Electronic Medical Records Overview
By: Deborah Daly
2014 is the deadline for any Medical Practice within the United States to have an EMR system in place and functioning to meet federal medical record requirements. EMR is an acronym for Electronic Medical Records and also may be called EHR for Electronic Health Records.
It is wise to contact several EMR software companies prior to purchase. Ask questions of the representative and a demonstration to ensure their product is an appropriate fit for your practice. Software selection is an expensive and vital decision and a support system for questions or concerns after the purchase should be a key purchasing factor.
Medical records are to be handled with the privacy of the patient as the foremost concern. Medical records for a child can be shared with the designated person responsible for the patient’s care. Please note that when a child attains the age of 18 years of age, the records are their sole responsibility unless the patient signs an authorization to release this information to another party.
EMR or EHR software requires the use of scanners to add the patient’s current paper charts and to add other documents received in a paper format. A discussion with the software company of scanner options is essential. The scanner purchased should be durable due to the amount of documents to be added to the new EMR or EHR system.
The system will be used by most of the practice personnel, which includes the Scheduling Department, the Billing Department, Medical Records Staff, Front office personnel, and the medical provider. Security is of great importance due to the wide scope of access, and some personnel will not have access to view the patient’s complete history.
Following is a review of the positive aspects:
1. The main positive aspect to EMR is a provider has ready access through his or her computer the patient’s past and current medical history.
2. The provider has the option to document the encounter into the EMR system during the patient’s appointment.
3. Reports from specialist and lab or imaging reports will be sent by electronic fax, and the provider has quick access for monitoring the patient. This feature is true for the primary care provider and specialist. Please note that imaging reports are written reports and do not include actual screen image displays. To obtain screen imaging the patient must secure these from the Imaging center who performed the procedure.
4. Most EMR systems have access for the patient to review their chart via a patient portal or some form of patient access to view their personal history. This feature is implemented by contacting the IT department at your medical care location to have a temporary password assigned to the patient so the patient’s records are secure. Printing reports is not always an available option due to privacy consideration. The patient will be required to sign an authorization to release and visit the clinic to obtain the necessary documents and could involve paying a fee for this service depending on the length or scope of the report.
5. A patient has the option with this system to have copies of their Living Will, DNR requests, and Power of Attorney available for review if the situation requires this information.
EMR has some negative attributes as follows:
1. EMR systems can put a financial burden on any medical practice. Cost of the software, training employees on a new system are both timely and expensive and essential items, and current paper charts require care when scanning for the information contained and easily read when referenced.
2. Providers will be typing information during the encounter so patients will be experiencing a changed atmosphere and may feel their care is less personal.
3. Patient registration may not seem comfortable or as personable due to the implementation of the patient completing required information on the computer.
4. EMR is considered to be a paperless system. The idea of using less paper and being more environmentally conscious is a noble idea. Reality proves that having an EMR system may lessen the paper burden but not completely eliminate paper use.
5. There will be an occasion when the computer system is not available due to a power outage or some other factor. Providers and support personnel may not have access to the patient information. This is of great concern for provider and patient.
The context of this overview of the EMR/EHR system and is not all inclusive and intends to educate and inform any medical practice considering EMR software purchase about some of the features that are or will be available and to answer some of the concerns that arise.