Today's Wound Clinic - Spring 2008 - (Page 21)

intech The Power of Paperless Understanding EMRs A s the wound care industry adapts to the paperless society and electronic medical records (EMRs), there is hesitation by some professionals to embrace the digital push.A large majority of healthcare transactions in the US still take place on paper. However, our editors Caroline Fife, MD, FAAFP, CWS and Dot Weir, RN, CWON, CWS; and other industry professionals such as N. Blair Hughes, MHS, PT, CWS, director of specialty programs and wound care services for Frederick Memorial Healthcare System (FMHS), Frederick, Md, explain that there are many reasons for wound care facilities to start embracing the technological advantages that are available in EMRs. Fife, chief medical officer at Intellicure, Inc. (The Woodlands,Tex) reviews the company’s option for EMR.Weir, discusses an EMR option that her facility has been using for years, provided by Net Health Systems (Pittsburgh, Pa). Finally, Hughes discusses the EMR option used at her center (FMHS’s Advanced Skin & Wound Care Center) since 2000, provided by Wound Care Strategies (Harrisburg, Pa). Regardless of their affiliations and personal experiences with the three different companies, Fife,Weir, and Hughes raise some very valuable points and are all advocates of adopting an EMR system in a wound care clinic setting. The Complete Electronic Medical Record Option Caroline E. Fife, MD, FAAFP, CWS n 1998, the Memorial Hermann Wound Center in Houston, Tex went live with a prototype version of an electronic medical record (EMR) specific to wound care. In 2006, the system was upgraded to the most current version of IntelliTrak, an EMR from Intellicure, which according to this author meets all of the legal requirements of an EMR. The Healthcare Information and Management Systems Society (HIMSS) defines the essential attributes a system must meet to qualify as an EMR. These requirements include that all data must be collected in real time, that is, at the bedside. HIMSS suggests some other tests to determine whether a system is really an EMR including: 1. It is the official medical record (in other words, a paper chart is optional and the EMR is really the legal chart). I 2. It meets HIPAA requirements. 3.The EMR checks information for reasonableness (eg, it warns if the number entered for blood pressure seems too high). 4. It supports electronic signatures. 5. It supports government endorsed message and content standards (eg, HL7). 6.The organization uses EMR data to measure and manage quality. 7. Clinicians perform no extra tasks for medical record coding and reimbursement (in other words, the calculation of the level of service is automatically derived from the documentation in the EMR). HOW IT WORKS FOR MEMORIAL HERMANN WOUND CENTER The HL7 interface means that when a patient is registered in the hospital’s electronic system (which happens to be Cerner), they are automatically registered in Intellicure, and wound center data in Intellicure can also flow back into Cerner (no scanning paper docu- ments). Computers are present in every exam room and 100% of all clinical information is entered by the nurses and physicians in the exam room. Data entry is facilitated by numerous click and scroll menus, which keep typing to a bare minimum. Nursing assessments such as those for pain, advanced directives, abuse screen, activities of daily living, and so on, can be done in seconds. The same is true for hyperbaric technical documentation. Cameras are cabled to computers, which allows digital photographs to be automatically archived to specific wound locations. All clinical charting is password protected and all data entries are tracked. Numerous other security measures allow Intellicure to be the legal chart. While the legal chart is the electronic one, the program automatically generates all necessary documents after data entry is complete, including prescriptions, home nursing orders, physician correspondence, nursing notes, and so on. For example, copies of physician correspondence or home nursing orders can be given to patients as they leave the clinic. Giving patients a copy of new home nursing orders prevents confusion: patients whose payers require correspondence to authorize certain procedures know that this task has been performed, and family members of elderly patients with complex problems appreciate being able to read over assignments and plans. The ability to hand these documents to patients at the completion of their visit has been one of the most beneficial effects of implementing a true EMR. EVIDENCE BASED MEDICINE As the center has used the system over the past 10 years, it has certainly used all of the benefits of the EMR noted earlier, but the most exciting Today’s Wound Clinic Spring 2008 21

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.