Article Date: 3/1/2004

instrumental strategies
This EMR Puts You in Control

OfficeMate's ExamWRITER can make your life easier. See how.
ROBERT N. ROSENSTEIN, O.D., F.A.A.O.

During my first decade of practice, I manually maintained patient records. Correspondence with doctors and patients was tedious, requiring hours at a typewriter. The second decade, recall and financial management gave way to computer automation. Correspondence and charting were still manual, and time consuming. Now in my third decade, manual medical charting has given way to electronic medical records (EMR). Now I can electronically document records chair side, resulting in comprehensive and legible records -- all with simple mouse clicks.

You're in control

OfficeMate's EMR, ExamWRITER, involves a system of predefined templates following the SOAP (Simple Object Access Protocol) format. Navigate it with mouse clicks, checking off boxes that translate into precise prose for medical records. You can easily customize templates for your practice with ExamWRITER. Further, you can customize your input on the fly during the examination; customizable fields are at every turn.

OfficeMate's ExamWRITER "template concept" deserves your attention. If all that's required is say, a contact lens follow up, then you can open a new "customized template" just for your practice. Decide which tests you require for that situation, click under the appropriate headings, then save. When you need that template, just open that file by clicking on it and entering the patient's data. ExamWRITER allows you to customize exam and check-up templates to meet your practice's needs.

Taking it apart

The ExamWRITER system is categorized. The history section captures the patient's chief complaint, medical problems, current drugs and surgeries. The vision section provides information on visual acuities, past prescriptions, current prescriptions, final prescription and trial contact lens information. You can automatically download automated refraction, subjective refraction, keratometry, vergences, Worth-4-dot fusion and stereoposis, among others, into ExamWRITER from Marco's Epic 2100 refraction system. (OfficeMate anticipates further integrations with digital refraction systems soon.) Examination includes virtually any test you can run in your office while you easily enter diagnostic and procedures codes into the system, giving staff an opportunity to apply the correct charges to the correct diagnosis.

An integral feature of ExamWRITER is Quick Code, which allows you to quickly assess whether you've met all of the requirements for a 99XXX billing code. If not, the program shows you which areas need more information for that coding level. The "plan" category covers surgery, medical and optical. The "recall" portion allows multiple recalls and/or scheduling. You can set annual recall and schedule the patient for multiple glaucoma follow-up visits.

My favorite is combining ExamWRITER templates with Quick Code. This is a potent chairside combination. I can check whether I've documented the intended examination in real time.

Communication made easy

ExamWRITER simplifies correspondence with practitioners and patients. It takes minutes to assemble letters that convey all of your documentation. Have you ever had a patient request handouts just after you explained his astigmatism? No problem for ExamWRITER. A few mouse clicks brings up a list of common conditions in easy-to-understand terms. Click on "print" and you're a hero.

DR. ROSENSTEIN IS IN PRIVATE PRACTICE IN DURHAM, N.C. CONTACT HIM AT (919) 471-4474.100

 


Optometric Management, Issue: March 2004