Challenges in Obtaining Complete Medical Record Data

By Lesley Brown, SVP of Product Management at Halfpenny Technologies

As previously discussed the potential benefits to health plans of compiling a complete picture of their member’s health status are abundant.  The more data and information you have about your members, the better help and guidance you can give them to ensure they receive the most appropriate and best care without redundant replication of services.  And without unnecessary cost!

Being able to obtain a comprehensive medical record for a member from a physician’s practice is one avenue that health plans can take to enrich their member’s health records.  Yet, technical and business challenges aside, being able to gather a comprehensive or full medical record from an EMR can be difficult.  Experience has demonstrated that all too often much of the key clinical information about a patient is missing from the “structured” components of Electronic Health Records.  And this occurs even when data is retrieved using “industry” standard formats such as the HL-7 C-CDA template and document structure.  This missing clinical data ranges from lab result interpretations, medication detail around frequency and dosing, allergy information to physician signatures.  An additional challenge is the inability to distinguish and interpret between actual missing data in a record from “null” data elements such as “no information documented” or “no known information”.  This absent information can be very challenging to find and retrieve from within an EHR system.  Experience has shown that reliance on “industry standards” such as the C-CDA templates isn’t sufficient.  Add in the fact that many different EMR’s are in use today by physician groups and hospitals, and these medical record systems are built in a proprietary way, making the challenge of finding that missing or incorrect information different between EMR systems and hence physician practices.  As a result of these challenges, healthcare providers who would like to gather clinical data in order to compile a more complete picture of their member’s health are faced with a project that is time consuming, extremely expensive, frustrating and can often result in disappointment and incomplete personal health information.

Looking to obtain a complete medical record on your members?  Halfpenny Technologies has been in the clinical data exchange business for more than 15 years and over that time have built reusable interfaces that connect to 90%+ of the top EHR vendors and LIS/HIS systems.  Halfpenny Technologies comprehensive clinical data exchange platform uses a multi-faceted methodology to obtain clinical record data.  We do not rely solely on the use of the C-CDA standard.  Halfpenny Technologies completes a quality assessment at each data retrieval stage identifying how full or complete a medical record is and highlighting missing sections or data elements.  We can then work with our customers to identify ways to ensure that clinical data is being acquired and stored correctly.  Halfpenny Technologies’ vendor agnostic approach allows the receipt of any EHR medical record data format and in return health plans can receive clinical data in the layout of their choice. Our continued investment in innovative solutions has uniquely positioned the company as a national provider of clinical data exchange solutions to the health care industry.

 

Ivy Creek Healthcare to Expand Physician Outreach Program

Clinical Data Exchange Solutions provided by Halfpenny Technologies solutions to assist in expansion

BLUE BELL, Pa.–(BUSINESS WIRE)–Ivy Creek Healthcare announced today an expansion of their hospital physician outreach capabilities through clinical data exchange solutions provided by Halfpenny Technologies Inc. (“HTI”). The HTI platform will facilitate the exchange of clinical laboratory orders and results to physicians, clinics and long-term care facilities that refer to the Ivy Creek three hospital system.

“Our team is looking forward to helping Ivy Creek expand into their surrounding communities through their clinical outreach initiatives with our clinical data exchange and business intelligence solutions,” Tim Kowalski, President & CEO said. “We have worked with over 95% of the EMR companies so we are uniquely positioned to assist in providing Ivy Creek’s patients with reliable, proven interoperability solutions that we deliver as a fully managed services delivery model. Our latest V7 release of our Web-based Clinical Orders and Results Portal will also be rolled out to assist their clients with a secure, easy to navigate system to create clean requisitions and to view results online.”
Read more here

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Paper Versus Paperless: The Difference in Patient Health Records

The other week, I went to my ENT about a minor condition I am receiving treatment. The doc came into my exam room with a smile and holding my health records in hand; a paper folder with the colorful letters “A” and “F” stickered on the outside and paper documents containing his handwritten information on the inside.

As the doc sat down, pulled out a pen and began to look through my chart of records, it dawned on me how archaic it appears for him to be handwriting his pages of notes which were held together by little paperclips. What happens if their only set of my medical records is misfiled or misplaced? What if someone spills coffee on my paper files and the ballpoint ink smears or, worse yet, disappears? What if my paper folder of records needs to be sent to one of his other office locations and is lost in transit? There are way too many ‘what ifs’ when all could be streamline smoother by switching to electronic records.

It just seems almost everything and everyone is thinking green and going paperless these days, so why not all physician offices? So I asked my doctor if any of his patients’ records were electronic. “Not yet,” he responded, but informed me that changing over to an Electronic Health Record (EHR) system was in the practice’s plan for 2012.

Recent research shows that the average medical practice spends more than $16,000 on the creation and storage of paper records on patients, each and every year, plus it exhausts an additional $12,000+ annually on the over 575 hours of manual labor it takes to maintain these paper records. Financial matters are not the only concerns. Storage of these files becomes an issue as does archiving and retrieval from the bottomless floors below, as well as, when to destroy the sets of records with the point of no return.

Then it happened. In between my visits, I called that doctor’s office with questions regarding my medication. The nurse on the phone was unable to respond to my concerns since she was not able to locate my paper folder of paper notes. As miserable as I felt at the time of my call, I would have to wait until my paper file was found for the answers. Ugh! Can 2012 come any sooner?

In addition to saving insurmountable costs and valuable time, switching paper to electronic offers numerous other advantages, such as simple remote and simultaneous access of patient information by multiple caregivers, better patient privacy, enhanced communication between practitioners and patients as well as among practitioners, and improved overall practice efficiency and revenue, including billing and collection. The icing on the cake? Improved quality of health care and enhanced patient services which would include no more misplaced patient files!

Thank goodness for the American Recovery Act of 2009 which is encouraging all physicians, hospitals and labs to change from paper to paperless. The Act requires medical offices to switch to electronic health records by 2014 with a whopping $25.8 billion on the line to modernize health information technology systems. The Recovery Act also specifies three main components of Meaningful Use staged over five years, including the use of certified EHR technology for the electronic exchange of health information to improve quality of health care. Exactly what I was stating! In addition, the Act has incentives. Healthcare providers who install EHR systems may receive up to $18,000 in the first year of EHR implementation, dropping to $12,000 if it occurs in 2014.

One of the best advantages of going paperless is the availability of exciting new technologies like receiving and sending lab orders via  a handheld wireless device, to wherever the physician may be … in the hospital, at home, or even on a tropical vacation … and having that same information automatically included in the patient health record! No more ballpoint pens, paperclips, or sheets of paper to be had. Instead is a smartphone or tablet in hand with the provider’s entire patient database within a finger’s reach.

Halfpenny Technologies, a leading provider of healthcare connectivity and integration solutions, offers healthcare providers and labs, alike, two mobile applications. The first is ITF-GoDoc®, a real-time smartphone app that enables physicians to securely access lab results reports – such as laboratory, pathology, radiology and other clinical results reports – right from their handheld mobile devices through push technology. It’s HIPPA compliant with configurable alerts and results filters.

The second is ITF-GoDoc® MobileOE, a fully-functional and integrated mobile CPOE (computerized provider order entry) platform designed for the Apple iPad, Motorola Xoom and Android tablets. This dynamic app allows orders to be dropped to any capable EHR, laboratory information, or billing and accounts receivable systems and features billing information prompts, ask-at-order entry questions, specimen types, and medical necessity checks to help ensure clean orders for receiving labs.

Less physical space, less manpower, and less errors plus more access, more efficiency, and more savings alone is enough to win the debate of “Paper versus Paperless” when it comes to patient health records. Loss of medical records and duplications will become a thing of the past. Electronically transmitting lab orders and pharmacy prescriptions will become the norm. Going paperless is also environmentally-friendly by eliminating paper altogether and saving Mother Natural’s precious trees. And don’t lose sight of the bottom line and clincher: better health care, better patient services, and way better revenue.

This is a no brainer. Hands down, paperless wins!