Specialty electronic medical records (EMRs) have revolutionized the way data are collected, collated, and delivered at the press of a button. But are you sure that the information that you are documenting within your specialty EMR is truly reflective of your Clinical, Operational, Regulatory, and Economic (CORE)* processes? Understanding how the final documentation is compiled is imperative to ensuring it is complete. Use the following checklists to better understand your specialty EMR and the steps for successful implementation.
If you are new to an EMR or simply need to review how your current EMR’s workflow pertains to work in your department, you may want to explore answers to the following questions:
- How does the EMR create the final medical record authored by the wound care clinicians and providers?
- How are signatures applied to the documentation?
- Who is responsible for the medical record requirements and what documents are part of the final medical record?
- Why are data collected in a certain sequence for a new or established patient?
- Is this sequencing constructed in the most efficient way to collect the information?
- Is the EMR missing data elements that are critical to documentation requirements, patient safety, and/or billing capture?
- If you need critical information to meet hospital documentation requirements or accreditation standards, how is this documentation addressed?
- Who maintains the software’s day-to-day functions or trains new users on the system?
Understanding how the specialty EMR is constructed and could drive efficiency in your department is the first step in choosing your specialty EMR. Remember, the goals when using a specialty EMR are to drive accountability of care; enhance care coordination through smart, efficient workflows and compliant documentation; improve care through evidence-based models; and optimize reports to drive compliance. In addition, to ensure financial success within your specialty wound care department, efficient processes must be in place to manage volume, support outcomes, and drive data/reporting. A comprehensive, interoperable specialty wound care EMR is key to the department’s success.
When considering a specialty wound care EMR, dream big! Create a checklist for documentation success, which may include the following:
- efficient scheduling module;
- secure patient and provider portals;
- secure email exchanges;
- intelligent workflows to meet the needs of all of the clinicians and providers in your department, as well as patients, who may access their defined information;
- enhanced clinical decision and practice management tools to alert users to medication errors and adverse drug interactions and to track test results and patient follow-up;
- flexible integration options with existing technology, interfaces to pull data in and out of your system, and clinical and operational compliance and audit mechanisms;
- clinical and operational compliance with the Office of the National Coordinator for Health Information Technology requirements and functionality that enables eligible clinicians and hospitals to comply with various regulatory programs that require use of certified EMR technology;
- audit trails to identify who completed the documentation and what actions were taken; and
- robust reporting for operations, marketing, outcomes, benchmarking, and more.
Whether you are using a specialty EMR for the first time or retraining on its functionality, the key to your successful implementation will be training staff based on your CORE processes. Defining these processes allows everyone to properly configure and understand their documentation. Consider the following checklist as you plan for your EMR implementation experience:
- partner with an EMR vendor that listens to and understands your clinical and operational needs;
- define your pretraining, go-live training, and posttraining goals;
- customize your EMR and allow your staff to review the software to become familiar with the menus and workflow;
- identify your department’s super-users and pretrain them for speed and efficiency;
- recognize that your staff’s learning needs are unique and your implementation program should be tailored to them, and work with the EMR provider to determine the best training strategies;
- determine each staff member’s role-specific documentation process and define “successful training” for each role (eg, scheduling a patient, uploading a photo, amending a locked record);
- create a training plan with the EMR vendor including presentation methods, classroom schedules/location, and staffing;
- allow your staff to use a test site/EMR playground prior to the EMR go-live;
- encourage staff feedback of the EMR process during training time and adjust workflow and subsequent training accordingly;
- define the processes and timelines for adjusting your staff’s workflow as the EMR is integrated within the department;
- ensure vendor support is available following your go-live; and
- schedule your posttraining objectives early in the process.
Time management and planning are key to successful EMR implementation. Ensure your training plan has realistic time frames for pretraining, go-live training, and posttraining. Understand the structure of your EMR and create roles and responsibilities for each user. Remember that training, whether online or in person, is not optional but required for successful learning. Last, for your specialty EMR to be integrated successfully in your department, you need time commitments from your staff and physicians. Best of luck, and feel free to reach out with any questions!
*CORE is a proprietary process developed by the author.