Top Five Keys to Solving Physician Interface Dilemma in Medical Billing and EMR Systems

Billing and claims management services and systems help healthcare providers manage rising costs of healthcare as well as increase overall administrative efficiency. The wider is the scope of solution the more benefit it delivers to the practice. The most important scope enhancement in the recent years is the addition of integrated electronic medical records (EMR) solutions, which is the heart of the medical practice IT value chain. The comprehensive nature of EMR consolidates 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 plain recording of patient encounter to useful decision support system.

The most critical part of any system is its interfaces to other systems, and especially, its human interface. Typically, EMR allows three kinds of input, namely, typing, dictation, and point-and-click templates. Most physicians choose dictation over typing and point-and-click templates for reasons of convenience and time efficiencies.

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

Dictation and Transcription

Medical transcription saves time in comparison to handwritten notes or typing. It intuitively matches the physician's working style, power of personal expression, and it is easy to dictate using a phone, PDA, or Dictaphone. Human transcriber or Voice Recognition systems transcribe the dictation into medical notes.

But transcription has multiple disadvantages:

• Incomplete. If notes are not captured immediately at the point of care, it is too easy to exclude important details.
• Costly Processing. Report generation using unstructured data is much more time consuming and expensive.
• Time delay for Accessibility. It typically takes 12 to 24 hours for chart turnaround.

Note incompleteness is the most important disadvantage of dictation and transcription because comprehensive medical notes are key to surviving a post-payment insurance audit.

Point-and-Click Templates

A point-and-click template presents a selection of data elements, a navigation mechanism, and a point-and-click process for capturing patient information. The doctor simply points and clicks selecting appropriate choices while the system fills out a complete record of selections, which makes up the resulting encounter notes. Such a structured approach offers multiple benefits:

1. Consistency. Structured data ensures note completeness and avoids missing important details. It enhances the ability to generate clinically useful reports, such as appointment reminders or disease management.
2. Customization. The doctor specifies the template layout to match precisely the workflow of the practice.
3. Lower Error Rate. Standardization of input precludes 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. It takes more effort to the notes using point-and-click templates than just writing or dictating.
• Data Entry Time. It may take too long to walk through all the required templates in front of the patient.
• Cost. As each practice has different workflow, template customization may be costly.

The added complexity of point-and-click templates is clearly justifiable because of guaranteed completeness, which is key to regulatory compliance and the ability to survive post-payment audit. The data entry time can be reduced too by allocating lion's time share on comprehensive documentation during initial examination and restricting documentation scope to note updates only during subsequent visits. Structured nature of point-and-click templates are naturally conducive for such time prioritization.

Although some physicians prefer familiar to convenient, and convenient - to better functionality, transcription must be viewed as an inferior component of interface array to modern EMR system, complementary to click-and-point templates. Modern physician office automation technologies combine both billing and EMR features and provide both kinds of interfaces adding to both efficacy and efficiency of practice workflow. Powerful Vericle-like technologies also facilitate rapid customization of point-and-click templates, optimizing physician's interface to EMR system, providing added degree of regulatory compliance, and reducing post-payment audit.