With the complexity of practice workflows and implementation, choosing the right EHR can be challenging for any office. Even more the number of EHR vendors certified for Meaningful Use Stage 2 has dwindled from Stage 1, making it a bigger challenge to find an EHR for Meaningful Use . However, to get started with switching to electronic medical records, you may only need a Basic EHR.
The National Center for Health Statistics (NCHS), defines a basic EHR as a system that include functions for patient history and demographics, patient problem lists, physician clinical notes, comprehensive lists of patient medications and allergies, computerized orders for prescriptions, and the ability to view lab and imaging results electronically.
A word of caution that if you plan on taking part in the Meaningful Use program and attesting for incentive payments, your EHR vendor needs to be ONC Certified. In addition, a basic EHR should have features that improve the following:
A basic EHR for Meaningful Use will have the ability to enter Patient demographics, Past Medical History, Current Medications and Allergies. In addition, this information should be easily stored in the patient’s chart for referencing later. You should never have to enter information twice and modifying entries shouldn’t be a hassle either .
EMR templates make it easier to capture necessary past medical history along with the capability to document the details of a HPI, Review of Systems, Physical Exam and Plan efficiently. A good EMR template will allow for either manual entry, voice entry and clickable data entry such as drop-down menus and checklists. This flexibility ensures chart notes contain the necessary documentation to stand up to coding requirements.
Progress notes and prescriptions are easily readable when entered with a computer. By typing and/or template entry, you will eliminate the need for deciphering sloppy hand-writing and/or prevent dangerous errors to the patient such as medication errors or drug interactions. [One report claims physicians had their medication error rates reduced by 50% nearly 1 year after adopting a commercially available electronic prescribing (e-prescribing) system]
A basic EHR for Meaningful Use although not as fully functional as a complete EHR, should still allow the user to track medical conditions over time and/or alert the physician when a patient needs follow-up work or testing. For example, decisions Support alerts are basic feature meant to assist the physician with making important medical decisions in a timely manner.
The ability to electronically receive lab and imaging results directly into your patient’s chart with an electronic interface will save you time and money and eliminate the need for paper copies.
As the adoption rates for basic EHR’s have varied with splits ranging from 21 % in New Jersey to 83% in North Dakota, many practices are still without an Electronic Health Records system. If your practice is still without an EHR, keep in mind you could suffer penalties in the near future. Don’t delay if possible. Get more information on a basic EHR to help you achieve Meaningful Use.