Consultation manager
A comprehensive consultation manager facilitates the recording of each patient-physician encounter to create either a complete medical record, or an abbreviated version. The patient record can be easily compiled during consultations without compromising your bedside manner, cutting down on paperwork and freeing more time for patient care.
Incorporating integrated file attachments and a flexible editor, the consultation manager enables filing of multi-media documents within patients’ medical records.
From the consultation screen, EMIS enables physicians to quickly reference reliable information through Web Mentor Library, an online decision support tool that links directly into your EMR system.
Data entry techniques
Rapid data entry is possible through a variety of techniques. EMIS accepts data to be entered into your EMR system through a combination of templates (pre-defined or custom), synonyms, coded classification or free text. Also fully integrated are dynamic links from the consultation manager to advanced decision support modules.
Even with limited typing skills, physicians and staff are able to easily complete consultations and navigate the system.
A timesaving feature of EMIS ensures that data is only ever entered once, and then populated throughout the system to avoid the need for data to duplicated across the EMR system.
Templates
Inputting patient data using a template is a simple method of standardizing data entry across the clinic.
Users can define a screen or series of screens that prompt for information in user defined situations. The data entered through templates can be pre-coded and therefore negates the need to search through the classification for the appropriate code and aids in code standardization throughout the system.
Links to advanced decision support and hyperlinks to websites can be embedded in relevant templates to expand the functionality of a template.
Synonyms
For speedy data entry, you can create your own synonyms and abbreviations to quickly enter commonly used phrases. For example, you can type ‘TATT’ to insert the phrase ‘tired all the time’ or ‘RFX’ to insert ‘examination of reflexes’ into the medical record.
Coded data
EMIS is compatible with the implementation of coded information. Coded data provides physicians with the ability to easily record, retrieve and analyze data.
EMIS encourages the structured recording of every clinical encounter, providing templates and synonyms, to enable you to rapidly record coded items or frequently used text phrases, without compromising the usability of the EMR.
Intelligent coding means a physician can insert coded data entries whilst typing free text in the consultation mode.
Read codes and ICD10 CA/CCI
EMIS incorporates a comprehensive 300,000 item dictionary of clinical terms we call Read codes – the sole coding system used in the UK – to enable physicians and other data users to accurately:
- record the details of clinical care (for example, diagnoses, histories, symptoms, investigations, therapeutic procedures and drug administration) on a computerized record;
- share and exchange computerized clinical information; and
- retrieve and analyze clinical information held in clinical information systems.
Recording information through coded data can help clinics to maximize income, through accurate coding and classification/analysis of patient care.
In EMIS, Read coded entries are automatically mapped to the current Canadian standard coding system, ICD10 CA/CCI to enable precise billing, in relation with the medical care given.
No longer does the accuracy of billing depend on the skill of the billing clerk. The intelligent billing engine will automatically pick the best fee code and tariff code for the data you have recorded in the EMR. The system will then pick the best combination of codes to maximize billings and reduce rejections.
Free text
Designed to be flexible, EMIS also allows free text information to be entered into the EMR system, for those times when coded information or templates is unsuitable.