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Published 2/1/2009
Charles E. Rhoades, MD

The more you use EMR, the more you benefit

After implementation, it just gets better!

Many essays, conferences, and instructional course lectures have been given on selecting and implementing an electronic medical record (EMR) system for your orthopaedic office. By now, many practices are using fully integrated EMRs; the next wave of learning is the continued refinement of EMR use in years 2 through 5 after implementation.

When EMRs were first introduced, e-prescribing was considered an advanced use. The recent inclusion of e-prescribing in the Physicians Quality Reporting Initiative (PQRI) makes it a primary function.

  • Your EMR system should include the following e-prescribing capabilities:
  • faxing a prescription to a pharmacy
  • printing a prescription in the office
  • e-mailing a prescription with a digital signature

The technology for providing this level of digital interface is well established in most fully integrated EMRs. Several national companies provide interfaces to network pharmacies.

The advantages of e-prescribing are numerous, beginning with an accurate record of the medications sent. Of equal importance is the fact that the record is legible. The only downside to e-prescribing is the slight increase in time it takes to issue a prescription. But the ease of refills, the accuracy of the record, and the ability to see summaries of medications taken by patients more than make up for the extra initial time required.

Forms for increased productivity are one of the great advantages of an EMR. They are a constant work in progress and will continue to evolve as the needs of your practice evolve. Forms can be specific for a practice, for an individual provider, for an individual organization that requests information, and for any other entity that interfaces with the system.

As users become accustomed to using an electronic interface, they can identify repetitive steps or repetitive communications that could be incorporated into a form. Forms enable rapid data entry of variables and automatic data entry of demographics, diagnoses, insurance plans, and other needed information. Mature EMR systems allow individual users to easily create the forms they need.

The best method for creating forms is a grassroots or bottom-up management chain. The need for a simple, easily modified form is identified in the day-to-day patient flows and work flows. Common forms include requests for Family and Medical Leave Act absences, handicapped passes, travel plan cancellations, work-related injury forms, return-to-work forms, and referral letters.

Physical therapy (PT) orders are particularly adaptable to EMR forms. Preset programs for any clinical condition and/or procedure can be created to automatically complete a PT prescription form; individual additions or modifications can be added at the clinic visit, and the form printed or faxed immediately. This creates a legible record of what was ordered that can be reviewed, copied, faxed, or changed easily.

Clinical checklists
The use of discreet data entry, medication records, lab results, and forms can provide very helpful checklists for physicians and staff. A preoperative check list for the surgery scheduler, for example, can list the patient’s diagnosis, use of anticoagulants, body mass index, history of any positive cultures, allergies, and current medications on a single screen. The ease and accuracy of this information can prevent costly errors in patient scheduling.

Specific checklists for different procedures—such as total joint replacement, rotator cuff repair, or hand surgeries—can easily be created to remind staff to schedule appropriate pre- and postoperative lab work, therapy, and durable medical equipment.

Flowsheets provide the longitudinal record of progress on many clinical parameters. Any parameter entered as a discreet data field can tracked. Pain levels can be entered at each visit and reviewed over any time period on one screen. Staff can enter pain at rest, pain with activity, and night pain separately to give the clinician a valuable measurement of the patient’s condition.

Magnetic resonance imaging reports by anatomic area can be entered into discreet text fields and easily reviewed. Lab values, patient weight, chief complaints, and many other elements of the clinical visit can be visualized and interpreted in an instant by clinicians using flowsheets.

Voice recognition
Voice recognition software is now an essential adjunct to the fully integrated EMR. The use of voice recognition allows physicians to enter accurate, free-text, individual descriptions of clinical conditions, histories, physical exams, and plans.

In addition, the free text can also be entered in discrete fields such as the history of present illness or chief complaint. Although certain numerical values such as range of motion can be entered in discreet data fields with voice recognition, entering them manually is usually easier.

Using voice recognition to fill in discrete text fields of a SOAP (subjective, objective, assessment, plan) note form allows rapid entry of individualized patient data in a retrievable format. The advanced user will gradually add individual macros and/or voice recognition templates that accurately recreate repetitive components of operative notes, office notes, and free-form dictation. These templates are best created by a physician user who is engaged and committed to developing them on a regular basis. Start with adding just one template or macro a day so that users can familiarize themselves with the macro and will not be overwhelmed.

Outcome measurements
Outcome measurements are the next wave of EMR applications. Certain outcomes—such as the time from injury to release to partial work or release to full duty—are easy to calculate and track if they are entered as dates. They can be recalled for specific procedures, physicians, and patient populations, or providers.

More advanced outcome measurements—such as improvement in Short Form-36; Disabilities of the Arm, Shoulder and Hand; or other outcome scales—can be integrated into existing EMRs. The data entry for the more complex data measurement instruments can frequently be delegated to a nurse or a physician assistant at the first visit and at the index measuring visit.

Maintaining outcomes in the integrated EMR will allow practices to monitor their outcomes, benchmark them against published standards, and participate in new pay-for-performance initiatives as they are created. Although a universally-accepted outcome standard does not currently exist, industry, government, and academia are working to create these standards.

Regulatory compliance
An EMR can also help practices meet regulatory requirements, such as those under the PQRI. A form can be developed to track e-prescribing, antibiotic prescription, antibiotic discontinuation, deep venous thrombosis prophylaxis, and other measures.

Most EMR systems can be adapted to alert you to patients who have procedures or CPT codes covered under PQRI. An EMR with a customizable alert system, data-screening capability, and an easy way to construct forms will help you respond to new regulatory requests from industry and government.

Coding management systems
Many EMRs now have modules that help physicians to code visits properly. The EMR software can monitor the appropriate level of evaluation and management codes by evaluating the entries required for each level of service. This helps avoid inaccurate coding.

Take your time
Every practice will adopt these advanced uses in a different order and on a different timeline. When a practice first implements EMR, the goal should be to accomplish simple tasks efficiently and accurately. As physicians and staff become comfortable with the user interface particulars of their selected EMR, they can take advantage of more advanced functions.

Charles E. Rhoades, MD, is president of Dickson-Diveley Midwest Orthopaedic Clinic P.A., and a member of the AAOS Practice Management Committee. He can be reached at crhoades@kcoi.com

For more information on selecting and incorporating an EMR system in your practice, stop by the Practice Management booth in Academy Row at the Annual Meeting. You can pick up the free EMR Primer developed by the AAOS Practice Management Committee. Or, you can download the primer and a free podcast on EMRs below.