What is an Electronic Medical Record?

An electronic medical record is a software that is developed to obtain patients history, and presenting complaint. It is literally an entire medical record recorded via computer. You may see the nurse as well as the physician enter the room with a tablet and a stylus. As they ask you questions they mark down your answers accordingly. This is then recorded directly back to the main computer. All records have now just become an e-file. In theory this is supposed to expedite care and make life easier for patient and provider. There are atrocities that can occur. Specifically ethical violations. Please see: http://www.peaceandhealing.com/medical/electronic-medical-record-fraud-emr/

For the most part, this system runs smoothly as long as the computer does not crash or a glitch in the program occurs. There are difficulties, adding new diagnoses, a learning curve that is much longer than hiring a new employee and stating, “write the record.” We all learned how to write, did we not? In looking at the competition out there selling their programs, everyone has the best, the most efficient. I was speaking at an urgent care convention on the topic of insect bites. During the break we browsed the exhibitions and listened to individuals, some physicians, some marketers touting their wares. The word “exhibition” is very appropriate here. It was humorous listening to a physician explaining why his EMR system was superb and it had not even been fully developed yet. When the booth ten paces down also had the best EMR system. So is life in the sales  market.

It is my assessment they are all very, very similar, and achieve very much the same effect. What is important, VERY IMPORTANT, is that the owner of your clinic or clinics is ethical. It is also important that they teach the employees the importance of coding properly. Up-coding the act of marking boxes on an exam to inflate prices can be done intentionally or unintentionally, especially if one is not aware of the outcome with billing.

Let us hypothesize why (EMR) Electronic Medical Records were developed.Was there this hypothesis that physicians got together and discussed this will be in the best interest of the patient? Was there a discussion that implementing e-records would be more proficient in terms of treating patient? Or, was there the insight that it would expedite care, less handwriting, which equates to more patients seen, which equates into more revenue. Hmmm I wonder. When the record was implemented then it was noticed that there could be up-codng and bills could be increased. Insurance companies could be charged for a higher service than was actually rendered.

Since 2008 there has been a twelve percent increase in EMR fraud cases. That number will clearly go higher in the years to come. There are clinics and physicians that are highly ethical and never over charge. I work at one at this time in my life and I feel blessed. I have experienced both ends of the spectrum on this issue and I will take the ethical one any day.

If you or your company is seriously looking at obtaining an EMR system. Look closely, get a variety of opinions, you know everyone has the best software, the best program. In the end it is how you instruct your clinicians and staff and reflect back on why you pursued medicine. Do not forget the patient. Spend the time, give eye contact, and do not just rely on the EMR. Rely on your skills and empathy.