Hospital clinic is cutting-edge with electronic medical records equipment
Gone are the patients' charts — folders filled with hand-written, sometimes hard-to-read information.
Gone are the pens and paper used by physicians and nurses that record patient information.
Hello paperless files and electronic documents.
For the past couple of months, Dr. Linda Skiles and certified physician's assistant Nita Bittle and their staff of St. Luke Physician Clinic have been documenting patient information on an electronic tablet instead of paper.
Data can be entered through a computer-type keyboard or hand written with a stylus which then is converted by the computer software to typewritten form.
Information includes current vitals, medications, past medical history, assessments/diagnosis, and current diagnosis.
The diagnosis screen includes an area for medical codes for insurance purposes.
Bills to insurance companies can be sent quickly because the charge information has been entered.
Preventative scheduling reminders also can be flagged on the patient's chart which would trigger a notice being sent to the patient to make an appointment.
Software in the small tablets, that resemble one-sided, small laptop computers, can store patient information and diagnosis of past visits, new information during a patient's visit, prescriptions, etc., and educational information.
Skiles demonstrated the versatility of the computer which included medical professionals being able to retrieve diagrams of the human body and enter valuable information.
Growth charts for children also are included.
For example, if a patient came in with a lesion on his head, Skiles could retrieve the diagram of a head and indicate the location of the lesion on the diagram. Space also is available for a description.
"This is particularly helpful for foot exams of diabetics," she said. A click of a button and a foot diagram was on the screen with numerous parts of it numbered. The physician can indicate the part of the foot with which the patient is experiencing problems and the parts that are OK.
The next time the patient comes in for a checkup, that information can be retrieved for comparison.
Regardless of the professional's penmanship, all charts are legible.
"Prescriptions can be faxed directly to the pharmacy," Bittle said, which reduces errors caused when the pharmacist can't decipher a physician's hand-writing on the prescription.
Two medical professionals can look at an electronic chart at the same time and can message each other.
Maintaining patient confidentiality is important to Skiles and Bittle. With this computer program, patient information cannot be retrieved except by those who have access to the system. It is much more confidential than paper charts.
"The entire system is wireless," Skiles said, "but the wireless access does not go beyond the office."
Personnel cannot take a tablet from the office and access information.
The computer software company provides a backup service and that information also is kept in confidential form.
In the coming months, St. Luke Hospital's radiology department also will go with the electronic medical records program which will enable the doctor's office to access X-rays and other tests through the electronic system.
Electronic data collection and storage is becoming more popular in the medical field with hospitals following suit. If St. Luke Hospital should install the system, physician clinic personnel would be able to access information from patients who are treated at the hospital's emergency room or as in-patients.
Even with a couple of months to get used to the system, a learning curve and time to input data will be needed before the office is completely caught up and familiar with the process.
For Skiles, Bittle, and their staff, the convenience is well worth the fuss.
"This will save us time in the end," Skiles said, which means more time to concentrate on what's really important — caring for her patients.