The use of electronic patient records is growing, and more physical therapists (PTs) and physical therapist assistants are using electronic documentation in their facilities/clinics. Understanding the nuances of electronic documentation and critically evaluating and implementing electronic systems is difficult for most clinicians.
Although PTs are not yet required or incentivized to adopt EHR systems for such initiatives as Medicare's Meaningful Use Program, which in 2015 will penalize eligible providers that do not meet the requirements for "meaningful use," physicians and facilities that are included in the program will expect the PTs with whom they share patients use compatible EHR systems. The following are resources for education and assistance in assessing and implementing electronic health records.
Guide to Understanding and Adopting Electronic Health Records
Part 1 - Decision
Background information on why there is a push to adopt EHR and a brief introduction to the federal issues that impact physical therapist practice.
Part 2 - Preparation
Basic information on what you will need to understand for successful adoption of an EHR system; this includes what constitutes an EHR and provides suggestions to help consider your current environment and workflow.
Part 3 - Selection
Expand your knowledge about the available types of EHR software and hardware. This section also provides considerations for choosing the right partner.
Part 4 - Implementation
Successful implementation makes a smooth transition when adopting an EHR. An organized approach and clear communication with all members of your facility's staff is described and suggestions for implementation are provided.
Podcast: Electronic Health Records: Overview
Compliance Matters: Key Provisions in the HIPAA Final Rule
PT in Motion (May 2013)
Compliance Matters: Selecting and EHR Vendor
PT in Motion (September 2012)
Contemporary Topics in Health Care: Electronic Health Records
PT in Motion (April 2012)
APTA HIPAA Resource Webpage
The Health Insurance Portability and Accountability Act (HIPAA) imposes numerous requirements on patient privacy and security issues. APTA offers informational resources and links for providers to learn about compliance with HIPAA regulations.
Health Information Technology (HIT)
Updates on HIT program development and legislation, as well as APTA's related advocacy efforts. November 27, 2012 Update: New guidelines on deidentification of protected health information.
How to Implement EHRs
HelathIT.gov has developed a resource for providers and professionals to help with implement EHRs. This is a 6 step process with many useful resources.
ONC Guidance on EHR Vendor Contract Negotiations (.pdf) - 6/26/13
This document explains a few key EHR contract terms and what you need to know about them. Understanding these terms may help you select an appropriate EHR system and protect your practice or organization from business and patient safety risks that may arise when you rely upon EHRs for critical aspects of your operations.
Created through a partnership between APTA and Cedaron Medical Inc, APTA CONNECT is a point-of-care, computerized patient record system designed specifically for physical therapists.
The Agency for Healthcare Research and Quality (AHRQ)
AHRQ and its community of contractors and grantees have developed tools to help health care organizations plan for, implement and evaluate health information technology (IT). These tools describe and recommend strategies for addressing some of the common challenges organizations encounter when working with health IT systems.
The Office of the National Coordinator for Health Information Technology (ONC) is the principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.
HealthIT.gov is a product of the joint efforts of the Office of the National Coordinator for Health Information Technology (ONC) and the Agency for Healthcare Research and Quality (AHRQ). It is intended that this site will eventually include content from other agencies within the Department of Health and Human Services (HHS) as well as other federal agencies in health IT such as Department of Defense/Health Affairs (DoD/HA), the Department of Veterans Affairs/Veterans Health Administration (VA/VHA) and others.