Across the United States the use of electronic medical records is increasing at a sharp rate—and with good reason. Electronic records allow you to not only access patient care files remotely, but also share information with other physicians who are caring for your patients, thereby greatly improving the efficiency of your office and patient outcomes. For these two reasons, the use of electronic records has received strong bipartisan support. However, there are still some pitfalls to avoid, and especially as you convert your office from paper to paperless medical records.
The method of paper charting has often caused angst in a doctor’s office simply because the indexer codes with one method and the retriever searches with another. Therefore, being proactive about how you set up your electronic system will simplify the transition for you and your staff. The following are some ways you can go about doing that.
- Create a standardized storage procedure to accommodate both indexers and receivers.
- Use OCR and auto-indexing barcodes to convert paper charts to electronic ones. These automated steps will minimize the amount of time an indexer must invest on each chart while still providing multiple avenues of indexing to assist in future retrieval. There also tend to be fewer user input errors when using these automated cues, which will greatly alleviate the amount of pressure on the indexer. In addition to the automated index keys, allow for as many index inputs as possible, and make sure the organization of the data storage suits the retriever.
- Involve both the indexer and the retriever. Their familiarity with the snags in previous coding systems should give them valuable insights when creating a new workable system for your office. As they collaborate on customizing the system, they’ll be able to maintain their professional autonomy while meeting practice-wide goals. Not only that, but the more engaged they are in building the records system, the more engaged they’ll likely be in future problem-solving efforts as well.
- Train your staff.
- A chief frustration is that the electronic systems are unwieldy and unfamiliar. To prevent this issue, find a system that works for the way you run your office, and then train yourself and your staff on how to use the new system. This extra step will increase your employees’ level of comfort and allow them to work more quickly and accurately with each patient during examinations, as well as during preparation, follow-up, and billing times.
- While staff training requires the investment of more time and money up-front, it will more than pay for itself in the long run. And it will also ensure good will from your staff. People typically resist change, so taking the time to train them on the new system will indicate that you’re investing in their jobs, not simply imposing another new procedure on them.
- Go as paperless as possible.
- The fewer number of pages that need to be converted, the less amount of work that needs to be done. The advent of the tablet and netbook has allowed medical professionals to enter information into the system while they’re assisting patients. The same thing can be accomplished by placing desktop computers in exam rooms. Doing so can not only help eliminate errors stemming from difficulty in reading a person’s handwriting, but also minimize the threat of HIPPA violations due to paper files being inadequately secured. Caveat emptor: Confer with your legal team regarding what pieces must be maintained in paper form.
- Keep paper sources that match your new system in case of a possible crash.
- In spite of the increased productivity and efficiency offered by electronic systems, they do occasionally crash. Make sure your office is prepared by having your staff maintain paper charts that mimic the electronic charts as closely as possible, and also by making sure that your staff remains familiar with the paper charts. By doing so, your office will continue to function even as the tech staff brings the system back online. And by creating an efficient records conversion system, the post-crash conversion and filing process won’t cause the same amount of headaches that it has in the past.
- Taking the plunge by introducing your office staff to a new records system can be nerve-wracking for everyone. However, clearly communicating with your staff about the changes and taking the time to review how your practice handles patients’ medical information will pave the way to a more efficient practice overall.
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