The primary achievement Electronic Medical Records (EMR) lay claim to is to save time. Everyone knows, time is money; so which of these products is best for you and your patients? The EMR technology is quite advanced already but, because it is so recent and the development costs are so high, many of the technical assets and shortcuts are not grouped into a single product. Each is disseminated according to whatever the doctor’s specialty may be, advancements only being made when necessitated by the field. The real vision for the future of this market will take the best of each field to make one universal system.
Let me take you through a virtual office tour, where I will demonstrate an imaginary software named Dreamware-2007. This imaginary software will take current existing components of software sold on the market and group all of the best features together into one single package. One of our best resources for this endeavor is the EMR consultant website (www.emrconsultant.com) which harbors, by far, the most extensive collection of EMR software throughout the world (over 300).
First, from the Patient’s Perspective:
So you decide you’re ready to see your doctor. Do you grab your phone to get the voice-mail of your chiropractor. No, not this time; you go to your computer, then to your doctor’s online appointment book.1 That’s right, there you reserve a slot in the time grid proposed to you online. You are required an upfront deposit which is not refundable, and charged if you do not honor your appointment. Your credit card number is entered and will be processed in the doctor’s office. Additionally, you are given your own password for future appointments. As the patient, your time is also valuable so, to expedite your visit to the clinic, you are asked, online, to answer a health questionnaire.2 You can also go online to sign an authorization to release documentation from other doctor’s offices. As the patient, all you will have to do is to enter those doctor’s phone numbers, fax and emails, and the computer in the doctor’s office will auto-generate the form that will be directed to those doctor’s offices that will be releasing the documents.
Even though you have yet to see the doctor; the clinic is receiving all of its documentation ahead of time, and the time grid for the day is filling up with no personal interaction yet;3 the computer has generated and sent faxes (or emails or phone calls) to other clinics to ask for the relevant documentation about you the patient.4
To remind you of your appointment, the day prior, a computer generated voice mail is left reminding you of the time of your appointment. After the prompt, you listen to the short message and push "#" to confirm, or another key if you need to reschedule. Simple as that. The system automatically provides an easy to read report for the doctor at the start of the next day.5
Finally, you’ve arrived at the clinic. In the doctor’s waiting room, a kiosk touch screen system asks you to enter your password if you have been given one from the online appointment. You enter it, and you are greeted by your own name and asked to smile for a picture from the camera mounted on top of the kiosk.
You are also asked by the system if you would like a biometric finger scan or a facial scan to be saved in the system to avoid your having to memorize any password for next time.
You are then asked to swipe your insurance card on the card reader. The computer informs you of the price of the basic visit, which is owed prior to seeing the doctor. Your insurance card also has medical information about you, which the system asks you to release, and prompts you to enter a password in order to be HIPPA compliant.
Now, at this point, if you have not filled out your health questionnaire online, you are prompted to a series of questions on screen.7 You do not need to type, but just to touch one of the check boxes on the screen; this online questionnaire is asked of you in the language of your choice (English, Spanish, French), but the doctor will see the answers in plain English. You even have an audio file to each question in different languages, allowing the non-reading patient to still communicate. Those questions are interactive, meaning specific answer prompt to specific new questions. The questions are also illustrated with picture video clip animations to make them easy to grasp and understood by the patient, while keeping the questionnaire relatively entertaining.
Once everything has been answered, you are asked if you would like to have an electronic file of this questionnaire sent to your email address in an encrypted format, should you need to consult someone else; there is also a service you can purchase for a server in the US to collect all your medical data from every doctor that you ever consulted.
On the doctor’s personal screen, a warning informs the doctor that a patient has checked in and is currently filling out the questionnaire. The waiting room touch screen health questionnaire subsequently generates a form on the doctor’s computer screen. Additionally, the lab report, MRI pictures, and hospital records are directly wired and transferred to the doctor’s system and seen on his/her screen.8 The records are not shown on the screen as a faxed or scanned document, but much better. Each bit of data has been entered from the start in a particular field according to a nationally used format (HL7 or Health Level 7). Those fields can be retrieved and compared from different years, and analyzed in a way that the association search between diseases and abnormal values are automatically made. The doctor will also create for all his/her patients specific questions which seem important in his type of practice which have programmed specific warnings to be triggered following specific answers or abnormal biological values.
Finally, the personal encounter occurs, in which the doctor meets the patient after checking the result of the electronic questionnaire and the matching queries from each of the different electronic patient files. The system has already given him the type of exam he should perform and what different ailments he may be facing through the use of statistical projection.
The doctor is prompted through the exam via touch screen. Each test to be performed is shown on a screen as an animation or video that he taps to select. The result of the exam can be generated in several formats: form, text, text and pictures.
The doctor is prompted to several diagnostic possibilities and, for each diagnostic, a menu lists the findings that prompted such a potential diagnosis. The final decision is up to the doctor.
Then comes treatment; the treatment must be recorded with enough precision for exact duplication by any of his colleagues. If the doctor is an MD, then this is done in a very straightforward fashion, e.g., "5 milligrams of drug twice a day." Anyone would be able to duplicate this treatment.
If the doctor does hands on treatment, such as a chiropractor, physiatrist, PT, OT, then some amount of system customization needs to be done, because no two "hands on treatments" are the same. Every chiropractor customizes his adjustment to a certain extent.
To make things easy, the software has provided the doctors with pictures from a hundred animated adjustments, mobilizations and modalities; for each one of those, therapeutic protocol is described with a biomechanical precision following a standardized description, enabling another physician to duplicate it. The most comprehensive database to date may be found at http://docurehab.com/TechniquesEX/index.html. The doctor merely needs to pick what he uses daily; further, he has the option to customize the technique he uses and keep it in his "often used" technique folder. Once in the folder, those techniques are retrieved by tapping on the screen and they become part of a menu that the doctor uses daily.9 With this software, the doctor has access to hundreds of techniques taught by schools, universities or fellow chiropractors, therapists, and MD’s.
Insurance companies have a tool to establish statistical data on the effectiveness of a given technique for specific ailments. As the technique is selected, the insurance code is automatically assigned to the billing section of the program. Insurance is billed online daily. Payments are electronic and correlated to the EOB (explanation of benefits) automatically.10
The patient’s medical record is wired and stored off site, backed up routinely so, even if a hurricane destroys the office computer, data can be retrieved instantly from another location.11
All the elements of the system just described already exist in the industry; they are not yet found in a single source of software because there are too many health specialists with different needs to customize all of them at once. Many of those nifty applications require that all the ones that you communicate with be on an EMR system with a standard communication format such as HL7, which is not yet the case.
But our current systems already provide the most services by automating the patient’s health history, the note taking and the billing function; those functions, alone, have cut down at least two-thirds of the office clerical duties.
The industry is now gearing up toward the medical exactness of differential diagnoses from data retrieval. I predict the economic impact will be huge on the health market. On the level of the practitioner, initially, the benefit will be more available time. Second, reproducible therapeutic approaches will be more exchangeable, and assessable using statistics. The tedious function of billing will be expedited. Finally, epidemiologic studies will be streamlined with outcome assessment automatically quantified for each patient and each condition. The initial investment of a good EMR system is recouped fairly quickly through better billing, better collections, better time management, as well as better clinical presentation—which all equate to better medicine overall.
Etienne Dubarry has been teaching for twenty five years nationally and internationally, has published book s and articles on chiropractic, techniques, and rehabilitation exercises, their electronic documentation duplication and classification. He is the CEO of DocuRehab, documentation and rehabilitation software which has posted on line for every one to use the largest collection of animated treatments and rehab exercises (2000+) .http://docurehab.com/ExerciseExport/index.html. He can be contacted at: