It’s no longer true that only the larger and more technically-capable practices are moving their medical record-keeping onto the computer. Most practices have trusted the computer for many years to hold the billing records of the business. But now most are recognizing that the increased capabilities of the computer to store images and other non-text based documents mean that the information that is the core of the veterinary practice – the medical record – is better held on the computer system.
Why is it better? Apart from the obvious saving of physical filing space there are more significant advantages in taking your practice to an electronic medical record or “paperless” system.
But first, what do we mean by paperless?
Your practice will not totally eliminate paper. Invoices, take-home instructions, medication labels, certificates, letters, reminders, or anything which you have to mail to your clients will need paper. Consider consent forms, new client sheets and payment authorizations? These will still have to be recorded in some manner and we will address these later.
You will be paperless in that you will no longer have the paper-based patient files that you currently store by the thousand!
American Animal Hospital Association (AAHA) Trends magazine for October 2000 described the advantages as being:
-
Increased organization: data can be displayed in a variety of different ways
-
Ability to determine who saw [created] what information on what date [and time]
-
Improved security by limiting file access to just that portion of the record that is pertinent to the user
-
Legibility
-
Electronic data exchange of digital images (X-rays) via e-mail
-
Standardized vocabulary and coding for conditions, diagnoses, and procedures
-
Improved practice efficiency: in a paper system, most of the information lies buried in large stores of paper files that cannot be analyzed economically.
-
One of the arguments against going paperless is the concern of security of the patient information. This is an very valid argument. In fact, we suggest that the patient records are the most valuable asset in any practice and that going paperless is more secure. If you look at the impact of a disaster, such as a fire, that destroys a paper-based practice, two of the most valuable assets which would likely be lost, are the client/patient database and the patient medical history. Copying and storing paper-based records off-site is totally impractical, but electronic backup is an everyday function. This advantage alone will justify any expense incurred in converting to electronic records.
There are other, more esoteric arguments for comprehensive electronic records. They become a knowledge base for information on the success of treatments experienced by veterinarians who may be no longer with your practice. How would that information be obtained from a paper-base record? This is an intellectual asset that must add value to the practice. This view is supported by consultants that specialize in practice valuation.
All of these advantages are valid, but from practical experience in implementing paperless systems, one advantage that is real and valuable is often overlooked - the saving of time spent looking for “lost” charts, as well as the time spent in retrieving and re-filing charts. This simple result has beneficial effect on how clients perceive the practice (we really do know what we are doing!), it allows front office personnel more time to spend with the client and to make calls to encourage compliance. Studies have shown that staff lose up to 15% of documents they handle and can spend 30% of their time trying to find “misplaced” documents (while the client is getting more and more frustrated).
Other practical advantages are:
· Everyone can access a patient record from any workstation. The same record can be accessed at the same time by more than one staff member. And it’s faster.
· Patient records can be printed and/or sent electronically to other practices, for referrals or if the client has moved to a different town.
· Reports and records required by government agencies, such as a controlled drug log report, have clear audit trails and are easy to produce.
· Consistency in the form of records between veterinarians in your practice.
Implementing a Paperless System
The prerequisites of implementing an electronic system are:
Commitment
The first requirement and one that will either make or break any attempt to convert to a paperless system, is complete “buy-in” by the veterinarians. Without total commitment by the originators of the clinical notes, the system will not work. This must not be taken lightly as the removal of the “secure” paper chart is often a traumatic step for some veterinarians and even more for some support staff.
A Modern Computer System
The next pre-requisite is a comprehensive computer software system that can quickly and simply handle all of the types of data you will need. These include
· Text
· Images
· Audio
· Video
Typically a system that is not fully compatible with Microsoft Windows will have limitations that will create difficulties in operating that discourage the use of the system.
As you will now be dependent on entering all information into the computer, the data entry methods used by the software are of critical importance. There are several ways that data can be entered into the electronic record.
· Keyboard
· Cut & Paste from other documents
· Direct capture from laboratory equipment
· Digital devices such as camera, digital x-rays, etc.
· Electronic Charts
· Scanning a document
· Voice recognition
· Handwriting recognition
· Touch-screen
Which of these is the most practical?
Obviously the keyboard is the most often used method of entering information. However, some veterinarians do not have the typing skills that are needed to make this method efficient without some software-aided shortcuts.
Cut and Paste is a common method used when reports from specialists and outside laboratories can be received electronically e.g. by email. Obviously Windows compatibility is essential to this function.
Direct capture is very common, with most equipment having a data export function that is relatively easy to use. Check that RxWorks has the connection support for your lab equipment. Remember that you also can key in these results into a pre-defined form if that is available and depending upon the number of results being recorded, this may be acceptable to your practice.
Capturing images from a digital camera is very simple in modern systems. The camera just needs to be attached to the computer and then using Windows functions combined with shortcuts provided by the software, the capture of the image takes seconds. Patient photographs as well as photos of lesions, etc. are normal uses. If you are lucky enough to have digital x-ray equipment, radiographs can be attached to the patient record in the same way. If not, taking a digital photo of the radiograph while on the light box, does pretty well.
RxWorks has pre-defined charts for common views such as eyes, teeth, skin, etc. Then by using the drawing tools already built-in to Windows to identify location of problems, you can create charts that are very similar to those done manually.
Scanning is an important method for those documents typically created outside of your practice and not available in electronic format. The documents entered this way will not be able to be searched for content as they are stored as images, much the same way as a photo. So scanning should be used as a last resort.
Voice recognition and handwriting recognition have made great strides in the past few years and in our experience typically can recognize between 85% and 95% of the spoken or written word. However, having to check and correct the remaining 5% to 15% takes time and those staff who have computer experience may prefer to use the keyboard.
Using touch -screens for menu driven items, such as electronic circle sheets has a lot of potential in saving time and increasing accuracy. But as most systems only use these for billing purposes they play no role in electronic medical records. A more problematic issue is that the computer system is being used to emulate the manual billing system with the separation of medical and billing records. The most beneficial use is to allow handwriting or drawing on electronic charts. A handwritten note can be captured as-is, without converting it to text as handwriting recognition does, but these notes cannot be searched and thus lose a major advantage.
From the above, you will see that the keyboard is still the primary vehicle for getting medical notes into the computer system. But without software-aided shortcuts, some veterinarians will continue to handwrite or dictate their notes for transcription by someone else. This has the potential of incorrect transcription and misinterpretation, giving rise to inaccurate medical records.
A Sound, Reliable Computer Platform
Your practice’s livelihood will now depend upon the reliability of your computer system. It is critical that you do not cut corners with your system platform.
What is the platform?
It’s the combination of the computer hardware, network connections, operating systems and the database manager used by your practice management software.
Let’s look at each.
The computer hardware will consist of
A computer that will act as the server where your database is located and is normally not used as a workstation if you have over 2 workstations in your practice
Workstations - the data entry and inquiry devices. These can be PCs, “dumb” terminals or a combination of the two.
Printers – for invoicing, client communications and also for prescription label printing. As you will sometimes need to print images, a color laser printer should be considered.
Scanner – for capturing paper documents that are need for the patient record.
These are pieces of equipment that critical to the health of your practice. Do not cut corners as reliability and support matter more than price.
Similar remarks apply to the network cards, routers or switches and cabling used in building your network. Reliability and ease of configuration are essential. Wireless networks have improved considerably, but their current speeds are not fast enough to support any network that transfers a lot of images – like a medical records system. This will no doubt change in the near future and the cabling could become a thing of the past.
Operating systems now fall into one of two categories – Windows or Unix-type(including Linux) systems. Both are extremely reliable systems, but Windows offers a greater variety of tools and functions and with more software being available, make it the operating system of choice. As was earlier stated, in order to take full advantage of the interchange of data between programs and avoid system failures, the practice management system must be written for Windows, not ported from another operating system.
No practice management system can function under the heavy stress placed on it by a paperless system unless the database used to build the system is sound, reliable and scaleable.
Modern databases have sophisticated addressing systems that replace the less reliable indexing systems used by older databases. A breakdown in linkage between records cannot be tolerated in a system that supports all of your practice functions. If the system was confined to only the billing function, database corruption could be acceptable, as you could reconstruct charges after correcting the problem. But if you need to get a medical record NOW, waiting for database index correction is not acceptable. Neither the client nor the veterinarian will be happy. Ensure that your system is developed with a modern supportable database.
Practice Management Software that supports paperless records
Most systems have evolved from billing systems and concentrate on keeping good financial records. A complete practice management system must be focused on the core function of the practice and that is the creation and maintenance of the patient medical record. All other functions are derived from that.
When you choose RxWorks you not only acquire an established and proven product, but also one at the forefront of the industry. RxWorks services over 1500 veterinary clinics around the World.
History
The company was started in the late 1980’s when Greg Robinson (a business analyst) and Rob White (a veterinary surgeon) developed a DOS-based veterinary practice management system. RxWorks achieved a high market penetration in Australia where it quickly became the dominant veterinary software package. Today, 90% of all veterinary practices in Australia use RxWorks.
In 1996 RxWorks software engineers and analysts began developing a Windows-based version of the software. The goal was to develop a leading edge veterinary practice management system that embraced the new technology, could be used around the world and easily fit into a local practice environment. RxWorks was released in early 1998 in beta form and by late 1998 was released as a full version. Since that time both market and vision-driven development has continued unabated. The international version RxWorks, is now one of the most feature packed veterinary software packages available in the World. RxWorks is rapidly becoming the most widely-used Windows-based package in Europe and the Asia/Pacific region and is now available in North America.
RxWorks design strategists realized from the beginning that medical record keeping and billing are totally inter-dependent. So the system was designed from day-one with that goal in mind. It’s not a billing system with a medical record module added on later or a medical note taking system with some billing and accounting features. It is The Veterinary Business System.
The consult or visit screen which is the one mainly used by the veterinarian and/or technician, consists of four areas.
The medical notes
The notes to be printed on the customer invoice
The billing details
Problem diagnosis
It is very important to understand that medical notes are entered first and then the necessary charges are entered – all on the same screen. Medical notes cannot be entered without entering a charge and charges cannot be entered without notes. From a practice management viewpoint, this one feature will help reduce frustration and stress by virtually eliminating the incidence of entering history but forgetting to charge!
Paperless record features
When we were reviewing the data entry methods, we said that the keyboard was the dominant choice for completing notes. We also commented on the use of shortcuts.
Shortcuts are techniques which reduce the keystrokes needed to enter a medical record.
The following shortcuts are available in RxWorks.
Four Methods of Recording Clinical History
RxWorks’s efficient Clinical Notes facility is one of its major advantages. Think of this: Our experience in 14 countries shows that it takes 3 minutes on average to enter Clinical Notes in a Patient record and if you carry out 20 consultations per day, then you spend 60 minutes of your day just typing! RxWorks typically saves an average of 2 minutes per consultation so you will save 40 minutes every day. Perhaps another 2 consultations or time for call-backs, research, etc.
RxWorks provides four methods to minimize typing time: -
Smart “TypeAhead” – as you type RxWorks fills in common words and veterinary terms. For example, if you type ‘fle’ RxWorks automatically fills out ‘flea allergy dermatitis’.
Standard Procedures – many procedures and diagnoses in veterinary practice are relatively routine often involving standard Clinical Notes and/or invoicing. Standard Procedures allow you to save a Patient record and/or an invoice and retrieve it in the future as a new history sheet/invoice and make modifications as required. Medical notes and their corresponding charge details are saved as a pre-defined template. Think of all the routine procedures and invoices – neutering, vaccinations, abscesses, flea allergies, geldings, corneal ulcers, minor surgeries, tumor removals, grooming, cesareans, retained fetal membranes, foot abscesses and so on where this feature will save time. You can use as many Standard Procedures as you like on each case record. This function is the most popular with our clients world-wide.
Charts – they say a picture tells a thousand words so what better way to save typing than to fill in a chart or diagram, take a picture or scan in an X-ray. Skin charts, eye charts, dental charts, AJC charts…whatever you want!
Examination Sheets – these are similar to the structured examination sheets used at Universities. You simply note normal or abnormal and add notes if you wish. You can customize your own examination sheets for each species.
Standard Procedures
Many charges for procedures are routine in veterinary practice. Similar to Clinical Notes recording, these standard invoices can be prepared in advance as templates. For example, a cesarean on a small dog can be set up as a standard procedure and then charged out routinely with minor alterations at the time for individual cases. This feature is excellent for ensuring that your staff maintain consistent charging or for quoting purposes.
Scanning, Digital Imagery and Video
These advanced technical features, available on Patient and Consultation screens, can be used for such things as Clinical records, E-mailing to specialists or public relations.
How do we deal with other paper documents?
Your system will not be paperless!
You will need to print invoices, take-home instructions, medication labels, certificates, letters, reminders, or anything that you need to send in the mail to your clients.
What do you do with consent forms, new client sheets and payment authorizations that bear the client signature? The technology answer is to scan them into the computer and attach them to the client record. To scan or not to scan, that is the question. The decision should be based on how often you need to look at these forms. They can be filed in date order in a paper file! They are business documents and are not part of a medical history. Keep them in a safe place in case there are any business actions needed.
However, there will be documents that are on paper that belong in the patient record. These could include specialist reports, laboratory reports and other documents that cannot be obtained in electronic format. These are best scanned in to the computer and attached to the patient record. RxWorks uses all of the Windows functions and provides simple tools to do that.
How do we start?
First the topics already discussed must be covered and the environment made ready for conversion.
Remember, a failure to plan is a plan to fail.
Decide what you are going to do with all of your paper records. Are you going to convert them or leave them as is and create new medical records on the next patient visit?
The conversion of you existing paper records is a monumental task, regardless of the size of practice unless it is brand-new.
Look at the advantages of a complete electronic history for a patient and compare that with the process needed to refer to a paper system for old activity and a computer screen for the new. Then look at the time and cost associated with each option. Given that a good percentage of your paper patient records will not be viewed again because of death, relocation or other reasons why the patient will not be back, it is quite possible that the conversion of all records will not be a viable option.
But there is another option. Patient charts can be converted as appointments are made to see them again. This is a compromise that has advantages. The quickest way to achieve this is to scan the old records. They cannot be searched for content as will the new electronic records, but they will be all in one location and can be viewed and printed if necessary. And you can get rid of the paper file.
Train your veterinarians and support staff on the time-saving techniques. Try to get a peer advocate in each work area who will carry out the training. This will improve commitment and full use of the system In RxWorks, Procedures can be customized for individual veterinarians. Use this as an encouragement for the veterinarian. Similarly Typeahead dictionaries can be customized for the practice. Work done in these areas will pay dividends when the system is operational.
Design and test the workflow process. How does the veterinarian get the medical history for a patient in an exam room? How is a veterinarian notified that a patient is in the exam room and how long have they been waiting? Who is responsible in ensuring that the front desk is notified of clients waiting to pay and how do they get the invoice details and any take-home instructions? These are workflow procedures that need to be fully understood – as there won’t be any chart being passed around the practice to trigger the events. RxWorks has built-in workflow functions that efficiently and simply handle work flow.
Schedule a time for changeover and ensure that all pre-requisites, including training and workflow processes, are complete.