Program is designed to help practices streamline EMR documentation
If your orthopaedic practice has not yet adopted an electronic medical record (EMR) system, such a purchase is probably in your future. Federal government incentive programs to promote adoption and use of EMR systems will prompt most orthopaedic practices to implement an EMR system within the next 5 years.
Whichever EMR system you adopt, you’ll find that using an EMR affects the way you interact with patients and document the patient encounter. If you use a paper chart, you probably write your notes (or dictate and have them transcribed) after the patient encounter. With an EMR system, you generally enter, save, and retrieve the digital information in real time—during the patient encounter. Although many EMR systems include templates that are supposed to help speed the process, the EMR-generated note is generally insufficient for orthopaedic documentation.
“In our practice, referring physicians, my partners, and I have seen substantial limitations in standard EMR-generated notes,” said William J. Mallon, MD, of Triangle Orthopaedics in Durham, NC. Consequently, Dr. Mallon and his partners—like many other orthopaedic surgeons—have developed orthopaedic-specific narrative templates.
“Narrative templates can solve the challenge of creating text-like notes that look like a typical doctor’s note with all the necessary information,” he explained.
But creating all those templates is very time-consuming. That’s one of the reasons the AAOS Electronic Medical Records (EMR) Project Team is introducing the Physician Narrative Exchange Program at the AAOS 2011 Annual Meeting in San Diego.
Save time, reduce liability, improve documentation
The Physician Narrative Exchange Program can help reduce the amount of time you spend creating narratives by providing access to a library of customized narrative templates developed by your peers. Each of the more than 2,000 ICD-9 codes used in orthopaedic offices will have at least one narrative template; some codes may have up to five choices. Templates will cover patient encounters for all evaluation and management (E&M) services, consultations, history and physical, diagnoses, imaging procedures, and surgical procedures.
Plus, by using the unique narratives for each combination of ICD-9 code and type of patient visit, you’ll be able to reduce the risk of “cloning” the note from the previous visit. According to many medical liability attorneys, simply cloning notes presents problems, particularly if an adverse event does occur. (See “Electronic medical records: Liability is lurking,” AAOS Now, July 2010, for a more complete discussion of this issue.)
Narratives are based on a SOAP (subjective, objective, assessment, plan) note format for each orthopaedic condition. Using the narrative templates will also eliminate the need to put everything in every note.
Try it out!
Complete information on the Physician Narrative Exchange Program will be available at the AAOS 2011 Annual Meeting in San Diego. Be sure to visit Academy Row—in the Sails Pavilion, Upper Level, near the AAOS Resource Center—to learn more about the program and view a live demonstration.
After the meeting, you can purchase a 1-year subscription to the Physician Narrative Exchange Program online at the AAOS Web site. A single subscription per office gives every physician in the practice immediate 24/7 access to the entire library. You can modify downloaded narratives created by others and customize the note for use in your EMR system, or submit your own customized narratives.
Jackie Ryan is a practice management program coordinator in the AAOS practice management group. She can be reached at (847) 384-4334 or via e-mail at firstname.lastname@example.org