Benefits of EMR

Electronic Medical Records: Benefits and Features

The worse thing that can happen to a medical receptionist is to have to tell a patient sitting in the welcome room of her doctor’s office waiting patiently for a copy of his medical record is that the medical record cannot be found. This situation is far too common and in these technologically advanced times, it is not only unacceptable, but also it is unnecessary. Electronic medical records should not be an option for records keeping; it should be the standard of quality care. A health care organization that uses electronic medical records expresses that they appreciate advancements in technology, convenience and are plugged in to the needs of the patient population. Implementing electronic medical records shows the commitment level of providers to an effective partnership with other health care providers which is instrumental in the coordination of care. Health care organizations must view electronic medical records “as the hub of the organization’s clinical information and as a tool in improving patient care quality, safety, and efficiency” (Wager, Lee, Glaser, & Burns, 2009, p.___). Depending on the type of functionality, electronic medical records can be quite useful in reporting health information data to various agencies. I will examine many beneficial features available in the practice management software of electronic medical records that will prove valuable for health care professionals.

Time-saving features

In an age of nursing staffing shortages, efficiency is a key component that expanded for the sake of the patient. An electronic medical record that provides nursing staff with keyboarding shortcuts when documenting routine tasks performed on a unit would be extremely helpful. The appropriate shortcuts would allow nurses to focus more on patient care and bedside recording. In addition, because physicians would be utilizing the electronic medical record system, handwriting will no longer pose a challenge. This is a time-saving feature as it will relieve nurses from the duty of contacting and following up with a physician for clarification.

Medication Management

Along with the many duties assigned to a nurse is the specific responsibility of administering medication to patients. The electronic medical record system can include a feature that measures the time, date, dosage, and type of medication given to a patient. The software can also provide an alert feature that would flag if there are any potential drug allergies and interactions for the patient. Included in the medication management feature of the electronic medical record is a weight calculator that would automatically determine the required dosage based on a patient’s weight. This is crucial in cases of children.Standardized languageNurses are responsible for so many aspects of a patient’s care. As explained by Lundberg et al. (2008), it is imperative that nurses communicate their impact on nursing care to their physician counterparts. The most appropriate way to ensure that this happens is by enlisting a standardized nursing terminology compatible to the needs of the health care organization. This feature would also support the needs of the patient through an improvement in communication between nursing staff and physicians. When standardizing nursing terminology, nursing data can be aggregated to improve “quality of patient care and patient safety” (Lundberg et al., 2008, p. 3).

Medical Information Sharing

Ensuring that electronic medical records software contain a feature that allows a comprehensive sharing of health information between health care organizations and providers. Moving from paper medical records will reduce or eliminate serious errors resulting from illegible writing (Burke, 2009). Electronic medical records offer a sense of reliability required in health care. Be able to integrate with other existing medical application and medical records systems across the country will ensure continuity of care. With an electronic medical record, historical information is essential in the ongoing care of a patient. Electronic medical records ensure that there is health information on a patient’s medical history to include the aspect of medication management, which is quite important when managing allergies and contraindications. The electronic medical record encourages and supports a partnership between health care professionals in providing treatment and diagnosis. “Health care providers need access to active tools that afford them clinical decision-support capabilities and access to the latest relevant research findings, reminders, alerts, and other knowledge aids” (Wager et al., 2009).

Web-based Centralized database

“A web-based, central database approach means that doctors need little more than a few standard PC’s and a high-speed internet connection” (Burke, 2009, p. __). This feature tends to be more user friendly as opposed to stand alone software options, which limit access from one computer system. With the web-based central database system, electronic medical records can be accessed from any secure location. And it eliminates the need for various record keeping systems as it will streamline multiple databases into just one that would contain all patient information. This also saves time in the retrieval process. In times of national emergencies, if electronic medical records are implemented on a wide scale, when patients are displaced, the important access to medical history does not have to be affected. Individuals needing medical services can be assured that their health would not be at risk because of the lack of medical information available. In addition, electronic medical records would provide for more timely care in these situations because many preliminary tests would not have to be completed to establish a medical foundation.Easy accessibility (manageability)A feature that permits medical history to be quickly and easily retrieved either from an active database of an archived system. For a physician, being able to review essential medical information on a patient can be quite detrimental to decisions that are required for healthcare delivery. Especially in cases of an emergency, life-saving decisions should not be delayed due to problems locating information in electronic medical records. The impression is that anything would be easier than searching through a paper document; however, electronic information locked in a “system” is just as useless as the time-consuming search through a traditional document. In addition to accessibility, health information contained in an electronic medical record must have a proper backup system.

Medical management tracking

As a patient concerned for proper compliance to various health insurance policies, referrals and authorizations policies are known to confuse not just practitioners but patients as well. A feature that permit patients to track various requests for referrals and authorizations as well as managing their referrals and authorizations for care would allow patients to share in the responsibility of managing their care. Oftentimes, if these specific “papers” are not in place prior to appointments, patients will have a larger financial responsibility. This feature provides the patient the ability to verify insurance compliance as well as the ability to track the number of visits allowed in a referral. The patient medical management tracking feature will also give patients a method to be proactive when referrals and authorizations are set to expire. Medical history linkConsistent efficient documentation of a patient’s medical care establishes a very important historic document for that patient. Any mechanism improving upon the existing process of paper tracking, will serve beneficial for the patient population. Electronic medical records undoubtedly meet this requirement. Frequently, when receiving services from a new physician or facility, patients are required to complete comprehensive medical history forms. Oftentimes, depending on the patient population or even the patient’s level of concentration, vital information on medication history, type and dates of surgeries, as well as the important component of family history, can be inadvertently omitted. This can results in an overwhelmingly large risk to the patient when trying to provide treatment or a diagnosis. An electronic medical record would resolve this issue as a patient would not be required to recall a possible extensive medical history when seeing a new health care provider. A link to a patient’s medical history is also valuable when one medical practitioner retires or is no longer in practice. The dreaded practice of transferring traditional medical records would not be necessary.Encryption componentAs mentioned earlier, patients want to know that they have full access to their medical records when the situation presents. In addition to easy access, in an age of identity threat, the patient population is also concerned with safety features that ensure the appropriate level of privacy. Laws protecting patient’s health information were traditionally developed on a state level, but with the advancement in technology, the transmission of health information is likely to cross state lines thus requiring federal intervention (Burke, 2009). Following federal guidelines established by Health Insurance Portability and Accountability Act of 1996 (HIPAA), encryption safeguards should be included in the roll out of any electronic medical records implementation. With electronic medical records, ensuring proper doctor-patient confidentiality is not just an ethical issue; it becomes an issue of personal security. It is important that patient information be protected and all avenues for misuse of information are continuously monitored.FEATURES FOR ADMINISTRATIONDocument ManagementWhen converting from a traditional paper medical record to an electronic medical record, there must be an initially process that would be extremely efficient in ensuring that the integrity of the historical record is maintained. An integrated feature that accomplishes the scanning and referencing of paper medical images into the patient’s electronic medical record is a requirement in the software. A “new” historical document that mirrors the paper file is crucial in the creation of the patient’s electronic medical record that will continue as the official document. Because these images are digitally uploaded into a database, there is a great deal of storage space. Even though this is the case, an appropriate method for archiving still needs to exist along with an effective data retention plan.

Medical Transcription

Having a feature in the electronic medical record’s software that provides an interface for transcription can serve both as more efficient as well as a cost savings. Many physician organizations contract out their medical transcription services. However, a transcription interface in the software can save time and money because medical notes would be directly linked to a transcriptionist.

Financial Management

Ask any medial office billing personnel and he will express that being electronically linked to a payment system will alleviate much of his workload because of efficiencies that are easily built into electronic medical records software. Most health care organizations have an electronic claims filing process already established; however there is can be a disconnect between the health care service provided to a patient and what is listed by a practitioner as completed in a given appointment. A functionality ensuring an audit of services rendered by a practitioner with services submitted on an electronic claim would prove especially efficient in work processes as well as efficient in managing accounts receivable and collection duties.

CONCLUSION

The health care industry is at a point in which there must be increased efficiency along with a reduction in costs. To accomplish this task, there must be changes made to the way health care professionals do business, even those professionals in direct patient care. As with any change, there will be some challenges. The need to evolve from the traditional paper medical record is long overdue. As discussed, instituting an electronic medical record within an organization is crucial in staying relevant in our continuously transforming world. The adage that instructs employees to work smarter not harder rings especially true in this instance. We have become a society that demands accessibility to almost everything. Converting to an electronic medical records system is as a part of this movement as anything else. The health care industry is suffering from a rise in cost associated with operating a health care organization. The implementation of electronic medical records will result in a type of cost and time savings technology that cannot be ignored.