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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 notes scribbled in a chart. 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 doctor’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.
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 doctors 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
complicating conditions.
This screenshot shows how a medical history can include all of the necessary
information for medical care including a complete review of systems, pain scale
levels, family medial history, conditions, surgeries, hospitalizations, and
habits such as smoking or alcohol consumption that affect overall health.
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 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 many doctors 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. Doctors
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 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 an insurance seminar and consulting business. She developed ClinicPro
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.
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