The Top EHR Best Practices You Should Be Following

So you’ve taken the leap and implemented an Electronic Health Record (EHR) System at your healthcare organization. On the one hand, you’re probably filled with equal parts hope and excitement because you know your agency is about to get more efficient. But on the other hand, you might be experiencing some anxiety around helping your clinicians and frontline staff learn this new system.

Well, fear not, because we’ve put together a list of savvy EHR best practices to help shorten the learning curve so you can make the most of your EHR system. 

EHR documentation

Proper documentation is a must in healthcare, but there are ways to make the process less painful and more efficient like taking real-time notes, even when you don’t have a WiFi connection, as well as using consistent file naming across the organization.

Note taking:

When it comes to patient care, keeping a record of each visit is critically important. Get in the habit of taking notes in real time. This minimizes the chance of forgetting key pieces of information. But don’t worry—you don’t have to document entire conversations. Keep the notes short and concise, and use consistent terminology to avoid unnecessary confusion.

Offline capabilities:

If you’re constantly off-site or go long periods without WiFi, consider a provider that lets you take notes and then automatically syncs them back to the main system once a WiFi connection is restored.

File naming conventions:

Creating a consistent naming convention for your files and folders is paramount to maintaining well-organized electronic directory and drive structures. Always remember to:

1. Keep file names short and relevant
2. If using dates, use Year-Month-Day format to maintain chronological order 
3. Include a leading zero for numbers 0-9 to maintain numeric order in the file directory
4. Order the elements in a file name according to the way the file will be retrieved. If records are retrieved by date, that element should appear first. 

EHR security & storage

Protecting patient data is a top priority when it comes to electronic health records. In addition to the best practices we’ve outlined below, it’s important that your organization has a security strategy and data storage plan in place in order to contain the damage of a security breach or data loss event.

Back ups:

To protect against a system failure and comply with HIPAA regulations, data backups for EHR information should occur no less than once per day. Onsite backup can be performed using:

• Tape drives
• DVDs or CDs 
• External hard drives
• Thumb drives. 

This is arguably one of the most important responsibilities, so make sure it’s tasked to someone of high competence.

Changing passwords:

The HIPAA password requirements stipulate procedures must be put in place for creating, changing and safeguarding passwords. Unfortunately, experts disagree on the frequency at which passwords should be changed. We recommend users change their passwords a minimum of once every 90 days.

A two-factor authentication also helps to fulfill this requirement. Whether by SMS notification or push notification, a person using a username and password to log into a database containing their personal information also has to insert a PIN code to confirm their identity. As a unique PIN code is issued with each log in attempt, a compromised password alone will not give a hacker access to the secure database.

Conduct regular reviews:

We recommend conducting an annual HIPAA security risk assessment to ensure that all of the storage tools at your organization are secure. A risk assessment will help to reveal the areas where your organization’s protected health information could be at risk.

EHR implementation & ongoing support

It’s important to have an EHR implementation plan in place before you begin the implementation process. Once implementation is complete, be sure to check out the ongoing support options your EHR partner may offer.

Develop a dedicated task force:

Training is imperative to realizing the full potential of your EHR system. Developing a dedicated task force will help aid in a successful implementation as well as support ongoing EHR training efforts for both new and existing staff. For long-term impact, find an EHR partner that provides ongoing training and support to new and existing clients alike. 

Alerts:

With an EHR system, you have the option of implementing a variety of alerts into your workflows. While beneficial, overuse can unnecessarily detract from patient care. Effective EHR alerts like admission, discharge, and transfer (ADT) notifications or screening reminders can help to streamline clinical efficiency and care coordination by quickly communicating critical patient information to providers through the EHR interface.

Support:

Take advantage of the free support offerings your EHR provider offers. But be mindful: some EHR systems cap assistance or charge for support calls. Remarkable Health offers a wide array of support options including both a dedicated support specialist and an account manager as well as free phone and web support, training webinars, a customer community portal, and more. 

An EHR software system can help drive success within your organization, but a strong focus on training, attentiveness, and consistency is imperative to realizing its full potential. Adhering to the EHR best practices outlined above will help ease the transition period when adjusting to an EHR system while improving consistency and efficiency across your organization.