Top 5 Keys to the Physician Interface Dilemma in Electronic Medical Billing and EMR Software Systems

Billing and claims management systems and services help health care providers manage the rising costs of health care, as well as increase overall administrative efficiency. The broader the scope of the solution, the more benefits it offers to the practice. The most significant scope enhancement in recent years is the addition of integrated electronic medical record (EMR) solutions, which is the heart of the medical practice IT value chain. The comprehensive nature of EMR consolidates a patient’s personal and administrative information, health history, prescriptions, treatments, and conditions. Its ability to perform such data aggregation at the point of care elevates its benefit from simple patient encounter recording to a useful decision support system.

The most critical part of any system is its interfaces with other systems, and especially its human interface. EMR generally allows for three types of input, namely typing, dictating, and point-and-click templates. Most doctors choose dictation over typing and point-and-click templates for reasons of convenience and time efficiency.

While the preference for dictation over typing is obvious, recent technological progress and regulatory compliance pressures make point-and-click templates superior to dictation.

Dictation and Transcription

Medical transcription saves time compared to handwritten or typed notes. It intuitively matches the clinician’s working style, the power of personal expression, and is easy to dictate using a phone, PDA, or dictation machine. Voice recognition systems or human transcriptionist transcribe dictation into medical notes.

But transcription has multiple disadvantages:

• Incomplete. If notes aren’t immediately captured at the point of attention, it’s all too easy to miss out on important details.
• Expensive processing. Reporting using unstructured data is much more time consuming and expensive.
• Time delay for Accessibility. It usually takes 12-24 hours to complete the chart.

Incomplete note is the most significant disadvantage of dictation and transcription because complete medical notes are key to surviving a post-pay insurance audit.

Point and Click Templates

A point-and-click template features a selection of data elements, a navigation mechanism, and a point-and-click process for capturing patient information. The clinician simply points and clicks to select the appropriate options while the system completes a comprehensive record of selections, which constitute the resulting encounter notes. This structured approach offers multiple benefits:

1. Consistency. Structured data ensures the integrity of your notes and prevents important details from being lost. Improves the ability to generate clinically useful reports, such as appointment reminders or disease management.
2. personalization The clinician specifies the layout of the template to precisely match the practice’s workflow.
3. Lower error rate. The standardization of the entry avoids errors of omission or spelling.
4. Faster decision making. Similar observations have similar notes, resulting in consistent decisions.
5. Immediate Accessibility for Processing. Since notes are created within the EMR system, they are available immediately upon completion.

However, point-and-click data entry also has several disadvantages, including

• Complexity. Notes using point-and-click templates take more effort than just typing or dictating.
• Data entry time. It can take too long to go through all the required templates in front of the patient.
• Cost. Since each practice has a different workflow, template customization can be expensive.

The added complexity of point-and-click templates is clearly justifiable due to guaranteed integrity, which is key to regulatory compliance and the ability to survive post-payment audit. Data entry time can also be reduced by assigning lion timeshare on full documentation during the initial review and restricting the scope of the documentation to look at updates only during subsequent visits. The structured nature of point-and-click templates are naturally conducive to such prioritization of time.

Although some clinicians prefer the familiar to the convenient, and the convenient to better functionality, transcription should be viewed as a lower component of the interface matrix for the modern EMR system, complementary to click-and-point templates. Modern medical office automation technologies combine billing and EMR features and provide both types of interfaces that increase the effectiveness and efficiency of practice workflow. Powerful Vericle-like technologies also make it easy to quickly customize point-and-click templates, streamlining the clinician’s interface with the EMR system, providing a higher degree of regulatory compliance, and reducing post-payment auditing.