The information included in the EHR would be similar to the information that would be included in a paper medical record such as:
- Doctor's orders
- Progress notes
- Past medical history
- Laboratory reports
- Radiology reports
- Vital signs
- Surgical notes
- Nurse's notes
- and discharge instructions
Benefits of EHR
- Accuracy: Software requires complete documentation for coding. Medical errors in a paper-based medical record system can sometimes be related to incomplete documentation and illegible handwriting. Electronic systems come with features that make sure all information necessary for patient care is included on the form. Some EMR software packages have edits in place that require the user to add additional information as needed.
- Faster Results: Electronic information can be shared with other health care providers or patients a lot faster than paper records by providing instantaneous access to the entire record. Multiple departments can add clinical information to the health record without having to locate or checkout a paper medical record chart.
- Lower Costs: EHR eliminates copying expenses in addition to less administrative and clerical support necessary for transcription, documentation and requests for information. Although, providers may have the initial costs of implementing an electronic medical record system, the overall costs are less than those associated with the paper record. Paper medical records have higher costs due to the necessity of more personnel to manage, access, file, and maintain paper charts.
- Patient Safety: One important safety feature of an EHR is medication management. Physicians have instant access to what types of medication a patient is taking to reduce adverse reactions and medication errors. With all patient information in digital form, providers are able to track clinical issues more effectively allowing them to easily identify areas of risk. Processes can quickly and accurately be put in place in order to improve patient care.
- A secure computer network and internet connection to prevent malicious hacking.
- Limited access of PHI to medical office staff when the information is not necessary for their particular job function.
- Tracking software to log and monitor each time a staff member accesses or retrieves information as a way to flag suspicious activity.
- Distribution of the medical office duties in such a way that prevents any one person from having complete access to a patient's complete health record.
- Create a list of all the capabilities you will need your EHR software to have. Evaluate your current system and determine what you will need to improve it.
- Research and compile a list of at least 10 different EHR software vendors. Create a spreadsheet of all vendors and what they have to offer so you can have a clear picture to base your decision on. Make sure you include the cost of each system, the features they offer and whether they are web-based or an on-site system. Once you have evaluated all the vendors on your list, eliminated the ones that don't meet your budget or don't meet all of your needs.
- Contact all the vendors you selected in step 2 to set up a date and time for you and your selection team to review the EHR software. Have everyone on your team take detailed notes.
- Discuss with your team their impressions of the EHR software programs offered by the different vendors. Ins some instances, you may want to visit other facilities to see how well the software operates in a live environment.
- Once you've decided on the best EHR software for your organization, it's time for negotiation.