Feb 27, 2003 – The most critical part of any Electronic Medical Record (EMR) is the method of data entry. EMR is about aggregation of patient encounter data at the point of care in order to provide a complete, accurate and timely view of patient information. An electronic medical record is not just a typed record of the patient encounter, but an extremely useful decision support tool.
Data can be entered into the EMR via either of two general mechanisms: direct entry by the physician using point and click templates or transcription of dictated notes. Point and click template entry requires data selection and navigation for capturing patient information. Transcription has been around for years for documenting patient encounters. Each method has its pros and cons.
POINT AN CLICK TEMPLATES
Most EMR systems allow providers to generate clinical documentation by selecting variable terms from pre-structured point-and-click templates. Users simply point and click to select appropriate choices from lists of choices to record a patient encounter. The end result would be a document that closely resembles a transcribed procedure note.
- Completely customizable templates.
- Consistent, complete and accurate data.
- Notes for similar type of exams will appear to be standard and similar.
- Stores / Organizes data for subsequent retrieval.
- Each click adds data elements to the database. Point-and-click systems create data that can be used to generate clinically useful reports, such as health maintenance reminders, disease management, etc.
- One of the major advantages of template based charting is the time needed to make the document available as a medical record. Since notes are created within the EMR, they are available immediately upon completion.
- It takes more time and definitely more concentration for a physician to navigate through a large data set to create progress notes using point and click templates.
- Templates must be customized, as per the physician’s requirement. Customization can be inflexible and costly.
- Output from templates appears too canned and identical, losing individuality for each patient.
- Difficult for physician to capture complete patient encounter on computer in front of a patient.
Transcription has long been the standard for documenting patient encounters. It is more convenient for a provider compared to handwritten notes or electronic data entry. There are some advantages to transcription in comparison to point and click charting. There are a few disadvantages as well.
- Corresponds intuitively to the physician’s usual method of working. Dictation remains the most intuitive and least time-consuming means of data entry.
- Physicians can dictate anytime, any where using PDA, Dictaphone or telephone at their convenience. Provides for more efficient use of doctor’s time.
- Providers need not change the way they practice just to accommodate an EMR.(EMR can interact with transcription service so that transcriptions can be attached directly into the patient’s electronic medical record, if such a facility is provided by the EMR vendor.)
- Requires minimal training for physicians.
- Provides expressive power to describe patient’s condition and other health related events.
- Details of the exam can easily be forgotten and omitted while dictating, if dictation is not captured immediately at the point of care.
- Cannot be queried for generating reports unless transcribed in pre-for-matted templates.
- Transcribed reports are not immediately accessible. Physicians normally wait 12 to 24 hours for charts to be delivered, with exception of those vendors supporting two to four hour turnaround.
For a physician, an EMR that fits into their practice workflow can be invaluable. A competent EMR will have a template driven charting feature and the ability to interact with a transcription services at the same time, Both are indispensable features of Electronic Medical Record software, as doctors are not unanimous on point and click charting or transcription. Such an EMR will be both efficient and cost effective.