Electronic medical records make treatment easier for doctors, patients
A visit to the doctor's office is going to be a little different now that the Nevada Medical Clinic is switching over to electronic medical records. According to Sherry Lakeman the change will benefit everyone, the patients, the doctors, the clinic and the clinic's workers who have had to file literally tons of paperwork generated by a busy practice.
"In the past when someone made an appointment a worker had to pull the record and bring it up so it would be available," Lakeman said. "Then after the appointment someone would have to take it back down and file it."
With the new process the records are stored on the clinics servers and doctors and nurses have laptop computers called lifebooks. Lakeman said the new process is convenient for the staff and doctors and improves patient services.
"Having it on computer makes it easier for the doctors to track information," Lakeman said. "When new meds are put in the system cross-references against allergies and interactions with any current meds the patient is taking. When a patient calls in for a refill we can pull the information up as they are on the phone instead of having to make them wait while we pull the chart and bring it up. We can fax the pharmacy directly from the lifebook, we don't have to print out a prescription and then fax it."
Lakeman said a faxed prescription is more accurate than a written one but there is one exception to faxing prescriptions; when it is for a controlled substance.
"The faxed prescription isn't written, it's typed so it is easier to read, we have fewer calls from pharmacies for clarification," Lakeman said. "When it's a controlled drug we have to write it on a secure pad and physically sign it."
Lakeman said she hopes the new system will enable the clinic to process patients quicker which would help get them in to see their doctor quicker and get them out quickly as well.
"When people come here they want to get back out as quickly as they can," Lakeman said. "Patient care will not only be better but patients will be serviced faster. Quality care comes first then our second goal is to get the patients in and out at their convenience."
Lakeman said that one doctor has already found the new system handy on a trip out of town.
"Dr. Thompson took his lifebook to Chicago," Lakeman said. "Any lab results that he's ordered that come in while he's gone he can check in and review from Chicago. If there's something he needs to change he can note it right there and call into our system and transfer it over. We don't have to give that information to another doctor to review. People don't always feel comfortable with another doctor making a change in their medications. A lot of times they will come back in a week later to their regular doctor and say 'Dr. So and so gave me this prescription while you were gone what do you think?'"
Another benefit is that the system will be accessible from the Nevada Regional Medical Center.
Other hospitals will be able to transfer information, but it will require extra steps.
"We've got an interface with the hospital," Lakeman said. "There are three computers over there, one on each floor, set up so they can call in and have access. We can fax records to hospitals in Kansas City and they can fax information to us and we can scan that in."
The nature of electronic records makes it easier to assure the records are safe in case of a fire or other disaster to the physical building they are housed in.
"We make a backup and take it off-site each night," Lakeman said. "With paper records if a fire destroyed them they would be gone. With electronic records we can reload the information onto a new computer system, even if we have to go somewhere like the hospital to do it and have that information available again."
With the growing regulation of the health-care industry electronic records make it easier to produce the reports that regulations require.
"We can produce the reports the government is interested in by calling the records up that match certain criteria," Lakeman said. "If there is some medical necessity that requires us to provide service outside of the government guidelines we can provide better documentation as to why it was necessary and get reimbursement so the patient doesn't have to pay for the service."
Lakeman stressed the records were secure and even if someone stole a lifebook from the clinic it would do them no good.
"The security is very tight with this system, we want as much patient confidentiality as realistically possible," Lakeman said. "Even if someone gets their hands on it there are several layers of passwords they would have to go through to get to the information and they just can't do it. After a few minutes the security screen would block them completely. They wouldn't be able to do anything at all with it."
While it has been a challenge to convert the records, that process is now in progress and the doctors and staff are starting to really like it.
"It's amazing how well they're doing and how well they like it," Lakeman said.