Computer age meets SDS with electronic records
Technology allows paperless charts, lifelong records
Imagine a day when you can locate any patient record with a touch of a button. When the boxes and shelves of paper files disappear. When you can instantly learn the medical background of your patients, including details of any previous surgeries, recovery patterns, and allergies.
That day is here. Physician offices, surgery centers, and hospitals are making use of computer-based patient records and gearing up for the ultimate goal: the paperless office. Computer-based medical records provide greater efficiency in same-day surgery programs and cost-savings in labor and record storage costs, say experts in health care technology.
"We are moving into a whole new era in medicine where a physician is not just blindly seeing a patient but has most if not all patient information at hand and has [swift] methods of checking information," says Peter Waegemann, executive director of the Medical Records Institute in Newton, MA.
With a computer-based record, nurses and physicians don't have to repeat basic questions to patients, says Waegemann. The information is readily accessible.
Computerized record-keeping has other advantages, from facilitating outcome studies to providing information to managed care payers, medical records experts say.
It also has clinical implications, with software that reviews the records to help physicians with their diagnosis and care plan. Software is available for emergency department care that acts as a physician's "assistant" by asking about pertinent lab tests and checking patient symptoms with possible illnesses.
Similar software will likely evolve for other fields, including same-day surgery, says Richard S. Dick, PhD, chairman and CEO of ASCENTechnologies, a consulting firm based in Alpine, UT, that specializes in health care information technology.
"Health care is one of the most information-intensive industries in the economy, yet it is one of the last holdouts in information technology," says Dick, who headed a study on the computer-based patient record for the Institute of Medicine in Washington, DC.
At Paradise Valley Eye Specialists in Scottsdale, AR, an ophthalmic practice with four offices that includes some refractive and other surgical procedures, computerized patient records have eliminated the nightmare of trying to locate patient records.
No one has to courier charts from one office to another or hunt for a file among the 200 that may be in use on a given day, says executive director Sarah Nelson. "The patients' charts are available at whatever time we need them," Nelson says. "When we have a patient calling us with a problem, rather than diving for a chart, we can go to any computer and pull it up."
Paradise Valley began using computer-based patient records in 1988, when the software -- and the concept -- were just evolving. Now, they have no paper records. The last paper patient charts were placed in permanent storage in 1994.
Each exam and procedure room has a personal computer. Before the patient comes in, the physician reviews a printout of the patient's previous medical record. That paper is shredded after the patient visit and is used just for the physician's convenience, Nelson says.
Don't forget back-ups
Physicians and ophthalmic technicians type patient and exam or procedure information directly into the computers. Each evening, the data base is backed up on computer tapes, and a staff member removes one copy from the office as a safeguard against fire or other disasters that could destroy the records.
Nelson acknowledges that physicians are sometimes reluctant to give up the paper system. But with the help of some in-house seminars -- including basic typing classes for ophthalmic technicians -- both doctors and techs have adapted, she says.
In fact, at Paradise Valley and elsewhere, physicians have discovered direct benefits of computer-based records. For example, because the software prompted the user to answer certain questions related to patient care, it ensures that proper documentation occurs, Nelson says.
Computer-based records are easy to read, and in many cases are more thorough because the technician types in pertinent information immediately, she says. "We have found that it's been a much better communication tool between the physician staff and technical staff," she says.
When BayCare Surgery Center in Green Bay, WI, opened March 7, 1994, it was geared for electronic medical records. The center has a local area network with computers in each OR, the admitting/discharge desk areas, the business office, and at the reception desk.
BayCare creates a paper record that follows the patient through the surgery center. After it is complete, with physicians' signatures, a clerk scans it electronically into the computer, where it is stored and cannot be altered.
Physicians like the system because they can quickly access information on a patient who may have had a previous surgery such as an arthroscopy on the other knee, says BayCare administrator Jeff Mason, RN, MBA. They also use the records for outcomes studies and quality reviews, and the computer makes dictation of an operative report easier and faster, he says.
Mason had initially ordered storage containers for paper medical records. The electronic version costs about the same ($10,000) but takes up much less space, he says.
"Now we have more office space," Mason says. "Our medical record space takes up the space of one computer on a desktop, and that's about it."
How safe is the patient information?
While many laud the greater use of computers in health care, the prospect of a medical database has evoked concerns about confidentiality and security of the information.
Dick predicts that patients eventually will have a lifelong, computer-based medical record, accessible to any physician they visit. But that is precisely what worries some critics of computer-based records.
"The bottom line for me is patient consent," says Beverly Woodward, PhD, a research associate in philosophy and sociology specializing in confidentiality issues at Brandeis University in Waltham, MA. "Putting patient-identified information in a computer network is akin to publishing it [without patient consent]."
Woodward opposes creating databases of patient information, and she says facilities should place strict controls on access to computerized records. For example, schedulers should not have access to clinical notes, Woodward says.
Dick agrees that confidentiality safeguards need to be in place, and he notes that Congress is considering legislation that would ensure privacy of patient care information. Senate Bill 1360 is pending in the Labor and Human Resources Committee.
"It's very important, however, to make a distinction between the primary patient record and the secondary record," Dick says. "The primary record would be used only for patient care. Other records might be created and aggregated for analytical purposes, such as outcomes studies, without the patient's name. It's important that privacy be maintained by all providers of that primary patient record."
He notes that the issue of confidentiality isn't confined to electronic records. "Today, patients don't realize the lack of security with a paper record," Dick says. "All you have to do is don a white lab coat and stethoscope and you can look at almost any record in this country."
Electronic signatures don't permit erasing
Concerns also have arisen about authenticity issues related to electronic records. A system should include physician passwords that act as an "electronic signature," say experts in computer-based paper records. Once data has been entered, it can't be erased but just shows as an addendum, they say.
For example, with the Alcon Ivy software produced by Alcon Systems in Fort Worth, TX, additions to a patient's chart aren't final until the physician types in a password and initials. Other security features can be added as specified by a facility, says product manager Mike Kleiman.
To make sure no paper record is necessary, Kleiman advises same-day surgery managers to check with their individual payers. But he notes, "In almost all cases, there are no qualms about providing an electronic medical record."
Be prepared to pay
Switching to electronic records may require a considerable upfront expense. For example, the WinIvy medical records software costs $5,000. Often, facilities must purchase additional computer terminals.
Yet, using computer-based records can save staff and physician time. For example, at Paradise Valley Eye Specialists, office workers don't need to spend their time filing charts. Letters to referring doctors can be generated from the software, so physicians save time and money in dictation and transcription, Nelson says.
Electronic records software also allows same-day surgery managers to analyze outcomes, Kleiman says.
If you're not ready yet to step onto this spur of the information highway, computer-based records experts advise that you at least begin to prepare for the future.
For example, same-day surgery managers could hold informational sessions for staff and physicians on computer-based patient records and encourage them to become familiar with personal computers, Waegemann says.
You can learn about individual software systems from the World Wide Web or about computer-based records from a book published by the Institute of Medicine in Washington, DC. (See source box, above, for more information.)
"It's almost a [certainty] that this is going to happen because of numerous pressures for greater documentation," says Dick. "[Same-day surgery managers] would best educate themselves about what this whole movement is all about." *
For more information about computer-based patient records:
You can get free access to the computer-based patient record (CPR) foyer of the World Wide Web on the Internet at [email protected]. This includes user comments about the software.
To order The Computer-based Patient Record: An Essential Technology for Health Care ($24.95 plus $4 shipping and handling), contact:
* National Academy Press, 2101 Constitution Ave. NW, Box 285, Washington, DC 20055. Telephone: (800) 624-6242. Fax: (202) 334-2451.
To speak directly to software manufacturers, contact:
* Alcon Surgical, Systems Group, Customer Service, 6201 S. Freeway, Fort Worth, TX 76134. Telephone: (800) 289-1991. Fax: (817) 568-7219.
* Datamedic, 20 Oser Ave., Hauppauge, NY 11788. Telephone: (800) 446-4021. Fax: (516) 435-8820.
* Keyfile Corp. (not specifically for medical records), 22 Cotton Road, Nashua, NH 03063. Telephone: (800) 453-9345. Fax: (603) 889-1511. E-mail: marketing @keyfile.com. World Wide Web: http//www. keyfile.com.
* Richard S. Dick, Chairman and CEO, ASCENTechnologies, 460 Peachtree Circle, Alpine, UT 84004. Telephone: (801) 763-9933. Fax: (801) 763-9966. E-mail: [email protected].
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