Electronic health records (EHRs) and electronic medical records (EMRs) are digital solutions that allow healthcare providers to store, manage, and share patient information securely. But did you know that these technologies can also optimize laboratory management? 

One key advantage of EHRs is their ability to integrate with various clinical systems, including laboratory management systems. This integration enables seamless transmission of lab test orders and results between healthcare providers and laboratories.

While this integration eliminates the need for manual entry and reduces the risk of errors, few healthcare providers use these digital tools with their lab platforms. Such slow adoption represents considerable wasted opportunities when sharing lab information, flagging abnormal results, and facilitating timely follow-up actions.   

Understanding the critical role of EHRs in lab management can transform a clinic into a safer and more efficient healthcare facility.

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Importance of Lab Management in Healthcare

Many laboratories are facing difficulties due to understaffing and outdated equipment. The laboratory technologists cannot keep up with the workload, which leads to delays in processing test orders and analyzing samples. These issues put patients’ health at risk, as they may not receive the necessary intervention due to the longer wait times.

Consequently, healthcare institutions must ensure efficient laboratory management. This standard will enable them to provide high-quality service to their patients. Here is a breakdown of impacted practice points:

Patient Care: Clinical laboratory tests play a vital role in diagnosing, treating, and monitoring patient’s health conditions. Accurate test results are essential for providing quality patient care and making informed clinical decisions.

Patient Safety: Proper laboratory operations management, quality assurance, and regulatory compliance are essential for ensuring the reliability of test results and safeguarding the patient’s safety.

Efficiency and Productivity: An EMR with strong lab management features, coupled with effective lab management practices, helps optimize workflow processes, resource utilization, and personnel productivity, resulting in efficient and cost-effective laboratory operations.

Compliance and Risk Management: Compliance with regulatory requirements and accreditation standards minimizes the risk of legal penalties and reputational damage to healthcare practices.

Research and Innovation: Well-managed laboratories can contribute to research efforts, innovation, and development of new diagnostic tests and treatments, ultimately advancing healthcare delivery and improving patient outcomes.

Need to boost your lab management? Our experts can help you learn how the EHR-and-lab system combo can improve things. Let’s chat today.

Integration of EHRs and Lab Management

At the outset, lab management may only require organizing test results and other lab data. However, healthcare providers and lab technicians also implement a secure EHR system, facilitating such functions: 

• Test Ordering: Providers can electronically order lab tests directly within the EHR platform, eliminating the need for paper requisitions. 

• Results Reporting: Once laboratory tests are completed, the laboratory information systems (LIS) swiftly transmit the test results to the EHR software, specifically integrating lab data into the patient’s electronic record. 

• Result Alerts and Notifications: Similarly, EHR alerts and notifications are handy for critical or abnormal test results that require immediate intervention by healthcare providers. 

• Decision Support: EHRs with decision-support tools can help providers interpret laboratory test results and recommend appropriate follow-up actions.

• Billing and Coding: Some EHRs automate laboratory test coding and billing processes, making accurate documentation of test services easier and payer reimbursement faster.

• Trend Analysis: Viewing historical test results in the electronic record allows providers to monitor trends and track patient health status. 

To facilitate the functions mentioned above, providers and lab techs need to focus on the common integration points between EHRs and lab management systems, including:

Health Level Seven (HL7) Interfaces: EHRs and LIS often integrate via the HL7 interface to transmit laboratory orders and results seamlessly.

Single Sign-On (SSO): This integration allows healthcare providers to access both systems using a single set of credentials, enhancing user experience and workflow efficiency.

Bi-Directional Data Exchange: EHR-LIS integration enables real-time communication between systems, which means that updates made in either system are reflected accurately in both.

Laboratory Test Catalog Integration: EHRs often integrate with LIS to access and display the laboratory test catalog, including test names, descriptions, codes, and specimen requirements. 

Data Mapping and Mapping Tables: This capability maintains consistent terminology and format so providers and lab professionals can facilitate the accurate transmission of lab orders and results between systems.

Benefits of Using EHRs in Lab Management

At 1st Providers Choice, we recognize that healthcare practices need essential features to help them leverage EHRs and lab system integrations. These capabilities help deliver the following benefits:

Improvements in Efficiency

Our EHR platform streamlines lab workflows and processes by automatically creating lab orders based on the patient’s diagnosis and making lab orders effortless. This automation reduces manual entry errors, minimizes staff burden, and accelerates ordering.

Accuracy and Data Integrity

Our EMR lab management software makes maintaining accurate records and minimizing errors easier. Our integrated EHR ensures seamless data transmission with laboratory systems by interfacing with over 300 labs nationwide (HL7 interfaces), minimizing errors and enhancing data integrity throughout testing.

Enhanced Communication

With 1st Providers Choice’s EHR, lab staff and providers communicate more effectively when receiving lab results as PDFs or discreet data directly into the EHR. These results are integrated into a flow sheet or graph for visual presentation, which supports collaborative decision-making.

Better Patient Care

EHRs contribute to better patient care outcomes by automatically flowing lab results to the 1st Providers Choice Patient Portal and notifying the patient to review them. This proactive approach empowers patients to stay informed about their health status and follow up with their providers, potentially avoiding unnecessary calls to the office.

Revenue Generation

Our EHR supports automated reminders to ensure patients don’t miss recommended labs, contributing to revenue generation for the practice. Integrated practice management systems like IMS manage the patient’s health maintenance, prompting when labs are due and encouraging patients to schedule appointments. 

Takeaway

In today’s healthcare landscape, EHRs are more than just digital repositories for patient data—they are transformative tools that can revolutionize lab management. By seamlessly integrating with laboratory information systems, EHRs streamline workflows, reduce errors, and improve communication among healthcare professionals. 

Tap Into Our Expertise 

The 1st Providers Choice EHR offers automated lab orders, real-time result notifications, and advanced data integrity. Our EHR lab management software helps healthcare providers optimize their laboratory operations, provide better patient care, and boost revenue generation. 

To unlock the full potential of EHRs in lab management, call (480) 782-1116 today. With over 40 years of trusted service and recognition by the Better Business Bureau (BBB) since 2010, 1st Providers Choice is confident in providing your practice with an integrated EHR that can transform healthcare delivery and ensure a healthier future for your patients. 

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Imagine a patient struggling with sleep due to breathing issues, seeking a diagnosis that might require the expertise of both pulmonologists and sleep specialists. Multi-specialty clinics make this journey seamless, offering coordinated care under one roof.

The patient could start by seeing the pulmonologist, who records the symptoms and visit notes in their EHR. During the appointment, the pulmonologist might decide to refer the patient to a sleep medicine specialist and order a sleep study. The sleep specialist would have instant and direct access to the information gathered by the pulmonologist. This convenience is one of the biggest advantages of multi-specialty clinics.

However, even in these clinics, the process might not always be perfect because not all EHR systems are created equal. Some systems are better suited for multi-specialty practices, so it’s essential to find the multi-specialty EHR software that best aligns with your clinic’s needs. 

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Challenges in Managing Patient Data in Multi-Specialty Clinics

Each specialty generates detailed patient records, so managing this large volume of data is crucial while ensuring accuracy and accessibility. An EHR system can help effectively consolidate test results, treatment plans, and follow-up notes from multiple specialties.

Also, different specialties use specific terminologies, coding systems, and clinical protocols. Harmonizing these within a single multi-specialty EHR system requires advanced customization to ensure that each specialty can operate efficiently without compromising the usability of the shared records.

Need for Coordinated Care

Patients often require coordinated care plans involving multiple specialties. For example, a patient with a chronic respiratory condition might need care from a pulmonologist, a sleep specialist, and a physical therapist. Your EHR system should be able to facilitate seamless integration of these care plans to avoid conflicting treatments and ensure comprehensive care.

Lastly, efficient scheduling is essential to manage appointments across various specialties without overlaps or excessive wait times. The EHR software should offer advanced scheduling tools that coordinate appointments based on specialists’ availability.

Essential Features of Multi-Specialty EHRs

Electronic health records and electronic medical records (EMRs) provide numerous benefits to clinics. However, for multi-specialty clinics where coordinated patient care is a focal point, specialists rave for a slightly different set of multi-specialty EMR software features.    

Case management should be a top feature on your checklist. Clinics use this tool to efficiently track and manage patient care across multiple specialties. With case management, you can maintain a detailed log of all patient visits across various specialties, including the date and time, the specialty consulted, the clinician involved, and the purpose of the visit.

Each visit is summarized within the EHR, providing a snapshot of the patient’s condition, diagnosis, and treatment during that visit. This ensures that all relevant patient information is easily accessible for future reference.

Many Specialties, More Features

While we already discussed the amazing benefits that a proper case management module could provide, that’s far from the only feature that you should be on the lookout for in your multi-specialty EMR software:

1. Clinical Documentation

EMR and EHR systems facilitate communication and continuity of care by storing detailed patient information, including medical histories, test results, treatment plans, and ongoing care notes from various specialties. 

2. Patient Registration and Scheduling

When patients visit the clinic first, their personal information, insurance, and medical history are entered into the system. The EMR system allows staff to schedule, reschedule, and manage appointments across multiple specialties, ensuring no conflicts.

3. Interoperability 

EHRs in multi-specialty clinics are often interoperable with other healthcare systems and laboratories, allowing seamless sharing of diagnostic results, referrals, and medical records critical for making informed decisions during consultations and treatments.

4. Specialty-Specific Templates

EHR systems offer specialty-specific templates and tools to streamline clinic documentation. For example, physical therapists use tools to document rehabilitation progress, speech therapists have templates for speech and language assessments, and occupational therapists utilize templates for daily living skills evaluations.

6. Analytics and Reporting

An EHR software provides powerful analytics tools to analyze patient data, which is valuable for improving patient care, managing resources, and meeting regulatory requirements. This platform also generates reports required for compliance with healthcare regulations, such as Meaningful Use and MACRA.

7. Billing and Claims Management

A built-in multi-specialty billing software allows EHRs to streamline billing processes by combining the specialties’ billing and coding systems. This feature ensures accurate coding for diverse services provided across specialties and efficient claims management.

Common Pitfalls to Avoid When Choosing an EHR

As a multi-specialty clinic, you can choose an EHR system that enhances efficiency and improves patient care if you know the common pitfalls of EHR selection and take proactive steps to address them. 

1. Overlooking Customization

It’s important to be cautious of healthcare documentation systems that adopt a one-size-fits-all approach. An EHR system that you can’t tailor to accommodate your specialties’ unique workflows and requirements can potentially hinder efficiency.

2. Ignoring User Feedback 

An EHR system that is not user-friendly can lead to frustration and decreased productivity among clinicians and staff. Prioritize systems with intuitive interfaces and workflows. Consider feedback from clinicians and administrative staff to check if the platform aligns with your daily needs and challenges.

3. Failing to Plan for Implementation

A poorly managed implementation process can disrupt clinic operations and lead to significant downtime. Develop a complete implementation plan that includes timelines, responsibilities, and contingency plans. Ensure the EHR vendor provides robust support during and after implementation.

Benefits of Investing in a High-Quality EHR System

Investing in a high-quality EHR system offers multi-specialty clinics significant returns on investment through:

Improved Billing: Seamless integration with billing systems minimizes administrative overhead and reduces the time spent on billing-related tasks, allowing staff to focus on patient care.

Streamlined Workflows: Efficient sharing of patient information among different specialties improves coordination and reduces delays.

Cost Savings: An EHR system provides a comprehensive view of patient history and previous tests, helping avoid redundant tests and procedures and reducing unnecessary expenses.

Enhanced Data Management: A centralized electronic system ensures that all patient data is easily accessible to authorized personnel, improving information accuracy and reducing the risk of data loss.

Better Health Outcomes: EHR systems can track and flag critical health metrics, enabling providers to intervene early and manage chronic conditions more effectively.

Takeaway

A robust EHR system unifies clinical, administrative, and financial operations. Multi-specialty clinics that invest in these integrated platforms benefit from enhanced care coordination, which ensures long-term success and paves the way for delivering exceptional patient care.

Tap Into Our Expertise

Ready to streamline your multi-specialty clinic’s operations? 1st Providers Choice offers customized EMR systems with built-in templates for over 30 specialties, advanced scheduling tools, and comprehensive practice management. 

For over 40 years, we’ve been the trusted partner for multi-specialty clinics looking to improve efficiency and patient care. Contact us for a free quote or schedule a demo to see our system in action. 

Electronic Health Record (EHR) Documentation is an efficient way of recording and enables healthcare providers in sharing patient information electronically. It provides a comprehensive overview of a patient’s health, including data such as family history, lab results, medications, and clinical notes. Furthermore, it allows healthcare providers to monitor patient health changes over time and make evidence-based medical decisions.

However, physician documentation challenges are inevitable, especially if the EHR system is at fault. As a result, these issues may lead to EHR and physician burnout, which can be very frustrating. 

Let’s take a look at the EHR documentation challenges and their impact on physician workload.

6 EHR Documentation Challenges and Their Impact on Physician Workload

Most physicians are only aware of the challenges of EHR implementation because it is a complex technological process. However, what about the documentation along with it? 

1. Spending too Much Time on Clinical Documentation

In the US, doctors are overwhelmed with the amount of time they should spend on using EHRs. On average, they spend 16 minutes and 14 seconds using EHRs, primarily for chart review (33%), documentation (24%), and ordering (17%). Well, it’s understandable that physicians may need to spend more time on clinical documentation due to various factors, like lack of training, complex EHRs, higher documentation requirements, and disruptions. Nevertheless, if the electronic medical record documentation has a poor user interface and system design, it may not be efficient and prone to errors.

Unsurprisingly, spending too much time on clinical documentation is a significant problem for doctors in the healthcare system. Not only does it limit the number of patients you can see, but it can also cause other issues. For instance, if you’re stuck in paperwork, you won’t be able to give the patient the attention they need and may miss important details that could lead to errors in diagnosis and treatment. Additionally, this extra documentation time can lead to EHR and physician burnout and fatigue, making you less effective in your job. Healthcare systems must find ways to reduce the amount of time doctors spend on clinical documentation to make sure patient care is up to par.

2. Meaningful Use – Merit-Based Incentive Payment System (MIPS) And Medicare Access and Chip Reauthorization Act of 2015 (MACRA) Documentation Requirements That Dramatically Slow Physicians’ Productivity.

As a physician, you always know that MIPS and MACRA documentation requirements require so much time for paperwork and reporting. Moreover, these documents can be challenging to understand and comply with. There are two reasons why:

1. The language used in the MIPS and MACRA documentation requirements is highly technical and hard to comprehend. As a result, you may need help following the proper regulations.

2. MIPS and MACRA documentation requirements are constantly changing — making it challenging to keep up with the latest changes.

Beyond that, if EHR systems aren’t up to the task, doctors could spend more time on clinical documentation and reporting, leading to extra work and exhaustion. Likewise, the requirements may call for physicians to document the same information multiple times, which could create a duplicate effort and needlessly use up resources. This situation leads to EHR and physician burnout.

3. Documenting Clinical Visits for Longer Hours

Physician burnout may result from documenting clinical visit notes for longer hours, which involves your personal time. You may have to extend your working hours for the following reasons:

• Ensure that the documentation is accurate, complete, and up-to-date. 
• Document patient visits for billing purposes, as well as for legal reasons. 
• Provide additional quality patient care, such as discussing treatment options or providing education about illnesses or other health-related topics. 

While all these reasons contribute to quality patient care, using your personal time for EHR documentation is not recommended. If you allow it, it can lead to physician burnout. It takes away valuable time you could spend on self-care, family time, or other activities that reduce stress and improve well-being. The situation may negatively impact your workload and decrease your satisfaction at work.

4. Inefficient EHR Software That Leads to a Lot of Additional Documentation Time.

An inefficient EHR software can cause you to spend more time on clinical documentation because it requires extra steps to find patient information, enter data, and navigate the system. Also, if the electronic medical record documentation system isn’t user-friendly, it can contribute to EHR burnout and frustration. EHR systems can also lead to inefficiencies and errors, especially if they’re outdated or have slow systems. Consequently, EHR software with inefficient performance can delay documentation because of lag times. In this case, you’ll probably need to outsource some of your clinical tasks.

5. The Decline in Patient Focus Due to Documentation Requirements

With the demands of electronic health record (EHR) documentation continuing to grow, staff may spend less time on direct patient care. This situation can be stressful and overwhelming. Moreover, they may be less inclined to engage in meaningful conversations with patients and their families, resulting in lower patient satisfaction. Suppose the EHR system is not designed correctly or implemented; it can add more to the EHR documentation burden and staff frustration, potentially leading to a decrease in the amount of time staff spend on patient care.

Meanwhile, the risk of copying patient notes forward – also known as ‘cut and paste‘ – can significantly affect the accuracy and integrity of electronic health records (EHR). This practice can lead to mistakes and inconsistencies in a patient’s medical history and keeping irrelevant information. It can also make it harder to spot changes in a patient’s condition, which can mean they don’t get the proper diagnosis or treatment and can put them in danger. And it can also increase the risk of fraud and malpractice, as it can be hard to tell who entered which information and when. To prevent this risk, healthcare organizations should have policies and procedures that help detect copied notes in EHR systems.

6. Lack of Training in Electronic Health Record Software

In the absence of proper EHR training, you may experience a few unfortunate outcomes:

1. Staff not trained to correctly use and document patient information can make medical errors and mistakes.
2. It can delay care when staff cannot use the system efficiently, negatively affecting patient satisfaction.
3. It can reduce the efficiency of the healthcare system when staff takes longer to complete tasks because they need to familiarize themselves with the system design, resulting in longer wait times for patients and decreased healthcare efficiency.

Therefore, audits are necessary. Doctors and senior nurses review the medical record in clinical documentation audits to identify clinically implied diagnoses. Its goal is also to identify and correct any errors or inconsistencies in the patient’s EHR and to ensure that the information is helpful for patient care, billing, and quality improvement.

Overall, clinical documentation audits serve to determine compliance with HIPAA and CMS regulations, which can prevent penalties and legal repercussions.

How to Improve EHR Documentation In Healthcare

Since healthcare technology, codes, and communication between providers and coders continue to change, it is essential to improve healthcare documentation continuously. Staying current requires constant communication among all healthcare personnel. Likewise, here are five ways to improve EHR documentation in healthcare:

• Provide training and support to staff on how to effectively use the EHR system. This process can include training on how to navigate the system, as well as on best practices for documenting patient information. Additionally, practices can provide regular updates and refresher training to ensure staff uses the system correctly and efficiently.
• Implement a streamlined documentation process. You can capture all relevant information by using templates and providing checklists and reminders. 
• Establish a quality control system to ensure the Documentation is accurate and complete. You should include regular audits of patient records to identify errors or omissions and give feedback to staff to help them improve their documentation skills.
• Utilize voice recognition software for your EHR system. It can help streamline the process of documenting patient information and facilitates fast and accurate transcription of patient information into electronic medical records.
• Offer your staff regular breaks and time off since it’s a great way to prevent burnout and keep them energized and fresh.

In conclusion, accurate and timely reimbursement is the main priority for any healthcare institution or clinic, which is why healthcare documentation improvement is so significant. Clinical Documentation Integrity (CDI) professionals should dedicate to documenting patient records accurately and completely. Therefore, healthcare providers like you can receive on-time payments.

Choose the Top EMR/EHR Software 

To ensure quality EHR documentation, selecting an EHR that offers customizable applications with template capabilities is essential. The right software can help reduce the frequency of errors and EHR burnout associated with poor documentation practices.

Over the years, we have assisted medical practices with EHR/EMR selection, implementation, and software usage. We specialize in providing customized EMR/EHR software to meet your practice’s specific needs.

Schedule a demo or contact us through the contact form for more personalized information. Let’s work together to find the best software for your practice!

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