Myths and realities of electronic medical records: 9 vital functions combine to create comprehensive EMR - Medical Records

Physician Executive, Jan-Feb, 2002 by Robert Hodge

Share

Exchanging information is key to EMR success.

Although the EMR allows multiple accesses at once, it is useful to send or call attention to specific pieces of information. For example, a provider might want to send the referring physician a discharge summary by directly faxing it from the EMR. Or, a nurse might want to have the provider be aware of an abnormal laboratory value. Many EMR's provide e-mail links within the record to send messages to personnel within the system and outside.

A sharing feature also allows providers to co-sign notes. This is very useful in teaching hospitals where a resident may compose the note and need to have the attending physicians review it, add documentation that they were present and sign it. This can save many trips to medical records to sign the hard copy.

Bill

A billing function within the medical record truly makes it possible for clinicians to do "one-stop shopping" in caring for patients. They can view the chart, record their impression, order tests and consults and then code the visit for reimbursement.

As with the manage function (physician order entry), look-up features for codes and other billing information are essential. Another useful feature is the ability to view a patient billing history to select codes used on repeated visits for chronic diseases such as diabetes.

Remind

Another strength of the EMR is the ability to compare data and produce reminders or alerts when the data does not comply with an established rule or guideline.

A common example is abnormal laboratory values. Often, EMRs flag these values (such as (H) for abnormally high) or highlight the value in different color to attract attention.

If the share function is available, an alert might be sent to the provider as an urgent e-mail or through a page.

In the Primer on Physician Order Entry published by the California HealthCare Foundation, reminders for basic error checks include:

* Duplicate therapies

* Drug-drug interaction

* Drug-allergy interaction

* Drug-lab interaction

* Hospital formulary

* Expiring orders

* Exception documentation for alert overrides

Reminders can also help manage medical conditions.

For example, Maviglia uses data from an electronic medical record to show that compliance with cholesterol treatment guidelines was poor. They plan to use this information to develop a sophisticated reminder system to help address deficiencies.

The remind function is where the EMR can make a real difference by improving patient care through comprehensive coordination and data assessment.

Comply

Compliance with regulations like documentation for Medicare reimbursement is an essential but time-consuming task for the clinician.

As with the remind function, the comply function can alert clinicians to deficiencies in documentation.

Applications such as E/M coding wizards are commonly used to scan the electronic documentation to determine if the requirements for the level of care selected are met.

If not, the clinician has the choice of entering the appropriate documentation if the service was performed or selecting another level of service.