Computers run the show for this savvy practice
Scheduling, check-in, records, billing linked
Physicians at Urology Associates of Southeastern North Carolina in Wilmington are using wireless laptop computers to review patient charts and create encounter notes right in the examination room.
They perform the tasks necessary to treat the patient, decide on what prescriptions to order, and enter the information into the computer.
Based on the data entered, the software recommends a CPT code for each procedure. The information is automatically transmitted to the front desk where a charge ticket with the calculated charges and any prescriptions are printed out.
Any paperwork is waiting for the patient at checkout without anybody having to write anything by hand.
It’s all a part of the practice’s new information technology system. (For information on the practice’s e-mail and voice mail system, see article, p. 76.)
The practice is implementing its second generation of electronic medical records and billing after five years experience with another system, says Richard Rutherford, CMPE, former administrator, now with the American Urological Association in Baltimore.
The practice’s electronic medical records are linked to the billing system. When a patient is registered and the demographic information is entered, the system automatically creates the chart.
The scheduling package is linked so when the receptionist checks in the patient, the patient’s name automatically shows up on the nurses’ work screen to alert them that there is a patient at the front desk.
With the new system, doctors have the option of dictating their notes verbally or using an office visit template that allows them to point and click at boxes of procedures they may be performing.
"It takes a while for the busy physician to retrain himself to follow that path. They are accustomed to gathering data mentally, stepping out of the room, and dictating it onto magnetic tape," Rutherford says.
Speak directly into the laptop
The laptops will soon come with built-in recording devices that allow the transcriptionist to access them through a network, he adds. "We eventually hope to reduce the amount of transcriptions."
With the previous system, the physician dictated the chart and the transcriptionist typed it and attached it to the electronic chart. "One frustration with electronic medical records is how difficult it is to go totally paperless. Even though all the information can be accessed by the computer, we still print out the chart notes and file them in the chart. The advantage is that we don’t have to go looking for the chart unless there is something really important," Rutherford says.
Ultimately, the computer system will automatically generate a referral letter back to the patient’s family physician at the conclusion of the visit.
"In the old days, if a physician wanted to write a letter to the patient’s family doctor, he re-dictated the whole chart note. With this system, he can dictate the chart note and tell the transcriptionist to send out our normal referral letter. It cuts and pastes the chart note into letter format," he says.
The transcriptionist can e-mail the letter back to the physician for review and an electronic signature. Then, the letter can be submitted by fax, e-mail, or regular mail if other technology isn’t available.
When the practice started its first electronic medical records project five years ago, the principals agreed that the electronic records would start with the first patient encounter after the system was implemented.
The physicians summarized the patient history in the first dictation summary so there was a reference point. From that point forward, all the notes were encoded electronically and accessible through the system.
With the new system, the practice will continue to pull charts for three months during the transition process.
"In the medical profession, there still is a lot of concern about the legal aspects of electronic records but every state is passing laws almost daily indicating the acceptances and the insurance companies are getting in line because of the speed of access and the information transmitted back," Rutherford says.
All staff, including physicians, were assigned a slot for a four-hour training session on the new system. "The staff has to be willing to practice to learn the new system. It’s a skill. It’s awkward the first time you do it, but the more time you spend, the quicker you can do it and the steadier you are," he says.
The practice has a Web site that is hosted by a service bureau for urologists, which provides a generic Web page and adds information from the practice.
"It has provided us with a tremendous amount of educational materials for the patients," he says.
Rutherford views the current Web page as a first step to give the practice a perception of how the patients access the page. The practice may create its own Web page in the future, he adds.
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