Electronic Medical Records (EMR)

EMR systems are rapidly becoming the standard for modern medical practices. What can EMR do for you? Many things, but mostly, EMR will make your practice more efficient and optimize your efforts and your medical billing operations. This article looks at some of the ways in which EMR will improve your operations.

Coding
Coding refers to the assignment of a CPT code and a diagnosis (ICD-9) code to a patient encounter. With most EMR programs, the program will determine the correct CPT and diagnosis code and enter this in to the billing software. This saves you time because you won't need to look-up codes. It also ensures coding to the proper digit-level (4th and 5th). Another great feature of EMR is that is will "up-code" when it is appropriate. For example, suppose the provider assigns a 99212 as the E/M code and then documents the encounter in the EMR system. The EMR system will automatically determine if sufficient documentation exists to up-code to a 99213. This feature alone can save your practice thousands of dollars per month and will literally pay for the EMR system.

Task Management
Task management is one of the greatest features of EMR and also one of the most overlooked. Huge inefficiencies exist in typical practices in the flow of patients. For example, at a particular moment, you may have two of your three exam rooms empty, five patients in the waiting room and one patient in an exam room waiting for a doctor. Meanwhile, the physician is on the phone, on hold, with a consultant physician. Nothing is getting done and everyone feels busy. With EMR, task flow is optimized so that the nurse moves patients and providers through the tasks as efficiently as possible.

One example is the wireless note feature. A provider can be in an exam room with a patient, even though he's waiting on an important phone call. When the call comes in, the nurse can wirelessly send a note that appears on the physician's handheld tablet. The physician can quickly answer the note and continue with his exam-room patient.

Another example of EMR task flow management is the entire office view of the practice. By looking at the main screen of the EMR, one can see the entire practice and what everyone (staff, providers and patients) is doing.

Documentation
Documentation is a great benefit of EMR. When the provider leaves the exam room, all documentation, referral letters, prescriptions and orders are completed. The provider can smoothly move from room to room. Also, the time in the exam room counts as face-to-face time for E/M coding purposes. A good EMR program has complete body diagrams and graphics that allow you to document exactly your findings. Another advantage is the default, normal findings feature. Each patient encounter begins with a standard template. On this template, that later becomes your medical record note, is a list of all your exam items with default verbiage already inserted. This makes it necessary to only document abnormal findings. The ease and speed of using EMR for documentation will eliminate the need for dictation and transcription services.

Is it worth it?
Only you can determine the cost-benefit balance of your practice. Many providers find that the cost savings of eliminating transcription costs pays for the EMR service in 6-18 months. A key factor is the provider's comfort with technology. If the provider embraces new technology and will use the EMR system, then it will pay for itself in improved efficiencies. If the provider dislikes computers and technology, then the implementation and realized benefits may be slower.

Your Medical Billing Company at Work
AccuStat Medical Billing LLC is a leader in practice management and billing operations in Texas. EMR implementation is part of the state-of-the art service at AccuStat. AccuStat recommends the MediNotes EMR platform. If you are considering outsourcing your medical billing operations and implementation of EMR, give us a call at (866) 846-2012 or send an e-mail to accustat@excite.com.