This article is the first of a two part series for pdaMD on a new wireless medical clinic that I am in the process of establishing in Richmond, British Columbia. Called 'Advance Medical', the strategy behind this clinic is the creation of a leading edge prototype small-group primary care medical clinic in British Columbia that will operate as a centre of excellence in primary care while making the best use of hard-wired and wireless technologies with tight workflow integration. In addition to utilizing best of breed EMR software, the practice will also have a web site that is designed for disabled access with information focused on providing resources and guidance in the local community.
Over the past four years, I have watched, tested, and written about numerous new technologies and information management tools. I have been fascinated by the concept of mobile computing for physicians. Physicians are becoming more sophisticated users of technologies, whether they are handheld based charge capture or diagnostic tools or desktop based Electronic Medical Records systems.
However, in my role as a physician and practice management consultant, I am ever reminded that there are three critical words that will ultimately determine the usefulness of any product in a medical treatment setting: Workflow, Workflow and Workflow. The tools have to fit into the daily workflow in a manner that is comfortable to the physician. PDAs have established a solid place in the physician's armamentarium in the move towards digitalizing the clinical encounter, however I think it is imperative that we continuously and critically examine how the increasing array of tools can be integrated in the most effective fashion.
I have used ePocrates qRx 4.0 in addition to a variety of Palm-based clinical calculators and clinical reference tools. However, I have found that unless the PDA application is integrated with the other day-to-day patient care activities, one is still required to run two parallel systems side-by-side. The handheld tools are useful, but the clinical encounter is frequently managed using a paper record or some other form of electronic medical record. In addition, although I find the PDAs to be useful tools, spending 8 hours per day for the next twenty years, peering at a 2"x2" screen doesn't appeal to me particularly.
So, how does this all fit together in an ideal setting? I want a sophisticated electronic medical record tool that will allow me to capture detailed patient information in a discrete format. It must integrate seamlessly with my billing software and deliver lab results transparently into my patient records, alerting me of the abnormal results and allowing me to easily communicate with my office staff and patients through voice, fax or e-mail. My clinical capture tool must weigh no more than four pounds, have at least 6 hours of uninterrupted battery life and must resemble my paper chart as closely as possible, providing seamless access to patient information, clinical information, drug interaction checking and Internet access allowing me to access any information necessary in order to reach a clinical decision before the patient walks out of the exam room. In addition, the tool must be wireless, allowing me to carry it comfortably from room to room and must have a large and legible color screen that allows me to easily demonstrate clinical findings, graphs or other pieces of information to my patients. It must be able to accept voice input and provide handwriting recognition in order to allow me maximum flexibility when inputting information from the clinical encounter in any format that is applicable to that particular patient encounter. My clinical management system must also allow me to carry a PDA for hospital visits and outside patient care that transfers billing and clinical encounter information into my office-based record on cradle or wireless synchronization.
Advance Medical will go into operation on October 1, 2001, so there is a great deal of activity at the present time, building and installing a network and configuring it for wireless access. I will be using an IEEE 802.11b 3Com® 11Mbps Wireless LAN with AirConnect Wireless LAN PC cards. In addition I will be installing Monarch Medical International's Cliniflow EMR software. After an extensive review of EMR software products available both within and outside of Canada, I have selected CliniFlow, a product that I consider to be the most comprehensive and flexible EMR tool currently available. Initially, I will be working wirelessly in the exam rooms using a Sony R505TEK - SuperSlim Pro laptop running Windows 2000 with a double capacity battery providing up to 8 hours of continuous use. At the time of writing of this article, the definitive tool for EMR input is not yet available - the Tablet PC. Expected to become available commercially in 2002, this device will fulfill many of the criteria on my wish list for a mobile computing platform. Until then, the Sony laptop will be my primary tool for patient data entry.
Despite the fact that increasing numbers of physicians are adopting technology in their practice of medicine, most of the articles one reads are anecdotal reviews of software or hardware by a single physician or group of physicians describing their own experiences. Outcomes information is scanty with regard to the effectiveness of technology in the medical practice. Although it makes sense that handheld prescribing tools, clinical information systems and Electronic Medical Records will allow physicians to provide a higher standard of care and avoid medication related errors, it is still not clear exactly how the average physician will move from a paper-based to a digital medical record.
I will be carefully documenting the entire process of conversion from a paper-based to a full EMR wireless clinic. Measuring the gain (or loss) in productivity from both the perspective of the physician and the office staff and determining where wireless technology provides the biggest bang for the buck. I will also be looking closely at PDAs and how these tools fit into the clinical encounter to achieve maximum productivity.
This first article is being written to provide a background framework for the process I will be following and to whet your appetite. If successful, I will be able to demonstrate gains in productivity and patient care while integrating PDAs, the Internet and Electronic Medical Records in such a manner that the clinic operates not as a collection of separate but related pieces, but as a single entity focused on providing enhanced patient care via a number of transparent technologies.
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Dr. Alan Brookstone alan.brookstone@cientis.com is CEO of Cientis Technologies, a leader in the application of Electronic Medical Records and the Internet for the health and wellness industry. He is also a practicing physician in Richmond, British Columbia