| Electronic medical record (EMR) software is the wave of the future for healthcare providers. Patient medical records can be extensive and complex, containing patient demographic and contact information, a summary of medical history, and documentation of each event, including symptoms, diagnosis, treatment, and outcome. Relevant documents and correspondence are also included. With EMR software, it is possible to store the entire medical record, or any part of it, on a computer. The advantage that EMR software has over traditional paper systems is that they provide greater data availability, transfer, and retrieval. This article will first look at the important components of EMR systems in general, and then it will look at three vendors who not only contain these components, but provide orthopedic practice-specific functionality as well.
The following are important components when considering EMR systems:
- Functionality
Often, lower-priced EMRs have limited functionality. However, you don’t want to pay for functionality you are not going to use.
- Data structure and organization
How easy is it to retrieve the information you need? Is there a summary page that is easy to get to and that provides the information you need?
- Record management
Does the system allow you to create useful reports? Can you scan numerous paper documents into the patient’s chart? If so, how easy is it to review these documents?
- Database integrity
Are there mechanisms in place to maintain database integrity?
- Data export to other systems
Does the system use a standardized transfer protocol such as HL7?
- HIPAA compliance
To be HIPAA compliant, there must be a log of anyone who has viewed or modified the chart, and any modifications of the medical record must be traced. Also, each note, lab report, and scanned document entered into the record must be signed by a physician.
- Communication
Does the system allow you to fax, mail, or email a recently completed not to other physicians? Is there a way to make hard copies of the chart, and can the software communicate with other offices?
Another important element of EMR systems is their practice-specific functionality. Misys EMR, OmniMD, and MediNotes are three vendors who include orthopedic practice-specific functionality in their EMR systems.
Misys EMR is a powerful electronic medical record solution that automates the management of clinical data, providing orthopedic practices a total EMR solution. Misys EMR allows you to easily review and sign electronic charts. Additionally, Misys EMR allows you t take a quick glance at patient medications, allergies, problems, procedures, chart notes, and clinical notes all on one screen on a patient summary page. The summary page is customizable, so you can display the information that you want to see. The Misys Document Manager allows you to important and store documents such as lab and pathology reports, discharge summaries, bone density reports, and EOBs. Once stored, documents can be easily retrieved for viewing, faxing or printing. Misys EMR provides orthopedic chart and form templates to enable you to quickly record chart notes and minimize data entry. The company has a dedicated Template Care Team that works directly with physicians to create orthopedic-specific templates to bring efficiency to your workflow.
OmniMD offers an EMR solution that addresses the vast information needs of the orthopedics specialty. The orthopedic specific EMR includes clinically-defined templates for common orthopedic complaints, history of present illness, and review of systems. The system also includes orthopedics specific ICD and CPT Codes that are used to capture accurate charges and quickly generate electronic bills. To meet the needs of the orthopedic practice, OmniMD offers the following point-and-click orthopedic-specific templates and forms:
- Fracture Visit
- Initial Adult Ortho Visit
- Orthopedic X-Ray/Plan
- Orthopedic SOAP Note
- Podiatry Visit
- Spine Exam
- Accidental Injury Form
- CMG Extremity Measurements
- Neck & Back History
- Neck & Back A/P
- Neck & Back Physical Exam
Charting Plus™ from MediNotes is a user-friendly point-and-click solution that allows you to quickly generate your notes based on symptom-based or diagnosis-based exam templates. The templates have predefined information consistent with a normal exam, so medical staff can chart by exception. The system is built on a traditional or wireless network, and therefore does not require an internet connection. The program includes over 5,800 medications (generic and brand name), and complete list of ICD-9 and CPT codes from the AMA. In addition, MediNotes offers an orthopedics package that includes the following templates for the orthopedic practice:
- Achilles tendonitis
- Ankle and foot pain
- Hand numbness
- Forearm and elbow pain
- Heel pain
- Hip pain
- Shoulder pain and injury
- Knee
- Spinal complaints
- Snapping or catching fingers
- Hand and wrist pain
- Joint problems
- Lower extremity injury
- Physical therapy plan of treatment initial evaluation
As medical specialties and sub-specialties become more complex and the medical field becomes more and more dependent on computers, the pressure on medical practices to keep up with technology will become overwhelming. EMRs are here to stay, and their return on investment is undeniable. EMRs are the wave of the future, and with so many options to choose from, every practitioner should be able to find the system that meets every need.
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