Essential Insights On Electronic Medical Records

Bruce Werber, DPM, FACFAS

   You should be able to visualize medications and allergies easily. The EMR system should track the progress or lack of progress of your treatment plan. The ability to link seamlessly from your note to labs and imaging is a significant plus as is the ability to order imaging and lab tests directly from your note.

   When it comes to writing a prescription, the system should include drop-down menus or auto-completing boxes. As you type the generic or trade name of medications, the computer displays the choices with dosing alternatives as well as drug interactions. Staff should also not have to re-enter pharmacy information. The computer will electronically submit the prescription to the pharmacy that the patient identified at check-in.

   When one prescribes physical therapy, the system prompts for input regarding frequency, duration, goals and prescribed modalities.

   When prescribing durable medical equipment (DME), the system prompts for all requirements to fulfill insurance documentation. It also prompts for invoices or a scanned copy of the invoice.

Using EMR To Connect With Patients And Other Healthcare Entities

Another key is the availability of an online portal for patients. This allows patients to:

   • input their past medical history, chief complaint and medications;
   • pay their bills;
   • message the office;
   • change their appointments; and
   • request prescription refills.

   Home instructions are available on the online portal and a link is printed on the instructions that patients receive at the check-out desk.

   The recall system is available to run at specified intervals so the staff can call, write or e-mail patient reminders to come in or follow up. A to-do reminder system for doctors and staff can help track at-risk patients, post-op patients and orthotic follow-up.

   This system should be capable of sending birthday and holiday cards if you are so inclined to send them. The system can also send out newsletters to patients and integrate with the telephone or postcard reminder system.

   With the EMR program, one can send a referral letter to the patient’s primary care and referring physician with a cover letter via e-mail or fax.

   The system integrates with other entities including imaging centers, hospitals and labs that you work with. This integration should be bi-directional, meaning one can place orders to the system and receive reports back once the testing is complete.

Salient Pointers On Coding With EMR

   The CPT, ICD-9 codes or descriptions should open as you start to type the code or description. It is important to have drop-down CPT coding while you are documenting your treatment plan and ICD-9 diagnostic codes as you complete your assessment. This coding automatically goes into the billing portion of the EMR for claims to be automatically transmitted electronically.

   The system should provide a suggestion for appropriate modifiers if necessary to avoid rejected claims. It should also suggest appropriate bullet points to fulfill the needs of E&M and/or procedure codes. For example, if one notes an ulcer debridement code in the chart, the system should prompt for the dimensions of ulcer, drainage, odor and wound type classification.

   The reporting portion of the program should be able to provide reports based on CPT codes or ICD-9 diagnosis to evaluate treatment outcomes and provide documentation for credentialing. The system should be upgradeable to the new ICD-10 codes with a tentative implementation date of October 2010. The system needs to be certified by the Certification Commission for Healthcare Information Technology (CCHIT) or other agency deemed to be qualified by the Centers for Medicare and Medicaid Services (CMS) to qualify for incentive pay and reimbursement.

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