Medical documentation in the age of EMRs!
The difference between EMRs and paper records is the difference between clunky file cabinets and cloud storage. Digitizing records makes them more accessible and transferable. And despite whispers of dissatisfaction there are several advantages of working with EMRs.
Let’s look at the obvious benefits…
Easy storage and no change in quality over time: There was a time when hospital rooms were filled with files. Electronic storage is much easier and saves a lot of space.
- Comprehensibility: Doctors are famous for their illegible handwriting. Thanks to the electronic records this is one problem physicians and patients need never worry about!
- Easily accessible: The electronic records can be easily accessed and shared among other authorized parties in an instant. To share paper records among other healthcare workers, it had to be converted to an electronic format by scanning.
- Better Security: Paper records are safe unless someone breaks into the storage rooms. Unlike paper records it is not a piece of cake to break into a secure storage server!
EMRs as life-savers!
EMRs make it safer and easier to share medical records. Vital information, such as blood type, drugs prescribed, and medical history, are easy to share at the time of need. During times of emergency EMRs are life savers and can help in quick medical decision making. The Blue Button feature in particular is a huge leap forward for the healthcare industry.
So why are people complaining?
Most physicians find it difficult and painful to work with EMRs. Doctors struggle to work with EMRs due to its complex interface and tough navigation. Most doctors complain that they have to extend their office hours to complete their notes. This has resulted in physicians opting for documentation short-cuts.
Documentation mistakes have become commonplace!
Doctors find the “click and drop down” capability of an EMR as a great feature. But it restricts physicians and not every patient complaint can be found in drop-down boxes! This leads to errors in the documentation process. And unless the next doctor audits the previous notes, it will continue to be shared.
The copy and paste feature adopted by doctors, also known as cloning is an easy and time saving procedure. It allows the previous documentation to be pulled into the current documentation. According to a survey the habit of copy and paste has been adopted by 78% of the physicians, who find it better than hand copying procedures which had oodles of error.
This has raised eyebrows and concerns. As reckless copy pasting can lead to duplication of data.
Tips on how to reduce EMR documentation risks!
- Audit your medical practice’s documentation procedure regularly. Invite someone outside of your medical practice to review your clinical records.
- Customize the templates you get from your vendor.
- If the EMR systems coding algorithm is updating E/M codes very often then you need to keep an eye on the coding calculator algorithms.
One size doesn’t fit all!
Customization is a time consuming and complex process. Some of the EMRs have customization features, where a doctor can customize templates according to the workflow of their medical practices. There are several template customization specialists who can help in customizing EMRs and better align them to the clinical workflow of practices.
The need for healthcare documentation specialists!
There is an increased need for granularity of medical data and specificity in documentation. It can be next to impossible for physicians, to manage, the almost unfair demand for pristine documentation. An increasing number of medical practices are opting to work with healthcare documentation specialists. Skilled professional experts who understand not just medical terminology, but have knowledge about clinical information systems, EMR templates and the Healthcare IT environment are the need of the hour.
Gone are the days of stay-at-home medical transcribers who typed out physician’s dictations. They’ve been elbowed out by medical documentation experts who have adapted themselves to the complex world of EMRs!