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EHR Templates

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OVERVIEW

Common problems with traditional paper medical records include disorganization, illegible handwriting and general incompleteness. EMR was designed to alleviate such issues – but it is not as simple as choosing an EMR and having it installed in a practice setting. It takes a significant commitment to preparation and customization on the part of staff to ensure successful and efficient adoption.

There are many benefits to utilizing an EMR with integrated practice management, billing and document tools - but to take full advantage of the EMR's efficacy, a practice should look to the variety of methods for customization. Customizing the Electronic Record system is done primarily through the use of templates.

By employing the features available in custom template design, a practice can modify the EMR to better fit their unique workflow needs. In fact, studies indicate that a creative level of customization is vital to the successful adoption of any EMR. (See link below for a great study published in Family Medicine, May 2010)

Electronic Medical Record Customization and the Impact Upon Chart Completion Rates

WHAT IS AN EHR TEMPLATE?

As noted in the above article and overview, one essential step toward successful adoption of any EMR is the use and customization of templates. A "template" in an EMR, is a tool for organizing, presenting, and capturing clinical data within the system. The majority of certified EMR's allow for customized templates, permitting practices to gather all relevant information for their workflow on a single convenient screen, while populating the information into the patients' medical record. The vast amount of information in a patients chart, such as scans, x-rays, lab results, etc., require careful organization for ease of data and content retrieval. Most EMR Solutions are packaged with a good number of pre-built templates - generally tailored to different specialties or visit types. For example, a doctor may have a set method to view/input information during a general check-up, but a diabetes patient visit would not follow that identical workflow.

The ability to utilize different templates allows a single EMR solution to be flexible. The provider may then simply choose the "check-up" or "diabetes patient" template at the start of the encounter and the EMR would automatically present a suggested workflow. Be sure to investigate the variety and availability of pre-built templates for your EMR solution.

BENEFITS OF TEMPLATE USAGE

Some important benefits of template usage:

  • Easy, standardized organization of clinical data
  • Single page views of patient data for quick reference
  • Ability to quickly manage an entire patient population
  • Time savings vs. having to browse through multiple patient files / pages
  • Drug interaction checks across a multitude of patients and products
  • Ability to quickly assess degrees of concern associated with FDA or CDC announcements
  • Increased percentage of chart completion
  • Standardized data capture, which helps to ensure accurate coding
  • More complete data fields which can lead to fewer under-billed appointments

WHY CUSTOMIZE TEMPLATES?

Pre-built templates however, can only go so far. No two practices are exactly the same. To make the most of an EMR utility and to increase the overall effect of the above benefits, a practice should further customize templates to better match their unique workflow.

It will take time and effort, but is not as complicated as it sounds. Template design in many systems is built for even the non tech-savvy clinician. Many EMR template tools allow for customizing "as you go". Meaning a template may be modified during an active patient visit - while the provider is documenting; saving changes to that note or view as a NEW template.

A good example would be to take that Diabetes Patient standard template above. If the physician had additional fields they wished to include on the progress note page, such as weight and diet tracking – he/she could add those fields to the single page during that specific visit and then SAVE that view as a NEW template. DiabetesPatient2.

Other examples of customization include:

  • Creation of quick-links to frequently used medications and diagnostic codes

  • Chart "by exception" capability: wherein a template will auto-fill all clinical fields with common data at the start of the encounter - so that the physician need only change what is out of the ordinary

Most EMR vendors will instruct their clients in template design. Buyers should ask for more detail about this feature beforehand and again during the training phase to ensure that the topic is covered sufficiently. After training, if staffing or level of competency would not permit internal customization, the EMR vendor will often create custom templates for additional fees.

However they are completed, thoughtfully designed templates will present immediate benefits in efficiency and ease of use for the practice.

Those involved in the aforementioned Family Medicine study agree: "We discovered that the template changes resulted in an increase in the number of charts completed within 30 days by nearly 5%, resulting in a substantial number of billable clinical encounters."

So even though a practice will likely invest some up-front time and/or additional money getting their templates up to speed, the investment is likely to pay off down the road.





Last updated: April 12, 2013




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