Electronic Records Save Hassle on Monday Mornings
Dr John Tilley, Lewisville, Texas

One of the most satisfying features of computerized record keeping is the hassle it saves, says John Tilley MD, a family doctor in Texas. He gives an example. "I have access to our records through the Internet, wherever I am. So, for example, when I'm at home I can review new lab results for my patients and leave instructions for my nurse. I can check up on referrals, change medications, print prescriptions, chart phone calls, do anything as if I were in the office.

"That can take a lot of pressure off on Monday morning. My nurse doesn't have to wait while I sift through lab reports before she can get on with her work, and I'm not distracted or delayed while seeing patients."

Tilley, who has been in practice twenty years has been using ChartWare to keep his records since 2003. His office, he says, is now "light years" ahead of where it was in tracking not just lab tests but also referrals to specialists, follow-up appointments, imaging procedures, and the whole range of what previously was done on paper.

"We had three cross-checking manual systems aimed at keeping on top of the paper flow and things still regularly fell through the cracks. Now our system reminds us, and keeps on reminding us, if something needs to be done."

The chief nurse is "ecstatic", Tilley adds, having been relieved of the burden of hunting for missing files, incessant follow-up phone calls, and misfiled lab results, even though the amount of documentation about patients is much more detailed than before. The front office staff has found more time for other tasks due to the efficiency of taking phone messages without paper charts.

"We not only know more about our patients but we can share the data, quickly and accurately, with other physicians. The orderly way it is recorded means we don't have the frustration of searching for the piece of information we need, which in a paper record can be misfiled anywhere in a chart that all of us have access to."

He also likes the system because of its flexibility. "That may surprise many doctors who are reluctant to go to electronic records because they think it will restrict their individual working methods. We've found it adapts easily to the wide range of patients and practice styles in family medicine.

"The patients seem to approve too. They appreciate the technology and I can't remember any of them ever saying they didn't like it."

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Laptop Computer Lets Doctor Do House Calls the Modern Way
Dr. Leo Kanev, Evanston, Illinois

Electronic record keeping "has made my practice possible," says Dr. Leo Kanev. "Without it I couldn't do my work in a way that suits me and my patients."

The special feature of the practice, which he started in 2001, is that it includes about a hundred patients whom he sees at their homes and who, for the most part, are very sick and medically complicated. "I have colleagues who make home visits whose car trunks are filled with paper charts," he says. "I use my laptop and it contains all the information I need."

When he goes into a house all he carries is the laptop and necessary medical supplies that fit in the same bag. "I've never had a negative response from a patient. In fact, many of them talk about it as though it's a piece of magic. 'You seem to know so much about me,' they say."

Their surprise is understandable, he adds, because the system is a highly effective way of ensuring that he has all the data at his fingertips. "I can tell at a glance what we did last time, what medications they're on, what we've tried before. I can see both old and recent blood work and other test results."

Sometimes the need for those details is urgent. "When I get called about patients in the middle of the night, I can look up their history there and then. Obviously, if they've been taken to the emergency room, that could be a matter of life and death. But even if all the family wants is the phone number of the pharmacy the patient uses, it can be a big comfort at a time of stress."

Dr. Kanev says that computerized record keeping isn't an expensive method for improving health care. "I started my practice the day my residency ended. I was already deeper in debt than I ever wanted to be. But for a few thousand dollars I was able to acquire the system I wanted -- ChartWare -- and it has worked well ever since. I have a completely paperless office. I don't need storage space for charts or transcription services."

The system also gives him peace of mind. "The reminders in it make it difficult to overlook anything important. It reassures me that I haven't missed any test results and that I have reviewed consultations notes that I arranged for. When you're going from house to house, those things are easy to forget and, with patients like these, potentially very serious."

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Electronic Record Keeping Customized for Rheumatologists Patients
Dr. Michael Thakor, Fort Collins, Colorado
Arthritis and Rheumatology Clinic of Northern Colorado

For rheumatologists the challenge for any electronic medical record system is the complexity of their patients ailments. Typically, before coming in, they will have seen several other doctors who have not been able to cure them. Many will be taking a wide variety of medications, always with the danger of adverse interactions, especially toxic. They are of all ages and types. The data on them cat scans, MRIs, lab tests -- can be voluminous. Many come back for repeated visits.

But Michael Thakor MD says the ChartWare system he set up when he started his practice in 2002, has worked admirably. Ive been able to customize it so that it can do everything I want. Weve never had a serious problem.

Sometimes the customizing is simply adding terminology of specific interest to the field of rheumatology. In other cases, it is the addition of a question that individual doctors find particularly useful: on each visit the system can be programmed to remind them to ask it. In still others, such as an examination, it can highlight abnormal conditions that are nevertheless common among these patients.

When still more flexibility is needed, doctors can use a so-called dictation module so that, while the bulk of the entries are still done by a click, they can add whatever words they want. I use this most often when writing to referring doctors so I can explain exactly what I found, Thakor says. But for most of his contact with other doctors the ordinary features of the electronic system give him all he wants. It simplifies everything, he says. It cuts out an enormous amount of onerous work, writing letters, checking transcriptions, worrying about not forgetting something. Now I enter information into the system and send it.

Better still, he adds, I can look at the data whenever I want to and its all in one place. Unlike paper files, it doesnt get lost or start missing pages as people dip into it.

The system has substantial rewards in other areas too. It fits very easily into the practice management system. I enter the coding during the visit and send it automatically. It cuts out the danger of forgetting what I did and entering the wrong code or of an error creeping in when someone else has to transcribe the information and send it separately.

Unlike many other doctors who have computerized, Thakor cant estimate how much time and money he has saved because he adopted the system from the beginning. I had only a slight acquaintance with computers before I opened my practice but it seemed clear to me that this was the way the whole field of medicine was going. It was very easy to learn, both for me and my staff.

He sums up his experience succinctly: What I needed was an economical and reliable system that could continuously monitor chronically sick people with complex symptoms -- and that is what I got.

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Accurate Records Give Family Doctor Peace of Mind
Dr. Ernest Thomas Los Gatos, California

At 4 oclock one afternoon recently Ernest Thomas MD, a family doctor in Los Gatos, California, had just seen his 35th and last patient of the day. "All the charts are done," he said. "Ill be home in time for dinner."

Before Thomas installed electronic record keeping seven years ago, he knew only enough about computers to do word processing. Even then he was repeatedly on the phone to Microsoft for help in getting himself out of a corner.

Now, using ChartWare, his records are totally computerized and he cant imagine them being any other way. "In all the time Ive used it, it has never once crashed and the only time there are any errors is when I make a booboo." Even then, he says, ChartWare staff have always been on hand to help him get back on track. "They really back up their product and give you the feeling that they care about you and your practice."

Thomas made his choice, after 36 years of doctoring, by trying every piece of electronic medical record software he could find at the American Academy of Family Practice convention. "But I kept coming back, four or five times, to ChartWare," he says. "I was taken by its flexibility and how easy it was to use. I saw nothing else to match it."

Thomas decided that he needed to computerize when he realized that the traditional records he was using probably couldnt stand up to independent scrutiny. "Sometimes I couldnt read my own writing," he recalls. "On top of that, I was paying 15 cents a line for transcription. Thats a pretty big check at the end of the day. Now at the end of the day Im not paying anyone."

He has been audited by Medicare which, he says, is like being interviewed on Sixty Minutes. "Everything was perfect," he reports. "They didnt find a single error."

He credits ChartWare with making his work much easier and quicker. He gives a simple example. "When I enter into the computer that Im giving a 35 year-old man a physical, the system immediately cuts out all prompts for tests peculiar to women. I dont need to think about those tests any more. But it will remind me to check for prostate problems and will flag it if I forget." For female patients, he gets the same reminders about pelvic examinations.

Similarly, the system prompts him to test blood pressure with the patient standing, sitting and lying down. "It saves me having to think about it." In a day all those prompts add up to a lot of time saved and worry shelved.

More importantly, information is entered while the patient is there. "When did the symptoms start, what makes them better or worse, have they occurred before? And what did I do about it? It all goes in there and then. Theres no time to forget details that might prove important later, no additional work to do after the patient has gone and no ambiguities if, at any time in the future, someone needs to check up."

The diagnosis codes also go in at the same time and can be checked against the other data so that not only are they accurate but also that anyone looking at them can confirm they are accurate. "Its a commonplace that most doctors dont keep good records," Thomas points out. "That makes them very vulnerable."

For one part of his work, patients recovering from substance abuse, accuracy is particularly sensitive. "People have relapses and quite often theyll say something like I really need some Vicodin, doctor. Youve never given it to me before. But I did give it to them and its there in the record to prove it."

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Computerized Records Surmount A Medical Emergency
Dr. Jack Devine, Lewisburg, PA
Susquehanna Medical

Physicians treating diabetics will never forget the day when the FDA suddenly and without warning ordered Rezulin off the market. The powerful and widely used drug, it turned out, could cause severe liver toxicity and in some cases irreversible liver failure.

The announcement, in March 2000, sent doctors across the United States urgently searching their files to locate patients who, all unknown to themselves, were at high and unforeseen risk.

For some it was a nightmare, plowing through a mass of papers put in at different times, updated here, amended there.

But for Jack Devine, an internist, the search took four minutes. Within a couple of hours his staff had called all sixty patients who were on the drug. Within three or four days he had seen virtually all of them and prescribed alternative medications.

"It made me feel that this is what doctoring is all about: protecting people who rely on me from serious harm," he says.

He could only do it, however, because six years ago he had completely computerized his patients' records. "Without that, we would have been riffling through nearly two thousand files for days and never certain in the end that we had found everyone".

Patients were quick to express their appreciation. "When you do something like that, people talk about it," Devine comments. With the bulk of new patients coming to him through word of mouth, the value to his practice as a business is clear.

At a time when practices all over the United States are fighting the twin pressures of rising costs and tighter regulation of fees, the choice may not be merely between degrees of doctoring but any doctoring at all.

"If I hadn't computerized the records, I'd have needed two full-time assistants. In this area that's over $54,000 a year in pay and benefits. I don't think my practice could have survived," Devine says.

Pennsylvania is one of a growing number of states in a malpractice crisis. The insurance Devine paid $5,000 a year for three years ago would now cost more than $20,000. "Even in our local area, three or four practices have closed, as have droves of others in the state as a whole," he says.

Devine went to electronic records only after a lot of thought. Until 1996 he had never owned a computer, either at home or in the office. Like most newcomers the feature he looked for above all was ease of operation.

What he particularly liked in the system he finally chose --ChartWare -- was how simply he could adapt it to his own specialty and personal way of working. "All the clinical terms I need are in there or can easily be added. As documentation requirements have increased, it has helped relieve me of repetitive time-consuming chores, while not interfering with the patient care methods I've built up for myself over the years".

He installed the new system in early 1997. By July of that year, and with the help of ChartWare staff, 95 percent of his notes were computerized. Before long that went up to 100 percent and all of them at the point of care.

By the time the patient walks out of his office, he says, the note is ready. "I make the note during the office visit so I don't forget something or, in the future, have to wonder what I meant by a hard-to-read handwritten note".

As for coping with complicated cases, Devine is emphatic. "I have never found anything I wanted to do with record keeping that I couldn't do with ChartWare," he says.

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Computerized Records Reduce Medical Mistakes -- And Ruinous Lawsuits
Dr.Cecil George, Fort Stockton, Texas

Well-publicized medical errors in recent months have sent shock waves among physicians, reminding them of the dangers to their patients and their own vulnerability to ruinous lawsuits. "Tragically, most of these mistakes could have been cured by the simplest form of cross-checking," says Cecil George MD, a family doctor in Fort Stockton, Texas.

"The first thing that needs to be done, obviously, is to organize work so that errors are minimized. Every doctor wants that," George says. "The second is to make sure that everything is documented so that, if a lawsuit is brought, the doctor has evidence to refute it. Electronic record-keeping can play a crucial role in both areas."

"One of the most common mistakes in all medicine is prescribing medications that have an adverse interaction," George points out. "The first thing I do, whenever I see a patient, is to go over current medications. With the hand-held computer I use, that takes a couple of minutes."

"By contrast, looking through the usual file of papers in doctors offices, with medications prescribed at different times and rarely updated, is so time consuming I dont think many doctors do it conscientiously."

"But even if they did everything right, doctors can still be successfully sued," he adds. "Courts take the view that if it wasnt recorded, it didnt happen. By the traditional methods of handwritten notes or dictation, a few omissions, illegible writing or just plain transcription errors can be enough to lose a case."

When George began using computers for charting patient records in 1987, his main aim was to save time and money. "But with one in three family physicians in Texas sued every year, it has also become imperative to have the orderly, legible, retrievable documentation that only computers can provide," he says.

Being somewhat frugal I balked at the idea of putting a computer in each of my exam rooms. I wondered if I could find a way to use a single portable computer to access my network and do my charting on the fly."

"I construct the entire patient note while I am in the patient's room, so I don't forget anything and I do it with a pen, not a keyboard. Ive customized my copy of ChartWare so that it reflects my own way of working and speaking. The patient record is then in a form that I can find quickly at any time. I can also use it to let my nurse or a specialist know exactly what Ive prescribed, forward an order automatically to a pharmacy, order a lab test and, if it ever comes to it, show a judge exactly what I did."

His patients -- he sees 35 or 40 of them every day -- like ChartWare too. "When I refer them to a specialist, they dont have to go over their medical history again or remember what drugs theyre taking or what theyre allergic to -- all that is in my note."

If patients find themselves in the emergency room, unable perhaps to describe their condition, "their record can be found and transmitted, quickly and accurately," he says.

"I cant conceive of going back to dictation or handwritten notes," George says. "I estimate ChartWare saves me one and a half fulltime employees, equal to around $45,000 a year in pay and benefits. For a solo practice, thats a lot of money."

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