August 2001 Bulletin

1st step for an EMR: define medical record

Electronic medical record needs content that meets your needs or toolkit to add your own

By Ronald B. Sterling

Electronic medical record (EMR) systems consist of two key components: the toolkit and the clinical content. The toolkit is the technology base that allows you or the vendor to add specific data items to the EMR. For example, you could add a question about seat belt use to an injury report in the vendor’s medical record. Some toolkits allow you to develop any clinical information you wish, while other toolkits allow for few changes to the underlying clinical record format. Some products do not allow for any changes to their clinical information. The clinical content is the various pieces of orthopaedic information that are used to describe and measure the patient’s condition.

When you are looking for an EMR, you must make sure that the clinical content will meet your needs, or the product includes a toolkit that will allow you to define your own clinical content. Even if the vendor has orthopaedic content, it may not reflect your specific area. Medical record content can be effected by your specific area of expertise (example: hands or hips), services offered (example: PT and ASC), and even your payers (example: employers). In order to measure the effectiveness of the EMR for your practice, you need to determine what are the important components of your practice’s medical record.

One of the more complex problems with EMRs is defining a medical record for your practice. If you wait until you have selected an EMR, you may find out that the product cannot handle the information you wanted to manage. For example, several practices have purchased systems to find that they must expend significant time and effort building clinical content that meets their needs.

In order to set the stage for your future use of a medical record, you should define what a medical record is. This process may take a long time depending on your practice and physicians, but the investment will be well worth the effort when you do move to a medical record.

Defining a medical record for your practice requires a focus on using a common format for all providers. Many EMR vendors are fond of saying that their EMR will let every doctor keep their own medical record in their own format. Although this may sound attractive, the results could be disappointing. Using different medical record formats and standards will add costs to implementing and maintaining the system as well as limit use. For example, you will have difficulty selecting records for reports if each physician uses different data items or measures of severity. Similarly, clinical staff could have difficultly locating information if each physician uses a different structure.

In order to establish a standard format, you can start with a paper form long before you invest in an EMR. A clinical form is a piece of paper that contains spaces for the various information that you would collect for a specific patient condition (example: evaluation of a shoulder injury). The form should not be designed to deal with every possible condition, but handle the key issues of care for patients and the practice. In the end, you may end up with a number of clinical forms that are used by physicians in the practice.

The form should include blanks for the information to be collected. In some cases, you can use check boxes for standard response items (example: duration and severity). You should also leave space for free form comments.

And what happens if your physicians cannot agree on a clinical form, use their own forms or don’t use any forms? These problems will just demonstrate the ability of your practice to take advantage of and implement an EMR. In the worst case, you will discover that the physicians are not ready for an EMR. And in the best case, you will end up with a paper standard that will help you evaluate EMR products and determine if the products can accommodate the nuances of your practice and clinical standards. More importantly, you will have a ready to go guide for setting up your EMR.

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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