I’m not an “EMR historian”, but my general understanding is that the EMR has and continues to evolve. When it first came to be, the EMR was an electronic replacement for the paper record.
Instead of filing paper notes and documents to a patient folder, you filed it electronically to a patient record. There are now aspects of the patient record that are considered in order to file information correctly. There are orders, encounters or visits, medications, procedures, and other items that are defined in the EMR. The information is now found in context. It can assist in alerts and decision support mechanisms to help the clinicians. It allows the information to be accessible for care coordination, MIPS, and compliance reporting.
The EMR has become more detailed in the way it holds and presents information back to clinicians. Internally created information is now correctly filed so it can create alerts, enable decision support, and be seen by clinicians.
Where many organizations fall down is in the filing of data and documents that arrive from external sources. Often, the process to get data into the EMR is manual and time-consuming. It leads to many organizations filing the documents at the “patient level.” This means the documents are grouped in the documents or media tab. They are only labeled with the data staff entered during manual filing.
New technology released over the past decade automates the filing of documents and data from documents to the EMR. Software associates data with the right procedures, automates matching of the patient, detection of document type, and extraction of key index data such as date of service.
Technology helps organizations improve the speed, accuracy, and consistency of filing documents. The process of filing the document can allow for better reporting.
If your organization has not accessed innovative technologies, then you should know what is possible today. Technology has advanced and it is possible to file internal and external information so your clinicians can find it with ease.
About the Author: Ellen Bzomowski
With 20 years of experience in data capture and voice recognition, Ellen’s experience has focused on achieving higher efficiency and automation in getting data where it will be most useful to an organization. At Extract Systems, she continues to focus on the same ideas and works to get the word out about how Extract Systems’ advanced data capture and redaction solutions make more data valuable and accessible while securing anything that is private. She holds an MBA from Northeastern University and lives and works in Boston.