When a physician sees a patient, he or she must document the visit in the medical record. One of the most time consuming functions is - having to go through a patient's medical history. This could include the patient's pre-visits, family and social history and recommended medication. Centers for Medicare & Medicaid Services (CMS) require that each component of the documentation contain specific elements. The number and complexity of these elements determine the level of service provided by the physician. The amount of reimbursement received for the visit is based on this "level of service." The physician is personally accountable for the content of the medical record and the charges submitted based on this medical record. CMS guidelines are the standard for not only Medicare and Medicaid reimbursement, but also most private insurance reimbursements.

Currently, most medical documentation is dictated and later transcribed. The physician or other office personnel then review the documentation for compliance with CMS guidelines and appropriate billing. Time delays and inaccuracies inherent in this system exacerbate its cost.

What if all these functions could be taken care of with a electronic medical record system that would not only speed up the doctor's interaction with the patient chart, but ensures better care for patients?