Losing the Paper Trail.

Electronic records save $3,000 a month, secure information and save time.

Medical practices that have paper medical records face problems with tracking files, inaccurate documentation and security. Several surveys at national healthcare technology conferences last year showed that

PROBLEM

At Southwest Primary Care Associates (SWPCA), we maintained a hard copy chart system that was difficult to keep track of, wasted the staff's time, and had the potential for misreading handwriting and, therefore, creating inaccuracies. Security was another concern of our practice, which has clinics that treat 7,000 patients a year in Tempe and Chandler, AZ. Written charts could have been viewed by anyone in the office who could get by the person at the front desk.

The paper trail started when a new patient filled out a form. The office put the form in a file that would be clipped together and routed to the back office for input on the patient's vital statistics and medical history. Then it was left for the doctor to review during the visit. Later the doctor would dictate the results of the visit. These notes were moved to another location to be transcribed overnight and put into the waiting folder that would be filed in a permanent location in the office. The transcriptionists often had 200 items a day.

With 50 percent of the practice in managed care, formal referrals meant the file would sit in another part of the office waiting for input by the records staff. When laboratory or X-ray results came in, files often couldn't be immediately found for review. About 80 charts often would be sitting in a milk crate at the end of the day awaiting physician or medical assistant action. If a patient called in with a question in between appointments, someone had to spend time finding his or her chart.

SOLUTION

The initial search for electronic medical records software was unsuccessful: Some software involved too much typing, or navigation was too complicated. We chose MedicWare, developed by MedicWare, Inc. and marketed by Companion Technologies, Columbia, SC., because its functions were similar to how we see patients. "Tabs" in the software windows relate directly to following a patient through their visit, from chief complaint through exam, assessment and plan, including prescriptions and patient education handouts.

COMPONENTS

Patient information can be entered in several ways: touch screen, voice recognition, pen pad, keyboard, word processing, mobile hand-held computer, scanner, mouse click entry or handwriting recognition.

In addition, documentation improves the accuracy for billing, including complex visits. The visit can be documented in a way that justifies the evaluation and management code based on HCFA guidelines. Sentences have "dropdown" choices that assist the doctor in building the patient's encounter notes. Once the physician has completed the encounter notes, the application recommends the correct evaluation management code based on the documentation.

BENEFITS

Charts are easily found on the computers. Doctors input their information at the point of service, and are finished with charts within 20 minutes of concluding patient appointments each work day. Transcriptionists are no longer needed.

There's no more sifting through multiple papers to figure out the last time a patient had a preventive screening. Lab reports can be found in 30 seconds. Prescription refills that used to take 20 minutes to fill out now take a few seconds. The system has saved hours of looking up drug interaction data. Also, only people who have a password can view charts and only those parts of the charts they are authorized to see.

While the purchase of the software and hardware required an initial capital outlay, the savings from no longer using transcription services, about $3,000 a month, counterbalanced it.

For more information from Companion Technologies, circle 175

SOURCE

Dr. Lori Kemper, D.O. Southwest Primary Care Associates, LLC Chandler and Tempe, AZ 480-705-9413

PRODUCT/COMPANY

MedicWare Companion Technologies www.companiontechnologies.com