The following was written in 2007.
While it is still applicable for some, this approach has not been approved for
"Meaningful Use" and is not eligible for government financial incentives.
Many of my colleagues are going out
and purchasing EMR (electronic medical records) systems for exorbitant amounts
of money. The process can be terribly difficult to accomplish in addition to
being expensive. Also, when I was researching EMR systems for my own office, I
found the annual maintenance fees for the software to be excessive. If you’re
one of the thousands who have already invested the time, effort and money to
convert to an EMR system then congratulations and I hope that you are satisfied.
This page is dedicated to those individuals who haven’t yet converted and want
to do so inexpensively and efficiently.
Some Key Reasons to move from paper
Cost Effective -
No expensive triplicate paper forms to purchase. Each new set of forms are
created with the touch of a button.
by reducing or, for routine pregnancies, eliminating errors of omission and
by increasing the accuracy of the data. Computerized forms analyze the
patient's data and performs calculations, validation, and reminders based on
the information entered.
by eliminating paper and facilitating duplicate data. Paper forms and charts
are almost impossible to back-up. In case of fire or flood, the pt. charts
are lost forever. Digital forms and charts are easily backed-up and the data
is more secure.
Keep the forms as
current as possible through easy modification and quick implementation.
Should there be a need to modify the forms in some way, the new form can
instantly replace the old without having to use up or discard the stockpile
of paper forms already printed. This will enable the forms to always utilize
the latest standards of care and be constantly improved without committing
to the printing of a large quantity of forms.
legibility. Computerized forms are typed and that makes them more legible
compared to handwritten notes. There should never again be a question as to
what the provider wrote.
efficiency. Paper forms require lots of paper shuffling. They require staff
to remove the pages from the chart, photocopy, and then either hand carry,
fax or mail these to pages when necessary. The paper then has to be replaced in
the chart. Electronic forms can be batch printed and/or faxed directly.
Also, because the charts are all located "virtually" in one location,
everyone will have access to the charts without having to waste time
"hunting" for them. And additionally, the charts can never be misplaced,
lost, or destroyed as physical charts can.
SmartOB® prenatal forms, they are created using the Microsoft Office family
of products. Because they are created in Excel with a VBA backbone, they can
easily communicate with or be converted to other Microsoft Office products
Years ago, I was researching EMR systems. I was too cheap to spend the many thousands of dollars necessary to
purchase a complete system and I didn’t like the idea of annual maintenance fees
even though I understand that it’s these fees that keep these companies in
business. I also couldn’t find a turn-key system that worked as efficiently as I
did with paper and I didn’t relish the idea of spending time learning a new
inefficient system. I researched do-it-yourself methods that would allow me to
easily and inexpensively convert my paper office to a paperless one. After much
trial and error, I am convinced that I found a way that was cost-efficient, that
was easily customizable to my needs and that I could do myself without having to
rely on third party vendors and pay what I considered to be huge amounts of
money on an annual basis just to keep the system up and running. I’m confident
that someday there will be low-cost, efficient EMR’s but until then, I share
with you what I've done.
Database Location, Back-Ups,
Charting Methods, Follow-Ups,
My first goal was to convert
all my paper charts into electronic charts. To accomplish this, I would need a
scanner and a computer and some software method of filing.
I know of many so-called
paperless offices and I don’t know of any one of them that is truly paperless.
They still get some if not most lab reports, consultations and dictations
delivered on paper. They then have to scan these into their system. A scanner is
essential. When considering the purchase of a scanner, my advice is to not be
too cheap. You will want a scanner with an Automatic Document Feeder and one
with a relatively fast scan rate of at least 15-25 pages per minute (ppm). I
initially purchased two inexpensive scanners and found them to be frustratingly slow and
with bad scanning software. I replaced them with
Visioneer Scanners and I have
found the speed and ease of software to be satisfactory. Expect to spend
approximately $900 on a good scanner (20 ppm with flatbed capability).
Computers as of the time of
this writing have become extremely powerful and I have no doubt that they will
only become more so over time. So my advice regarding them should remain true.
The scanning and filing tasks that you will be requiring of any computer made
today, even one of the least expensive, will not tax the machine's resources so
just about any desktop computer will do. I keep my billing software separate
from my EMR system and I use desktop computers for billing. Because I am a solo
practitioner, I chose a laptop because I liked the idea of having all my charts
with me at all times. I initially thought that I would do all my charting on my
laptop, carrying it from room to room and charting on it as I would paper, so
years ago I
bought a tablet PC. This allowed me to create forms in “Journal” and write on
them as I would my old office forms. "Journal" was an amazing discovery. It came
free with the tablet computer and Microsoft knew what they were doing when they
wrote it. Any Word or Excel file migrates easily and perfectly as a Journal
file. I believe "Journal" has been replaced by Microsoft's "One Note" that may
function similarly. "Journal" made the switch from charting on paper to charting
exactly the same way but on a Tablet computer effortless and painless. This system worked
fine but now that I was charting on a computer, I realized that a computer
could function as more than just a digital piece of paper. For computational
tasks, I found “Journal” to
be somewhat limited.
If all you want to accomplish is to practice the same way you always have but write your notes
on a computer that you can take with you into every
room (can be networked to a central office database), this is all you need. I still use the tablet as my PC
and I have migrated some of my forms to other formats that do work for me. If you don’t want to carry your
computer, you could put desktops in every room or have a desktop in your office
and do all your charting there.
I am a strong believer in the
software “Paperport.” Paperport allows
you to file all your electronic
charts as if they were paper and also see the thumbnails and quickly view them
better than any other software I have found. I do my file management from
scanning to chart viewing through Paperport. Paperport scans all pages to .pdf
format and easily converts my Office forms to .pdf format. You can then
manipulate the pages stored in the .pdf format as easily as you can with paper
pages, including moving, copying, printing and stacking. Each patient’s chart becomes a
folder and within each folder are subfolders for Notes, Insurance, Labs, etc.
The advantages of this compared to paper charts are amazing. I have never
misplaced a chart since converting to this system. Filing is a breeze and there
is no fumbling with fasteners, etc. And the cost savings compared with
traditional paper chart folders, dividers, labels, etc. are substantial.
I think almost everyone is
familiar with Microsoft Office and I hope you are as well. I use Microsoft
Office extensively. I use “Word” and “Excel” to create my forms and “Outlook” to
track required follow-ups and sync to my PDA. If you don’t have a PDA (I use an IPAQ running Windows Mobile
[in 2007 I switched from an IPAQ to a PDA phone running Windows Modile 6.0.
Rather than updating this constantly, assume that I will continue to upgrade as
the technology continues to improve.]), I suggest you consider purchasing one for
reminders, and other software, i.e. Pharmacy. Creating forms in “Word” for
things like H&P’s and Consultations is relatively straightforward. I use “Excel”
to create and manage my Encounter forms, easily changing diagnosis and procedure
codes as needed.
A NOTE TO THE OB/GYN
I have also used “Excel” to
create my GYN Progress Note Forms as well as my prenatal forms. The
prenatal forms are named “SmartOB®” because they are. These forms conform to current guidelines and monitor many of
the tasks required in the standard obstetrical management of a patient’s
pregnancy. The forms calculate the patient’s gestational age at each visit based on
the Final EDD and determines if any of the routine labs for that gestational age
are missing or if the values are abnormal. For example, if the one hour glucola
is not documented on the chart after 24 weeks, then the forms warn the user to
document it. Likewise, if the one hour glucola is 140 or above and there is no 3
hour GTT documented, the forms also warn the user to document that. In addition,
along with increasing the accuracy of the data and helping to prevent errors of
omission, the forms have also been designed to maximize the efficiency of the
prenatal visit. More information about what the forms monitor and how the data is managed can be obtained on
the SmartOB Prenatal Forms page.
Ideally, you can keep the database on your main
office computer that is accessible by many
machines within the office network and even access this data remotely with
programs such as GoToMyPC
or even via Remote Desktop Connection using Windows.
For portability, you may also elect to keep all or some of your charts or files
on a portable hard drive or even a USB Flash drive. If you do decide to go this
route, you really should use an encrypted drive for security reasons.
How many medical offices that
use paper charts have a back-up of all their files? I would guess almost none.
With electronic charts, all you need to do is use a “sync” program to
efficiently and effortlessly back-up every chart you have in a few minutes. You
can also periodically "copy" all of your charts to a back-up drive but that is
less efficient. What a “sync” program does is compare the file structure that
you want to back-up to the file structure of the target drive. My new favorite
program for this is “Synchronize
It!” and I set the sync to “Duplicate.” I
maintain and work with only one file structure and use a portable hard drive as
a back-up to that file structure. It’s difficult for your patient data to be
more secure than that.
*You probably already know
this, but it is critical that the main database is protected and manipulated
directly and NEVER backed-up or sync’d FROM a peripheral database. Doing this
can have catastrophic results in the database and destroy the integrity of the
Before I converted to
electronic charts, I had always used a
numerical charting system both for ease of use and for patient security. I found
it more difficult to misplace a paper chart if filed numerically and I didn’t have to
keep shifting charts around as the practice grew and the number of Jones went
from 1 to 100. Even before HIPAA, I thought it was a good idea to not have
patients’ names on the outside of paper charts. I still use that system, but now it’s
unnecessary. If I were to do it again, I would consider using a Patient Name
system as it is impossible for charts to be misfiled by the computer. However,
the numerical system does still hold the advantage in case of duplicate names.
For this reason, my folder naming convention includes both the patient’s number
followed by the patient’s name and I use the number primarily for filing.
An example of a chart name is: 2104 Jane Smith. This would appear in a
list after chart 2103 and before chart 2105. However, when I am called after hours by a patient and I want to look up their
chart and I can’t remember the number, I simply do a search for that patient’s
name using Windows “File Explorer.”
All my office charts are in a
folder called “Office Charts.” I have a standard chart folder template
that contains all the
subfolders and a New Progress Note template. To create a new chart I simply copy
and paste the chart folder template into my “Office Charts” folder. I usually
create 10-20 of these new charts at a time in a matter of seconds (your time will depend on
how fast you can click on the “Paste” button or hit the key combination
“shift-insert”). As new patients come in, one of the chart folder templates
is renamed to the corresponding patient number and name of the new patient.
You may elect to do either all or some of your
charting directly on the computer. It is easy to create and type on
pre-formatted Word or Excel forms that you create yourself. You may also choose
to create the forms, print them out as needed and then scan them into the
patient's chart after the visit. Each patient can have their own
unique new progress note based on a standard form. The information that is unique to
them and that doesn’t change often such as date of birth, past medical, surgical and
family history, allergies, etc. is typed in and then the form can be printed for
each visit or used directly in the computer by saving the template before it is
used for that visit. At the end of the visit, the progress notes may be
converted to .pdf and stacked onto the older notes or the progress notes as well as any copies of
consents, lab orders, prescriptions etc. are scanned into the patient’s chart.
However you decide to chart, the choice is yours.
How do I ensure proper
follow-ups? So far, much of this is done the old-fashioned way. For Pap smears and labs that we send out from the office, we use the
same old method we always have. We have a lab tracking book that has a copy of
every lab requisition sent out of the office. Every time a lab comes back, that
requisition is removed from the book. Any outstanding labs are tracked down on a
regular basis. Every patient who leaves our office is given a follow-up
appointment. For every no-show, appropriate documentation is then performed
depending on the level of need for the follow-up. For follow-ups outside the
office such as 6 month repeats for abnormal mammograms, I enter the follow-up as
task in “Outlook.”
If you’ve done any research
into switching to EMR, you already know the cost of the systems out there. If
you are a solo practitioner as I am with only one office and wish to have all
your charts with you at all times, you can get away with as little as the
|1 Desktop Computer
1 Flat Screen Monitor
|1 Laptop Computer
|1 Laser Printer
||$200 - $400
||$900 (Paperport is
with a Visioneer scanner)
|Peripheral Hard/Flash Drive
Annual Maintenance Fee
Piece of Mind & Control
Yes, the total cost of a
Do-It-Yourself EMR system with electronic charts can be less than $3500 (prices
as of 2007 may drop over time). Of
course, you could opt to purchase a state-of-the-art machine for more
than $4000 or you may need many machines and networking connections if you have
multiple practitioners and/or multiple offices. But the cost in all cases is
significantly less than any turn-key system. In addition, there are no
maintenance fees. And I think most importantly, you have total knowledge and
control of the way your office runs. You have the ability to completely
customize your forms and change them any way you want and as often as you want. All
this was important for me but may not be for you if you belong to a large
organization with your own IT department.