Working with medical records data in an EMR

The central focus of EMR software is on medical records: creating, updating, searching, and displaying the entire contents of patients’ charts. As you compare different systems, try to stay focused on these essential features. Get answers to questions like these:

• Does the EMR system recognize all the procedure and diagnosis codes your practice uses?
• Can the system handle multiple offices and several doctors?
• Does it support the style of charting your practice prefers?
• Are there multiple ways to organize and view patient medical records?
• Are labs, x-rays, and other types of information easy to manage and access?

One of the biggest decisions to make when switching to medical EMR software is how you will enter patient data into their medical records. There are two aspects to this question: what method you’ll use to enter information, and what equipment you’ll enter it on. Popular data entry methods include:

• Keyboard and mouse combinations – some doctors may be comfortable typing notes, while less technology-inclined physicians may prefer to select from lists of exam codes and diagnoses.
• Touch screen applications are very quick to use for standard procedures and codes, but can be very inefficient when the information you want to enter doesn’t fit the template neatly.
• Speech recognition is very fast, but some doctors may not be comfortable with dictating notes while the patient is in the room. (Keep in mind that you may also want to simply record doctors’ notes for later transcription.)
• Handwriting recognition lets doctors continue to work in a familiar style, but can balk at the messiest handwriting.

Your hardware options are basically several different sized computers:

• You can install desktop computers in each exam room, or purchase laptop computers for each physician. This may increase your initial expense, but it can reduce the time doctors spend entering information. They’re also familiar to many users and can be used for more than just EMR.
• Tablet PCs are specialized, clipboard-shaped touch screen computers designed specifically for EMR applications. Doctors can easily use them while meeting with patients.
• PDAs are even smaller than tablets. They can be cheaper and more portable, but may be less efficient to operate than full-size computers or tablet PCs.

One of the best ways to proceed is to choose an EMR system that supports multiple data entry methods. This lets you start with one method and later switch to another, or support multiple modes for different doctors.

Whichever method you choose, be prepared for a slowdown in productivity when you first implement the new system. Once users get used to the new system, productivity will gradually increase.

You’ll also have to consider how your existing paper medical records will be incorporated into the EMR system. Some practices choose a “day forward” technique, in which records are scanned and converted into the system only as they’re accessed – for example, when the patient comes in for a visit. This turns a daunting project into a more manageable ongoing task. You can also opt for a total conversion, hiring a document conversion company that can provide high-speed scanners. Generally, it’s not worth the added expense to take this path.