Your Medical Records Go Electronic

When was the last time you had a tuberculosis test or tetanus shot? Keeping track of your shot records, past medical procedures and medications, let alone your entire family’s records, is difficult.

Imagine managing the records of thousands of individuals and needing to track down one simple bit of data at a moment’s notice. This is where Electronic Medical Records (EMR) comes in.

EMR is a centralized platform that contains accurate health records on each patient. This platform allows authorized providers and clinical staff immediate access to patient health information.

Upon command, an EMR system can generate a summary of a patient’s demographics including his or her medical history, documentation of each encounter, symptoms, diagnosis, treatment and outcome, medical record and coding cross references such as history of allergies and adverse reactions. EMR also cross checks allowable codes to prevent any billing errors.

Benefits to implementing EMR include:

• Improved patient safety
• Improved physician access to information
• Reduction of dependence on paper-based documents
• Physician satisfaction through ease of documentation, e-prescribe, order/receive lab and radiology results, reporting tools, and clinical navigation
• Increased productivity
• Transition from paper charts and paper dependent workflows to a more streamlined and efficient approach

Karla Silva and Adrian Michael, M.D., are working together to ensure the transition to EMR at the Paul L. Foster School of Medicine is free from glitches.

Silva, the EMR implementation project manager and section manager of the EMR Department, believes that one of the keys to this project’s success is the participation of the physicians.

“Every physician should not only embrace the technology change, but the culture change as well, ” Silva said.

She said the physicians would take the lead and work with the rest of the clinical team to make clinical decisions for the project, and it is not an IT project.

“We are only the facilitators for the implementation and continuous support of the system.”

Adrian Michael, M.D., chief EMR officer, represents the physicians in planning, implementation and the continued use of EMR. Michael, who is also an assistant professor of rheumatology in the Department of Internal Medicine, believes the implementation of EMR will help physicians deliver clear and complete information during patient encounters, along with exceptional medical care.

He is currently gathering input from identified “physician champions” in each specialty area.

“I would love not only to see this campus completely on electronic medical records,” Michael said, “but to also have the physicians thoroughly satisfied with the system, and the modifications to their work flow which comes along with it.”

The team effort also includes a steering committee which provides overall leadership and vision, a project team to keep the project focused and progressing, a technical team which participates in hardware and networking decisions, and the clinical teams that make decisions regarding the standards for the clinics.

An EMR implementation consists of the following phases: initiate, plan, design, prepare, execute, and go-live and closure. The campus is currently in the initiation phase, which started on Dec. 20.

The go-live date for the first clinic, which will be the Department of Family and Community Medicine site, is scheduled for Aug. 30. The Department of Obstetrics and Gynecology will follow in mid-November and the Department of Pediatrics outlying clinics in mid-December. The rest of the departments will be implemented in 2012 and completed by the first quarter of 2013.