The Electronic Pediatrician Returns

First of two parts:
Why you and I need an electronic medical record

By Andrew J. Schuman, MD

Computers have long fascinated me, especially their potential to help physicians expedite and improve their care of patients. Regrettably, in my small private practice, I have not always had the financial and technical resources to put computers to the test. Over the past few years, though, the growth in technology has changed things for the better: Computers have become much less expensive, disk drives are more spacious, and operating systems can now be used with confidence by even the most technologically challenged. So, after monitoring the evolution of the electronic medical record (EMR) over the past 10 years, I’ve just recently moved my office to an EMR charting system.

There are many reasons why EMRs have yet to be put into use by most medical practices. An EMR requires a computer network and, sometimes, shared Internet access. Starting up a complex computer network requires knowledge of hubs, different operating systems, and networking protocols. Because most MDs don’t have this knowledge, they often need to hire a costly, local computer networking firm to do the job. Later, if network difficulties arise, a networking technician must visit the office to resolve even the simplest problem. Two worst-case scenerios: Data from an EMR is lost; and the system crashes and remains down for hours, or even days.

The combination of extra cost, start-up complexity, staff training, and fear of downtime has kept most physicians from switching to an electronic medical records system. According to the latest statistics, only 5% of physicians now use such a system. A closer look at the benefits of an EMR, however, may entice the most frugal and cynical pediatrician to go electronic.

The paper chase

All pediatricians have a paper-based system in place to expedite and track patient visits, radiographic reports, telephone calls, and referrals, in addition to generating prescription refills and making referrals. Unless your practice has already migrated to an EMR, chances are your office’s "system" calls for dozens of encounter sheets, telephone message forms, school physical forms, vaccination forms, and other paper records. Copiers work overtime, and charts are bursting at the seams.

Although practices try to simplify or streamline the medical paper chase by using checklists and check sheets whenever possible, the process remains a "bulky" one. What’s more, in the rush to move patients through a busy office, many notes are hastily written and illegible. Far too much time is spent deciphering them. The amount of wasted effort perpetuated by this inefficient, archaic system is, I find, amazing.

An "organized" chart is a collection of patient demographics, insurance information, medication and problem lists, visits and physical exams, lab and radiograph reports, and consultant notes—all of which can be reviewed only one page at a time. It is truly an art and a science to use the present-day paper chart effectively to manage the care of patients. It is not only difficult to find what you’re looking for when you need it, but it is very easy to miss information critical to a patient's care.

The benefits of an EMR

An EMR presents physicians with a new "paradigm" for care, to use a Dilbert expression. All office personnel—from the receptionist and billing staff, to the nurses and physicians—can access an electronic database that links all information input. With an EMR, information about a patient’s medical history, active and inactive problems, vital signs, lab values, and consultant reports can all be seen by the physician on the screen with a few clicks of a mouse. The program can be set to throw up a red flag when, for example, a lab report needs to be reviewed, an action is required, or a follow-up visit is called for. Best of all, a good EMR prints legible prescriptions, school notes, lab order forms, super bills, and referral letters.

Consider the difference it would make in your practice style if you could become more organized and paper-free! Studies have shown that an EMR can increase workflow significantly. An EMR can reduce patient-management time and errors, and can augment your bottom line by helping increase your patient load through enhanced efficiency. Just think how much a single call from a pharmacy questioning your orders slows things down! With an EMR, this becomes an infrequent event.

The drawbacks of EMRs

Despite the benefits of an EMR, some obstacles must be considered. All pediatric practices are not created equal. They require different amounts of in-office technical expertise and information-system support and do not all have large financial resources from which to draw. Physician input into the decision to purchase a system varies greatly—from 100% involvement to none whatsoever. A pediatrician who works for a hospital-owned practice or multispecialty group, for example, must use whatever system the clinic administrator chooses. Administrative decisions are based on the cost of hardware, software, and maintenance or data backup. Everything must be weighed against the increased productivity brought about by EMR use.

Making the choice

An independent physician may decide to adopt an EMR based on the same considerations as a large practice, but he or she has fewer financial and technical resources for the start-up. The industry makes several different models of EMRs because it recognizes that physicians and administrators both want a voice in which EMR system is adopted. Here are three types to choose from:

—The "enterprise solution." This huge, extremely expensive EMR system is best for a network of linked practices, a multispecialty group practice, or a hospital. The cost, depending on hardware, is often in the six-figure range.

—The "Internet solution." Physicians using this approach rent a virtual Internet-based chart rack which costs several hundred dollars a month for each user. Data are theoretically secure, and most systems have easy-to-navigate screens that build a coherent patient note. Although some of the data may reside on local hard drives (which can crash), the whole database exists in cyberspace on a different computer (which also can crash). If the Internet connection dies, so does access to your vital information—unless you had the good sense to print out all information generated. A paper backup, of course, defeats the advantages of the EMR, which encourages a paperless office. On the plus side, software maintenance and upgrades occur behind the scenes at the server end, and the liability concerns for patient confidentiality belong to someone else for a change. An advantage of this system is that an interested physician can test the waters without making a major commitment or substantial outlay of cash; records are printed as usual and included in patient charts.

—The "streamlined solution." The third alternative makes much more sense to physicians who believe the true goal of an EMR is to make the office as paper-free as possible. In this system, all software operates from a server linked with client computers. Networking options now include a wireless portable or laptop computer. Data are backed up many times daily, and all patient information exists in the computer database. Costs vary from just a few thousand dollars to tens of thousand of dollars, depending on the system chosen.

In most good EMRs—but predominantly in streamlined solutions—paper documents can be scanned or optical character recognition can be performed so that laboratory and imaging reports and consultants’ letters can become part of the EMR.

Intrigued by the potential of an EMR? In the second part of this Electronic Pediatrician article.

DR. SCHUMAN is adjunct assistant professor of pediatrics at Dartmouth Medical School, Lebanon, N.H. He practices pediatrics at Hampshire Pediatrics, Manchester, N.H., and is a contributing editor for Contemporary Pediatrics.

Why you and I need an electronic medical record.

Contemporary Pediatrics

August 2004;21.