Computer Consult

By Robert Lowes

Build an EMR for next to nothing

• Microsoft Word, Windows Explorer, and your fax machine can give you an EMR.

• Scanning records sidesteps the problem of incompatible computer systems.

• Microsoft tools like AutoCorrect can speed up data entry.

Internist Robert Novich in New Rochelle, NY, knows that you don't have to spend a fortune on an electronic medical record system.

Four years ago, Novich built his own EMR, and its main components were things he already had—Microsoft Word, which came with his office computers, and a fax machine. His homemade EMR has revolutionized his solo practice, especially when it comes to patient care. "I feel like a brand new doctor," he says.

Before he took the EMR plunge, Novich practiced medicine in the chaotic world of paper charts, which seemed to play hide-and-seek with his office staff. It could easily take 10 minutes to track down a chart. Such delays hindered communicating with patients and fellow doctors alike. "Having to make critical decisions without access to charts threatened the quality of care," he adds.

Novich enlisted his son, Jeff—then a college student and now a computer consultant—to help turn him into a digital physician. Their goal was to create an EMR that would cheaply and easily integrate with Novich's existing charts, simulate paper filing, and provide quick access to information. They decided against buying a commercially available EMR system for several reasons.

"One, these programs cost too much," says Novich. "Two, they typically demand a rapid, all-or-nothing conversion to computerization, and we wanted to proceed more slowly. And three, we hated the idea of being locked into a proprietary system. We didn't want to depend on a vendor for software updates or worry about whether it would be in business a year later. Instead, we wanted a combination of popular, easy-to-use, and low-cost software programs that we could customize to our liking as time went on."

The backbone of the system they devised is Windows Explorer, which helps you organize files into a directory of folders and subfolders. Patient records are filed alphabetically. There's a folder for each letter of the alphabet, with a subfolder for each of Novich's 3,000 patients.

Two data streams flow into this cyber-filing cabinet. The first consists of the notes Novich writes for new-patient visits, follow-up visits, physicals, phone consultations, and the like. For each type of visit, Novich created a form in Microsoft Word. The forms walk him through the questions and topics that he normally touches upon in patient encounters.

Jeff easily customized Microsoft Word so that the various forms are listed in a drop-down menu labeled "templates." When Novich clicks on the desired one—the form for a male general exam, for example—it automatically gets pasted into the patient's file with a macro, a small program that automates repetitive tasks. Then Novich types away.

Novich calls himself a slow typist. But thanks to computer wizardry, he can churn out a 200-word note in a minute or two. A Microsoft Word tool called AutoCorrect enables him to create an entire phrase, sentence, or paragraph by typing just a few letters or numbers. He has an arsenal of 60 or so abbreviations at his disposal.

The other data stream flowing into his EMR consists of the information his office usually receives on paper: Letters from other doctors, lab and X-ray reports, ECGs, referrals, etc. These are converted into static electronic images and stored in the patient's subfolder. Initially Novich tried digitizing these documents with a scanner, but the machine was hard to use and frequently broken. So he simply started running the paper through the office fax machine, which was essentially a scanner connected to a phone line. He faxed the documents straight into the office computer, a trick made possible by a software program called WinFax PRO, which cost less than $200. Adobe Acrobat, another inexpensive program, allowed Novich to convert digitized documents into PDF files. "The advantage of working with PDF files is that you can label and annotate them," says Novich.

Last fall, Novich replaced the fax machine with a combination fax-scanner-printer-copier that cost less than $300. Office staffers rely on the scanning mode for digitizing documents, but they use the other functions, too. It's the kind of machine a practice like his would buy whether or not it had an EMR, so it doesn't represent an unusual investment.

Novich has encouraged other doctors and laboratories to fax records and reports to him instead of mailing them. Since they're faxed into his computer, that saves his staff the drudgery of digitizing the documents themselves. He operates a bit differently with his main lab, which posts test results on its Web site and expects doctors to print out hard copies. Novich simply "prints" them directly into Adobe Acrobat, bypassing paper.

Novich reasons that if he worked in a large institution like the Mayo Clinic, which has its own hospitals, physician groups, and ancillary services, he might be able to dispense with scanned documents and receive clinical data as he would e-mail—and in one standard format. "However, as a solo practitioner, I receive this data from dozens of independent sources, and our computer systems don't talk to each other," he says. "But I can file scanned documents from anybody."

Another facet of Novich's life as a digital physician is writing prescriptions electronically. At first, he wrote them using Microsoft Word, but that proved too cumbersome. Then Jeff created a special program that lets his father use drop-down menus in a Web-page format. The program is actually part of an Intranet—a private Internet—that Novich accesses through Microsoft Internet Explorer. Now Novich can produce a prescription with his computer almost as fast as he could scribble it on a pad—and it's legible. Plus, his prescription program is a database, meaning that he can do things like track a subset of patients who use a particular medication.

Given that Novich's entire practice resides in his computer, he takes backup very seriously. At first, he copied patient charts onto a laptop computer using a wireless connection, but it took 30 minutes. Then he switched to burning them on CDs, which was quicker. "Now I back them up in only three minutes on an external hard drive that I take home every day," he says.

Health care informatics experts would probably view Novich's EMR system as rather limited. After all, it lacks a database that would allow him, with a few keystrokes, to identify, say, all his diabetic patients who haven't had their yearly eye exams. And his EMR doesn't integrate with his practice management software or his prescription-writing program. However, by building an EMR with universal programs like Microsoft Word and Adobe Acrobat, he knows that he'll get regular, reliable upgrades. And he doesn't worry about Microsoft or Adobe going under and leaving him high and dry.

But the bottom line for Novich is that despite its shortcomings, his system works extremely well for him. "We've made a quantum leap in office efficiency," says Novich. "My staffers can pull a chart in seconds rather than minutes. That reduces the time spent providing patients and doctors with the records they request. Because we've eliminated most of the paper shuffling, my people have more time to talk with patients on the phone and deal with insurers."

Novich has noticed an improvement in how he cares for patients, too. Documenting patient encounters using his computerized forms forces him to ask all the right questions, so his exams are more comprehensive. And because he's not drowning in paper, he has the time and energy to focus on follow-up, such as calling patients to make sure they've gotten the blood work or X-rays that he ordered.

"It's ironic—I'm into high technology now, but I'm more involved with my patients than ever," says Novich. "That's why I feel like a brand new physician."

The author, who is based in St. Louis, is a Senior Editor of Medical Economics.

 

Robert Lowes. Computer Consult: Build an EMR for next to nothing. Medical Economics Jun. 6, 2003;80:29.