quarterly career check-up//January 2008

Emerging Technology - Electronic Medical Records

In groups and practices nationwide, improving the quality of a patient’s experience at the facility is always a primary concern.  Many new technologies are developed yearly to decrease wait times, control patient information, assist physicians in organizing appointments, and provide patients with a more satisfying experience.  One of the greatest aids to this end is the implementation of an electronic medical records system.

Many electronic medical records systems have been under development for years. The process began when physicians began scanning older patient records to preserve patient information and avoid the cost of storing paper files. The majority of electronic records dated prior to 2000 are of this type. Eventually, as computer systems became more prominent in medical settings, physicians began implementing electronic systems to maintain patient information, schedule appointments, and track test results.

Benefits of Electronic Medical Records

Many physicians believe that the proper implementation of a quality electronic records system in any practice will improve patient health, safety, and satisfaction substantially in years to come. The benefits of electronic medical records include:

• Improved patient care. With electronic records, patient records are less cumbersome to maintain with less potential for medical errors, as well as improved quality and safety.
• Access patient information anywhere. With electronic records, patient information can be accessed in the clinic, examination rooms, operating rooms, and even another physician’s office. You can also have the ability to access and transfer records when you are out of town.
• More time with patients. When information is easily accessible to the physician, it improves his/her ability to effectively utilize the patient’s time in the office. Some new electronic record systems also include the ability for patients to fill out paperwork at a computer, reducing processing time.
• Reduced risk. Electronic records systems can be automatically backed up on a routine basis on-site, as well as off-site, decreasing the risk of data loss substantially. In case of a fire or natural disaster, patient data can be restored easily. If a paper record is destroyed, there is no way to retrieve it.
• Improved legibility. Electronic records present all patient information in a legible, computerized format. Using an electronic system can also substantially reduce transcription time and costs.
• More efficient office processes. Implementing electronic systems in a facility can improve staff accuracy, billing procedures, appointment scheduling, and many other functions.

Security and Patient Privacy

As with all medical management systems, data security and patient privacy are paramount. Advancements in the latest electronic record systems have set the standard for security and privacy. In many cases, electronic records help facilities to improve Health Insurance Portability and Accountability Act (HIPAA) compliance.

• User authentication. Electronic records systems will allow you to control who has access to the system. Some systems also allow you to establish permission levels, meaning you will be able to control which users have access to what information.
• Access logs. Most systems generate extensive access logs, allowing you to monitor which users have accessed specific information and patient records.
• Encryption. Most systems also employ data encryption procedures to make the system less susceptible to foreign intrusion.
• Confidentiality agreements. All employees who have access to the system should be required to sign a confidentiality agreement to ensure security.
• Routine maintenance. Strict office policies should be implemented to ensure the security and preservation of your system, including routine network maintenance and password protection policies.

Tips for Enhancing Exams with Electronic Records

Implementing an electronic records system in your facility can have many benefits. Here are a few key tips for ensuring your transition from paper to electronic records provides the best experience for your patients and staff.

1. Use mobile computer monitors. Large, fixed-position monitors can make interaction with a patient difficult. Consider investing in portable tablets or flat-screen monitors on mobile arms.
2. Focus on the patient. Whether you generally take notes during an exam or afterwards in your office, it is easy to inadvertently keep more eye contact with the computer screen than with your patient.
3. Learn basic computer skills. Removing the hand-written element during patient examinations can be a substantial learning curve for many physicians. Consider using note-taking and exam templates to make the process smoother.
4. Allow open-ended discussion. Most record systems provide customizable templates to make the patient care process more regular, but don’t customize them so heavily that your notes no longer allow for documenting an important patient dialogue.
5. Don’t wait until the examination to collect patient data. Some systems offer the ability to integrate front-office patient forms that allow them to fill out certain information themselves with a computer. Others rely on input from nurses or staff. It is important to determine how much information should be collected before the patient is seen by a physician in order to effectively use your time.
6. Maintain dialogue with patients during the exam. Even as you are looking for information in the patient’s record, explain to them what you are doing as you do it.
7. Customize the system for your style. Every physician’s examination style is different. Electronic systems are highly customizable to allow for this. Don’t feel obligated to change your natural behaviors to accommodate the new system.

The development of electronic medical record systems can be an extensive and costly process. However, physicians nationwide continue to install and develop computerized systems to improve the patient experience and to maximize their in-office time. To help ease the cost for smaller groups and practices, the American Medical Association is aggressively seeking a full, refundable federal tax credit to aid physician practices in the cost of purchasing and implementing clinical technology, including electronic records systems.

If you are currently seeking a new permanent position or locum tenens contract or are looking to fill a position in a facility that maintains electronic medical records, Linde Healthcare and Kendall & Davis can help. To begin working with a dedicated physician recruiter today, contact us at 1-866-480-3874.