STS News, Summer 2018 -- Most cardiothoracic surgical practices have converted, are converting, or will convert from paper medical records to electronic health records (EHRs).
The benefits of an EHR system include transparency, improved documentation and communication, reduced omissions, improved reporting, remote access to records, and increased collections. The improved documentation is reflected in both better legibility and content of notes. Transparency and communication impact care teams spanning both the inpatient and outpatient areas, as well as referring physicians and patients.
The ability to customize and optimize the EHR to your practice is a powerful tool. Many teams decide to standardize their documentation. You can build templates that ensure you capture all relevant clinical data and succinctly communicate with referring providers. You also can capitalize on discrete fields to capture data required for database reporting and billing requirements. As more EHR systems offer the option of releasing notes to patients, you can establish protocols for how you want those notes to look. Although standardization can be time-consuming, especially if you have many stakeholders and require consensus for practice changes, it is a worthwhile investment that can really pay off.
The benefits of an EHR system include transparency, improved documentation and communication, reduced omissions, improved reporting, remote access to records, and increased collections.
The transition to electronic records is not without its challenges, however. Staff members tend to require “staged learning.” They need to be trained and allowed to use the EHR system, with subsequent ongoing training to evolve their electronic documentation and streamline their work. This implementation requires time, resources for ongoing evaluation, and a lot of patience.
Another challenge is downtime. Paper charts never have downtime, but EHRs do. Generally, the frequency of downtime is not a significant issue, but you will need to develop procedures that accommodate downtime.
One very important aspect to consider when implementing an EHR is exam room setup. Some feel an EHR reduces patient interaction by putting the physician’s focus more on the computer than on the person in the exam room. This perception can be minimized by paying close attention to where the physician and the patient will be seated in the exam room, as well as ensuring that templates are in place so that the physician can complete the required fields quickly.
As with any transition, there will be challenges moving from paper records to an EHR. What you can count on needing is patience, time, and resources to build the system, to continually train your staff, and to tweak the setup. What you can expect in return are practice improvements that help with efficiency, communication, documentation, and reporting.