CLINICAL DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. MEDICAL COMPUTING Impact of an Electronic Medical Record on Diabetes Practice Workflow Jerome S. Fischer, MD Electronic medical records (EMRs) enable us to use technology to simplify and streamline many of the processes in our practice of medicine. The potential advantage of using EMRs is that it allows clinicians to access the most comprehensive and useful compilation of patient data from past encounters, thus improving decision making and avoiding errors that can occur when important information about patients is not available or recalled. When the Diabetes and Glandular Diseases Clinic endocrine practice first contemplated the purchase of an EMR (Logician, by Medicalogic), concerns about cost, implementation timeline, and staff skills were the critical issues.1 Now, with more than 16 months of EMR use behind us, the effects on our daily workflow have been the most impressive benefits of our conversion to an automated system. Implementation Process Indeed, although tedious, analyzing our pre-EMR workflow proved to be extremely valuable. For example, when we dissected the processes involved in a typical patient encounter (checking in the patient, transferring the patient into the physician's office, completing the visit with the physician, and subsequently discharging the patient with appropriate prescriptions and instructions), we identified many small components, any one of which could inhibit the flow of patient care. The components that most often disrupted optimal workflow were those involving the documentation and/or retrieval of medical record information using paper charts. We realized that physicians and other health professionals spent an inordinate amount of time frantically flipping through the pages of our multi-tabbed patient record folders. Chart acquisition and review seemed to be more time-consuming than actual patient contact and became the rate-limiting steps in our efforts to provide efficient and cost-effective medical care. Using computers has permitted a more efficient set of procedures that are smoother, have fewer operator errors, and are enriched in informational content. This hopefully is improving the quality of care that the clinic offers to patients. The original schematic of our check-in system and of patients' flow through our office provided a skeleton for the construction of an encounter form that included the accumulation of specific old and new data that could be presented in a concise one-screen format. Linking lab, demographic, and history information allows for a rapid assessment of problems. The display also provides cues to meeting guideline requirements, including the American Diabetes Association Standards of Care. This display also improves our ability to interpret laboratory tests obtained at the visit and reviewed later in the day. The EMR-Modified Workflow 1. The patient is checked in by a medical assistant (MA), who pulls the chart up on the screen and opens an intake form, which was customized for the practice. An important feature that all EMRs should offer is the ability to modify such forms. 2. The MA interaction obtains substantial information, including old and new medications and recent hospitalizations. The form also collects information about many of the important ADA-recommended processes of care, including last dilated eye exam, smoking cessation counseling, and frequency of home blood glucose testing. Information about more general health maintenance activities and/or screenings, including mammograms and bone densitometry measurements for osteoporosis, is also collected. 3. Patients who are having return visits have data such as HbA1c values already available for review through the link with the laboratory information system. This is especially valuable for ongoing diabetes care. 4. Having access to the EMR in the exam or consulting room allows the physician to refer to problem lists and thus ensure that all active problems have been addressed and that documentation about them has been updated. The rest of the history and physical is then obtained. (This is still done the old-fashioned way!) 5. Medications are reviewed and new or refill prescriptions can be printed accurately and quickly from the Medispan database that also automatically identifies any potential drug interactions. The database also contains patient information handouts that can be customized and given directly to patients. The prescription writing feature has been a major time-saving and quality benefit of the conversion to an automated record system. 6. At the conclusion of the patient visit, the physician inputs the planned follow-up, which can include specific disease-related protocols or suggestions for standard required testing. Appointments for subsequent visits and lab testing are entered into the record. Logician templates are used to quickly provide hard copy printouts with patient instructions (for example, a new insulin dosing schedule), and new or renewed prescriptions are printed. 7. After the visit, the results of any ordered labs become available on the computer for review, comment, new instructions, and prescriptions. 8. The EMR has an e-mail-like system of flags that is used to notify staff about reports and to communicate among the practice's health care professionals. These flags identify lab results that need to be evaluated, reports that need to be signed, and other patient care activities so that they can be rapidly attended to between patient encounters or whenever there is available time. When there is a report to review, the physician can access the patient's chart electronically if she requires additional information before deciding how to respond. Once a decision is made, the physician can send a flag to the MA with appropriate instructions for communication to the patient. The system of flags is very efficient, as is the access that Logician provides to patient records for all authorized personnel. Logician supports simultaneous access to the same record by multiple health professionals, reducing the time and cost of moving charts among the various personnel in a practice. Logician has resulted in a marked improvement in the clinic's overall efficiency. Paper charts are now rarely requested, whereas in the past, each physician requested 10 or more charts each day, especially for post-visit review of lab results. Even more noticeable is the ability to quickly manage telephone calls from patients, again without the paper chart. An encounter form can be called up on the screen with all the patient's medications, problems, prior lab results, and encounters accessible with a mouse click. The final intervention is recorded and can be flagged to the appropriate staff member. Even insulin dosages and medication changes become prominently incorporated into the chart so that they are readily available for the next encounter. This information is readily available when one physician provides care for a colleague's patient while taking call. Confidentiality In addition, users have a certain level of privileges. In other words, there are restrictions on which portions of the record they can see and, more importantly, on which components they can alter with revisions or additions of information. Almost all medical information related to a specific patient must be approved by the physician designated as that patient's primary provider. In a sense, this may be more protected than a paper chart. Safety Once a document in the chart has been signed, it cannot be altered. Corrections require an additional entry. Furthermore, at present, the practice has elected to continue with a paper chart as a legal backup of both dictation and laboratory reports. The flowsheets and intake forms are, for now, an extension of the chart, but they can still serve as a management tool. Conclusion To date, the practice has used the paper chart as a template for developing electronic pathways. With improvement in voice recognition and further progress in acquiring and integrating data from outside sources, these traditional patterns will be radically altered so that efficiency and quality of care will be further enhanced. Reference 1Fischer JS, Blonde L: Electronic medical records in clinical practice. Clinical Diabetes 17:43-45, 1999. Jerome S. Fischer, MD, is an endocrinologist at the Diabetes & Glandular Disease Clinic in San Antonio, Tex. Lawrence Blonde, MD, is head of the Section of Endocrinology, Diabetes, and Metabolic Diseases and vice chair of the Department of Medicine at the Ochsner Clinic and Alton Ochsner Medical Foundation in New Orleans, La. Copyright © 1999 American Diabetes
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