Lamberts R 2003 "Electronic health record in Evans Medical Group."

At first (in 1996) "we could customize the content through the use of text templates, but this would not put data into the database that could be gotten out in later notes. The forms made by [the vendor] to input the data were not to our liking, as they did not fit into our workflow, so we paid them to make a form that would help us get the data where we wanted. We did not have computers in the rooms, so we made templates on paper that pulled the data from the database and gave us the information we needed during the visit. We would change information on the paper and have one of our assistants input the data at a later time. For more complex text, we dictated and had the transcriptionist input directly into the program."

"The first major step in making the EHR more than just a repository of chart notes came when the [vendor] gave users the tool for customizing the form templates. The "Encounter Form Editor" was a program designed by the programmers at [the vendor] to make clinical content in a graphical interface that allowed data to go directly into the database. I quickly became proficient at it and made numerous forms for our practice. This enabled us to become increasingly efficient with the use of [the EHR] and caused the data in [the EHR] to become more usable."

"We have provided much of our own technical support, installing new upgrades ourselves and troubleshooting problems with the help of technical support. My office manager has had to double as an EHR project manager and technical person, although she has no formal computer training."

"We interface with our practice management system, taking demographics from the PMS and putting them into our EHR. We are looking into various solutions to allow EHR data to cause billing in our PMS and omit the paper Superbill."

"We...interface with a major Lab in our area, importing lab results as discrete data directly into the patients' database."

"Encounter data is input into the chart via questionnaires filled out by the patient and input by the nurses. They are mainly using forms designed by me using the Encounter Form Editor. Clinical information is also input by the clinician in the exam room, either by typing while the patient talks, using structured data (radio buttons, drop-down lists, etc.), or typing after the encounter. We have not used a transcriptionist in nearly 6 years."

"If a patient requires a medication, we prescribe on [the EHR], printing out the prescription and giving it to the patient. If a consult is required, we send a flag to our referral coordinator and she handles the various aspects of the referral process... We use the orders feature on [the EHR] when ordering labs or radiology tests. We have gotten the local labs and radiology departments to accept our printed form as a lab requisition (we had to modify it to meet all of their requirements). This allows us to link problems on the patient's problem list with the ordered test, and makes the authorization process easier. Patient education is provided using handouts within [the EHR] and handouts we have made ourselves."

"Phone call management, although still a major problem, is much easier using our EHR. We have a custom form for phone calls that contains our own protocols as to how to handle various medical situations. This allows nursing to handle a significant percent of the phone calls without getting approval from the physician."

"The chart is always available and the patient's medication list is usually accurate. Careful monitoring of narcotic medication is much easier since all prescriptions are input into [the EHR]."

"Interfacing with the 'paper world' continues to be a challenge. Dealing with the abundance of illegible old records from patients' previous physicians provides the greatest challenge. We presently pick out what studies and notes need to be included in the record and have them scanned in. We are also scanning in all consults, hospital dictations, procedure notes, and radiology reports. We have minimized expense by using a high school student to scan in the documents and using an OCR program to convert them to rich text format, and copying them in to the patients' charts."

The clinic searches their EHR to find patients overdue for vaccinations and preventative care. "We are using monetary incentives of patient volume to motivate our staff to aggressively go after these patients. We have not been doing this long enough to see what its effect on outcomes will be, but clearly it offers better care for the patients while improving our bottom line."

"We are also improving our quality by using increasingly robust clinical content... These forms have ... been very good tools for patient education. When I show patients their cardiac risk with and without cigarettes, the impact can be significantly more than a stern "don't smoke" from me. Perhaps the most significant impact has been on my management of blood pressure. In the past, a patient over 65 with a blood pressure of 145/80 would not catch my attention. Through the use of the ... clinical content, I have discovered the impact that lowering the blood pressure to 118/70 has on cardiac risk (sometimes cutting it in half). I now routinely beckon the patient over to the computer and have them see their risk go down with the improvement of the blood pressure. Now, instead of me just throwing another pill at them, they understand why we want good blood pressure control."