Using Health Information Technology

Medical assistants use health information technology (HIT)— computer hardware and software information systems that record, store, and manage patient information—in almost all physician practices. 

Practice Management Programs 

A good example of HIT is practice management programs (PMPs), specialized accounting software programs used in almost all medical offices for tracking charges for patients’ services and treatments, billing insurance companies and patients, recording payments, and collecting overdue accounts. Most programs also have the ability to schedule patient appointments. Since PMPs can send information electronically, rather than just on paper, cash flow is improved because physicians receive payment in less time than when they send in paper claims and wait for checks to arrive in the mail.

Practice management programs facilitate the day-to-day financial operations of a medical practice. Before PMPs became so universally used, manual accounting systems logged all of this information by hand, a time-consuming and cumbersome process. Now PMPs automate that work, so staff members can work more efficiently and in a timely manner. 

 Not all medical offices use the same PMP, but most programs operate in a similar manner. Initially, the program is prepared for use by entering basic facts about the practice. Often a computer consultant or an accountant helps set up these records. Information about many aspects of the business is entered, including:

  Patient data Information about each patient, such as name, address, contact numbers, and insurance coverage.

 Provider data Information about each provider, including facts about providers, referring providers, and outside providers such as labs, radiology, and ambulatory surgery centers. 

 Health plan data Details about the companies that insure the practice’s patients. 

 Transaction data The dates of patients’ past visits along with records of their illness and treatments, as well as payments collected. 

Once the initial setup and data entry are complete, the PMP is ready to be used to accomplish many of the daily tasks of a medical practice.

Electronic Health Records  

Another HIT application is rapidly becoming critical in physician practices: electronic health records, or EHRs. While patients’ financial records have been electronic for over a decade, clinical records—the documentation of a patient’s health entered by doctors, nurses, and other health care professionals—until recently, have been stored in paper charts. An electronic health record (EHR) is a computerized lifelong health care record for an individual that incorporates data from all sources that provide treatment for the individual. EHR systems are set up to gather patients’ clinical information using the computer rather than paper. Most EHR systems are designed to exchange information with—“to talk to”—the PMP and to cut out the need for many paper forms.

PM/EHRs  

Some software programs combine both a PMP and an EHR in a single product called an integrated PM/EHR. Data entered in either the PMP or the EHR can be used in all applications, such as scheduling, billing, and clinical care. For example, if a receptionist enters basic information about a patient in the electronic health record during the patient’s first visit to the practice, that data is automatically available for the medical assistant to use in the billing program. Facts such as the patient’s identifying information, type of health insurance, and previous health care records must be entered only once, rather than in both programs. PM/EHRs greatly improve administrative efficiency.

A Note of Caution: What Health Information Technology Cannot Do Although computers increase efficiency and reduce errors, they are not more accurate than the individual who is entering the data. If people make mistakes while entering data, the information the computer produces will be incorrect. Computers are very precise and also very unforgiving. While the human brain knows that flu is short for influenza, the computer regards them as two distinct conditions. If a computer user accidentally enters a name as ORourke instead of O’Rourke, a human might know what is meant; the computer does not. It might respond with the message “No such patient exists in the database.”