effects of lithium. The high reading represented a transitory elevation - which is acceptable - and not a steady-state level. The physician advised her to discontinue the lithium at once, which, fortunately, she had the sense not to do. The lessons here are self-evident, but I will iterate them anyway. Patients taking monoamine oxidase inhibiting drugs in whom an unusual symptom develops should have their blood pressure recorded. The diagnosis of toxic effects of lithium should be confirmed by a steady-state lithium level, not by the level from a random sample taken less than 8 hours after the last dose. Quite serious results could follow a failure to heed these dictates. The appearance of patients like these in emergency departments is likely to be common, because they are extensively warned about possible side effects and counselled to go to an emergency department if necessary.

icians. And let's be reasonable Who wants to subsidize one's future competitors? We cannot expect our expatriates to refund our $100 000 investment in them. Perhaps it would make sense, though, to do as granting agencies do and ask for acknowledgement. To each letter from down south one could append a note such as "The training that allows Dr. X to make a bundle in the United States was made possible by the generosity of the taxpayers of Canada." John Westerlund, MD 6-432 Warren Dr. San Francisco, Calif.

The chartless office: Some practical considerations

I read the article by Dr. George Southey (Can Med Assoc J 1991; 144: 1301-1304) with interest. The principal advantages Morton S. Rapp, MD of computerized medical records Community Mental Health Services Unit are that they are quickly accessiWhitby Psychiatric Hospital ble, they impose organizational Whitby, Ont. discipline on the users if they are well planned, and they are always legible, clean and appetizing. With Thinking about a little forethought they speed up moving south? the process of compiling reports immeasurably, and a printout oncerning Canadian phys- from a computer is vastly superior C iicians moving to the Unit- as a hospital admission note to ed States (Can Med Assoc the scratchy efforts that we are so J 1991; 145: 202, 203), may I used to. offer a suggestion? Most of the software develUS medical training can be oped for the Apple Macintosh very expensive, involving costs of computer automatically keeps over $100 000 (US) during medi- track of the date and time (to the cal school alone. Subsidized Can- second) of changes to individual adian medical students bear far files. If the files are frequently less of the true cost of their educa- backed up on a "write once read tion. Trainees who move to the many" (WORM) drive an audit United States to practise thus trail can be conducted of the enjoy the best aspects of both changes in any file from the time systems: they get an excellent edu- it was established in the system. cation for next to nothing and, Confidentiality can be maintained once in practice, are not taxed to by the use of one of the various pay for the training of other phys- forms of security software. 768

CAN MED ASSOC J 1991; 145 (7)

Yes, it does cost a lot. But the sheer pleasure of using such a system makes it well worth while. Even the effort of transcribing essential information into the system allows the doctor to remember facts about his patients that have been lost for so many years in the morass of paper. The billing and accounting are merely accessory features of a medical office computer system. How do I know this? I have just established my own medical office record system. I even wrote my own software. I succeeded because I took many years of studying and research to plan it - and it is a joy to use. Erik T. Paterson, MB, ChB Box 0, 1000 Northwest Blvd. Creston, BC

As the vendor and supporter of the Medcal COSTAR system used in Dr. Southey's clinic I am disappointed in the misleading photograph that accompanied his article. Abel is a direct competitor of Medcal COSTAR and is certainly not part of Southey's "chartless office." Publishing a photograph of Abel is comparable to publishing an article on a Rolls Royce car with a picture of a Volkswagen or writing about a lung condition and showing a picture of a heart. A picture is worth a thousand words. Other than this the article was excellent. John Angus Vice president Micro Management Systems Ltd. Winnipeg, Man.

[This article was a discussion about some general aspects of creating a chartless office and not about a particular computer software system. The accompanying photograph was for illustrative purposes only and was not meant to promote any software product. -Ed.] LE ler OCTOBRE 1991

The chartless office: some practical considerations.

effects of lithium. The high reading represented a transitory elevation - which is acceptable - and not a steady-state level. The physician advised he...
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