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Don't rush to paperless office. (Guest Editorial).

With the advent of the Health Insurance Portability and Accountability Act and the push toward electronic medical records, it seems clear that the great majority of U.S. physician practices eventually will transition to a completely paperless system of patient medical records.

Some medical offices are already there, but for most practices, paper remains a fixture. Indeed, a recent survey of medical groups conducted by my consulting firm, MediNetwork, indicates that only 23% of group practices have implemented some form of electronic medical records (EMR).

That's not necessarily a bad thing. It's better to use a functional paper-based system of patient record keeping and office management than to jump into an electronic system that does not provide enough efficiencies to justify its cost and the disruptive transition. Unfortunately, many physicians approach EMR in just this way. Often, it is the strictly paper-based practices that want to convert to electronic systems in a matter of weeks. Driven by HIPAA concerns or, more frequently, by peer pressure, these practices will attempt to run before they have learned to crawl.

Typically, these practices will implement a point-and-click system, with the physician using a laptop, PC, or handheld device to access a patient medical record form. Customized for each medical specialty, these pull-down systems drive the patient encounter, prompting the physician with a variety of options that can be clicked on based on the patient's response to questions. The pull-down menu also indicates appropriate billing for whatever services the physician provides or for any tests that are ordered.

These "experts" systems are designed to transfer the knowledge of the physician (the expert) into the machine. In accordance with HIPAA, these systems have been developed with sophisticated firewalls to make them secure.

The problem is that patient encounters are not so easily scripted. Patients and physicians are subject to nuances in behavior and vocabulary that frustrate categorization. Terminology is one sticking point. All of the physicians using a system must agree to use the same terms. This works in theory, but in practice one physician's urine analysis becomes another physician's UA. With time, these variations multiply and spawn a tower of Babel effect in which physicians are presented with an ever-increasing selection of terminology that not all of them understand.

In addition, patients come in an amazing number of shapes and varieties. Each time a patient responds in a manner outside the parameters of the existing point-and-click system, that response has to be entered and assimilated. It doesn't take long before the potential responses and the potential choices offered by the system become unwieldy.

Soon, physicians can find themselves dealing with a process that is no more efficient than paper, and sometimes less so. This both limits the number of patients who can be seen and adds to the impatience that patients often feel in the doctor's office.

Until these challenges are addressed, physicians may be better off transitioning to less sophisticated forms of EMR that let them maintain their current practice styles and don't alter the dynamics of the patient encounter. The key is to use a method that electronically transcribes the physician's notes and diagnosis and integrates these into the patient record. Physician notes can be electronically entered through voice recognition systems or through electronically transcribed handwriting systems.

In this way, patient information is stored and retrievable and can be integrated with billing and coding. Meanwhile, the patient encounter proceeds as it has in the past. The physician retains autonomy over the encounter and the patient is not troubled by what he or she may believe is cookbook medicine. Yes, HIPAA is on its way and it's becoming a paperless world. But that doesn't mean physicians have to immediately embrace every technologic innovation that comes along.

MARK JOHNSON is president of MediNetwork, a Dallas-based information technology firm.
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Author:Johnson, Mark
Publication:OB GYN News
Date:Oct 1, 2002
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