Adaptation of an electronic medical record


Anne-Louise Ignacio

Unit: Individual Project

I propose the adaptation of an electronic medical record in place of the traditional paper medical record in a pediatrician’s office.

Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.  With this in mind, I believe that there is a great need be able to ensure that important medical information is accurate and at the same time easily accessible. 

Drawbacks of paper medical records:

• They can be incomplete, torn, worn, misplaced, or lost.

• They also require a lot of storage space

• Requires extensive administrative time from your staff.

Objective:

To convert from paper medical records to a more accurate, reliable, and efficient filing system called electronic medical records or EMR, which will tremendously improve the quality of services provided by the physician to its patients and thus, improve satisfaction of the patient in terms of services/treatment received.

The advantages of electronic medical records are many:

1. Health Maintenance Reminders: The clinical importance of reminding patients for checkups is essential for quality of care - but it also can boost your revenue with more patient visits.

2. Increased Office Space: If your practice currently utilizes paper charts, your file rooms can be converted to serve a greater practice purpose. Additional exam rooms and patient education centers are just a few of the new uses that investing in an EMR can offer your practice. EMR significantly reduces wastage of space due to additional paperwork in the office. Since all the record will be electronic, there is no need to devote extra space for these papers and can be utilized for other useful purposes.

3. Improved Per Visit Revenue: Physicians that depend on dictating their office visits sometimes forget to document every aspect of a patient visit.  Missing this information causes physicians to miss additional revenue from being able to code at a higher level.  By structuring your EMR to prompt you (and thereby, you documenting) detailed aspects of the patient visit, you can increase your per visit revenue by being able to satisfy a higher level of service.

4. Improved Efficiency:  When it is easy to find patient charts, physicians and staff spends less time wandering around the office in an attempt to find them. Therefore, considerable time and effort is saved by implementation of this system.

Most practices can expect to earn their investment money back, as long as they avoid the pitfalls by planning for a successful software implementation.  EMR’s can cost anything from $10,000 to $40,000. This depends on the needs of your office. It will be customizable, will grow with your practice, and can be easily adapted to provider specifics. Depending on the size and number of files involved, conversion into paperless records could take anywhere from 3 to 6 months.

Who are the main people or departments that need to be involved in this project?

Since this is a relatively small office, the physician as well as its staff would be essential. This can be done in-office as well as out of site. Therefore, all the employees in the office along with the physician will be involved in the project as the new system will be utilized and used by everyone in the office and it is necessary to understand its usage, peculiarities, features, advantages and risks.

What are the risks involved?

There are certain risks when converting from paperless to electronic records. One of them could be the time the staff will have to dedicate to reach the result.  However, with proper planning and allocation of work, this should not be a problem. Some of the major risks are:

• significant loss of time and effort on transformation of these data to electronic forms

• transfer of incorrect data which can be fatal for patient’s treatment in the future

• lack of understanding on part of the employees to use the system which may lead to generation of incorrect information about a particular patient.

Why would your project be considered a project?

Converting a medical office’s system from paper to electronic is a project since it is an undertaking that encompasses a set of tasks or activities having a definable starting point and well-defined objectives. (Webasyst, n.d.) It involves a particular objective, which needs to be met by a predefined set of activities in a particular manner and should be completed within a predefined budget and schedule. It involves activities outside the normal routine of business and encompasses resources of the business/profession.

References:

Expert system applications Inc. EMR benefits. (n.d.). Retrieved on March 24, 2006 from website: https://www.expert-system.com/emrbenefits.htm

Webasyst. Project. (n.d.). Retrieved on March 24, 2006 from website: https://www.medrecinst.com

Using the project you created in Unit 1 Individual Assignment, put together a presentation for the customer that includes the following:

1. Briefly describe the first five points of the Project Scope Checklist in relation to your project:

What are the project objectives?

List the deliverables.

Identify the milestones of the project.

List the technical requirements.

What are the limits and exclusions?

Identify the Project Priorities.

Create a Work Breakdown Structure.

Create a Responsibility Matrix.

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Business Law and Ethics: Adaptation of an electronic medical record
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