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How do Electronic Medical Records work?

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There are many different systems available, but the basic idea is that when a patient sees a doctor for a visit, whether it is for a sick or well patient consultation, the information collected in the visit is entered into the patient’s computerized file. The paperless chart is neatly organized with subfolders such as: x-rays, lab results, office visits, emergency room visits, medicines, phone calls and so forth. During each office visit, phone call or hospital stay, new information can be entered into the chart in several ways. Most systems have different “templates” that the doctor uses on his lap top. A template guides the physician through a standard protocol of questioning, depending on the patient’s reason for the visit. For example, as the doctor questions the patient’s recent health, a question on the template could be, “Have you had a fever?” The doctor would click on “yes” or “no”. If the answer were, “Yes”, then other questions regarding the severity and duration of the fever would follow. The template enables the doctor to get thorough information without having to take the time to type out all the information. However, there are certainly times when a Yes/No format or similar format is inadequate. In such cases, some software systems allow the physician to dictate his observations and treatment options with a speech microphone attached to the lap top computer. This voice file is sent to a transcription service, properly transcribed and then the completed file is placed back into the appropriate place in the patient’s computerized chart. All of this takes place over the internet! Language dictation software has been developed and is used by some physicians. However, there tends to be a low percentage of errors, such as the word “two” transcribed instead of “too,” which necessitates final editing, whether by the doctor himself or a transcription service.

After the initial consultation with the doctor, he or she may order a series of lab tests or medical imaging tests. The orders for the tests, the scheduling for the tests, the billing and payment for the tests, receiving and reporting the results and any other necessary assessments and plans would all be carried out within the electronic medical records system. Of course, common sense takes precedent over the convenience of the internet: a physician would choose to reveal a difficult or challenging diagnosis over the phone or in person rather than through the internet.

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