COMPUTERS * INFORMATIQUE
Te chartless office: Somie practical considerations
George Southey, MD ABEL Computers Ltd.
he chartless office in which patient-record and administrative functions are performed by computer was once thought beyond the reach of physicians in small practices and those who do not have a terminal passion for computerization. This is no longer the case, as advances in technology have put the fully computerized office within the reach of solo practitioners and small group practices. In a chartless office most of the medical record is stored in computer files and a paper file is maintained only for items best kept in hard copy, such as electrocardiogram results and signed consent forms. Getting rid of the T
-for a small group practice the bill will likely be in the $25 000 to $35 000 range, with cost depending on the system chosen and practice size. For a solo practitioner the basic cost will be around $18 000. This is in contrast to a basic billing system, which costs about $6000.' If you cannot justify the expense on financial grounds will a chartless office let you re.:
George Southey practises in a small family medicine group in Oakville, Ont. His chartless office uses a Medcal COSTAR system. MAY 15, 1991
It will likely cost a small group $25 000 to $30 000 to create a chartless office CAN MED ASSOC J 1991; 144 (10)
The chartless office is usually able to operate without a paper chart for 90% of patient visits.
duce expenses or generate more income? - or on less tangible ones, such as improved quality of care and enjoyment of practice, don't spend the money. Computer salespeople will point to many ways their system can justify its cost, but take this information with a grain of salt. The first rule of office computerization is that the cost justification probably does not exist unless it has been demonstrated by another customer in a similar office. Ask for references and follow them up. Of all the medical office functions that can be computerized, none requires more thought or carries a bigger price tag than the decision to computerize patients' records. When a medical record is stored in a computer, doctors either need a printout of the record,
or access to a computer terminal that allows them to look at it. This means that a terminal will be needed in each examination room, the reception area, doctor's office and the nurse's station. Doctors who rely on printouts will probably have eliminated the cost savings the chartless office offers. Staff will be trying to maintain both a paper and computer file, and clerical work will be doubled. The software needed to run a chartless office is expensive to buy and maintain. There will also be additional start-up costs, because all office staff will have to be trained to run the new system; only the receptionist will need
good typing skills. In the chartless office, information from office visits, laboratory results, consultation letters
and other reports must be entered into each patient's computerized record. This data entry requires staff time, but the chartless office may actually demand less clerical time than a paper-based one. Once the material is in the computer record, there is little need to move or sort paper. The chartless office is usually able to operate without a paper chart for 90% of patient visits, and minimal chart preparation is needed each day. Refiling time is minimal, as is the space needed to store records. When all patient information is in a well-organized computer program, there is tremendous potential for improving the quality of patient care. The database can be searched on the basis of diagnosis, physical finding, medication, laboratory result, or any combination of these headings. The benefits that result from having this information at the doctor's fingertips are restricted only by the physician's imagination. To ensure that a computer package will meet your needs and allow full computerization of your office, make use of someone else's experience. Visit an office where the system is used and talk to the staff and doctors about its day-to-day functioning. Does it do what the vendor says it will? Are some features still under development? Do you need to be a
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CAN MED ASSOC J 1991; 144 (10)
LE 15 MAI 1991
rocket scientist to use it? Of all computer functions, keeping track of patient data is probably most difficult. To maintain computerized records without keeping a paper chart, several requirements must be met. The Canadi4n Medical Protective Association (CMPA) recently outlined these.2 They have not been tested in a Canadian court. The CMPA says there should be: * Contemporaneous recording to enter automatically the time and date of each entry into the computer record. * Flexibility of programming that allows the medical record to be written using the physician's own words. * A feature that identifies and records where access to the system originated and who sought the information. * An audit trail that indicates when a record has been modified and by whom. * A paper record producible promptly upon request. Each provincial billing agency can set requirements for computerization. For instance, the Ontario Health Insurance Plan (OHIP) requires that physicians submitting claims via computer disk retain a hard copy of the source document for 7 years (Harry Colt, Ontario Ministry of Health: personal communication, 1990). The
MAY 15, 1991
If you cannot justify the expense on financial grounds - will a chartless office let you reduce expenses or generate more income? or on less tangible ones, such as improved quality of care, don't spend the money.
source document is the computer printout describing the details of each claim. OHIP has no other specific requirements relating to computerization, but says all systems must conform to requirements set by the College Of Physicians and Surgeons of Ontario. The college outlined these in a recent notice to members: * There must be a clear audit trail that indicates when an entry is made and who made it. * The computer system must be able to supply a paper copy of the electronic record on request. * Modifications of a record are not allowed without preservation of the original entry and an audit trail indicating when the change was made and who made it. Confidentiality of records is a
concern in the chartless office, just as in the paper-based one. The computer system must restrict access to records. Security measures can include individual passwords needed to gain access to different levels of information, or automatic shut-off of the terminal if it is not used for a set time. Programs and data must be protected from the accidental introduction of a computer virus. Physicians should never use pirated software, never take software from a computer bulletin board, use only disks known to be safe, and employ antivirus programs such as Vaccine or Scan.3 OHIP is confident its security systems will prevent the accidental transmission of a computer virus (Harry Colt, Ontario Ministry of Health: personal communication, 1990).
CAN MED ASSOC J 1991; 144 (10)
Software is the key that turns the computer into a useful tool and the choice of key is vital. In Ontario more than 300 programs are available to perform medical office billing, but the market is dominated by a small number of vendors (Peter Berwick, Ontario Medical Association: personal communication, 1990). In Ontario there are 16 vendors with more than 100 customers. Some systems offer more than billing, but be suspicious of what they can actually do. As well, how complicated are they? Staff should be able to use the system immediately after the training session. If they are confused and frustrated by it, you will need either another system or another staff. There is usually only a single company selling each office system and it is important that the one selling yours will be around to maintain it and provide future enhancements. The vendor should have numerous satisfied customers you can contact. Reliable companies will be prepared to state in a contract that if they stop supporting a particular system they will provide the program's source code. This will allow you to get software support from a computer consultant of your choice. The software purchase must be accompanied by an adequate maintenance agreement - this usually
Even if you choose the right system and right strategy for introducing it, be prepared for some disruption.
spending money if something better may come along before your cheque is cashed? Simply because the most valuable parts of a computer system are the information it contains and the ease with which you can retrieve it. If the information remains safely stored and the program undergoes regular enhancements, your investment was a good one, regardless of technologic advances that take place. Even if you choose the right system and the right strategy for introducing it, be prepared for some disruption - efficiency will suffer as new methods are being learned. Patience, support and tutoring will help minimize time spent on this learning curve. From personal experience, I know that with proper research and planning it is possible for a small practice to become fully computerized. The chartless office that results can provide physicians with both professional and financial benefits.
costs 10% to 15% of the purchase price. The vendor does not need to be in your community to provide this support, but long-distance charges should be included when estimating your system's final cost. "Do you have an IBM or a Macintosh?" is a question many physicians hear. However, basing your choice of computer system on the machine that runs it is analogous to choosing a doctor on References the basis of where he or she has hospital privileges. Usually the 1. Anderson P: Getting started. Physician's Manage Man 1990; 14 (5): 26choice of a particular doctor, or 27, 32-33, 37 computer program, is more important. 2. Computerized medical records. Can Med Prot Assoc Inf Lett 1990; 5 (1): 2-3 Regardless of your choice of hardware, something better will 3. Covvey HD: Safer Computing. Healthcare Comput Commun 1990; 4 (2): 40 exist next year. So why bother
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