Integrating Electronic Health Records (EHRs) with Claims Processing Systems: Challenges and Best Practices

Authors: Veeravaraprasad Pindi

Country: India

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Abstract: This paper describes the challenges that hospitals and clinics face when integrating EHRs with claims processing systems and presents best practices to overcome these challenges. Electronic Health Records (EHR) and Personal Health Records (PHR) are considered critical cornerstones for advancing health care communications and decision-making at the point of care delivery. A growing number of health care providers are implementing EHR systems within their own organization to streamline patient care. This includes larger health care delivery organizations which are now implementing EHR systems across their inpatient, outpatient, and ambulatory care settings to ensure holistic patient care. However, it is important to note that EHR systems on their own do not fully optimize communications, decision-making, or workflow for health care providers or for their patients. EHRs, along with other health information technology (HIT) components, are specifically designed to support internal and intra-organization data and workflow processes [1]. These systems also aid in promoting seamless interactions among different care providers and departments, ultimately improving the overall quality of patient care. New applications and software have revolutionized the process of sending Word documents and Excel spreadsheets over the internet. However, the need to transmit clinical information from a patient's Electronic Health Record (EHR) to a health plan's claim processing system has raised questions. There are self-interests that make a mundane interest of health care providers and payers to proactively set the rules and aggressively build the framework for these exchanges. The paper also provides some best practices shown to aid both the providers and the payers with integrating EHRs into claims dealing systems [1]. Data troubles consist of divergence of values, a divergence between internal and external code values and the problem of extra data elements required for the evaluation of the claim that are not required for the clinical record. While it is possible to validate batch charges with the C/HS claims processing system, problems with integration continue in regard to real-time validation, when charges can go missing, and when entering these charges. Establishing a mechanism that checks charges and is real time has been known to be hard – not to mention expensive. There is necessity in the workarounds to check charges that lack proper information (for instance, CPT codes) or contain mistakes. The main issue that is encountered in EHR-Claims interfaces is that these interfaces handle EHR and claims data, which have different workflows and kinds of data. Some of the workflow issues are as follows – all the charges need to be billed in a batch, as the claims processing systems do not permit real time charges verification. This paper therefore points to the need for finding solutions to issues of missing data and coding errors [2]. These differences present a challenge for combining the two systems because of these disparities. Introduction. EHRs are documented to have been adopted in many hospitals and clinics within the United States of America. In the eligible or participating healthcare facilities, the EHR system is used in gathering any kind of patient information necessary and it is used in filing claims for services given to patients [2,3].

Keywords: EHR Integration Claims, Data Interoperability, Health IT, Medical Billing, Patient Data, Data Standardization, Interoperability Standards, HIPAA Compliance, Data Security, Healthcare Workflow, Regulatory Compliance, System Integration, Electronic Medical Records (EMRs), Health Information Exchange (HIE)

Paper Id: 1780

Published On: 2017-09-07

Published In: Volume 5, Issue 5, September-October 2017

Cite This: Integrating Electronic Health Records (EHRs) with Claims Processing Systems: Challenges and Best Practices - Veeravaraprasad Pindi - IJIRMPS Volume 5, Issue 5, September-October 2017.

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