A: Your medical record has gone from a paper chart to an electronic chart. Your physician is now able to view your entire medical history via a computer system called an electronic health record (EHR). The electronic health record is organized in a way that permits your physician or medical provider to easily see various aspects of your medical history in an organized manner. The electronic health record is also referred to as an electronic medical record (EMR).

A: The benefits of the EHR are significant. The application of a computer allows the physician to type in your information into the system or download information from other databases, such as the hospital’s laboratory system or x-ray reports. In some cases, your physician will be able to view x-rays done at our imaging centers. A provider can access all of the patient’s medical, surgical and clinical information at the push of a button.

The EHR also improves physicians’ productivity by allowing better documentation that is standardized, legible and accessible by associates. Because the physician types the information into the EHR, it provides improved legibility which helps to reduce misinterpretation of clinical information such as medication and dosage information.

Communication of patient information from various other Community Care Physicians’ providers is another feature of our EHR. Our physicians can access your medical records when they are not in the office. This is especially helpful when they are covering for another physician and need to review your medical information when called by the emergency room or you.

A: The major benefit of the EHR for patients is the access our Community Care physicians and non-physician providers have in understanding the various aspects of your medical care. We no longer are working in the dark because a paper report isn’t available or filed incorrectly in the office. The EHR gives your provider access to your files when they are out of the office, so your records are immediately available when they’re needed. Patient records are immediately accessible so the doctor can provide care with the most current information at the time it’s needed.

All prescriptions are completed electronically as well. Your doctor can print and sign them or fax them directly to the pharmacy from the computer. Once the prescription is in the system, it is easy to renew. There is no need to question handwriting. Furthermore, this system provides better documentation in prescribing medications.

A: Yes. An electronic health record is more secure than an ordinary paper chart. Confidentiality is a large part of healthcare and is upheld with the computerized system. The system is HIPAA compliant and requires password and log-in for each user. There are multiple layers of security- not everyone can access all aspects of a patient’s record. This differs from a paper chart that anyone can pick up at anytime and read. Audit trails are utilized to track which charts are viewed by which log-in and what part of the record is accessed. There is also a signature authority to track who accesses what in the electronic health record. Automatic log-offs ensure records aren’t accidentally left open for someone to breach.

A: The piles of charts, labs, and messages that sit on a desk, in a drawer or on a patient’s chart are replaced by electronic ‘tasks’ (a request to supply information or perform an action). This promotes effective communication and maximizes efficiency. For example, a telephone triage call to the doctor, review results, and signing notes are all sent to the specific provider’s task list so they know what needs to be completed. There is greater ease in coordinating test results, referrals and script writing.

The chart pull among staff and chart prep for physicians are also eliminated. This reduces the amount of effort and time wasted so more time can be spent administering medical care.

A: No. This technology provides real time decision support for providers. The computer doesn’t tell the doctor what to do; it simply makes accurate information accessible so the doctor can make the medical decision.

A: Computers and computer applications have changed the way we live. Today much of our activities are supported by computers. Medicine is no different. In the future, our EHR will be able to talk with every hospital and other medical provider in the Capital District, and possibly in the world. Efforts are underway to have different computer EHR systems to share information in a secure and efficient manner. At Community Care Physicians we are always seeking ways to connect our physicians and non-physician providers in ways that improve the timely care and servicing to our patients. One way to connect with our patients via the EHR is through a patient portal known as “iHealth”.