Love them or hate them, electronic medical records (EMR) have become an integral component of today’s medical practice. Have you brought them into your practice? What do you think of them if you have? If you have not, why and what are you waiting for?
I have been using EMRs of various types for at least the past six years. Prior to incorporating them into my practice, I used dictation for my charting. There was definitely a learning curve with each system I have used but I have gotten very comfortable with using them in my practice.
I have found that EMR systems have positives and negatives. The primary positive regarding EMR is the completeness of the record. The templates help to make sure all elements of a complete note are included. The note includes the chief complaint, a well-documented history of the present illness, a pertinent review of systems and a physical exam that covers all the necessary components. These notes help remind the physician to cover these elements. One can then list the assessment completely with all diagnoses that apply. The inclusion of all the elements of the treatment plan, listed with the medical necessity, completes the record.
Legibility is another significant advantage of EMR. Since I have always used either dictation or EMR, legibility has never been an issue for me. However, in reviewing charts for malpractice cases or notes from other physicians when a patient transfers to my office, some notes are completely illegible.
A complete EMR system also can tie together the scheduling, charting and billing (either done internally or externally) into an efficient practice management software system. The system can increase efficiency and productivity, decrease errors and certainly simplifies storage concerns.
The negatives are as concerning as the positives are exciting. Overly complete notes, or notes that have so much unnecessary information in them, make it difficult to extract the important elements. In the past, sometimes it seemed as if I added stuff to my note just to make it as long as possible. I figured the more, the better, right? I have since learned otherwise. When I read EMR notes from other physicians, it can be very difficult to make out the important concepts of the patient’s exam and treatment.
Are Templates A Blessing Or A Curse?
Another big issue is that all the patients start to look alike from a medical note standpoint. I use templates in my practice, such as my new patient heel pain template or new patient neuroma template. I have this set up to have the ability to make changes as needed from patient to patient but all these patients’ notes start to look the same. I think sometimes I make my findings fit my template instead of adjusting my template to fit my patient. When you have 40 or 50 charts to do and you are trying to keep on track with your schedule, it is easier to take the path of least resistance. This is no excuse on my part. It is just reality.
Electronic medical records can be very time consuming when you are first implementing the system into your practice and the system or templates may not be set up the way you like to chart. You may have to make your own templates. This has a learning curve and takes even more time. Developing a way to make the EMR work within the parameters of your practice can also take some trial and error.
The other thing I am guilty of with EMR is building a new note off an old note. Again, this saves time and helps me stay on schedule while still allowing me to get home at a decent hour. I make the needed changes from visit to visit but, honestly, they usually are minor. Is this wrong? I do not know, especially if you are using templates anyway.
I prefer using templates instead of assembling the note as I go since templates tend to be more complete and designed for the problem I am seeing. I have made several templates of my own and use those from my software company. I also share templates with other physicians.
Other Ways To Maximize Productivity And Efficiency
My staff usually calls new patients before their appointment to obtain their history and review of systems. If this does not get done, patients will fill out the traditional paperwork in the waiting room and we subsequently enter the information into our system. I try to chart after seeing each patient and prior to seeing the next one. I use a treatment order sheet with the subjective, objective, assessment and plan section on it for me to take notes during the encounter with the patient. I usually only record pertinent findings, both positive and negative. Sometimes I get behind on my charting and this helps me to chart at a later date if needed. This is not my preference but we all get busy and I hate making people wait. On follow-up visits, the staff takes the patient’s chief complaint and history of present illness on the same form.
Electronic medical records are here to stay and will continue to evolve and improve. Overall, I think it is a good thing for the medical community but it is not without its problems. Be patient with EMR, get to know it, work with it and bring it in slowly to your practice if it is new for you. Continue to evaluate your notes critically and look for ways to let EMR make your practice more efficient and profitable.