by Dr. Alan Brookstone

After learning curve, expect both predicted and surprise benefits

As with any tool that you might use in your office, the only way to determine the true benefit is to implement and use the product over a period of time.

Although one of the major concerns of physicians is the potential for reduced efficiency in the office in a situation where one has to input clinical information into a computer, physicians who have used Electronic Medical Records (EMRs) report just the opposite. During the introduction phase there is a definite learning curve during which the value of the EMR is not quickly obvious, however other benefits soon become apparent.

In this last of the article series, I will relate some of the experiences of physicians who have implemented EMRs and discuss some of the predictable and unespected benefits that were encountered.

Dr. Vince Di Ninno, a family physician based in Medicine Hat, Alta., has been using EMRs since 1995. His story mirrors that of other physician who have adopted EMRs but with one slight difference; he was one of the developers of the original patient record component of the software that he currently uses. In 1994, frustrated with the inability to decipher notes in the medical chart and with some experience in software development, Dr. Di Ninno began developing an electronic patient chart. When the patient chart was integrated into a billing and scheduling product developed by Jonoke Software, JonokeMed™ was launched. (www.jonoke.com/jonokemed)

According to Dr. Di Ninno, many physicians are scared off from implementing an EMR because of the initial capital outlay, the fear that the keyboard will slow them down, the financial impact of being able to see fewer patients and the concern that the computer will be intrusive in the physician-patient encounter. Di Ninno has experienced just the opposite in his practice, particularly with regard to the number of patients seen. In the past, he would see 40-50 patients per day, but would spend a number of hours each evening dictating letters and checking billing. Now he sees the same number of patients but, in his words, "I now have time for coffee and generally I leave my office earlier than in the past."

How did he achieve this unexpected efficiency? The key, according to Di Ninno is the fact that billing, clinical record taking and referral letters are all completed at the time of the patient visit with a more accurate audit trail and greater accuracy. This has resulted in time savings during and at the end of the day. What about the physician who is not comfortable using a keyboard? This was taken into account when developing the physician interface with extensive use of drop-down menus, windows and buttons that allow for the input of clinical information with minimum need for the keyboard. Information input is also speeded up through the use of templates for specific conditions. Templates not only allow for the use of standardized, system-specific questions, but may also hold the key to the practical use of Clinical Practice Guidelines, Using JonokeMed™, it is possible to build the clinical practice guideline into the question-taking template resulting in the information being available and relevant to the clinical problem being addressed.

One of the more interesting capabilities of JonokeMed™ is its ability to work in a multi-platform environment. As the software is written in database language called 4th Dimension, it is possible to run the software on both a PC and Macintosh system simultaneously sharing files between both systems. Accoring to Dr. Di Ninno, with high-speed Internet acess he is also able to perform disease-specific searches while in the examining room and can print and provide the information to patients in a SOAP-type format.

Dr. Ron Brown, a Cumberland, B.C.-based family physician has also had a great deal of experience working with EMRs. He uses software developed by Clinicare Corporation of Calgary (www.clinicare.com). One of Dr. Brown's key interest areas is data entry and he has used voice dictation software extensively over the past two years to enter data into the EMR.

Although he has become proficient at using voice dictation, he admits that using the software effectively requires a great deal of time and training. Despite his experience with voice dictation, Dr. Brown still carries a dicatation machine and the information is transcribed into the chart after the patient visit. One of the great venefits he sees in the EMR is the ability to send referrals to specialists via e-mail. He also recommends that purchasers of EMR software stick with an established vendor due to the change and instability in the industry.

Having had some experience in the U.S. healthcare system, Dr. Brown notes significant differences between the U.S. and Canada in terms of the design of EMRs. In the U.S., most of the EMR products are designed around coding issues and outcome analysis. Another area in which Dr. Brown has a key interest is the future and he believes the Internet will be the key to the cost-effective implementation of EMRs. There is no Internet-ready EMR software currently available in Canada but from a cost and efficiency perspective, the Internet will answer certain specific problems. The ability to access a bureau type service through a high-speed Internet connection will provide easy access to medical records and reduced cost, as there will be no need to invest in expensive servers and in-office networks.

Dr. Peter Long is a family physician in Port Rowan, Ont. and has been using an EMR developed by Mac Medical since 1989 (www.healthcaresoftware.com). In his words, "The early EMR was a little rough, but now it is amazing." Sharon Long who is both his wife and medical office assistant has worked in his office for 10 years. According to Mrs. Long, one of the great benefits is that she doesn't have to pull charts, ever! This has been a great time saver. Hardware in the office consists of three networked Macintosh computers. Because Dr. Long sees a large number of elderly patients, he is able to work out of one primary examining room. Lab results are automatically downloaded into the patient charts and bookings and callbacks have been simplified. In the office this has translated into a savings in terms of staff, as there is no need to have an employee in the office pulling and filing charts, and blood and lab results. X-ray results and consultant reports are scanned using OCR software and are then filed electronically in the patient record. The paper reports are then shredded.

The EMR and billing records are backed up daily on a Zip disc with one copy kept off site. Should the clinic be faced with a disaster of some sort, the EMR is easy to resotre. Two of the previously unforeseen benefits have a strong clinical perspective in terms of two groups of special needs patients. Dr. Long has two diabetic patients in his practice who are also illiterate.

He is able to sit with these patients in front of the computer and graph their blook sugar levels on the screen to create a graphical representation of the level of control. Another benefit of the EMR is the instantaneous access it provides to blood results and clinical information if requested by physicians or patients.

Although the EMR requires a front-end investment and a period of implementation and training, in the long run I believe it is able to save time and provide greater continuity and quality of care.

From Family Practice, The Maclean Hunter Newspaper for Family Physicians
April 7, 1999, Vol. 11, No. 7, p. 28