Electronic record saves ENT practice time, money

Benefits include better use of protocols, outcomes

(Editor’s note: In the January issue of Patient Satisfaction & Outcomes Management, health information experts advised medical groups to implement an electronic medical record as a way of improving outcomes management. Here is an example of how one group has successfully made the transition from paper to computer-based records.)

Other physicians sometimes ask Tallahassee, FL, otolaryngologist Duncan Postma, MD, what he gains from an electronic medical record. His answer: Time, money, and improved patient care.

To be precise, Postma calculated that Tallahassee Ear, Nose & Throat-Head and Neck Surgery expects to save $54,600 in staff, transcription, and paper supplies annually with the system. Instead of spending 45 minutes dictating notes at the end of the day, physicians spend a total of about 15 minutes typing into the computer during patient visits and another 11 minutes after they finish seeing patients.

Some 95% of referring physicians surveyed said the computer-generated notes are as good or better than the dictated ones. Another survey showed 81% of patients thought having their record on a computer would allow for better care. And Postma has designed outcomes studies to compare different treatment choices among the five physicians in the practice. For example, by the end of the winter, he hopes to determine the most effective treatment of ear infections in children with ear tubes.

"There are some start-up aches and pains," Postma acknowledges. "But it really has been worth it. You’re saving money, but you’re giving the patient better care."

Postma’s interest in an electronic medical record began about four years ago, when the practice purchased a new billing system, the QSI Practice Management System. He began looking into available systems.

Then, as the practice prepared to open a satellite office three miles away, Postma worried that charts would get stuck in one place while the patient was in another.

When QSI purchased Clinitec, an electronic medical records software company based in Horsham, PA, Postma became a "beta" or testing site. Postma knew that an electronic medical record would have to be cost-effective, so he wanted a system that could help cut back on transcription costs.

With the NextGen software, physicians use templates that are set up for different types of office visits or diagnoses. They fill in boxes or click on a menu of choices to enter the patient information. For example, a template for cough provides spaces for frequency, duration, distribution during the day, as well as other associated problems or symptoms. (See template sample , above.)

When the physician is ready to create a document to send to the referring physician, with a click of the mouse those abbreviated boxes become part of a narrative. For example, the information on cough would be restated, "The cough started 5 months ago. This problem recurs every few minutes and seems to be steady throughout the entire day."

Templates written to fit the practice

Postma and nurse practitioner Tricia Skinner, ARNP, wrote the templates to suit the practice, including the macros that translate the data into physician notes. Developing the templates required the physicians and Skinner to discuss the clinical aspects of their work and to agree on similar methods.

The templates become like protocols because they guide the clinician to ask a uniform set of questions or to follow certain steps in a physical exam. "It prompts physicians and me to know that patient education is available," says Skinner. "It prompts me to do a complete neurophysical exam [when appropriate]. Templates become clinical pathways."

Templates have other uses, as well. Physicians can query the system to search for certain data boxes in the templates, allowing a wide range of studies focusing on symptoms, treatment, and outcomes.

Postma and Skinner have developed more than 150 templates related to otolaryngology. Postma estimates that each template required at least eight hours of work. Those templates are now available to other medical groups for a charge ($750 for one physician or a lower per-physician rate for groups).

The cost-effectiveness of an electronic medical record will depend on the particular practice, its needs and staffing. Software costs vary but are generally based on a per-physician fee. Postma also purchased additional PCs for about $2,500 each and now has about 26 for use by clinicians.

The practice has eliminated the positions of two part-time transcriptionists and reassigned one-and-a-half equivalent employees who pulled charts. During a transition from the paper charts to the electronic one, clerks scanned operative and X-ray reports into the system.

Perhaps the most remarkable aspect of Tallahassee ENT’s transition: They did it without hiring a computer specialist. Skinner has spearheaded much of the work. "I have never felt that I was very computer literate," says Skinner. "My computer experience [previously] was limited to playing solitaire on the computer and writing my master’s thesis on it." She was leary of taking on the responsibility, but Postma considered the clinical background to be more critical than the computer knowledge.

Postma was right. With the help of technical support from the software company, Skinner has been able to handle any problems that arise.

Reinstallation only took four hours

In fact, early one morning Skinner arrived at work to discover that the system had crashed the night before when lightning struck a nearby electrical transformer. All the records were stored on backup tapes, but she needed to reinstall the system.

Within four hours, Skinner had everything working as normal. In the interim, the practice saw patients and recorded information on paper, as they would if the paper chart had been misplaced. That is the only time in three years that the system has crashed, she says.

The practice has wrestled with some other issues common to electronic medical records. The software allows for automatic locking of records, which means that the information recorded during a patient visit could be changed or erased. The practice hasn’t used that mechanism yet because it is still sorting out occasional errors in which patient information is placed in the wrong record, such as between a son and father.

"Right now we keep hard copies of the daily notes in a daily folder," says Postma. "If there were ever any [question] about a security issue, we have that hard copy."

Accessing the system requires access codes. The phase-in period of the system was also slow, as it took time for physicians to become accustomed to the new way of recording patient information. In fact, two physicians still use some dictation to amplify the computerized record.

Still, the electronic medical record has been well-integrated into the practice’s care delivery. "The first thing I usually do [when I come to the office] is go to the computer," says Skinner. "Now the computer is a natural part of my life."

[Editor’s note: For more information about the NextGen system, contact Clinitec International, 200 Welsh Road, Horsham, PA 19044. Telephone: (215) 657-7010. World Wide Web: http://www.clinitec.com.]