Electronic Medical Records

Healthcare system replaces time-consuming review process with a content-management system for developing and maintaining evidence-based order sets.

In the spring of 2008, Aurora Health Care experienced tremendous growth and was set to launch two healthcare facilities. The creation, adoption and maintenance of clinical order sets within the hospitals and clinics at Aurora was time consuming and inefficient. The process for summarizing clinical evidence, creating, reviewing and standardizing order sets, particularly in reaching a consensus among the physicians, was slow.

An Aide for EMRs

By Farida Ali, CEO, Dynamic Computer

The industry is witnessing the beginning of a trend of including automatic identification and data capture (AIDC) with electronic medical-record (EMR) adoption. EMR adoption has lagged despite a strong push from both private and public entities. Simultaneously, there has been an increase in the adoption of real-time locating systems (RTLS) and other technologies in the healthcare market. The paired adoption of EMR and AIDC systems holds the highest potential for improving patient care, reducing costs and minimizing risks.

AIDC refers to methods that automatically identify objects and then capture data about them directly into computer systems. These include radio frequency identification (RFID) technologies, bar codes, biometrics, optical character recognition (OCR), voice recognition and other electronic means of automatically identifying people and tagged objects.

Electronic medical records system links to Web-based software, providing a secure and reliable way to connect with various practice-management and EMR systems.

With the increasing adoption of electronic medical-record (EMR) systems, Winchester, Va.-based Piedmont Medical Laboratory (PML) knew it needed to find a secure and reliable way to interface with the various practice management and EMR systems used by its physician practices.

While many larger national labs are offering connectivity services, such as electronic test ordering and results reporting, to their physician practices, PML did not have the internal resources required to develop and manage the integration process – a significant competitive disadvantage that was resulting in revenue shortfall and potential loss of clients.

The time and cost clinicians and staff spent on maintaining a high level of patient care, while facing the administrative challenges of a paper-records system, was significant in the decision to go digital.

In 2008, Memorial Hospital of Sweetwater County (MHSC) decided to implement an electronic health-records (EHR) system, due to the time and cost clinicians and staff spent on maintaining a high level of patient care, while facing the administrative challenges of a paper-records system. The amount of excess time and money spent on caring for patients using an inefficient paper system was time consuming and costing the hospital too much, according to Linda Simmons, RN, and vice president of operations and chief nursing officer at MHSC.

With the criteria to achieve meaningful use now with the Centers for Medicare and Medicaid Services (CMS) for rule making, provider organizations that want to receive incentive funds under the Health Information Technology for Economic and Clinical Health Act are turning their attention to achieving the program’s specific care goals. Central to these are the use of computerized physician order entry (CPOE), and deployment of evidence-based order sets and other clinical decision-support tools.

By using electronic records, physicians no longer need to rely on nursing staff to interpret written orders or protocols appropriately.

For decades, narrative transcription has contained a wealth of important patient information. Dictation is the fastest, easiest way for physicians to document encounters and the output, a transcribed report, is easily read by downstream users – clinicians, coders, billers, payers.

Medical group decided that to be most successful with EMR adoption, 100 percent physician population utilization would be necessary.

Today, 40 physicians at Slocum-Dickson Medical Group (SDMG), a physician-owned medical group located in New Hartford, N.Y., are using real-time speech recognition to dictate into their electronic medical record (EMR) system.