Electronic Health Record Software

Advances in technology have made record-keeping much faster and more efficient. It used to be that medical notes were handwritten and then had to be typed. Other options were to dictate the information and have someone transcribe it. Medical offices of the past would have stacks of paperwork from floor to ceiling containing records they needed to keep. But with the software programs that are now available, record-keeping can be better managed and less time-consuming.

Identification

• Electronic health-record software can be used with a PC or Mac, and is specially designed to store valuable patient data. This includes patient information, treatments received, insurance coverage and prescription history. It usually consists of predesigned reports and templates, so the physician and other medical staff can quickly enter information and retrieve it whenever necessary.

Benefits

• Electronic health-record software centralizes all patient information in one place, and provides quick and easy access to it. There is no need to search for a patient's chart and dig through piles of paperwork to get the information that is needed. All of the patient's information--such as previous appointments, test results, referrals and medications--is immediately available to the health-care provider. In addition, the software helps to cut down on transcription and storage costs, and reduces paperwork. Electronic software also allows the health-care provider to access patient information from anywhere, even when he is not in the medical office.

Types

• Electronic health-record software can help in many areas of patient care. Just like physicians, software programs can be tailored to specialized fields. You can purchase a system that is specially designed for cardiology, internal medicine, urgent care, pediatrics or any other field of medicine. Electronic health-record software can be used to create and process prescriptions, notes that can be submitted to insurance companies for payment, billing and scheduling materials, and patient reminders about needed treatment. Office notes from a patient's visit can be quickly and immediately entered into her record, with no need to wait for a transcriptionist to return the notes.

Features

• Some programs allow the patient to interact with the software. Patients can fill in intake forms, schedule an appointment, request prescription refills and send questions or comments to their physician without having to travel to the office. This saves both time and money for the patient and physician. Electronic health-record software can come in two forms: The first is a slate, on which information is entered via the use of a digital pen. The other option is a convertible style which has its own keyboard. Most models operate wirelessly. The slate style is lighter and has more advanced features, such as speech and handwriting recognition. However, some users may prefer the convertible model so they can enter information via a keyboard. The choice is matter of personal preference.

Considerations

• One of the drawbacks of electronic health-record software is that it raises the chance of a physician's and/or patient's privacy being invaded. Hackers can enter the system and obtain private information about the patient and physician. A second downside is that there can be a large learning curve to using the equipment. Both the physician and staff must be comfortable with the technology, and there may be some upfront costs in terms of training. The software can help to cut costs and save time; however, steps need to be taken to ensure privacy for all.