29 Tips on Checking the Clinic’s EMR System

  As the wound care industry adapts to a paperless society and electronic medical records (EMRs), there is hesitation by some professionals to embrace the digital push. As the new Presidential administration makes a push for electronic medical records, the following are tips and takeaways for improving a clinic’s workflow with use of an EMR system.

  1. All data must be collected in ‘real time’, which is at the bedside.

  2. It is the official medical record (in other words, a paper chart is optional and the EMR is really the legal chart).

  3. It meets HIPAA requirements.

  4. The EMR checks information for reasonableness (eg, it warns if the number entered for blood pressure seems to high).

  5. It supports electronic signatures.

  6. It supports government endorsed messages and content standards.

  7. The organization uses EMR data to measure and manage quality.

  8. Clinicians perform no extra tasks for medical record coding and reimbursement (in other words, the calculation of the level of service is automatically derived from the documentation in the EMR.

  9. Computers should be present in every exam room and the nurses and physicians in the exam room should enter 100% of all clinical information.

  10. Data entry is facilitated by numerous click and scroll menus, which keep typing to a bare minimum.

  11. Cameras can be cabled to computers, which allows digital photographs to be automatically archived to specific wound locations.

  12. All clinical charting should be password protected and all data entries should be tracked.

  13. Giving patients a copy of new home nursing orders can prevent confusion. Patients whose payers require correspondence to authorize certain procedures know that this task has been performed, and family members of elderly patients with complex problems appreciate being able to read over assignments and plans.

  14. The ability to hand these documents to patients at the completion of their visit is one of the most beneficial effects of implementing an EMR system.

  15. Since 100% of all patient data is collected, data can be analyzed and reported in an almost infinite fashion.

  16. Reports can be generated on billed revenue, profit loss statements, product utilization, referring physician utilization, patient outcomes, quality assurance, healing rates, marketing effectiveness, etc.

  17. Data from one facility can be compared to aggregate data from all clinics using an EMR system, to provide benchmarking services.

  18. With an EMR, documentation errors link directly and immediately to problems with billing and coding and can bring clinic operations to a standstill until they are corrected.

  19. Even the most technologically reluctant will come on board when improved efficiency becomes apparent.

  20. Significant time can be saved by simply not having to hunt for charts anymore.

  21. Clinic workflow does change with an EMR, because somewhat more time (about 10% to 15%) is spent in the room with the patient (usually increasing patient satisfaction). Far less time is spent completing tasks later.

  22. Documentation is complete when the staff exits the room. As a result staff overtime will be cut down or eliminated all together.

  23. Think of the medical record not as a product, but a set of processes supported by technology.

  24. The goal is not to create the ultimate medical record, but a more efficient clinical process.

  25. The EMR ultimately selected would have to meet unique requirements—it that would meet the needs of patients, staff, and stakeholders.

  26. Any successful program must be based on the particular department’s process. Process is crucial, and pulls documentation, patient care, and payment together.

  27. There should be no duplication of work, and no transcription services needed.

  28. The system would have to be compliant with all regulatory agency requirements, have extensive reporting capabilities, and be able to grow with the changing technology capabilities.

  29. To ensure financial success, the software must allow for maximal efficiency, provide auditing functions, assist in the quantification of work performed by clinicians and physicians, produce multiple clinical and operational reports, benchmarks and outcomes, and capture spin off revenues from referrals and tests ordered.