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The nemesis of healthcare providers is the electronic medical record or EMR. Why is it so hard to find the perfect EMR? Walk past any clinician workroom and there are usually exasperated sighs as users try to solve the tech riddle of the day. From lockouts, to system down time, to smart phrases and jelly beans; it’s a dizzying array of jargon and clicks that leaves users lost in the virtual wilderness. Let us not forget training your Dragons and other speech recognition software. Here we’ll explore ways to optimize your electronic medical record and how to stop drowning in dictations no matter which EMR you’re using.
Electronic medical record platforms
There are various electronic medical record platforms on the market. For the sake of brevity, I’ll mention the platforms that are the most popular. Athena Health seems to be widely used among retail clinics and private practice. E-Clinical works is also widely used among private practice clinics and family medicine. The Godzilla of EMR’s is EPIC, an intricate platform able to connect institutions across states. It is the premiere platform of the VA network.
If you haven’t heard of EPIC, you will. It no doubt will be coming to an institution near you soon. In ranking ease of use, I found Athena Health to be the easiest. Athena’s easy click templates could be completed within minutes. E-Clinical works comes in second due to its intuitive formatting and jelly bean system. How can you not like jellybeans? Then EPIC comes in third. The amount of personalization options in EPIC is well, epically overwhelming. What do all these platforms have in common? They all have customizable templates, unlimited clicks, and personalization options.
How to use personalization of your electronic medical record to your advantage
1. Learn to type.
Typing is essential for using any EMR. You not only need to know how to type but how to be proficient. You can practice typing on websites like keybr. You’ll need to have some level of speed in order to get through your notes as efficiently as possible.
2. Optimize usage of your speech recognition software
If you have Dragon or Fluency Direct software for dictation, create key phrases and format lines of text or even paragraphs to be entered into your note with a key phrase of your choice. For example, if you wanted to have your whole assessment and plan entered for a typical diagnosis only using a few words, you could. Don’t skip out on a one to one session with the speech recognition specialist. Take advantage of placing the software on your smart devices as well so that you can dictate anywhere.
3. Format templates
Keep your templates limited to the basics so that you can add on as you document. The most important aspects of a note include basic components like patient demographics, chief complaint, history of present illness; past medical, surgical, social, and family history; physical exam, diagnostics, and assessment/plan. You can create templates based on type of note, age range, and commonly seen diagnosis, to name a few options. Pretty much anything you do repetitively can be customized into a template, including frequently used orders. If the platform offers a mobile option for smart devices, be sure to download it so that you can work remotely.
4. Don’t click every option available
These EMR’s usually have unlimited clickable options. Avoid the temptation to populate your note to make it “look pretty”. This always leads to a black hole. Only chart what’s pertinent. Providers can be very conscientious about their documentation and feel the need to not only create accurate presentations of the clinical situation, but also to make the notes “pretty”. This is a time wasting mistake. Just like the old TV show saying, provide “just the facts ma’am”. This way you won’t get hung up on documentation.
5. Chart as you go
Don’t wait until end of the shift to start working in your EMR. The most effective way to move through your day is to “pre-chart” if you have that option. Pre-charting is where you can create a “skeleton” note before seeing the patient. If you don’t have the option to pre-chart, start your documentation as soon as you see the patient. Log-in and do your medication reconciliation. Document your review of systems, allergies, and chief complaint right there in the room with the patient at the beginning of the visit.
I know this can feel like an interruption in patient care, but remember to make eye contact as you move through the sections. After brushing up on your typing skills, you’ll also be able to type without having to look at the screen or keyboard too often. Anything else can be done once you leave the exam room. Always try to document your assessment/plan immediately after the visit.
Utilizing an electronic medical record can be a complex transition for healthcare providers. With these tips stop letting your documentation pile up and learn to optimize your EMR usage. Spend less time on notes and more time with your patients. If there are any mobile friendly options download corresponding Apps. EPIC has a mobile App called Haiku. So does Fluency Direct for mobile dictation. All of these options will keep up with your busy pace throughout day and allow you to take work on the go. These tips are especially useful if you’re on call.