Making the Transition to Electronic Medical Records

by Angela Stevens on June 3, 2009

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While the medical profession is, by nature, a cutting edge business driven by new technology, new science and new treatments, the medical office is mired in the same antiquated record keeping described by Charles Dickens in A Christmas Carol, which was written in 1843. Handwritten and kept on paper. Making the switch to Electronic Medical Records (EMR) won’t be easy for most healthcare providers, but in the long run, it will be less costly and far more useful.

Health Records

The reluctance to make the change to EMR is reasonable. Medical histories are filled with intensely personal information. Some patients aren’t concerned about the security of their medical records, but others are justifiably worried about the implications of a breach on their insurance, the outcome of a lawsuit, or even their career. Combined with the threat of computer hacking, the cost of upgrading to a new and secure system has kept medical offices in the dark ages of record keeping. Insurance companies and pharmacies are already online, though, and patient medicine has been tracked electronically for many years. The information is already out there, and the technology has proven itself. Healthcare providers just need a way to tap into the benefits.

This transition will be beneficial to every facet of patient care from the insurance companies and the medical staff to the patient himself. Unfortunately, the burden and cost of transition falls solely on the healthcare provider, who is unlikely to have the same kind of deep-pocket resources enjoyed by the insurance and pharmaceutical companies. Finding affordable software that meets the requirements of the medical office, or having software custom-built, can be quite a challenge. Before undertaking the search, it’s a good idea to define your needs. What should the software do? The first step is to define a list of goals.

Here are some ideas to begin with:

  • Track dates – This may seem obvious, but think forward to the next level. Instead of simply recording historical data, make the dates work. For example, imagine Mary, a 47 year old patient who had her first baseline mammogram at 45. She should have a new one every one or two years, but who is responsible for remembering? A well designed system can send Mary an email, text message, or a digitized phone message to remind her to make an appointment, and flag her record for staff follow-up is she does not respond. I know I would greatly appreciate this if my primary care physician’s office or my women’s care office would adopt this practice.
  • Appointment times – What if patients could log in and see available appointment times and claim them? Furthermore, what if the system then sends email, text message, or digitized voice message reminders? Elderly patients may even have a backup contact for a caregiver.
  • Doctor’s instructions – Patients can log in to check details, instructions or request refills, cutting down on staff time spent on the phone. Information regarding their medicines can be linked to their records, in case they have general questions.
  • Prescriptions – The patient’s pharmacy of choice can be included on the record, and drug refills can be transmitted directly to the pharmacy, eliminating lost and forged prescriptions.
  • Templates – During flu season, for example, a doctor will see many patients with the same symptoms, make the same diagnosis, prescribe the same medicines, and dispense the same advice. Common problem templates can cut down much of the daily data entry, saving time and improving workflow for doctors and staff.

    Electronic Medical Recording is far more sophisticated than simple scanning of paper documents. In order to make a system searchable and workable, to access the patient data in any meaningful way, the records must be abstracted; that is, the data must be pulled from the documents and typed in. Chances are data entry of patient histories will be the most time consuming part of the transition. It’s a daunting proposition, but well worth it in terms of quality patient care.

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    { 2 comments… read them below or add one }

    Ed Botsko 06.03.09 at 10:02 am

    This is a very important issue that the physicians have been avoiding for quite some time. For a while I worked with a company called mdtv who provided a method of remote diagnostics for physicians. It let them communicate in a variety of ways and created an electronic patient folder that would contain hand written notations, menu select results, device motoring results such as fetal monitoring, various dermascopes and record a tv copy of the consultation. It was primitive because of the state of hardware at the time, but it really opened doors. The most receptive participants were states with sparse population and remote clinics and the military where base hospitals could consult with battlefield doctors in real time. The company folded because the physicians were not receptive, but it was the start of a wonderful tool that could be vastly expanded with today’s technology…Who is setting the standards for capture/display of medical records? How fliexible is it?

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    Angela Stevens 06.10.09 at 3:36 pm

    Ed, great insight! We agree that electronic medical records will be successful as long as the doctors are onboard and the software solution is flexible. While doing research for this blog topic, we came across an excellent article by the NY Times on EMR. It has excellent links to the various software solutions on the market: http://bits.blogs.nytimes.com/2009/04/05/health-care-industry-moves-slowly-onto-the-internet/

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