One of the most challenging areas to train a new technician on can be the EMR system, especially if they are not familiar with a previous EMR system. Very few ophthalmology practices are still using paper charts so understanding how to navigate your EMR is crucial.
When implementing a new system, the company usually offers to have a trainer come to your clinic to set up/train staff on the new system. There are often “super-users” which are techs that underwent additional EMR training that are available for all technicians to ask questions to throughout the implementation process and beyond. If possible, a trainer(s) should become a “super-user” as they will have to train new hires on the system. Once your staff is familiar with the basics of EMR it is time to dig deeper.
By utilizing “super-users” in a scribing and training function they can recommend adjustments to your system that will make both the work-up and exam more efficient. For example, canned notes may be altered so scribes can quickly select a drop down note and make additions/deletions as necessary. Having to do less typing saves a substantial amount of time. If you are unsure how to create or alter canned notes you may want to reach out to your EMR support system. Some EMR systems may allow you to make custom changes to the work-up pages if technicians find it more efficient to change or add “buttons.”
Ensure that scribes get additional training on how to locate and add findings in the exam and billing section. Most EMR systems will alert the scribe or physician to what CPT code can be billed based on the work-up and findings. For example, a physician wants to bill a comprehensive eye code 99214 but the EMR system may create alert reminding you to check off the mental status box. Paying attention to the billing alerts saves time on the back end for the biller and makes auditing more efficient. It is bad practice to continuously ignore billing alerts if you EMR system has that capability. During the examination many EMR systems will link a drop down finding to a diagnosis code under the assessment/plan and billing section. For example, a finding of 2+ NS OU when selected from the drop down will link to ICD code H25.13 for nuclear sclerosis bilateral. Again, this is a substantial time saver during the exam and requires less typing. In most EMR systems the less typing the scribe does the more efficient the exam. Significant amounts of typing should be reserved for editing canned notes or adding details to the patient summary.
New techs and scribes should be trained to use the EMR system in the most efficient way possible. Using drop downs and canned notes for common findings gives the physician and scribe more time to review the chart prior to signing. Understanding your EMR system can be one of the biggest time savers for your practice.