April 2001 Bulletin

Key to EMR is current transcription process

Preparing now can jump start transition to electronic medical records

By Ronald B. Sterling

The implementation of an electronic medical record (EMR) system is an involved process that requires a lot of decisions and even more planning. Whatever your timetable, you should prepare now for your transition to EMR.

A key preparation strategy involves your current dictation and transcription process.

The lack of any clinical information in the EMR is the dilemma on day one. Everything is in the paper record. Indeed, any EMR effort will require both paper and computer medical records for a period of time that could last a year or more depending on a number of factors. This creates a massive logistical problem that increases costs and disrupts patient service and flow.

The average orthopaedic practice spends between $12,000 and $16,000 per year per doctor transforming dictation to the written word. In most cases, the transcription is stored in word processing files in a computer.

A non-disruptive EMR preparation strategy is to capture transcription in a form that can be used to jump start your future EMR. In order to capture and retain information for future use, you must organize your transcription documents and secure them for future use.

In many cases, transcriptionists save all of the documents from a tape, doctor, or day in a single file. Typically, these files are stored in computer subdirectories organized by type of document, time, practice location or provider. Unfortunately, documents stored in this matter will not make good candidates for loading information into your future EMR.

In order to capture your transcripted documents now for future assimilation into your EMR, consider the following:

One document per file. Only a single document should be stored in each file. Thereby, you can manage, track and account for each document.

Consistently record key identifying information in all documents. In order to load a file into an EMR, key identifying information must be consistently entered in the file. For example, the patient name, number, date of birth, physician name, and one or two other items should be consistently recorded in every document file. When you load these documents into your future EMR, the programmers will be able to easily identify where the transcription information should go.

Securing your document. In order to use transcription documents in an EMR, you must be certain that the electronic file is the image of the document that is in the patient record or was sent out to a referring physician, patient or other party. Your practice will have to make some adjustments to the procedures used for transcription as well as invest some money in a repository for your document files. A document repository will store and manage your documents so that you can limit access to the documents. Improving security over the documents will help you meet selected requirements of the Health Insurance Portability and Accountability Act (HIPAA) as well as limit the problems with multiple versions of documents.

Prevent or track changes. In order to build a set of documents that could be used to start up your EMR, you want to be confident that the documents have not been modified and that they reflect the information in the patient’s file. After the document is completed and approved, the document should be locked from further modifications. You may want to allow annotations through the document manager, but you ultimately want to be able to view the original document as it was on the approval date.

Your move to an EMR can capitalize on a substantial annual expense for transcription. By planning now, you can create an asset that will have enduring value to your practice and EMR plans. This investment will pay substantial dividends when you bring up your future EMR with several years of transcripted documents available online on day one.

Ronald Sterling, CPA, MBA, of Sterling Solutions, Silver Spring, MD, is a nationally recognized expert on electronic medical record and practice management systems.

Computer Link welcomes suggestions about future topics for the column and questions about the use of computers in orthopaedic practice. Send your suggestions to the Bulletin at AAOS, 6300 N. River Rd., Rosemont, Ill. 60018.

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