Choosing Electronic Medical Record Software

The idea of change isn’t a welcome one for most physicians. Changing old habits and work flow can be a very scary process for doctors. Training on any new system can be an intimidating process.

As a result, many physicians find themselves procrastinating and searching for the perfect electronic medical records solution that does everything with zero effort to implement. It’s almost like a quest for the Holy Grail. However, in the meantime, they remain in a rut of inefficiency by continuing to handwrite or dictate their notes.

Unfortunately, not only are handwritten notes and prescriptions extremely inefficient, they are notoriously illegible. According to the Institute of Safe Medicine Practices, illegible prescriptions result in more than 3 million preventable adverse drug effects each year in the U.S.

Furthermore, since documentation requirements for physician reimbursement have become increasingly stringent, illegible notes can lead to significantly reduced income. They can also trigger time-consuming audits that ultimately result in costly penalties and refunds of payments back to the payers. This just adds one more layer of potential problems for physicians that continue with the traditional methodologies.

Electronic medical records have emerged as a way to address these concerns. In fact, federal officials have recently announced a program slated for early 2008 that will urge doctors to incorporate electronic medical records into their practices. The program provides cash incentives to doctors from Medicare for switching to electronic medical record systems and providing the government with updates on quality improvement markers for their patients.

Despite the fears amongst physicians resisting the switch to electronic medical records, it is possible to find EMR software with a low learning curve that will facilitate a smooth transition. Here are some questions to ask yourself when you begin your research.

Is the EMR software an intuitive system?

You don’t want to spend weeks or months training on a new system. All EMR software will have a learning curve, but some are more intuitive than others. The best EMR software will be one that you adopt quickly with minimal training and allows you to create more detailed notes with less effort. The ideal system should be able to be integrated it into the daily work flow of your clinic within a few weeks, rather than several months.

The right EMR solutions should save time. The age-old adage “time is money” applies in this situation. You don’t want to take 100 steps just to create a simple visit note. Instead, you want an EMR software program that streamlines the charting process as much as possible. Some EMR programs require so many steps to create a note that it’s like filling a salt shaker one grain at a time.

If you choose the wrong EMR software, the inefficiency of learning and using the new system may actually outweigh the inefficiencies of your current non-EMR system. Look for software that offers a free trial, so you can give it a test drive and see how easy it is to learn and use before you spend big bucks on it.

Does it have customizable templates that eliminate redundancy?

With customization, you can document your notes and patient records using the words and format that you prefer, rather than be forced to use the words and format offered by the software. Many EMR programs offer global templates for all users. This “one size fits all” mentality means that all users use the same templates (i.e., the same words) to describe dissimilar patients.

The result could be called charting by approximation — trying to fit a square peg in a round hole. Some doctors have described these sorts of notes as “vending machine notes.” EMR systems with customizable templates will allow you to create notes using your own words and style and will therefore more closely reflect your thoughts.

Having customizable templates means that you will be able to save and reuse certain frequently used phrases, forms, procedural descriptions, prescriptions, etc., so that they don’t have to be manually re-entered each time.

Many EMR software programs do not allow much in the way of customization by the end user. In these instances if customization is even available, it must be done by the software company and is both prohibitively expensive and time consuming to deploy.

This is another reason to test drive the system before you commit to a specific program. Well-designed EMR software should allow you to customize prescriptions, templates, chart format, follow-up letters and after-care instructions. Printing options for these items should also be customizable, yet simple and smooth to configure with minimal support.

Will your EMR software allow multimedia attachments?

Look for EMR software that allows you to attach multimedia like photographs, X-rays, scanned documents and ECGs to your patients’ records. A picture is worth a thousand words and can describe injuries and other clinical findings much more accurately than words.

Photographs can also more accurately and efficiently document changes in time over subsequent visits. Having scanned ECGs attached to visits makes it faster and more convenient to review and compare to prior ECGs since with only a few clicks of a mouse, you can have all the information you need for your patient.

Not all EMR software is created equal. Accuracy, efficiency, intuitiveness and expense are all key factors you need to consider when choosing EMR software. If you make the right choice, you will soon find yourself using electronic medical records and wondering why it took you so long to make the change. If you keep waiting and searching for the Holy Grail of EMR software, you will only prolong the inefficiencies and inadequacies as well as the potential risks of your current methods.

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