| Billing and claims management services and | | | | information. The doctor simply points and clicks |
| systems help healthcare providers manage rising | | | | selecting appropriate choices while the system fills |
| costs of healthcare as well as increase overall | | | | out a complete record of selections, which makes |
| administrative efficiency. The wider is the scope | | | | up the resulting encounter notes. Such a |
| of solution the more benefit it delivers to the | | | | structured approach offers multiple benefits: |
| practice. The most important scope enhancement | | | | |
| in the recent years is the addition of integrated | | | | 1. Consistency. Structured data ensures note |
| electronic medical records (EMR) solutions, which is | | | | completeness and avoids missing important details. |
| the heart of the medical practice IT value chain. | | | | It enhances the ability to generate clinically useful |
| The comprehensive nature of EMR consolidates | | | | reports, such as appointment reminders or |
| patient's personal and administrative information, | | | | disease management. |
| health history, prescriptions, treatments, and | | | | 2. Customization. The doctor specifies the |
| conditions. Its ability to perform such data | | | | template layout to match precisely the workflow |
| aggregation at the point of care elevates its | | | | of the practice. |
| benefit from plain recording of patient encounter | | | | 3. Lower Error Rate. Standardization of input |
| to useful decision support system. | | | | precludes errors of omission or spelling. |
| The most critical part of any system is its | | | | 4. Faster decision-making. Similar observations |
| interfaces to other systems, and especially, its | | | | have similar notes, resulting in consistent decisions. |
| human interface. Typically, EMR allows three kinds | | | | 5. Immediate Accessibility for Processing. Since |
| of input, namely, typing, dictation, and | | | | notes are created within the EMR system, they |
| point-and-click templates. Most physicians choose | | | | are available immediately upon completion. |
| dictation over typing and point-and-click templates | | | | However, point-and-click data entry also has |
| for reasons of convenience and time efficiencies. | | | | several disadvantages, including |
| While preference of dictation over typing is | | | | - Complexity. It takes more effort to the notes |
| obvious, recent technology progress and | | | | using point-and-click templates than just writing or |
| regulatory compliance pressures make | | | | dictating. |
| point-and-click templates superior to dictation. | | | | - Data Entry Time. It may take too long to walk |
| Dictation and Transcription | | | | through all the required templates in front of the |
| Medical transcription saves time in comparison to | | | | patient. |
| handwritten notes or typing. It intuitively matches | | | | - Cost. As each practice has different workflow, |
| the physician's working style, power of personal | | | | template customization may be costly. |
| expression, and it is easy to dictate using a | | | | The added complexity of point-and-click templates |
| phone, PDA, or Dictaphone. Human transcriber or | | | | is clearly justifiable because of guaranteed |
| Voice Recognition systems transcribe the dictation | | | | completeness, which is key to regulatory |
| into medical notes. | | | | compliance and the ability to survive |
| But transcription has multiple disadvantages: | | | | post-payment audit. The data entry time can be |
| - Incomplete. If notes are not captured | | | | reduced too by allocating lion's time share on |
| immediately at the point of care, it is too easy to | | | | comprehensive documentation during initial |
| exclude important details. | | | | examination and restricting documentation scope |
| - Costly Processing. Report generation using | | | | to note updates only during subsequent visits. |
| unstructured data is much more time consuming | | | | Structured nature of point-and-click templates are |
| and expensive. | | | | naturally conducive for such time prioritization. |
| - Time delay for Accessibility. It typically takes 12 | | | | Although some physicians prefer familiar to |
| to 24 hours for chart turnaround. | | | | convenient, and convenient - to better |
| Note incompleteness is the most important | | | | functionality, transcription must be viewed as an |
| disadvantage of dictation and transcription | | | | inferior component of interface array to modern |
| because comprehensive medical notes are key to | | | | EMR system, complementary to click-and-point |
| surviving a post-payment insurance audit. | | | | templates. Modern physician office automation |
| Point-and-Click Templates | | | | technologies combine both billing and EMR features |
| A point-and-click template presents a selection of | | | | and provide both kinds of interfaces adding to |
| data elements, a navigation mechanism, and a | | | | both efficacy and efficiency of practice workflow. |
| point-and-click process for capturing patient | | | | |