White Papers

NEW YORK, NY - January 17, 2004 - The most critical part of any Electronic Medical Record (EMR) is the method of data entry. An EMR uses aggregation of patient encounter data at the point-of-care 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. The data can be entered into the EMR via any of the two general mechanisms: direct entry by the provider using point-and-click templates, or transcription of dictated notes. A point-and-click template indicates that each data element which is to be inserted requires selection, navigation, and a point-and- click process for capturing patient information. Medical transcriptions correspond intuitively to the provider’s usual method of documenting patient encounters via dictation.

Providers are not unanimous on any specific method of data input. Some are comfortable with keyboard typing, a few like to use the mouse, and some want to dictate part of their notes. OmniMD^™ EMR offers all of these options for data input. For a provider, the EMR that fits into the practice workflow is invaluable. OmniMD^™ EMR has a template-driven charting feature and the ability to interact with a transcription service at the same time. Both are indispensable features of Electronic Medical Record software.

Point and Click Templates
The OmniMD^™ EMR system allows providers to generate clinical documentation by selecting variable terms from pre-structured point-and-click templates. Users simply select appropriate choices from list to record a patient encounter. The end result is a document that closely resembles a transcribed procedure note.

Advantages

• Completely customizable templates
• Provides consistent, complete and accurate data
• Notes for similar type of exams will appear to be standard and similar
• Store / organize 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 short time needed to make the document available as a medical record. Since notes are created within the EMR, they are available immediately upon completion.

Medical Transcription

Medical Transcription has long been the standard for documenting patient encounters. It is more convenient for a provider as compared to handwritten notes or electronic data entry. The OmniMD^™ web and pocket PC compliant-transcription suite can be used along with OmniMD^™ EMR. With the OmniMD^™ medical transcription system, providers can dictate and save voice files on pocket PC and routes it to the transcription service. Providers can review and sign off transcribed reports online then they are automatically attached to the corresponding patient EMR.

Advantages

• Dictation remains the most intuitive and least time-consuming means of data entry.
• Physicians can dictate anytime, anywhere using PDA, Dictaphone or telephone, at their convenience.
• Providers need not change the way they practice just to accommodate an EMR. OmniMD^™ EMR can interact with transcription service so that transcriptions can be attached directly to the patient's electronic medical record.
• Requires minimal training for providers.
• Provides expressive power to describe patient's condition and other health related events.