What are your practice's goals for having an electronic medical records (EMR) system? It is important that your practice understands the answer to this question.
Do you want a truly paperless office?
Do you hope to make your practice more efficient overall?
Are you in preparation for 'pay-for-performance' reviews?
Do you expect electronic medical records to be the norm in the future?
Does any of it even seem possible?
When moving from a paper office to an electronic one, a challenge faced is what to do with the many paper-based forms that are currently in use at the practice. Some of these forms are federal and state requirements, while others are simply frequently used at the practice on a daily basis.
At our practice, we have so many forms, we don't know the exact number. We're putting a binder together which will help us evaluate which of the forms are truly necessary, which are gathering duplicate information, and which are relatively unused and can be discontinued.
Our goal was to enter as much documentation as we could to the EMR system. Many of the forms needed to be made into templates which could be filled in electronically. You'll have to select the forms that need to be incorporated into the EMR system and which to fill out manually; the creation of custom templates costs time and money.
The paper forms will have to be scanned into the system and saved as images. The downside to this type of scanning solution is that the data stored in this way has limited uses. This 'read-only' data is not easily accessible for research or data mining. Still, some practices running on EMR systems have already discovered that some paper forms are integral elements in overall workflow, even if shredded after use at the end of the day.
One way to reduce paperwork without needing to switch to a full EMR system is e-Prescriptions. Prescriptions can be sent electronically to the patient's pharmacy, without the need for a doctor to look around for a prescriptions pad and write it out by hand.
Also take into consideration the communication between medical practitioners - a majority of them won't be ready for EMR in the immediate future. Estimates state that around 7 to 10% of all medical practices are currently using EMR. Some systems can create documents from the clinical exam, then either print them and send out by post, or transfer them to digital to send to a referring doctor by fax. The legal terms for transmitting medical information by email have become increasingly complex, and would require another full column to discuss properly.
If you are scanning all of your paper records into electronic format, you still might not be able to totally eliminate the use of paper at your practice. Some forms of paper record-keeping need to be kept for regulatory and legal reasons. So, don't sell the file cabinets just yet. It could be quite a long time before we see all documentation stored electronically.
Peter J. Polack, M.D., F.A.C.S., is founder of emedikon, a medical practice management consulting firm and president of Protodrone, a software development company specializing in medical practice applications. He is managing partner of Ocala Eye, a large multi-specialty ophthalmology practice. Find more useful articles and podcasts at http://www.medicalpracticetrends.com
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