A guide to PPE for an independent practice

As an independent physician, you are probably requiring your patients and your staff to wear masks or other face coverings in your practice. The Centers for Disease Control and Prevention (CDC) has recommended that everyone wear masks to help prevent the spread of COVID-19 during the pandemic. You and your staff will be further protected by taking advantage of available personal protective equipment (PPE).

PPE refers to the protective clothing, gloves, face shield, goggles, face masks, or other equipment you may use that is designed to protect you from the spread of infection. While PPE is commonly used in healthcare setting such as hospitals and laboratories, donning PPE for every patient visit throughout the day may be a new experience, one of many during COVID-19.

However, when used properly, PPE acts as a barrier between infectious materials such as viral and bacterial contaminants and your skin, mouth, nose, or eyes (mucous membranes). The barrier has the potential to block transmission of contaminants from blood, body fluids, or respiratory secretions.

The CDC offers a number of recommendations regarding PPE for an independent practice. The organization suggests that you consider three key things:

  • The type of your anticipated exposure. This is determined by the type of anticipated exposure, such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing.
  • Linked to the first recommendation is the durability and appropriateness of the PPE for the task. This will affect, for example, whether a gown or apron is selected for PPE, or, if a gown is selected, whether it needs to be fluid resistant, fluid proof, or neither.
  • Fit. PPE must fit the individual user, and it is up to you to ensure that all PPE are available in sizes appropriate for your staff members who must be protected.

The CDC has also provided a guide on using PPE that will be helpful for you and your independent practice:

  • Donning PPE. One example of properly putting on your PPE is to:
  1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).
  2. Perform hand hygiene using hand sanitizer.
  3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel.
  4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.
  5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.
  6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
  7. Healthcare personnel may now enter patient room.
  • Doffing PPE. One example of properly taking off your PPE is to:
  1. Remove gloves. Ensure glove removal does not cause additional contamination of hands.
  2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in a gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.
  3. Healthcare personnel may now exit patient room.
  4. Perform hand hygiene.
  5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
  6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.
  7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.

The US Food & Drug Administration (FDA) advises that all personal protective equipment (PPE) that is intended for use as a medical device must follow the FDA’s regulations and should meet applicable voluntary consensus standards for protection. This includes surgical masks, N95 respirators, medical gloves, and gowns. When these standards and regulations are followed, they provide reasonable assurance that the device is safe and effective.

Anthony Pappas
September 8, 2020

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California Medical Association calls for retention grants for independent physicians

While many healthcare providers across the country are overworked and understaffed because of the COVID-19 pandemic, many independent physicians are struggling. In fact, a number of independent practices have had to lay off staff and even close temporarily because of a drastic reduction in patient visits. The California Medical Association (CMA) is taking steps to try to help independent physicians remain financially solvent through the coronavirus outbreak.

Patients are delaying primary care and other non-essential healthcare visits because of the coronavirus and that is significantly impacting independent practices. The CMA estimates that approximately half of the medical care in the state is delivered by solo and small practice physicians. It recently surveyed its members and found that:

  • 50% of the physicians participating said they’ve had to lay off staff, including nurses and office staff
  • 11% have closed down their practices temporarily.

Concerned that another wave of independent physicians may be forced to close their practices as the coronavirus shutdown continues, the CMA is lobbying the governor of California, Gavin Newsom, to provide financial aid in the form of retention grants issued by health insurance companies. The organization argues that patients are continuing to pay their insurance premiums but since the physicians’ offices with no patients are not submitting claims for reimbursement, they aren’t seeing any of that money.

Retention grants provided by health insurance companies would enable primary care practices and other healthcare providers to remain solvent throughout the crisis so they will be there for patients after it is over. As Dustin Corcoran, the organization’s CEO, says, “Three months down the road, we’re going to have high demand for physician services, surgical and primary care, and we’ve got to be able to meet that. Physician practices operate on very, very thin margins. They don’t have the reserves that payers have to weather the storm.”

In addition, the CMA estimates “statewide, up to 34% of Californians (more than 13 million people) could lose access to their physician absent financial assistance to maintain the financial viability of physician practices. Should California lose this critical piece of the health care infrastructure, health plans and insurers will be unable to maintain their physician networks and will be unable to meet the demand for medically necessary care that is building as the State’s health care resources are currently focused on treatment of COVID-19 patients.”

Elation Health supports independent practice during this crisis.
Check out our COVID-19 Financial Guide.

Financial assistance is available in California and across the country, but it often either has to be paid back or comes with restrictions that some independent practices may not meet. For example, Blue Shield of California is distributing advance payments and loans, totalling $200 million, that will have to be paid back after the crisis has passed. Federal aid is based on how many Medicare patients the healthcare provider typically sees.

The CMA is also pressing Gov. Newsom to ask the Centers for Medicaid and Medicare Services (CMS) for a waiver that would allow California to repurpose some Medi-Cal funds that would also be used as retention grants for independent physicians.

Anthony Pappas
May 27, 2020

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Tips for keeping your practice open during a pandemic

As an independent physician, you are also a small business owner. While you are focused primarily on providing quality healthcare to your patients, you also are understandably concerned about maintaining the viability and financial stability of your independent practice during the coronavirus outbreak.

The American Medical Association (AMA) recently posted a checklist of actions that you and your staff can take to keep your independent practice open during the COVID-19 pandemic.

  • Implement a process for rapid decision-making and planning. Establish a plan now for how you and your staff will respond quickly and effectively to potential issues such as what to do if a clinician or patient tests positive for COVID-19. Communicate that plan with your staff.
  • Understand your insurance coverage. Are you covered for COVID-19 related liabilities? You may be covered under the Department of Health and Human Services (DHHS) Declaration under the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19, which provides liability immunity for activities related to medical countermeasures against COVID-19.
  • Evaluate ongoing financial obligations. Review your financial statements and investigate possible alternatives in case of revenue loss. You may be able to request accommodations for debt payment from vendors or creditors if necessary.
  • Make a financial contingency plan. Determine how you will continue to keep your independent practice financially stable through the pandemic. Loan options may be available through the Small Business Administration (SBA) or state or local authorities.
  • Assess current and future supply needs. You may face challenges in securing certain types of supplies and equipment for your practice during COVID-19. Be prepared by stocking up on supplies you will need in the coming months, whenever possible.
  • Understand how to continue business operations. Local orders to stay at home or maintain social distancing could affect your practice. Most medical practices are considered essential businesses, but there may be other complications that you will need to address regarding building access or your staff’s ability to go into the office.
  • Consolidate administrative resources, including coding tools. Compile a “quick guide” of essential resources for meeting immediate needs if you or your staff find that you will need to work remotely.
  • Manage workflow. Determine whether you need to postpone or reschedule appointments that are not essential during the coronavirus pandemic, to protect your staff and patients and to conserve your supplies.
  • Utilize digital health tools. Telehealth is an option for patient visits that will enable you to continue to provide quality healthcare in a virtual setting. Explore options for telehealth and communicate your plans to staff and patients.

Elation Health supports you and your practice as you explore telehealth options. Learn more here.

  • Communicate guidelines for employees. Your employees are concerned about the coronavirus pandemic as well. The more you communicate with them, the more you can reassure them about precautions everyone in your practice will be taking. The Centers for Disease Control and Prevention (CDC) has published helpful guidance for you and your staff on how to plan and respond to COVID-19.
  • Plan ahead for employee furloughs. Recognize the possibility that your independent practice might not be able to sustain full staffing levels during the pandemic. Understand your legal obligations and requirements regarding employee furloughs and continue to communicate with your staff regarding the situation.
  • Stay abreast of new care delivery flexibilities. Regulatory requirements are changing constantly, in response to COVID-19. Assign a staff member to stay current on regulations regarding your practice in your state and local area.
  • Prepare for exposure incidents. Understand what to do if a staff member or patient tests positive for COVID-19. The CDC has also provided recommendations on prevention and control for patients with coronavirus.
  • Identify and implement COVID-19 specific clinical protocols. Establish protocols for your independent practice regarding symptomatic persons, triage and surveillance, infection control and isolation practices, communication with and reporting to public health authorities, and facility access and security.

Anthony Pappas
May 7, 2020

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A Guide to Delivering Care Through Telehealth

Telemedicine is becoming more critical for the health and safety of physicians and their patients. During the COVID-19 pandemic, in-person office visits significantly increase the potential for exposure to the virus for all concerned. Telemedicine, or telehealth, is typically conducted via electronic means, whether that is through a video call or a voice-only telephone call, and enables the provider to maintain social distancing while still interacting in real time, providing quality healthcare services to the patient.

An article published in the American Journal of Managed Care in April 2020, suggests that “telemedicine is poised to address several unique challenges posed by the COVID-19 outbreak.” The article further states that “the CDC, as well as several state public health agencies and numerous industry associations, have indicated that telemedicine systems should be considered as part of healthcare provider coronavirus response systems.”

The Centers for Medicare & Medicaid Services (CMS) has also expanded its coverage of telehealth for Medicare patients, as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Changes, as outlined by the American Medical Association (AMA), include:

  • Effective March 6 and throughout the national public health emergency, Medicare will pay physicians for telehealth services at the same rate as in-office visits for all diagnoses, not just services related to COVID-19.
  • Patients in all settings, including in their home, and across the entire country, not just in rural areas, can receive telehealth services.
  • Physicians may provide telehealth services to new and established Medicare patients.
  • Physicians can provide telehealth services from their home. The AMA has received clarification from CMS that physicians do not have to add their home to their Medicare enrollment file.
  • Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.

As an independent physician, you will need to ensure that you are properly scheduling, completing your patient encounter, and billing for your telehealth services. Elation Health has prepared a Step-by-Step Guide to Telemedicine to help you with implementing the technology in your practice so you can be better prepared to deal with the latest healthcare restrictions and guidelines.

Check out the Telehealth Guide and contact us with any questions you may have about practicing telemedicine during the COVID-19 pandemic.

Our team has compiled a list of helpful articles as a guide for you and your practice as well, as you transition through the new healthcare regulations and guidelines. In addition, we have prepared a series of videos to help you learn how to more effectively communicate with your patients, understand the latest COVID-19 billing and telehealth practices, and keep up to date with the latest in eOrdering.

Elation Health continues to work diligently to ensure that you have all the information you need to safely provide quality healthcare for your patients during these challenging times.

Anthony Pappas
April 22, 2020

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Budgeting for your small practice

Do you know how much your independent practice spends on overhead every month? Do you have a clear picture of your monthly revenue? Have you set financial goals for your practice? As an independent physician, you are in the business of helping people become and stay healthy. You are also in the business of keeping your practice healthy. Learning more about budgeting for your small practice will enable you to do just that.

Your practice is a business. Budgeting for your small practice helps you understand how to more efficiently and effectively run that business. Operating from day to day without a clear understanding of your financial situation is like going on a trip to an unknown spot without a dependable GPS. A budget that is properly prepared and reviewed on a regular basis offers useful insights into the financial health—present and future—of your practice.

Budgeting for your small practice involves some basic steps:

  • Keep your budget simple – and useful. What works for another physician’s practice might not work for yours. Your small practice has basic expenses each month and has a relatively stable source of income. Use those to set up categories that are meaningful to you and your practice.
  • Track what you spend your money on, on a regular basis. For example, your categories might include staff compensation and benefits, office rent, equipment expenses, laboratory expenses, and office supplies.
  • Use actual dollar amounts – percentages are relative and may be misleading. It will be particularly important to be able to review dollar amounts for increases or decreases when you look for trends in your practice’s finances.
  • Review your budget monthly or quarterly. Periodically compare your actual expenses and income with your budget then make changes where necessary. Look for numbers that vary from what you expected, determine how much they vary, and then determine the reason. You can use this analysis to act on what you’ve learned and focus on a solution for financial viability.
  • Look for trends. As you review your actual numbers from month to month and year to year (comparing the same months against each other), take note when a category appears to be increasing or decreasing significantly. If expenses are increasing, it might be time to review your suppliers. If income is decreasing, you might need to be proactive in marketing your practice to new patients.

Learn more about a budget-friendly electronic health record (EHR) solution
for your small practice.

It’s never too late to develop a budget. Rick Gundling, CMA, senior vice president for healthcare financial practices for the Healthcare Financial Management Association, relates budgeting for your small practice to preventive medicine. “If you think of a practice as a living body, the budget is like a vaccine,” he says, “Having one doesn’t mean your practice’s health won’t go off track, but the risks are minimized. And when you check in on a periodic basis, that’s like your financial stethoscope.”

Anthony Pappas
March 12, 2020

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How to discuss the cost of care with patients

Patients are facing increasing out-of-pocket healthcare costs and, subsequently, independent physicians are seeing an increased need to discuss the cost of care with their patients. It has been estimated that approximately one-fourth of all patients in the US have trouble paying their medical bills. In addition, research has found that increased out-of-pocket expenses are associated with lower adherence, delayed or missed care, and higher mortality, so a discussion about costs could be critical for better outcomes.

An article published in the Annals of Internal Medicine by Dr. Caroline Sloan of Duke University Hospital and Dr. Peter Ubel of the Fuqua School of Business discusses the need to engage patients more fully regarding the costs of their care, to reduce the financial barriers as well as surprises that patients sometimes receive with their healthcare bills. Dr. Sloan and Dr. Ubel suggest seven strategies to effectively discussing the cost of care with patients:

  1. Ask patients about potential financial hardships. A study of internists found that most relied on clues from their patients that would hint at their struggles with the cost of their care. Physicians should be more proactive in their discussions with patients regarding their ability to pay, rather than waiting to find out a patient is not taking prescribed medications or following care directions because they are too expensive.
  2. Discuss costs. Just as physicians discuss diagnoses and prognostic information, they must keep patients informed about their financial prognoses to enable those patients to anticipate their out-of-pocket expenses.
  3. Anticipate and help patients plan for costs. Direct costs such as medications, diagnostic tests, and procedures can be expensive, but most patients are concerned about the indirect costs of office visits, such as lost income, transportation, and child care. When discussing the costs of care with patients, these costs should be anticipated and planned for as well.
  4. Explore out-of-pocket costs routinely. Physicians and patients will become more comfortable with discussions related to financial issues when those conversations are held more routinely. In one study cited by the authors, patients perceived an increase in cost-of-care conversations (44% to 65%) and a reduction in cost concerns (53% to 36%) when the conversation was incorporated as a routine part of the office visit.
  5. Integrate conversations about the cost of care into your workflow. The authors suggest three strategies for more smoothly integrating the cost conversation into the independent practice’s workflow:
  • Give one person the role of out-of-pocket cost problem-solver, so they can develop expertise and efficiency
  • Use the electronic health record (EHR) to document patients’ financial needs
  • Use the EHR to gather data on costs and/or insurance coverage, when available.

Elation Health’s EHR solution can help your independent practice
communicate with your patients more effectively about the cost of their care.

  1. Enlist the assistance of clinical staff. Ancillary staff can aid in incorporating cost of care conversations into the practice’s workflow as they have more flexibility and are probably better able to relate to the patients’ financial situations.
  2. Include conversations more consistently. Studies have shown that physicians who continue to have cost of care discussions with patients continue to get better at them. In addition, those independent physicians who include these conversations in their patient visits take costs into account more often when they are making medical decisions for those patients.

Anthony Pappas
March 5, 2020

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What are the benefits of independent physicians and practices

Independent physicians who manage their own practices tend to have a closer connection with their patients and experience lower burnout rates. Although independent physicians are considering employment options in larger numbers, overall those providers are typically more content in their own practices. The benefits of independent physicians and practices include:

Autonomy. An independent physician can see as many or as few patients during the day as make sense for the viability of the practice and for the wellbeing of the patient. The patient sweet spot for an independent physician varies greatly, depending on the complexity of the problems the provider needs to address with each visit and on the practice’s finances and infrastructure.

Lower burnout rate. That autonomy contributes to a lower burnout rate among independent physicians. In fact, according to one major study, “13.5 percent of physicians in the small practices studied had experienced symptoms of burnout, compared to a national rate of 54.4 percent.”

Improved level of patient engagement. Independent physicians also have more control over the amount of time they spend with each patient and the communication that happens after hours with those patients. The doctor-patient relationship is significantly enhanced in an independent practice.

Opportunity to collaborate with other physicians. Independent physicians who want to collaborate with other providers, to join forces for the purposes of negotiating contracts, for example, have options available to them. Independent Physician Associations (IPAs) and Accountable Care Organizations (ACOs) give providers group power while enabling them to maintain their autonomy.

Focus on providing quality care, not on corporate priorities. Another major study found that “small, physician-owned practices, while providing a greater level of personalization and responsiveness to patient needs, have lower average cost per patient, fewer preventable hospital admissions, and lower readmission rates than larger, independent- and hospital-owned practices.”

Anecdotal as well as statistical research has shown the many benefits of independent physicians and practices, that contribute to more satisfied providers, successful practice management, and higher quality care for patients.

Anthony Pappas
February 21, 2020

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Finding the best EHR for small practices

Searching for an electronic health record (EHR) solution for your small practice can be challenging. Many EHRs either offer too little or too much, depending on your independent practice’s needs. Finding the best EHR for small practices involves determining exactly what your practice does need and then searching for the most appropriate solution for those needs. While this may seem a daunting process, there are a few key points to keep in mind to make finding the best EHR for small practices a little less challenging.

One of the main considerations for an independent practice searching for an EHR solution is whether that solution will be server-based or cloud-based. For a small practice, a cloud-based EHR is typically preferred as the maintenance and updates are handled by the EHR provider rather than requiring an in-house IT department.

With a cloud-based system, much of the configuring, security and software is handled by the EHR provider, eliminating a significant bulk of the work for the small practice. Since the server is created and managed by the EHR provider, the vendor is more likely to meet HIPAA patient information confidentiality standards, which also makes future expansions of a practice an easy task rather than a complete overhaul of the system.

When tasked with finding the best EHR for small practices, the independent physician may also consider the need for useful features such as e-prescribing and electronically ordering laboratory tests and results. Of course, cost is a major consideration as well for a small practice. The system should provide the efficiency the practice needs within its allotted budget.

A small practice with limited staff does not have time to sit in a training class for several hours and cannot afford any downtime with patient records. Independent providers must ensure that their staff can be easily and quickly trained on the new EHR system and that customer service is readily available when users have questions. Data transfer is critical as well, to enable the practice to continue providing quality care in a seamless and effective manner in the transition to the new EHR.

Anthony Pappas
February 19, 2020

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Independent physicians guide to 2020

Many of the changes that independent physicians can anticipate in 2020 are continuations of policy, regulations, and other challenges faced by both doctors and their patients over the past several years. Healthcare costs will continue to be a concern as will reimbursement and billing policies. A few newer issues of concern in 2020 include the shortage of quality healthcare workers and the patient’s increasing desire to have healthcare provided more conveniently, through the use of technology when possible.

Healthcare costs

Healthcare costs are a concern for patients and physicians every year. In 2020, however, patients will increasingly expect price transparency and about three-fourths of them will look up procedure costs online so they can be better informed about what to expect. Legislation is also being considered that would eliminate “surprise” billing so patients are not alarmed when they receive a bill after treatment. Education is key to help patients better understand and prepare for the costs of their care.

Prescription drug prices are also a major topic for 2020. Several major drug makers increased their list prices on 50 prices at the beginning of 2020. While the Lower Drug Costs Now Act passed through the House of Representatives, its survival in the Senate is seen as doubtful. Independent physicians need to be aware that their patients will be increasingly concerned about drug prices in 2020 and may need assistance with managing their prescriptions.

Value-based payments

For independent physicians who see Medicare patients, there are some changes for 2020. The Medicare Physician Fee Schedule conversion factor increases slightly, from $36.04 to $36.09. This will probably be the last significant increase in the conversion factor as there will be no inflation update in the next six years.

Independent physicians participating in Merit-based Incentive Payment System (MIPS) will face escalating penalties, particularly those who do not report any quality measures in 2020. It will be very important for independent physicians to focus on that quality reporting in 2020 so they can avoid the negative payment adjustment in 2022.

The value-based care movement has impacted payments from many private payers as well, as they see the value in paying for the quality of healthcare outcomes rather than for the quantity of office visits. Experts predict this will be a growing trend in 2020 and beyond.

 Learn more about how physicians can use the data in their electronic health records (EHRs)
to maximize reimbursement and to help patients stay healthy.

 Staffing

One of the challenges that independent physicians may face in 2020 is a shortage of qualified clinical staff. Healthcare professionals, such as nurses, are growing older and retiring and there are fewer younger people filling their positions. One estimate is that the US will need approximately one million more nurses in 2020. According to The American Nurses Association (ANA), there will be more registered nurse jobs available through 2022 than any other profession in the United States.

Convenience of care

Patients are increasingly looking for ways to save money and to use technology for their own convenience. Their healthcare is no exception. Telehealth, connecting with the independent physician via telephone or video calls, is growing in popularity, which creates challenges for the provider who operates in a traditional practice to improve access for patients.

Telehealth has also been recognized by the Centers for Medicare & Medicaid Services (CMS) as a viable alternative for seeing patients, especially younger patients and those who live in rural areas. Telehealth services are included in the 2020 Physician Fee Schedule and CMS is allowing Medicare Advantage beneficiaries to access additional telehealth benefits, starting in plan year 2020.

Anthony Pappas
February 4, 2020

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The development of electronic health records

The question of who invented electronic health records (EHRs) actually has many answers, but the development of EHRs can be traced back to the early 1960s. Traditionally, patient medical records had been kept on paper, in files. Those files were marked with various identifying information, often including the patient’s last name and an ID number, which may have contained part or all of the patient’s Social Security number. Those files were kept in cabinets or on shelves designed especially for medical records.

In the 1960s, Larry Weed, an American physician, researcher, educator, and entrepreneur, developed the Problem Oriented Medical Record. With this, Weed introduced the idea of electronically recording and maintaining patient data. Weed may be identified as the person who invented electronic health records themselves. In 1972, however, the first electronic medical record (EMR) system was developed by the Regenstrief Institute, according to the University of Scranton. Regenstrief’s EMR system was expensive and so was not attractive to physicians for use with their patients. The system was used, though, “by government hospitals and visionary institutions.”

As the personal computer became more common and more affordable, and as the Internet developed, EHR innovations also developed. Web-based EHRs started to emerge. In 1991, the Institute of Medicine (IOM), a division of the National Academies of Sciences, Engineering, and Medicine, led the way toward computer-based patient records by sponsoring studies and reports on the relatively new concept.

Throughout their development, EHRs have been identified by many names, including electronic medical records, computerized medical records, longitudinal patient records, and electronic charts. A Pearson Higher Ed publication states that “in 2003, the IOM chose the name electronic health records, or EHR, because ‘health’ means ‘a state of well-being.’”

The IOM subsequently established eight core functions that should be performed by an EHR, including:

  • Health information and data
  • Result management
  • Order management
  • Decision support
  • Electronic communication and connectivity
  • Patient support
  • Administrative processes and reporting
  • Reporting and population health

According to Pearson, these “eight core functions … became determining factors in the evolution of EHR, and the ability to perform these functions is the criteria by which EHRs are judged.”

Anthony Pappas
January 28, 2020

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