American Health Information Management Association (AHIMA) published a report that said 80%-90% of physicians use the function of copy & paste, while 20%-78% create notes from copied texts. It is not a surprise that physicians are making lot of mistakes while making notes in their Electronic Health Records (EHR) because of this practice.
Risks of copy & pasting in EHR
Physicians usually copy/paste the previous visit’s treatment plan as a follow-up. This may be dangerous to the patient’s condition in an intensive care unit (ICU), where minor incorrect information may cost their life.
Copying previous data in a hurry will put the patient in fatal risk, as the charts are not up-to-date with new details of the patient’s condition.
This is not only a risk for the patient, but may also be problematic for your Revenue Cycle. Let’s say physician copies patient clinical details from previous visit in the new chart and sends the details to billing department. The billing staff may create a duplicate claim, which is going to be declined by the insurance provider. In case if the claim is processed, then the physician will have to bear penalty during the audit.
Copy and paste issue in Electronic Health Records (EHRs) is a huge concern among healthcare professionals. Director of AHIMA, Diane Warner highlighted this issue while speaking at the MGMA event in 2013. Warner said that large number of medical errors had been the result of copy/paste function in EHRs. Also, physicians would bill inappropriately for the services they never provided.
She added that most of the physicians are using this function without the purpose of committing fraud by duplicate billing, but their unawareness has landed them in great troubles.
However, copy/paste is not a risk in every template. Physicians can use this function to copy demographics, some long standing histories and allergies, and regular medications.
But the best practice of data recording is to take down information on every visit of the patient, or inquire if there has been any change in previous demographic details of the patients. This way, the physician will avoid the possibility of any fatal mishap or audit fraud.
When I’m told of a generic Electronic Health Record (EHR) deployed at a pediatrician’s practice, the image of a small child wearing a free-size shirt comes to my mind. In simpler terms, it is too big for the child.
Similar to the oversize shirt on a six-year-old analogy, a generic EHR has been built keeping in mind the specifics for adult care. With a Pediatric EHR Software, however, vendors have incorporated the requirements of pediatricians into this specialty-specific software.
In addition to children-specific ranges, different categories such as more precise dosage scales (as children have less intake capacity than adults), growth charts and pediatric templates are also available.
Stop viewing your EHR as a government-enforced requirement and start focusing on how your practice can benefit from it. Here’s how you can do so:
Customize your templates
There are numerous customizable templates including those for abdominal pain, weight loss and adolescent psychiatry to choose from. Customize your favorites list to save time during patient encounters.
Next, tweak your templates to best suit the needs of your comfort and practice. Vendors offer free customization of a particular number of templates during the initial implementation process, so I’d advise you to do so right at the start.
However, if you haven’t done so or if you realize the need for changes later on, the vendors will charge a modest price. Don’t think of it as an added cost, but instead as an investment. This is because you’ll save a lot of time and effort if you accumulate patient visits over time, and that will be a huge cost saving in itself.
Tracking your patient
A pediatrician’s relationship with a patient is a long and delicate one; one that needs to be handled with the utmost care and responsibility. The effective documentation of clinical encounters, sick and wellness visits for example, will be pivotal in the estimation and analyses of different growth trends and illnesses.
You must also integrate customizable screening questionnaires with your progress notes for tracking behavioral issues such as anxiety and autism to identify if the patient suffers from such conditions. The results can be electronically shared with relevant industry specialists such as psychiatrists to cure the issues early on.
In addition to the time-saving by which you can see more patients and earn more money, you’ll attract a lot of new patients. How? As you’re ensuring better care, satisfied parents will refer your practice to other parents. Moreover, industry specialists to whom you’ve referred patients for further treatment will refer your name to those seeking pediatric care.
Additionally, this Top Ranked EMR Software automatically creates growth charts via clinical calculators using data such as patient BMI, length, etc. This way, you won’t have to spend additional time and schedule more visits diagnosing issues that the system has calculated for you, and you can move to the treatment straightaway.
The family profile feature can help enhance efficiency. If the records of a child’s siblings are present in your database, the data doesn’t need to be re-written and can simply be attached. In addition to identifying genetic trends, you must use this tool for group scheduling patients belonging to the same family to save time. Numerous new clients will also come your way as parents usually take all of their children to the same pediatricians.
Use pamphlets, kiosk computers at the reception, other such mediums to get your patients (or parents in the case of younger patients) to use your patient portal. The younger generation in particular is very tech savvy; make the most of this.
Once they realize that they can receive education and wellness material online, view their lab results and clinical encounter data, and order refills online, they will rush to this medium.
Moreover, when they can communicate online, you will be able to solve most of the simpler problems without scheduling visits. The time saving will be immense, and you will be able to schedule other patients during these slots.
You can always assign your nurse or some other staff member to handle the portal, and to direct the more important issues your way.
These are some of the most efficient methods you can use to optimize revenues at your pediatrics practice using an EHR built specifically for a pediatrician. The key here is to optimize the usage of your EHR, which will automatically optimize revenues for your practice.
Electronic Health Records (EHRs) have been designed to drive more productivity at practices, while improving healthcare of patients. For a specialty practice, it is recommended that they adopt an EHR which is specific to their practice needs and workflow. Same goes for Oncology.
Oncologists have the option to adopt an Oncology EHR that can be purchased from the market after some careful research. Some vendors offer Oncology specific modules that can be integrated into a general EHR to make it practice specific. Others offer EHRs that have been specifically designed and developed for Oncologists from the scratch.
Oncology patients require complex treatments that stretch over a long period of time, resulting in extensive data recording and management. Generic EHRs do not offer Oncology specific modules to assist physicians to identify symptoms, apply procedures and treatment of the patients.
Some useful features
A suitable EHR for Oncologists should offer features that are integral to patients’ diagnosis and treatment, such as:
- Calculation and administration of drug dosage during chemotherapy
- Specific charts and diagrams to assist physician in diagnosis
- Manage and follow-up clinical trials
- Oncology specific provider note templates
- Comprehensive library
- Integrated charge capture for billing
How Oncologists benefit?
Specialty EHR acts as a support system for Oncologists that enables them to create most detailed medical record that result in timely and accurate diagnosis and treatment of patients. Oncologists can remain updated with patients’ conditions and modify medication and cancer treatment accordingly.
Specialty EHRs support Oncologists gives complete access to patients’ past and current medical records and library that prompts a timely calculation of the patient’s stage of cancer, as mentioned in the American Joint Committee of Cancer’s staging criteria (AJCC).
Some of the other benefits include the interoperability functionality that is extremely helpful to Oncologists. Most of the cancer patients have more than one physicians providing them treatment simultaneously. This is necessary for each physician to be aware of the medication and treatment provided to the patient, so that there is no clash that may be fatal for the patient.