medical coding training at home.
Medical Documentation
Electronic Medical Record (EMR) software has changed the way Doctors document patient visits. More and more Clinics are leaving handwritten or transcribed notes behind. Handwritten notes are difficult to read and transcribed notes are expensive. An EMR resolves these problems. The change is not always an easy one, but has great benefits that make the effort worthwhile.
Benefits
There are benefits to EMRs. The number one advantage to implementing an EMR is "no more chart-chasing." It has been a time-consuming task to keep track of all the charts in a medical office. Clinics often joke about searching the clinic for a chart, and finally finding it in the trunk of the Doctor's car.
Having all the patient data at your fingertips improves patient care, increases workflow and grows profitability.
It has been reported that when a paper chart could not be found Doctors would see patients without knowing the patient history or what previous treatments had been given. Doctors often had to wait a week or more for transcription to be placed in the chart. An EMR eliminates these problems. With an EMR all patient data is instantly available and organized for easy referencing. Having chart notes accessible to the billing department on the same day as the visit improves insurance payment times.
The cost of paper charts, transcription and postage for referral letters will be eliminated with most EMRs. When these costs are all added up, the total is usually significant.
Another advantage is that forms and templates are auto-populated with patient demographic and insurance information that has been gathered at the time the patient registers; this improves efficiency and accuracy.
Many EMRs have template libraries that follow the 1995/1997 EM Documentation Guidelines. Because of this Doctors tenderness to document more completely and that improves profitability.
Disadvantages
There are also some disadvantages to EMRs. An EMR can take 1-12 months to get it fully functional.
Some EMRs have templates that are cumbersome to use and these can slow Doctors down.
Occasionally there are computer "glitches" that can shut the EMR down and cause a disruption of workflow.
Also, some EMRs can be very expensive to purchase and maintain. Not only does the Clinic need to purchase the EMR software, but there can be huge hardware costs involved. Having a Network Administrator is important and this will be an ongoing expense.
EMR Implementation
Every Clinic will have a unique implementation plan but there are some things you can do to "streamline" the process.
Start with a Plan. Laying out an Implementation Plan with calendar benchmarks will keep the momentum moving forward. Make a Plan and Follow the Plan; make adjustments when needed.
Part of the Plan might include names, phone numbers and dates:
Hardware Provider:
Cabling Vendor:
Telephone Vendor:
Network Administrator:
Log-on Passwords:
Practice Management Software:
EMR Tech Support: On-site, Remote
Support Contract: Annually, one-payment only, per-use
Internet Connection: Cable, T-1
EMR Training Schedule:
Walk-Through Date:
Go-Live Date:
Questions To Answer:
How many Providers:
Do Providers support going to EMR:
Does anyone have concerns about EMR implementation? What are they? Can they be addressed?
Computer experience of Providers:
How do they want to document: Tablet, PC, Speech Recognition, Picklists
Where will Providers document: Office, Exam Room, Nurses Station
Who can be trained as Power Users:
Will all or part of the paper chart be scanned into EMR:
Will the Provider or the MA be documenting the history portion of the template:
How will patient flow be monitored:
How will MA be notified there is a patient ready to be roomed:
How will Doctor be notified patient is ready to be seen: In which room:
Who will document the Chief Complaint:
Who will document the HPI:
Who will document the medical history:
How is the Superbill filled out: Who fills it out:
Does EMR interface with billing:
How is insurance information obtained:
When is insurance verified:
Is driver's license copied:
When is co-pay obtained:
How is co-pay documented:
How is the Superbill being handled:
Does EMR have a coding wizard:
How do billing codes get to PMS:
Does EMR allow associations of ICD-9s
If so, what are top 10 diagnoses:
Does EMR have insurance company list:
How is this list kept current:
EMR Templates
Are templates being used in exams:
Are templates adequate:
If not adequate, what type of templates are needed:
Who will maintain templates:
Does provider use macro treatment plans:
Would providers like to use macros:
How are Addendums handled:
Prescriptions
How are prescriptions written:
Is there contra-indication blocker:
How are prescriptions refilled:
Are prescriptions faxed to pharmacy:
Who keeps pharmacy #s current:
Orders
How are requisitions handled:
How are requisitions tracked:
How are labs handled:
How are labs tracked:
Is there a tickler file for future orders:
How are regular visits scheduled:
How are patients reminded of routine care:
Referrals
How are referrals handled:
How are referrals tracked:
Who keeps referral #s current:
How are referral reply letters handled:
Flowsheets
Does EMR trace results with flow sheets:
Are flow sheets customizable:
Are flow sheets adequate:
Patient Education
How is patient education handled:
Is patient education adequate:
Surgery
Do providers do in-house procedures:
How is authorization handled:
Do you have adequate consent forms:
How are operative reports generated:
How is surgery booked:
Illustrations
Do providers use illustrations in exams:
Are illustrations user friendly:
Do providers take digital images:
Are digital images easily imported:
Scanning
Does EMR have scanning capability:
Are scanned documents user friendly:
Reporting
Does EMR have reporting capacity:
Are reports adequate:
Does EMR allow e-mailing of data:
How are medical records copied / sent:
HIPAA
Does EMR have security settings:
Does EMR have audit trail:
Messaging
How are phone messages taken:
How are phone messages sent:
How are phone messages opened:
How are phone messages replied to:
Backup
Is there a backup system:
Who backs up:
When is backup done:
Does someone take backup disk home:
Training
Who needs training:
Create training schedule:
Transition Process
Discuss transition to going paperless
Discuss gradual vs. one-day implementation
Expectations
Discuss expectations
Discuss problem resolution
Discuss guarantee
Are you working within a budget
Hard Copies
History and Physical Exam
Follow-up exam
Surgery booking slip
Postop exam
Prescription
Requisition
Superbill
Business cards
Illustrations
Logo on disk
How you implement your EMR will depend on your Doctors, your specialty, and the size of your Clinic. Hopefully, the EMR will have enough tools that every Doctor can find a match for his/her needs. You may expect the EMR to slow you down at first, but Clinics usually regain their optimal productivity in a few weeks.
Overall, most Clinicians like their EMR because it makes them more efficient and profitable. Implementation is not a "breeze," but with adequate training and support you can overcome any obstacles in a relatively short period of time.
medical coding training at home.