From Paper Charting to EMR | How to Avoid 5 Most Common Mistakes
As a physical therapist, I know the importance of documentation for clinical care and reimbursement. I have performed medical documentation in paper charts, as well as several EMR systems. I also had the great learning experience of working for a busy sub-acute rehabilitation facility during a transition from paper charting to EMR. I learned that transitioning from paper charting should not be taken lightly; great steps must be taken for proper planning and implementation. In my experience, I found several major mistakes during this transition period. Here are my experiences and suggestions for a facility about to undergo the transition from paper charting to electronic medical record systems.
Mistake 1: Under-training the clinicians and staff. One of the main features of EMR is that it allows for smoother and more efficient means of documentation. Each clinician wants a way to make documentation easier and the process of getting paid more streamlined. So, we all have great incentive to make EMR documentation work. However, if staff are under-trained, they can easily get frustrated with the new system. For example, if a clinician knows how to care for their patient, but cannot find the right icon to enter their diagnosis code or treatment intervention, frustration and even anger are bound to ensue. It is crucial that the clinicians, office managers, and all staff members are properly trained in the new system prior to launching.
Mistake 2: Expecting immediate success and high productivity. Let’s face it; people don’t like change. Administrators must be prepared for a little resistance from seasoned clinicians. For some clinicians, using computer systems for documentation can be a daunting task. They may type slowly or have difficulty navigating menu options. Once you get past the initial resistance, you must allow for learning. It will take time to learn a new system and you will need to re-educate continually. You should not expect the productivity standards to be upheld during this transition period. By allowing a little extra time for documentation in schedules, your therapists will feel appreciated and respected.
Mistake 3: Assuming the IT developers know what the clinicians need. Healthcare clinicians are smart individuals, but most of us do not write program software. For the IT professionals, writing programing code is mundane, yet they do not know the details or requirements of medical documentation. When implementing an EHR system, it is important that the system has all the requirements specific to the needs of physical therapy. With bestPT, the EMR system has been developed with the therapists in mind. The system is thorough and complete. In addition, bestPT offers supportive, knowledgeable and available customer service in case of difficulty with the IT portion of clinical documentation.
Mistake 4: Improper planning for storing health records. What happens to all of those large binders, paper charts, and paper reams? Well, you must think about how you are going to store past patient records. In addition, you will likely need to input many of these clients into the new EMR system. Establishing a protocol for accessing and storing paper information will be crucial for a successful transition.
Mistake 5: Picking an electronic medical record program without support. With the vast amount of EMR systems available today for healthcare providers and physical therapists, it can be confusing to know which one to choose. Make sure that you choose an EMR system that comes with people behind the system. You need a support team behind the EMR. That is why bestPT is an easy answer when transitioning your clinic from paper charting to electronic charting. The bestPT programs keep you compliant with the latest functional codes, PQRS reports and diagnosis codes. In addition, they provide great customer care for any other clinic needs.
A great strategy for a smooth transition from paper charting to EMR, is to gradually introduce components of the new system at regularly scheduled meetings, prior to launching. By breaking down the system into components and learning modules, your staff will feel as though they can absorb the information without feeling overwhelmed. For example: first explain the system for billing, then explain the system for entering patients, accessing and inputting health information, etc. In addition, be sure to give them resources for contacting customer service and always be open to questions and opportunities for further learning. When choosing bestPT for your EMR system, you can ease their anxiety by ensuring great clinician support.
Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.
Dr. Amy Vant, DPT