Iowa Chiropractor Dr. Lauri Wondra has been using a tablet PC-based automated practice management system for only a few months, but she is already on the way to her goal of doubling her patient volume to fifty visits per day. She hand-scribes some of her SOAP notes, but her use of electronic text linked to on-screen helpers plays an increasing role, one that continues to grow as she customizes the text with her own specificity elements and writing style. Dr. Lauri and her husband, Tim, also a chiropractor, have a young, progressive practice and, early on, the two decided that, to fulfill their growth and service goals, electronic office systems would have to play a part. Dr. Tim plans to open a second practice in a nearby community.
The most obvious benefit of electronic notes is the ability to employ standardized text in performing examinations and recording SOAP notes during patient visits. Doing so avoids the labor and distraction of hand-scribing, enabling doctors to preserve the intimacy of the patient visit and assure the quality of examinations, while accelerating visit procedure.
Helper-supported electronic notes software on a pen-based tablet also confers the ability to amplify text ad hoc with hand-scribed electronic notes to whatever extent the doctor chooses. However they are generated, storing the notes in a flexible, concept-based electronic database that builds the file automatically, visit-to-visit, precludes any need for the traditional paper jacket—along with the filing and maintenance that it implies.
The availability of the intelligent database, in turn, establishes the ability to automate production of interim and final reports and to eliminate the archaic, time-consuming processes of analysis, dictation, and transcription. An intelligent, template-based report writer can identify and selectively import specific fields that he/she needs to generate comprehensive, fully compliant clinical reports, literally, in seconds.
Expenditures of time and money for transcription services evaporate. Insurance claims and their supporting documentation can be dispatched quickly, even bypassing the hard-copy stage if the doctor and payer are set up to do so. The impact on cash flow cannot be overstated.
One cannot ignore the argument against electronic notes: that, although they support the precision and consistency that are critical to documentation of diagnoses and treatment, the uniformity that can result could reflect an indifferent attitude, even suggest to payer personnel reading the reports that indicated treatment might not actually have been performed. Regulatory discipline and/or professional censure are appropriate for the few unethical practitioners who might be guilty of this.
Fortunately, there are features within electronic clinical notes and reporting solutions that allow doctors to maintain unquestioned integrity as well as the uniqueness of their SOAP notes and reports as they gain the dramatic savings in time and effort afforded by standing text. These features are document cloning and documentation mutation.
Cloning allows doctors to import all or part of the data in any previously completed SOAP or exam note to create a new document, avoiding the need to begin with a blank page and reentry of personal, diagnostic, symptom and treatment information for each patient visit. Doctors can replicate any previous document, with the newly created document independent of the original and open to such modifications as are appropriate.
When treatments and conditions do not change from visit-to-visit, a mutation capability allows doctors to modify the cloned document using their own stored terminology to indicate that the patient visit has, in fact, occurred and that a treatment/exam has been performed. Time required to reconstruct the document is saved and the likelihood of a claim or billing challenge is avoided.
Simple observation is enough to convince almost anyone that paper processes in the chiropractic office—in any office—represent an enormous drag on productivity. And beyond the cost factors, the ever-present potential for challenges by medical examiners, regulators and litigators informs us that you can’t risk files getting damaged or lost. Increasingly, legal rulings demand that electronic files be available in litigation proceedings if requested.
In the contemporary clinic, electronic notes form the basis for reliable and systematic records. Using them leads to greater productivity and profitability, a more streamlined practice, and more effective communications with patients, payers, and other professionals.
Gregory T. Church is vice president and general manager of the Healthcare Business Division of ACOM Solutions, Inc. He can be reached at 866-286-5315, Ext. 401, or email [email protected].