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Residency Insight

Electronic Medical Records: If not now, then when?

The terms Electronic Medical Record (EMR) or Electronic Health Record (EHR) have become commonplace discussions within our profession. Clearly, computers have had a strong place in the front office of most practices for well over a decade now, with the majority of insurance claims being submitted via electronic rather than paper means. However, it really has not been until very recent years that computers have made their way into the back office or treatment rooms.

More likely than not, your hospital or large clinic environment is using some degree of electronic management for health information. Most hospitals and health systems have strongly embraced electronic imaging for radiological services and viewboxes / x-ray film are quickly becoming a thing of the past. This is a much needed step to assure the availability and integrity of these images, and I can tell you that it has made a huge improvement in the way we care for patients at our University hospital. As many of you know, it was commonplace for the old x-ray folders to be checked out, in a resident’s car trunk, or lost. This was not only a problem for your bunion case pre-op, but was a huge medical-legal liability.

The next big step that is being taken is the transition from paper to electronic charting in the hospital, clinic, and private office environments. Again, because of the shear volume of information and number of transactions, hospitals and large group clinics have led the way to this technology, but the industry is rapidly being embraced by private practices as well. In particular, the Veterans Administration Medical Centers were way ahead of the pack with their VistA software which has been credited with vastly improving the quality of care at our VA Hospitals and Clinics. CMS has now made an office based version of this EHR software available to private practitioners through a vendor licensing program (http://www.vista-office.org/). Another very popular EMR program that has been embraced by many podiatric practices is Charting Plus by Medinotes (http://www.medinotes.com). If you search the internet, you will find numerous other providers and software reviews.

Speaking from someone who is working very hard to transition a hospital clinic deeply rooted in paper charts, I can tell you that the time for EMR is now. If you are just starting practice or preparing to, I strongly encourage you to take the step toward EMR now rather than later. It has been proven that EMR is advantageous over paper charts in numerous categories. These include fully searchable database for research, coding capture allowing higher billable documentation, data safety, universal availability, increased office efficiency, and decreased medical errors. There is really little debate that we are moving this direction, so getting involved now will just make the transition that much easier…

Any stories, feedback or questions about the experiences that you've had in your residency program? Let's make this forum more interactive. We're not looking for gems here...just the sharing of your personal experiences. Please share your comments by sending a note to jsteinberg@podiatry.com

John S. Steinberg, DPM
Editor, PRESENT

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