MedicalTranscription.com

What is an Electronic Medical Record?

Many of us have heard rumblings of things to come in health information management... new code sets coming out, data encryption technologies, confidentiality and security requirements and more. Some of us have already been asked by our physician clients, "What can you do for our practice in terms of a paperless system?", and replied only with the panicked sound of "Hominahominahominahomina..", without even realizing that what we're being asked is really beyond the scope of the medical transcriptionist. But we are the frequently looked upon as "the health information know-it-alls" by the medical practice and it would serve us well to "bone up" on what EMRs are and how a practice might explore them -- of course, in a manner that includes our service as the continued provider of medical transcription.

To put it in a nutshell, an electronic medical record is one that exists in a digital format, which like any other digital file, can be easily transported and stored on varying computer systems. Many transcription services that are already providing documents in a digital format, either via e-mail, ftp, direct modem or any other method, are in a sense creating an electronic medical record, albeit in a very limited state.

As we know, a medical chart contains many documents other than the transcribed patient note, OR report, or consult letter. The patient chart is a collection of lab reports, photographs, prescription copies, radiology reports, EKG tapes and more, and when viewed in its entirety, provides the physician with an overall picture of the patient before him.

A complete electronic medical record, therefore, will incorporate all of these elements AS WELL AS the transcribed patient note into a digital format that can be easily accessed and stored. Some of these elements, such as those created by hand like prescriptions and hand written notes, as well as EKG tapes and photographs, exist as "images" within the electronic medical record. They can then be accessed and viewed, but rarely can be used as data elements when searching for specific information found within them.

The EMR is attractive for a great many reasons:

Accessibility: An electronic medical record, depending upon its structure, can be accessed by multiple people from multiple locations. A physician seeing a patient in his satellite office can view the entire patient chart remotely without essential patient documents leaving his main office. A patient following up with a physician after an ER visit might have information that can be accessed from across town, or across the country. Different departments within a health care facility can view the EMR, as can multiple physicians in differing specialties who collaborate on patient care. The design of the EMR dictates its functionality in terms of access.

Storage: A common problem in many medical practices is that of patient record storage. Additionally, with new security regulations coming out, the patient records will need to be stored in a central location with limited access, thus making space even more of a commodity. When patient records are stored in an EMR format, "space" is not nearly the issue that it once was. The average CD-ROM holds approximately 600 MB of information, or about 100,000 pages of text. Images, however, will take up more space but the result is clear: CD storage is far better than paper.

Coding and Billing: The data contained in the electronic medical record can be easily "viewed" or "processed" for coding and billing procedures. The coder or biller can access the record as easily as the medical providers, and when the entire patient record is easily accessed, less information "falls through the cracks" and the insurance carrier is billed more accurately for reimbursement. Additionally, there are now coding "engines" that can process digitized medical information and perform coding and billing tasks with less human intervention.

Informatics: The data contained in the EMR has many other uses. A physician can easily determine the status of one patient, or of a group of patients. Trends can be analyzed in terms of prescribing habits based on symptoms, diagnosis, physician, geographic area or just about any other parameter. Outcomes linking specific drugs in specific cases can be tracked and predicted, clinical trials can be analyzed in any number of different ways. Costs can be contained by analyzing treatments and their success. The possibilities of data use are limitless.

What Does This Mean to the Medical Transcription Service?

Obviously, medical transcriptionists are not going to become the providers of entire electronic medical records systems, unless they are very large and aligned with IT specialists within this emerging field. But it does make sense for the medical transcription service to at least understand the basics of EMR, and it probably wouldn't be a bad idea to learn in advance which EMR systems are out there, and which ones allow ease of integration of the product of medical transcriptionists, i.e. the dictated document, into the EMR.

A well prepared medical transcription service will have done a bit of research into how word processed documents are interfaced into the various EMRs, and what the features are, for the magic day when asked, "How can your service help us change into a paperless medical practice?"