Finding an end to the mighty pen (and paper)
Finally going truly paperless is an option
Physician practices can’t afford to wait any longer to convert from paper medical records to electronic systems. If you think some physicians you contract with would never make the switch, evidence exists that may help convince hospital managers otherwise.
We spoke with a North Carolina orthopedic practice administrator who parlayed a $140,000 initial investment into a gradual conversion from paper charts to a paperless environment. The results: a decrease in supply costs, a reduction in file staff, a 30% increase in transcription productivity, a marked decrease in stress among office nurses, and a possible recoup of costs within two years after the purchase.
John Nosek, MPA, CMPE, administrator of Greensboro (NC) Orthopaedic Center says the chance to cut costs of off-site storage, decrease time spent by nurses retrieving charts, and preclude having to hire more file clerks in the future prompted him to push for a paperless environment.
Eliminating patient charts took time, but there are some gradual steps you can relay to physicians to facilitate their "paperless plight." Greensboro Orthopaedic broke it down the following way:
1. Give physicians a mechanism to provide good information for the new system.
First, Nosek got the physicians to use a digital recording system, eliminating the hand-held units that seemed to guarantee lost or misplaced tapes. Then he developed a structured dictation format that included information on the exam, the treatment plan, and medications. "The headings were set up the same as in charts," he says. For instance, if a report on what medications were commonly prescribed by Dr. Jones was requested by a managed care organization auditor, it would be available.
2. Input dictation from physicians directly into the computer system.
The new system eliminated the addition of paper to the charts. Once the notes were in the system, Nosek says, they stayed there. They were not automatically printed out for inclusion in a paper chart.
3. Eliminate chart use during exams through patient-oriented summaries and a physician champion.
Nosek wanted the physicians to have ample time to see the new computerized system work in tandem with the old one. He started with one physician champion, a computer savvy doctor who was anxious to be a part of the new program.
Ease doctors gently into new system
He initially provided the physician with both the old-style chart and a new three-page patient-oriented summary (POS). The POS includes the patient demography, information on the last three visits, the last five surgeries, the last five lab tests, radiography reports, and medical history. "That’s what is important. Not an ankle break from 20 years ago," Nosek says.
After two weeks, the physician was given just the POS, but the chart was pulled and left at the nurses station. Another two weeks passed, and then the chart was pulled but not sent up. Finally, after another two weeks, the chart was not pulled at all.
Once the first physician went successfully through the system, another two doctors were brought on board, then another three, and finally the three oldest and most senior physicians. "They were the hardest to sell, but there was a lot of peer influence at that point."
4. Implement an imaging system to scan outside documents directly into the computer.
This eliminated the addition of outside paper to the patient charts. "There is still paper we print the POS and all the image documents that have come in since the last visit," Nosek says.
5. Introduce a wireless pen/pad system.
Nosek will begin introducing a pen/pad system in the next six months. "The physician will take that from exam room to exam room. There will be no POS, but the doctor can scan the history electronically." One drawback: Images can’t be sent this way it takes too much memory. The practice is considering having physicians look at the image and dictate a note on it.
The cost of the hardware is about $2,000 each, Nosek says. However, the addition of specific software and the wireless antennae will bring the cost up to $10,000 each. (For more information, see story, above left.)
A post-mortem of the change
Nosek says there are more than financial benefits to the paperless system. "Our dictation is much more complete and thorough with the new program," he says. "We looked at the dictation before and after for 10 patients per doctor. The after notes are much more complete."
There is also improved morale, Nosek says. "Stress levels are down, especially among the nurses who were always waiting for a chart," he says. Two of the transcriptionists have also been able to start working from home.
"We gave them modems, and their productivity has increased by 30%," says Nosek. "There is less chit chat, so they concentrate more, and there hasn’t been any turnover in 18 months. That’s a real plus for us."
Not that the process was completely smooth. One physician still insists on carrying a chart into his appointments. "He needs to have something in his hands," Nosek explains. But there is no longer any information being added to those charts.
But that is the limit of the obstacles, Nosek says. "We were careful. We had an implementation team that included someone from management information systems, a physician, a nurse, a representative from billing, and me. We met regularly to work on every issue from the dictation template one. It was all circulated to the physicians for them to sign off on. Nothing was finalized without their input."
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