How Your Doctor Uses Electronic Health Records

By Karen Scoles, M.D., Medical Director of Information Systems

It’s very likely that you won’t be alone with your primary care or specialty physician during your next check up or follow-up visit. Many physicians and other providers are using a computer, tablet or other electronic device during office visits.

ckhs-stock-images-220In most cases, the computer will be making your medical record available to your physician. It will contain your medication and allergy list, your diagnoses list, consultation notes from other physicians, hospital records and laboratory and radiology results. Much of this information can be displayed in a convenient flow sheet form and present a longitudinal record of your care. Your doctor’s assistant may have entered your vital signs, blood sugar and reason for the visit before your physician sees you. Your physician/provider will review this information and may add to your record while speaking with you and examining you.

At the conclusion of your visit, the Electronic Health Record (EHR) system can provide patient specific recommendations about necessary preventive care and alert your physician to the need for interventions or changes in your treatment. Your physician can use the computer to order tests or consultations, send electronic prescriptions, be alerted about possible medication interactions, trend your results or progress with your healthy lifestyle choices, recommend appropriate resources or use a reference tool to answer a question. All during your visit!

At the end of your visit, your physician provider can generate a summary document of your visit, reminding you of care recommendations for the continued good health of you or your family member. Your physician can securely communicate with other physicians and soon will be able to securely communicate directly with other physicians using Health Information Exchanges. After your visit, your physician or provider can securely communicate with you about test results or additional recommendations for your care. You can access important components of your health record securely and communicate back to your provider.

EHR benefits include reduced paperwork, making important health information available to those who need it to, improved care coordination and safety, reduced unnecessary tests and procedures and providing patients access to their records.

While there is no question that EHRs can improve care and outcomes, there can be concerns that the computer can be a barrier to effective patient – physician communication. It’s really important that physicians/providers take time to think about how to use the computer as a tool to enhance visits with our patients, and not have the device become a distraction.

For more information, visit www.paehealth.comwww.healthit.gov.

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