Electronic Medical Records
Electronic Medical Records are the system of record for most patient diagnosis data, physician progress notes, and procedures. This is especially true in the U.S. healthcare system after 2011 when the first incentive payments for Meaningful Use of Electronic Health Records were paid. The requirements for healthcare providers to attest for meaningful use with electronic medical records are detailed and complex. A summary of the requirements is in the Code of Federal Regulations (CFR) § 495.22 Meaningful use objectives and measures for EPs, eligible hospitals, and CAHs for 2015 through 2018.
Medical necessity is determined by clinical documentation. How procedures are documented and coded and ultimately reimbursed will depend on two things: 1. The system of record that contains discrete data supporting the documentation, better known as an electronic health record (EMR) or electronic medical record (EMR) 2. The quality of the coding which will soon be based on ICD-10 CM for all HIPAA Covered Entities when diagnosing patients and ICD-10 PCS for all HIPAA Covered Entities who bill for inpatient medical procedures.Our team can assist with :
- Selection of healthcare IT vendors
- Proper implementation of electronic medical records
- Compliance with the HITECH Act Information Safeguards and HIPAA Privacy Rule and HIPAA Security Rule
- Vendor contract negotiations
- Implementation and configuration
- Clinical documentation improvement for ICD-10
- Clinical scenarios to evaluate EMR readiness for ICD-10
- Meaningful Use Attestations
- Meaningful Use Audit Defense
- Led multiple electronic medical records (EMR) / Electronic Health Record (E.H.R) implementation projects for hospital systems.
- Create and maintain training courses to further the technical education of customers in software development practices and reporting methodology.
- Advising EMR vendors on preparation for ONC ATCB Certification and proctor examinations for Meaningful Use Certification of elctronic medical records
- Deep understanding of Meaningful Use of EMRs
Our experience includes full life cycle implementations of electronic medical records including:
- eClinicalworks (eCW)
…and a host of oncology-specific systems. Our partner acted as the EHR technical advisor to American Society of Clinical Oncology (ASCO) for five years. Leading Systems:
- ARIA (Varian)
- MOSAIQ (ELEKTA)
- OncoEMR (Altos Solutions)
- IKnowMed by US Oncology (McKesson Distribution)
Small oncology systems
- Rabbit E.H.R.
- iClinic Ambulatory (MDLand)
- MedSymEHR : Multispecialty, (MedSym Solutions)
- Oncology System – EHR/CIS (Integrated Clinical Care)