Electronic health records (EHRs) have become indispensable to modern healthcare. When implemented and utilized effectively, EHRs can improve patient care, increase practice efficiency, and improve health outcomes. However, EHR systems can become cumbersome without proper management and fail to live up to their potential. Follow these ten best practices to get the most out of your electronic health records.
1- Track Patient Data Over Time
One of the key benefits of EHRs is the ability to have a patient’s full medical history in one place. This comprehensive profile helps you make informed care decisions based on trends and changes. Set up your EHR to present longitudinal views of patient data so you can easily track vitals, test results, medications, diagnoses, and notes across all visits and providers. This avoids having to piece together fragmented information from separate encounters.
2- Implement A Logical Workflow
An EHR system should mirror and optimize your real-world clinical workflow, not complicate or constrain it. Set up an intuitive workflow within your EHR to promote efficiency. For example, customize templates, tabs, shortcuts, macros, and screen flows to match exam sequencing, diagnostic protocols, and documentation needs. The system should adapt to your process, not the other way around. Having an EHR that logically follows your workflow makes adoption much easier.
3- Utilize Data Entry Automation Features
Data entry and documentation can become burdensome if not managed well. Leverage the built-in automation capabilities of your EHR to reduce repetitive manual inputs. For instance, use preference lists, smart phrases, voice recognition, macros, and templates to streamline data entry. Set up shortcuts, hover-overs, and data verification tools to speed up documentation. Automating mundane tasks allows you to focus on patient interactions.
4- Integrate Outside Data Sources
EHRs should not exist in a silo. Integrate your system with outside sources to eliminate redundant data entry. Set up real-time interfaces with pharmacy systems, labs, imaging centers, HIEs, patient portals, wearables, and other systems to pull information directly into the patient record. For example, a healthcare document scanner can automatically scan paper records into the appropriate patient chart. Integration preserves data integrity and provides a seamless workflow.
5- Enable Patient Engagement Features
Today’s EHR systems include tools to engage patients in their own care. There are many opportunities to connect, from patient portals to self-scheduling to secure messaging. Promote patient access to their record, test results, care plans, and educational materials. The ability for patients to view and participate in their care from home improves outcomes and satisfaction.
6- Optimize Templates And Data Displays
Default EHR templates are notoriously suboptimal for many specialties. Work with your vendor to customize templates, layouts, tabs, and data displays to best suit your needs. For example, problem-oriented charting allows physicians to organize by diagnosis versus date. Visit-oriented views work better for episodic care. Ensure key data elements are prominent and unnecessary fields are removed to prevent clutter. The right display and layout drastically improve usability.
7- Promote Interoperability And Data Sharing
Data trapped in siloed systems helps no one. Follow industry standards for interoperability to exchange data securely across systems. Participate in regional health information exchanges (HIEs) so patient information is accessible wherever they seek care. Use Direct protocols to share summaries, referrals, orders, and results with other providers. Adopt certified EHR systems that meet modern interoperability requirements. Seamless data sharing improves coordination and the patient experience.
8- Train Staff On Effective Use
Any EHR system is only as good as the users who leverage it. Provide comprehensive training to staff on properly using the system to support clinical workflows. Conduct periodic refresher training to reinforce best practices, particularly after system upgrades. EHR proficiency results in engaged users who fully utilize capabilities and provide input to refine configurations. Ongoing education is key to long-term success.
9- Maintain Good IT And Security Practices
Complex EHR systems require robust IT support and maintenance. Work closely with your IT team or vendor to ensure optimal uptime and performance. Maintain vendor support contracts for prompt issue resolution. Follow cybersecurity best practices to guard against threats like ransomware. Back up data regularly. Plan for how you will continue operations if the EHR system goes down. Without vigilant IT and security, you quickly lose faith in the EHR.
10- Involve Clinicians In Enhancement Decisions
Continuous improvement is key to EHR adoption. Involve clinical staff in decisions about enhancements and new features. Understand where workflows are breaking down or could be streamlined. Solicit ideas for optimizing templates, shortcuts, order sets, and protocols. Clinicians who feel heard are more likely to fully embrace the system. Ongoing user feedback ensures the EHR evolves with your practice.
Following these best practices allows you to harness the full potential of your EHR investment. A system tailored to clinical workflows, with robust data and interoperability, and engaged users translates to better patient care. Treat your EHR not as a static technology but as a platform for continuously improving efficiency and outcomes. With proper management and optimization, your electronic health records will enhance your practice for years.
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