Increase Your Office Efficiency with EMR
Electronic medical records offer multiple benefits to your patients and your practice.
BY DAVID E. SILVERSTONE, M.D.

A computerized medical record isn't just a typed record of the patient encounter, but rather a dynamic and highly useful tool. Modern electronic medical record (EMR) systems have the potential of increasing office efficiency and assuring availability of a patient's medical records, in addition to improving the accuracy and completeness of medical charts.

• An EMR system can interact with billing software to assure accurate charging and coding.
• Messaging software can allow the recording of non-visit patient encounters and can improve interoffice communication.
• An EMR system can offer patient education opportunities through customized, easily prepared patient education documents.
• Medication modules can facilitate screening for allergies and drug-drug interactions. They can also make managing requests for refills easy, as the chart doesn't have to be pulled and you usually won't need to be consulted.
• Letters to referring doctors and the patient's other physicians can be easily produced. Records are always legible and can be accessed remotely.

EMR Means Efficiency

To illustrate the power of an electronic medical record, consider the following scenario:

It's a Monday morning. You're at a satellite office. One of your patients calls the main office complaining of a sudden loss of vision in the right eye after having slipped on a banana peel in the supermarket the day before.

The operator in the main office takes the call and enters the patient's symptoms into the telephone call template. While she's on the phone with the patient, she e-mails the template to you in a satellite office. The e-mail pops up on your screen while you're examining another patient. You determine that the patient needs to be seen immediately, and you respond to the e-mail by saying that the patient should see you or one of your partners immediately.

The operator tells this to the patient and the patient chooses to see one of your partners, who's in another satellite office. A note about this conversation is automatically posted in the EMR.

An hour later, the patient arrives at the second satellite office. The patient's entire chart is available to your partner because all records are on a central computer in the main office, which can be accessed seamlessly by all satellite offices.

When the patient arrives, the staff discovers that the patient's insurance has changed. The patient doesn't know if a referral is needed. The staff enters the insurance information into the chart and electronically contacts the insurance company to determine eligibility and referral needs. The visit is approved. The patient's insurance card is scanned into the electronic practice management (EPM) system and attached to the visit.

Handoffs Go Smoothly

Your partner has never seen this patient before, but because the record is electronic, well organized and easily legible, he instantly knows everything that's important to know about the patient's ocular and medical history. Your partner has access to the entire chart even though the patient is usually seen in your main office and has never been seen in that satellite office before.

Your partner examines the patient. The entire medical and eye history of 10 years pops up on his computer monitor. He sees that the patient had cataract surgery 3 months before, also has open-angle glaucoma that required a trabeculectomy a year ago by a glaucoma specialist who still follows the patient, is currently taking timolol and latanoprost, is a steroid responder, is allergic to sulfa and latex, and has diabetes and thyroid disease, which is being closely monitored by an endocrinologist.

Your partner sees that the IOP in the affected eye has ranged from 15 to17 over the past 5 years but is now 9. The patient's visual acuity without correction after cataract surgery was 20/25 but is now 20/30, and the patient is noticing many floaters and difficulty with the superior visual field.

	With EMR, an ophthalmologist seeing a patient for the first time can immediately access the patient's complete medical history.

Your partner obtains a visual field and dilates the patient. On dilated exam, a retinal detachment threatening the macula is noted that's consistent with the visual field. Your partner makes a drawing of the detachment. As the detachment is threatening the macula, he also takes a digital photo.

Your partner then e-mails another partner in your group who does retinal surgery and is in the main office. He asks the retinal specialist to look at the patient's chart. Because the chart is electronic and stored centrally for your practice, the retinal surgeon has immediate access to your partner's exam, including the retinal drawing, the digital photo, the visual field, and all of the past records.

The retinal surgeon then e-mails back a message to arrange for the patient to go to the surgical facility for a detachment repair. Your partner tells the patient that the retinal surgeon has just reviewed the record and needs to operate as soon as possible. The surgery coordinator then starts arranging for the surgery.

Your partner's exam is then automatically coded by the system. He has performed an intermediate exam, a visual field, fundus photos and a retinal drawing. The system recognizes all of these elements and codes the exam properly, including charging for the additional testing. The charges are immediately transmitted to the billing software and the patient's insurance is billed.

A medical exam note is then generated and faxed by the system to the patient's endocrinologist, who faxes current medical information to your office. That information appears on the screen of your surgery coordinator, who electronically loads it into the patient's chart. The surgical facility is contacted and arrangements made for surgery later that day.

Everyone Communicates

The surgery coordinator then automatically generates an admission note for the surgical facility, attaching the endocrinologist's faxed note. The coordinator electronically faxes all of this information to the surgical facility. The patient and the retinal surgeon then both arrive at the surgical facility. All records are there. The patient has uneventful surgery.

At the completion of the surgery, the retinal surgeon enters a note into a hand-held computer (the patient's chart was downloaded into the hand-held device before the retinal surgeon left the office). An operative note is completed and prescriptions for medications are entered. The prescriptions are then faxed via a wireless card in the hand-held computer to the patient's pharmacy and the patient picks them up on the way home. When the retinal surgeon returns to the office, this information is automatically uploaded into the patient's chart. The procedure note triggers a billing code, which is then transmitted to the EPM system. The insurance company is then electronically billed for the surgery.

Information Transfer is Easy

By now, it's nighttime. You're home after having had a busy day, but you want to know what happened to the patient. You contact the office over the Internet and see that the patient had a detachment and had it successfully repaired. With all of this information, including the patient's telephone number, at your fingertips, you call the patient to convey reassurance and encouragement.

The morning after the surgery, the patient sees the retinal surgeon who that day is in yet another satellite office. The chart is instantly available, however, since it's stored electronically in a central location. The retinal surgeon electronically faxes a report to the patient's internist, simultaneously e-mailing a copy to you. The glaucoma specialist is also programmed in the system to receive a copy of the report and it's automatically faxed. The report is generated without the use of a transcriptionist. There's no delay and lost charts are no longer an issue.

Two weeks later, the insurance company challenges the claims. Your insurance clerk has immediate access to the entire medical record and can electronically fax relevant records to the insurance company. There's no need to search for a patient chart, as it's electronic. The insurance company is now satisfied and payment is sent. The insurance company automatically deposits the payment in the bank and the Explanation of Benefits is automatically posted into the patient's financial record.

Three weeks later, you receive a letter from the patient's attorney, who's pursuing the accident in the supermarket that apparently led to the detachment. The office is able to generate a copy of the medical record for the patient's attorney.

EMR Pays for Itself

The preceding account isn't fiction. It represents the state of the art in electronic medical records today in many practices. The result is improved and efficient patient care. EMR also means a better quality of life for you, as the medical record becomes an ally and a tool, not a document in hieroglyphics that needs to be deciphered and which is often unavailable at critical times.

Your entire practice is now a team that can deliver the highest quality of care in the most efficient manner possible. The medical chart has been transformed into a valuable tool serving you, your staff, and the patient.

These systems aren't inexpensive. They require adding at least part-time information technology personnel to your staff. The result however is such a major improvement in the management of medical information by your office that the cost is justified by the quantum leap in quality of care alone. Eliminating lost charts, improved efficiencies in billing, the easy transfer of medical information around your practice and between your offices, and the decreased need for transcriptionists all produce financial efficiencies that help to cover the cost of the system.

It wasn't long ago that most practices had manual practice management systems. Now, it's virtually impossible to manage a medical practice without an EPM system. Similarly, the traditional paper chart is being replaced by EMR systems and the benefits that we and our patients will receive will be even more dramatic.

David E. Silverstone, M.D., is Clinical Professor and Assistant Chief of Ophthalmology and Visual Sciences at the Yale University School of Medicine and Yale-New Haven Hospital.