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Aug 17 2010   10:06AM GMT

Patient data capture: Your key to reducing the learning curve on EHR use

Posted by: Jenny Laurello
Data management, EHR usability

Guest Post: Stephen Dart, Senior Architect, EHR Product Line, AdvancedMD Software, Inc

Among the many characteristics you should evaluate in an EHR is its use of pre-built encounter templates. The physician, new to clinical automation tools, needs a starting point, and typically wants to minimize the time it takes to get productive on a new system. To reduce the learning curve, the EHR should offer a range of pre-built visit type templates  and support a variety note capture methods, so the physician can select the input method  most natural to them, including keyboard, point and click, writing stylus, and voice-to-text.  Additionally, short-cut abbreviations should be offered as part of the encounter templates, to further facilitate data capture. 

Another feature you should look for in your EHR is its ability to capture and store discrete patient data – such as weight, diagnosis, medications, lab results, review of systems, plan of care, and health maintenance protocols. When captured as discrete data elements, as opposed to a textual document, your system is in a better position to produce detailed statistical output that can support reports and trend analysis research. This will be critical going forward to provide support for the proposed meaningful use standards for interoperability.  This will be difficult for textual-oriented systems to achieve.

Converting patient visit notes into correspondence is another area to evaluate. There may be patient data the physician wants to include in a referring physician letter, for example. That data may have been captured in a previous visit or is information that is outside the scope of the current encounter documentation. This is accomplished using query technology that can embed specific information pulled from anywhere within the system — demographics, charts, notes, medications, lab results, even financial information. Not all EHRs are designed with this range of flexibility. The benefit is that the physician can generate a more personalized letter that delivers a much broader view of the patient than information gathered during the most recent encounter.

 For more information, please visit AdvancedMD Software, Inc

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