In the near future, electronic medical records are going to be a requirement for long-term care providers.  Have you evaluated where your facility is in the process?  There are so many options available however where do we begin?  The HealthCap Risk Management team perform on-site visits around the country and have the luxury of testing new systems on a regular basis. 

Through this process we have identified that many facilities have entered into agreements with a provider of electronic records and within a short time discover the program does not meet their needs.  This is a horrible waste of time, energy and financial resources!  There must be a better way to evaluate a program prior to a long-term commitment. 

Here are a few ideas that may assist in determining whether a particular program would work for you. 

• If your facility cares for residents with physician orders for treatments (pressure ulcers or other types of treatments) ensure that the program provides a specific area for weekly documentation. 
• There are programs where weekly wound documentation is not an option and the documentation does not meet the standards of practice.
• If the system allows for inputting and tracking incidents and accidents consider how this information will be accessed and who has privileges.  
• Secure access to the electronic record is especially important for the investigation component of an incident/accident as the Quality Assurance privilege could be waived if non-members of the committee are able to gain access to the information. 
• If the incident report option is available, is there a process for electronic signatures?  If not, the facility truly will not be “paperless” as the incident reports must be printed off to be signed. 

These are a few of the questions you may consider asking prior to entering into an agreement for an electronic medical records system.  It is also a great idea to include direct care staff in the process of evaluating systems.  Their input is invaluable and could save time and money in the long run.  Good luck and remember to discuss options with your HealthCap Risk Manager during their annual visit.