ElectronicMedical Records: Epic Software
ElectronicMedical Records: Epic Software
Electricalmedical records systematically collects and store information ofpatients from the first time visit digitally. Due to the improvingtechnology, our facility has adopted the Epic system for documentingthis data. The software assists in integrating functions related toregistration and visiting schedules, patient care, and clinicalsystems for the health workers (Dranove, Garthwaite, Li., & Ody,2015). It is also used in the payment systems and billing of theinsurance providers. It has a database that stores the order entriesby the physician and applications of practice management. Therefore,it has replaced the previously used paper charts which has thuspromoted the interactions between patients and the healthcareworkers. Despite concerns such as distraction of physicians andbreaching of patients confidentiality, reports have associatedelectronic software such as Epic with improved care (Dranove et al.,2015).
Whenthe patient arrives at the emergency department, a brief history isrecorded in the software by the staff in the EMR department beforethey are seen by the triage nurses. This information becomesavailable to all the members of staff connected to the program. Thenurse in charge subsequently records their findings, and by the timethey are seen by the physician, all the required information,including laboratory and radiological findings, is on the database.In case of admissions, the records are availed to the staff in theward.
Theuse of Epic software in the facility as opposed to paper records isassociated with several benefits in provision of comprehensive careto the patients. In some instances, the handwriting used on paperrecords are illegible and may lead to misinterpretation of theinformation (Koppel & Lehmann, 2014). Additionally, according toDranove et al. (2015), the hard copies of these files are usuallycumbersome to store and retrieve. Therefore, some facilities have toput up with long queues which usually delays treatment of thepatient. Koppel and Lehmann (2014) indicate that information recordedin digital systems such as Epic allow faster retrieval of previouslab results or radiological findings which make it easier to managepatients. The Epic system, particularly, offers a summary of thepatient regarding their major illnesses, previous surgeries, allergyto medication, and any other medical history. In contrast, studieshave found that up to twenty-five percent of paper charts go missing,over twelve percent of those found have some details missing, andover twenty percent of lab tests are re-ordered because the previousones cannot be accessed (Koppel & Lehmann, 2014).
Epicsystem has made a transition to incorporate ICD-10 which has replacedthe ICD-9 while the CPT coding for physician services and proceduresin the outpatient department is maintained. The software provides forspecific recording of information within it user web which caters forbroad spectrum implementation of the ICD-10 coding system (Carson,2016). Some of the master files used in this coding include VCG fordiagnosis, LQH for follow-up visits, EAP for procedure carried out onthe patient, and LGL to advice on best practices based on evidence(Carson, 2016). Using this coding, health workers can click at thesummary tab of the patient to previous and new diagnosis, and toupgrade ICD-9 codes present to ICD-10. The diagnosis can be displayedby their terms or its ICD-9 code. On the other hand, CPT codes arealso being applied in the practicum to identify procedures done onthe patients in the facility and updated in the Epic software. Theinsurance companies also have an access to the CPT codes to determinethe payment for the nurses and physicians. The use of these codingsystem, alongside the software, has led to improve care of patientsin this facility.
Carson,K. (2016). Improving Accuracy of International Classification ofDiseases Codes. Journalof EMR, 135(4), 616-620
Dranove,D., Garthwaite, C., Li., B. & Ody, C. (2015). InvestmentSubsidies and the Adoption of Electronic Medical Records inHospitals. Journalof Health Economics, 44,309-319. http://dx.doi.org/10.1016/j.jhealeco.2015.10.001
Koppel,R., & Lehmann, C. U. (2014). Implications of an emerging EHRmonoculture for hospitals and healthcare systems. Journalof the American Medical Informatics Association, amiajni-2014.