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Electronic medical record adoption and use for medical staff

HIM Connection, October 22, 2003

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TOPIC: Electronic medical record adoption and use for medical staff

Electronic medical record (EMR) implementation means better times for physicians and HIM staff--eventually. Until we all get there, however, there will be plenty of bumps along the implementation road for an EMR. In spite of these bumps, there is no avoiding it: if you're not already using one, an EMR is in your future. Medical and HIM staff can work together in order to make the transition a smoother one.

Physicians can and should play a vital role in the development and implementation of the EMR in your facility. But be prepared for frustration on their part because physician documentation is often the last piece of the EMR pie to be implemented in health care facilities. That's why there is more electronic medical recordkeeping in many physician offices than in hospitals.

Even if the hospital is not paperless, it often uses pieces of an EMR. Examples might be online access to transcribed reports such as H&Ps, radiology, and lab reports, electronic signature capability, and nursing documentations such as flow charts and assessments.

Tips for working effectively with an EMR:

1. Physicians should be encouraged to consider an EMR for the office practice.

2. Find out what is available for the practice and take advantage of the EMR capabilities in the facility.

3. Physicians and the rest of the medical staff should feel encouraged to join the EMR design team and all voices should be heard.

4. Encourage even those who are not computer experts to work with and champion for the EMR.

5. If physicians or other medical staff are not already computer literate, they should consider taking a computer course.

As the leader of the health care team, the physician holds the key to the success of any EMR application. So when your facility starts including physician documentation or computerized physician order entry (CPOE) in its EMRs, the staff should support this initiative and doctors should feel comfortable providing the appropriate physician input during the design process. Even if some of the medical staff is computer-phobic, a well-designed EMR will improve workflow and patients' clinical outcomes. Built-in decision support services embedded in an EMR and CPOE will, in the long run, make for a better practice, and translate into safer care for patients.

This week's HIM Connection was adapted from an excerpt of the handbook, "Documentation Improvement Handbook for the Medical Staff," by Jean S. Clark, RHIA, and Richard A. Sheff, MD. Go to http://www.hcmarketplace.com/Prod.cfm?id=1814&s=EHIMC for more information or to order.

Check out the Editor's Choice section below for solutions to your records completion problems.

Sincerely,

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com

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