history. In addition, the doctor is alerted to any back surgeries that might contraindicate chiropractic care.

 

The above screenshot shows how a medical history can include all of the necessary information for chiropractic care.

Emergency Medical Situations

Perhaps the most useful feature of a personal health record is the ability to communicate critical medical information in an emergency situation, especially if the patient is not conscious.  Emergency responders, whether it is an emergency medical technician on scene or an emergency room doctor at the hospital, need quick and easy access to a patient's medical records.  Most of the time, critical information is not available to assist doctors in making appropriate decisions; medical history is often sparse.   Is the patient allergic to anything?  Is a patient on medication?  Is the patient pregnant?  There are hundreds of questions that impact the quality of emergency medical care.

A personal health record can fill in the gaps and make the information instantly available.  Within the last month, ICER-2-GO (in case of emergency record to go) released a software update that allows an emergency medical record to be browsed on any computer with Internet access or on a browser-based cell phone.    It is the only personal health record software available with this advanced technology.

Here's how it works.   ICER-2-GO software prints an emergency medical record ID card for a person's wallet, refrigerator or glove box.   Using the instructions on the ID card, emergency responders have instant access to critical medical information that can save a person's life.   Imagine that your grandmother suddenly becomes unconscious while shopping.  In her purse, there is an emergency medical ID card.  Using his cell phone, the EMT brings up your grandmother's medical record and realizes that she has diabetes and that she had a heart attack two years ago.  Can you see how information like this would be critical in an emergency situation?  When she is transported to the hospital, emergency room attendant has access to her complete medical history.  Wouldn't you want this type of information available for your family members and for your patients?  You can even test ICER-2-GO software prints an emergency medical record ID card for a person's wallet, refrigerator or glove box. Using the instructions on the ID card, emergency responders have instant access to critical medical information that can save a person's life. Imagine that your grandmother suddenly becomes unconscious while shopping. In her purse, there is an emergency medical ID card. Using his cell phone, the EMT brings up your grandmother's medical record and realizes that she has diabetes and that she had a heart attack two years ago. Can you see how information like this would be critical in an emergency situation? When she is transported to the hospital, emergency room attendant has access to her complete medical history. Wouldn't you want this type of information available for your family members and for your patients? You can even test how it works by following the instructions on this card from your computer or from your browser-based cell phone. A complete emergency medical record will appear in your screen. This wealth of information can literally save a life.how it works by following the instructions on this card from your computer or from your browser-based cell phone.   A complete emergency medical record will appear in your screen.  This wealth of information can literally save a life.

 

How You Can Become Involved

While most chiropractors will not be in the position of providing emergency medical care, they can inform their patients of the technology that is available to them to handle emergency situations.  Chiropractors can also choose to make the software available from their websites and ask patients to complete the comprehensive personal health record prior to their initial visit.  This complete report can become part of the patient's chart and be used to substantiate necessity of care in the event of an audit.  Then, should the patient ever require emergency medical care, their medical ID card will allow emergency responders instant access to their medical records.  By informing your patients about this software, you can decrease the amount of time necessary for gathering history information while you are also potentially saving a patient's life in an emergency situation.  You even have the opportunity to become a distributor and generate an ongoing revenue stream in the process.   It is the ultimate win-win scenario.

If you are interested in learning more about the benefits of a personal health record, visit www.icer-2-go.com or call 928-203-0394.

 About the Author

This article was written by Marilyn K Gard, MBA, CEO of ClinicPro chiropractic software and ICER-2-GO LLC.  Visit the ICER-2-GO website at www.icer-2-go.com or call (928) 203-0394 for more information about becoming distributors of this time-saving and life-saving technology.

Marilyn Gard was diagnosed with multiple sclerosis in 1984, three years after starting a chiropractic insurance seminar and consulting business.  She developed ClinicPro chiropractic software in 1994.  In 2003, she designed ICER-2-GO software as a way of eliminating the drudgery of filling out paperwork with every visit to a new doctor.  The software was originally designed as a desktop software that saved medical record information to a USB or flash drive.  Marilyn quickly learned that the idea of saving information to a USB drive was a poor business model for emergency situations.  Ambulances didn’t have computers.  Emergency rooms wouldn’t allow a USB drive to be placed into their network for fear of viruses.   Because she was committed to designing a health record software program that could be accessed at the scene of an accident, the software was redesigned in 2008 to work online.  In October 2009, an interface was created that totally solves the weaknesses of the prior business model.  ICER-2-GO medical records can be accessed from any browser, either on a computer or on a cellphone.  Emergency responders have instant access to life-saving medical records.  In addition to addressing emergency medical situations, ICER-2-GO (In case of emergency to go) serves as a complete medical history. In the near future it will be integrated with the ClinicPro EHR to allow two-way communication between doctor and patient.
Chiropractic software, or chiropractic practice management software, is specifically designed to run a chiropractic office. It includes chiropractic procedure codes such as 98940 and 98941. It includes chiropractic diagnosis codes for subluxation and neural muscular skeletal conditions. It is HIPAA compliant and complies with the guidelines for Medicare chiropractic coverage. In addition to providing chiropractic software, creative concepts in communication writes articles for local and federal chiropractic organizations and publications. ClinicPro chiropractic software is committed to providing the best chiropractic practice management software in the industry along with the best technical support available for Chiropractic software.
As a chiropractor, the needs for clinic software differ from a medical practice. Chiropractors primarily use two procedure codes: 98940 and 98941. In addition, electronic medical records for chiropractic practices differ significantly from medical practices. Chiropractors do not use electronic prescriptions, lab tests or immunization registries. Chiropractors need to record x-ray findings, visit plans and functional limitations. Chiropractic software by ClinicPro provides the best chiropractic practice management software in the industry.
 In a chiropractic office environment, the use of chiropractic software streamlines the functioning of the office. Chiropractic software should include an appointment scheduler that allows chiropractors to set up visit plans. It should include chiropractic procedure codes for x-rays and adjustments such as 98940 and 98941. It should include an integrated electronic medical record that allows chiropractors to record Medicare mechanism of trauma. Using an EMR to record documentation notes and physical exam findings streamlines the overall functioning of the chiropractic office.