Essential Insights On Electronic Medical Records

Author(s): 
Bruce Werber, DPM, FACFAS

As healthcare moves further into the digital realm, having a competent electronic medical records (EMR) system becomes a necessity and not just a high-tech toy. This author discusses key attributes to look for in an EMR system, how these systems can streamline the practice and how to decide upon a particular system.

   As physicians, we are not fully schooled in how to implement a process of evaluating electronic medical record (EMR) systems to make our businesses run effectively and efficiently. As computerized systems have been developed over the years, I have seen some highly effective products come into vogue and then drift into obscurity because they really did not help a DPM run a business.

   With healthcare reform at our doorstep, we are all looking for that one system that will cure all of our difficulties. Accordingly, let us take a closer look at what an ideal system should provide and how to decide which system works best for you and your staff. I do not believe the perfect system exists yet. While there are systems that have many of the desired attributes, other systems have some of these attributes and charge extra for the add-ins.

Emphasizing Ease Of Use

   The EMR system should have an intuitive interface that does not require years of cryptology training to understand. The menus should be concise and clearly direct the users to the function they need. There should be drag and drop capability for inputting and changing information.

   The system should offer preloaded information such as drop-down zip codes so one does not have to enter the city. Staff should not have to continuously re-enter all of the same information as “cut and paste” or “drag and drop” must be available for all fields. Physician names/addresses, physical therapy and radiology labs all should be preloaded to eliminate inputting repetitive information.

   Optical character recognition (OCR) is helpful to process insurance cards and driver’s licenses. The system should have an OCR engine that can pull the information into the proper fields. Then the staff only needs to proof the information and store scanned images and patient photos.

   The EMR program should have the ability to access a central server of health information such as Google Health or any number of online services that are developing to maintain patient health information. Having this capability will potentially provide a bonus percentage from CMS. (Greenway or Noteworthy software have this capability).

   The system should have the capability of inputting information by typing, writing, speech or even by scanning in a written note. Each doctor has his or her preference and a setup that allows this type of flexibility is very important.

   One should be able to allow macros, pre-written paragraphs that one can call up by key combination or certain speech commands. The system should also have templates, whole notes pre-written with spaces one can fill in to personalize the note.

What To Look For When It Comes To Documentation And Writing Prescriptions

   The charting system needs to be intuitive as well. One must be able to create a solid note that fulfills all of the legal and insurance requirements. This means that you fully document all of the aspects of an encounter to cover requirements of evaluation and management (E&M) coding. A solid charting system also ensures that you have covered all aspects of consent and documentation when it comes to discussing potential risks and complications.

   The EMR program should permit the physician or staff to review past medical history with each encounter. This way, you can easily see past diagnostic testing and treatments as well as what you might be considering for the next visit.

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