Digital record keeping is here to stay – and is evolving in leaps and bounds. The vast array of hardware and software available can be confusing to even those well versed with the current digital technology. In order to differentiate between the vast arrays of available technology, industries tend to create their own vernacular for them.
In the current healthcare scenario, every patient encounter requires to be documented – both for future reference as well as for the facility to be reimbursed for the services performed. With the increase in healthcare services, the quantum of data has also increased manifold times. Along with increasing in sheer quantity, clinical data is also becoming increasingly complex.
Computers are now an integral part of our daily lives – in fact it is very difficult to trace an aspect of our lives that is not touched in some form or other by computers and/or computer assisted work. While there will always be debates on the advantages vs. disadvantages of allowing machines to take over human work,
The Health Insurance Portability and Accountability Act (HIPAA) is a set of viable guidelines that dictate the security of health information which is stored/ transmitted via an electronic medium.
These guidelines are subject to change in a timely fashion and the medical practitioners ought to keep themselves updated with these changes and ensure that their billing is compliant with the HIPAA security standards.
Modern physician’s office can be bisected into two parts- the medical practice and the ton of paperwork and documentation that comes with maintaining a health care facility.
Even a small heath care center or an individual’s practice has its own share of record maintenance. This is why investing in a credible electronic medical record (EMR) system is necessary.
The risk of personal identifiable information falling into the wrong hands or even finding its way into the public domain is a fear that we constantly live with, in this age of digital records and internet. We saw the reality of this fear when personally identifiable information of about 80 million individuals was potentially exposed by the data breach at Anthem.
April 28, 2016 witnessed the release of the proposed rule that is intended to guide the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) which aims to reward clinicians and physicians engaging in activities that support and drive positive patient outcomes. MACRA, once implemented in totality, will change the way physicians taking care of Medicare patients are paid by CMS.
All healthcare facilities – irrespective of whether they are a business enterprise or a charitable institution – have to be financially viable in order to continue to provide services. Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability.
It takes just a jiffy to send an online message – compare that to the days gone by, when paper-based systems made sending messages an onerous task. That is an improvement in our fast paced world today, or is it? The ease and speed of instant messages has resulted in people sending and receiving far too many messages which take more time and concentration to read,
Information Technology and computers are supposed to make our work easier, faster and accurate. However, the transition to digitized record systems seems to be causing a whole new category of patient safety errors. From ordering medication dosages larger than required to making entries in the wrong patient’s records – are these user errors in the making or are they due to a poor system design?