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Better Medicine Through Electronic Record Keeping

Electronic Medical Records (EMRs) appear to be all the rage among medical practitioners these days. They’re appearing in offices around the country, allowing doctors, nurses, therapists and the like greater flexibility and confidence in their practices.

Medical recordkeeping has always been the bane of the medical profession that falls into that most dreaded of categories: a necessary evil. Few people actually enjoy doing paperwork that sits in a file waiting for a regulatory body to review the work and make sure that the Is are dotted and the Ts are crossed. The point is to make record keeping a substantial part of treatment, allowing for quick and complete reviews of the care provided so that clinical interventions can be altered, increased, dropped or whatever needs to be done. It turns out, record keeping isn’t the evil side of the medical profession; it’s a critical tool for patient evaluation, decision making and sharing information.

For years, the computer didn’t help matters much. Not long after physicians became enamored with the clarity and storage capacities of electronic record keeping, they were accused of spending more time staring at computer screens and typing notes than attending to their patients. Systems had to change; software had to adapt to mitigate complaints that physicians were more concerned with patient files than with the patients themselves.

Now, software is faster, clearer and more intuitive. Natural selection has weeded out the cumbersome software, leaving practitioners with more elegant choices. Every specialty, from dentistry to behavioral health, saw improvements across the board in customized software. This included packages that allowed doctors to chart success and share interventions with clinicians in other settings, all in real time. A physician can record a patient’s unusual wounds and a social worker or psychiatrist will know immediately whether or not the patient might be at risk for self-harm. General practitioners can share information with emergency rooms contributing instantly to improved decision making at times when it may be a matter of life and death.

The advantages of EMR and EHR (Electronic Health Records) are vast and viable – all good, you might say. EMR software aims more for in-house results, while EHR systems are geared for exchanging information with other clinics. Their benefits overlap, however. They include:

Going paperless – In this day and age, there’s no need to clutter an office with paper. Paperless offices are not only better for the environment, but they save extremely valuable space in the office. Think about those rooms dedicated to patient files; they might, someday, be a thing of the past.

Instant billing – Software can make the transition from billable hours to invoices instantly, allowing the clinic manager to keep up to date on the office’s revenue streams.

Clarity and uniformity – There’s something to be said for uniformity in recordkeeping. Physicians who are used to “shooting from the hip” in their filing system can be doggedly trained to be much more consistent in their records by using software that requires you to follow protocol. If the diagnosis always appears on the top of page two, for example, then physicians, nurses, insurers and everyone else will always know where to look to find the information they need.

Easy to use, hands-free systems – Some systems make use of voice recognition technology that allows physicians to speak their notes into a microphone as the computer does the typing for you. Look, Ma, no hands.

Spot changes you might not have noticed – Behavioral changes that indicate addictions, for example, can be hard to spot over time, but accurate recordkeeping can help practitioners stay focused and notice items that might have otherwise slipped through the cracks.

Faster still means cost-effective – Think of all that time spent not having to type and not having to send a nurse or secretary to the file room for John Doe’s paperwork — it adds up. Faster systems allow you to see more patients, which increases your revenue, all while improving your care.

Instant results you can share – Electronic records allow lab results to not only arrive faster, but they arrive in a consistent form, without forcing doctors to try to read horrible handwriting, which might lead to mistakes. Lab results can be shared with others, including patients who may be anxious about their specific condition.

Charting patient progress – Systems customized for your practice can make instant charts of how a patient is doing over time. If the issue is blood pressure, weight loss, blood sugar statistics or other data that may need comparison from day to day, month to month or year to year, the EMR programs can do that at the push of a button. Instead of leafing back month to month to check on what a patient’s weight gain or loss might look like, ask for a chart. The year’s weight data will appear in a form that makes it easy to see if changes have occurred long-term or not.

About TessB

Tess Bryan is an influential health writer for Healthynewage magazine

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