How to Evaluate an EMR today...

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The Healthcare Information and Management Systems Society (HIMSS) frames healthcare public policy and industry practices. According to HIMSS, the following are the essential attributes and requirements on an EMR:

• Provides secure, reliable, real-time access to patient health record information.

• Functions as clinicians’ primary information resource (i.e., it is THE medical record).

• Assists with delivering evidence-based care (i.e., many EMRs give suggestions or reminders to aid with patient care).

• Captures data used for continuous quality improvement, utilization review, & risk management.

• Captures the information needed for reimbursement.

• Can support clinical research, public health reporting, and population health initiatives.

• Supports clinical trials and other research.

An EMR meets the security requirements which allow it to be the legal medical record and thus, paper files are optional.

What is an Automated Medical Record (AMR)?

This is usually a “template driven” document production system, whether on a single computer or stored online. In general, an AMR lacks the interconnectivity of an EMR. Because the information stored on such a system doesn’t comply with legal requirements for electronic medical records, a paper file must be maintained.

What is an Electronic Health Record (EHR)?

This implies a sophisticated level of interoperability within the community. The implication of the word ‘Health’ as opposed to the word ‘Medical’ (in EMR) is that it is a longitudinal record of an individual patient’s health record. In other words, an AHR or an EMR might be part of a patient’s total EHR.

EMR Evaluation Tool:

The following are features of EMRs. When evaluating a system, ask yourself if the program can perform these functions. Remember that an AHR may be sufficient for many practitioners, so just because a program does not meet the requirements of an EMR does not mean that it will be useful. It may be necessary to determine what your needs really ARE.

1. FUNCTIONALITY

General Points:

Does the system record ALL patient clinical data and not specific metrics of interest?

Can it function as the LEGAL medical record?

If you use this system, can it substitute for the paper chart so that a paper chart is not necessary?

Is the system used for POINT OF SERVICE DOCUMENTATION (not retrospective data collection)?

Does the system meets hospital security standards for EMRs?

Data Capture: Does the system . . .

Allow you to record and review lab results?

Allow you to record and review radiology reports?

Allow you to record and review other test results?

Allow you to record and review progress notes?

Allow you to record monitor current and past meds and med refills?

Documentation functions: Does the system . . .

Create the Review of Systems (ROS) using only “point and click technology” (no typing, transcription or voice recognition)?

Allow you to create “free-form” notes if you wish?

Allow you to create notes using a combination of point-and-click and free-form technologies?

Give you the ability to Customize templates (without relying on vendor)?

Allow you to create and maintain problem lists?

Allow you to create and maintain medication lists?

Allow you to Identify allergies?

Does the system document over all patient care?

Wound care documentation: Does the system . . .

Record wound measurements?

Select wound care products with “point and click” technology?

Allow you to update your product list (without support from the vendor)?

Automatically archive digital photos labeled by location (i.e. there are no manual steps in archiving the photos)?

Does the system automatically Graph wound measurements over time?

Prescription writing functions: Does the system . . .

Receive drug-interaction alerts when writing prescriptions?

Receive drug-allergy alerts when writing prescriptions?

Automatically print prescriptions?

Automatically update the medication list with new prescriptions?

Documenting labs and tests: Does the system . . .

Allow you to enter lab orders?

Allow you to enter radiology orders?

Allow you to record interpretations of labs?

Allow you to record interpretations of tests?

Perform the following correspondence function: Does the system allow you to . . .

Automatically generate consultation letter to the referring physician with copies to other health care providers?

Automatically generate treatment updates to the referring physician?

Automatically attach the initial photo and a follow up photo of the wound to correspondence?

Perform the following patient education function: Does the system allow you to . . .

Automatically print out pertinent educational materials with patient’s name on them when final documents are printing?

Document that educational materials have been provided?

Perform the following security functions: Does the system allow you to . . .

Maintain security related to patient information (e.g., password protection, audit trails)?

Perform the following coding and charge-capture functions: Does the system allow you to . . .

Receive E&M coding advice for the physician?

Capture appropriate charges automatically from the notes?

Provide an internal “Acuity Scoring System” to determine facility level of service?

Guide correct coding of the wound or ulcer?

Link any procedures to the wound code?

Perform the following practice analysis functions: Does the system allow you to . . .

Perform your own analyses of patient outcomes (without vendor support), such as time to healing of stasis ulcers, etc.?

Find patients with certain characteristics?

Create reports of clinic functions (e.g., levels of service over any time period, patient acuity score by staff)?

Track inventory: Does the system allow you to . . .

Tack inventory using bar code system?

Automate supply ordering?

Automate clinic inventory tracking?

Allow automated DME ordering of wound care supplies?

2. SOFTWARE INTERFACES

Does the system interface with the hospital EHR (via HL7 interface)?

3. OVERALL EASE OF USE AND FLEXIBILITY

Does the system allow individual user-specific customization?

Does the system minimize data input (i.e, do you have to enter data more than once somewhere, either on paper on in the EMR)?