Introduction:
In the early 1980s, I sat in front of my office computer. It was a 286 HP Vectra desktop with a 10 Gigabyte hard drive. The salesman assured us we would never need anything bigger or better. The salesman told me a lot of other things too. It was all foreign. I had no idea what he was talking about. I felt like I had been parachute dropped in a foreign country of pure techno-babble. It was then that I decided that I had to be technically informed or be at the total absolute mercy of a salesperson. I didn't like this feeling. (Ironically, this is no doubt how many patient's feel).
At any rate, I was fascinated by this Vectra box with a brain. A brain that seemed to reach out and accomplish tasks, analogous to a nerve impulse with sodium and potassium ions flowing down an axon terminating in an electrochemical synaptic junction with consequent changes in host behavior. The PC, together with the user and the software reminded me of "Abnormal Psych 101", "There is no twisted thought without a twisted molecule." Now, if only I could place this PC in all my treatment rooms so I don't have to keep running out to the front desk. My goal since then has been to put a computer in my pocket.
I can't say enough nice things about a Palm. I started with a Palm and still use a Palm. I totally believe in the Palm philosophy of simple is better. Einstein said it best "Make things as simple as possible and no simpler." (1879-1955)
In 2001, I want more than what a Palm OS can accomplish. I want a computer in my pocket. The Palm for all its benevolence as a reference tool does not have the power of a computer. Reference material is a good and necessary objective, but crunching data and viewing the result right on the handheld device, in a multi-tasking environment is the front end foundation of Electronic Medical Records (EMR).
Objective:
The objective of this writing is to express how I use a PDA throughout my day, to chart patient encounters. As a Chiropractor, I treat musculoskeletal problems of somatic origin. Hence the software I use is presently designed to treat and chart trauma.
Design:
My office consists of simple peer to peer Windows 2000 server that contains my practice management program called Medical Business Automation www.mbanet.com. I use www.eclaims.com for my electronic billing. I use MS Office XP Professional with MS Outlook for communicating with my other office staff.
Material:
I have a mixture of Linksys and D-Links hubs and routers including a Lucent RG-1000 wireless Access Point, networked to 6 desktop workstations running an eclectic collection of 2000 Professional, Windows 98 and one Linux box. I have 9 treatment rooms in 2500 square feet. I use a wireless Fuji pen notebook, when needed (www.digital-doc.com/wireless.htm). My PDA of choice is an iPaq 3670 with 64 Megs of RAM. I use a Palm m505 as a backup for reference material and contacts, etc.
Preparation:
The first thing I do every morning, before a patient encounter, is exercise. Without my custom exercise routine, there is no way I could be at my mental or physical best. My usual routine consists of exercising my right Flexor digitorum profundus by pushing the sync button on my Palm m505. My Palm desktop settings are set to update ePocrates (www.epocrates.com) and other reference material and synchronize my desktop Outlook 2002, with the desktop overwriting the handheld. I then head for my 6 oz. forearm/wrist routine (prophylactic for carpal tunnel) by dropping my iPaq in its USB cradle. Seamless synchrony takes place automatically with my settings enabled to synchronize all the files. This dual synchrony setup (Palm and iPaq Pocket PC), ensures that my Palm and Pocket PC are symbiotic and non parasitic. I love the prudent simplicity of the Palm OS and the power of the Pocket PC. Both of my handheld units enjoy the same basic medical programs, in most cases. While there remains a plethargy of Palm applications, my iPaq is my personal panoply. The pocketpc has all the medical applications I need and can do so much more. The pocketpc OS has a steeper learning curve than the Palm OS, but so did Windows compared to DOS.
Method:
My workday begins by downloading my patients for the day into my iPaq. I use a custom SOAaP program that is designed for musculoskeletal trauma called Digital-Doc.(www.digital-doc.com) I use a custom Visual Basic utility on my desktop (part of Digital-Doc) that reaches across my network, and imports my calendar database (an Access *.mdb) file from my practice management system (PMS). The program imports the data into an Active Sync subdirectory on my iPaq. This subdirectory is automatically synchronized with my iPaq anytime the iPaq is placed in the cradle. With the iPaq in the cradle, I then open the options menu on my Digital-Doc software and tap on "Import the Calendar." The entire process of importing 50 patients and loading them into the Digital-Doc software takes less than 10 seconds. I then remove the iPaq and head for my first patient encounter. If the patient has not seen my iPaq I show it to them. The software has a bitmap picture of a person. I then jokingly, ask them if they recognize themselves.
I then ask the patient to physically, "Touch where it hurts." Asking the patient to touch on their body where it hurts, helps obviate any miscommunication. Looking at an image of a body, I simply tap on the area of chief complaint, the box lights red, and all dropdown menus are loaded to match that specific area. All choices for patient complaints, exams, and diagnosis are only pertinent to that same area of the body. The body part chosen is specifically correlated with the appropriate corresponding customizable choice. No superfluous, irrelevant choices!
I then choose the chief complaint, and continue the encounter asking them about severity, frequency etc. I can cycle through each SOAaP screen in this manner, tapping and picking and choosing. Alternatively, an even quicker and preferred method is to choose a template based on the anatomical area that the patient has indicated is the area of their chief complaint. I simply click on options, load template, and save. 1-2-3 and I am done! Change only what is different.
At this point I can read or print the entire note in Pocket Word or save and move on to the next patient. I should mention that the Objective portion of the software, also includes a comprehensive customized exam grid (user can customize for their specialty) that can be used for an extensive examination. In my case, as a chiropractor, the grid is setup for vitals, inspection and palpation, ROM, Orthopedic and neurological exam, medication, X-Ray, etc. This grid can be altered for virtually any health specialty.
Entering a patient history on the fly is quite easy with the combination of pop up choices and Transcriber. This saves time and makes it easier to enter data without typing!
One of the features of this software is a recommended treatment reminder. I can program it for say 6 visits. When the patient reaches his 6th visit, the program reminds me. I use this to remind me that a report is due for 3rd party re-imbursement, or the patient should be re-evaluated. If instructed, the software will remind me of a patient's birthday as well. I considered having my iPaq sing happy birthday but I felt that might be a bit too much. Additionally, I can schedule the patient from the iPaq with a field that pulls up a virtual appointment book. This can be helpful to check your schedule on the road. On occasion, I will dictate a verbal note, which is also saved in my chart directories on the Pocket PC for easy retrieval and sync. I can listen to this wave file on my iPaq or my desktop computer.
My iPaq has 64 Megs of memory. I can hold all my patient encounters on this device and don't have to upload the data to my PC in order to make more room. My old Palm software mandated daily uploads. Only the last visit was stored on the device. I have all my patient visits on my iPaq. I only need to archive them when they are no longer being actively treated.
I can search all my patient files with a search feature in the Digital-Doc software. This is extremely important to have all the patient data at my disposal. For example, if I am looking for a particular test like MRI, I can search all my charts in a second. No pulling of a paper file that is archived in the next room. The information is in front of me in seconds. Additionally, while out of the office, or in the hospital, I can use this search feature to follow up on a patient by searching for a specific key word or phrase that I might put in the comments section of my software.
I use Pocket Anatomy to show patients pictures of the area of their complaint. Showing the patient the muscle or anatomical area that is injured is a great help in assisting the patient's understanding of their pain. With biomechanical injuries, part of getting well, is understanding, what is wrong and how to prevent reoccurrence. A simple color picture says so much. I also cut and paste my own pictures for this purpose that I store in a separate subdirectory for medical pictures.
5MCC is a constant resource as well as LexiDrugs. These days, it seems that most people are on one prescription or another and it is imperative to know how this prescription affects their physiology and symptoms. Chiropractic treatment and contraindication to treatment can often be contingent on a careful history that includes medications being consumed.
HIPPA oriented Password protection is also included the Digital-Doc software that I use. I set my time for 10 minutes. The device automatically shuts down in the "absence of user determined use." This feature would prohibit unwanted users from seeing patient information.
A Word on Fee Capture
Digital-Doc has the ability to capture fees due for services when the patient encounter notes are made. This information can be saved for passing to the person posting charges, or to my PMS for electronic billing to www.eclaims.com.
End of Day:
At the end of the day, week or month, or literally whenever I decide, I can "Build my Charts" by date range, for all patients or individual patients. I can keep them on my iPaq which then synchronizes with my desktop as soon as I drop it in the cradle. I can print my charts to my Infrared HP 2100 LaserJet or alternatively, I can go to my desktop PC and open the charts for printing or editing.
Desktop:
My Digital-Doc software application automatically synchronizes with my desktop Access.mdb file via Active Sync. From my desktop, I can run Access reports and queries, sort data, and merge with MS Word. I can make changes on the desktop Access file and then restore to my Pocket PC if desired. It works bidirectionally. I am presently working on a document management system that will enable the desktop PC to manage soap notes, charts and execute important custom reports. This will be the backend of Digital-Doc.
Backup:
Presently, I have a dual backup option. I can do it manually via coded software or automatically with Active Sync. Automatically, my table and data are backed up with Active Sync as soon as my iPaq is placed in the cradle. However, I can also backup my data right from my Pocket PC via the options menu of my Digital-Doc software. With a desktop utility, the entire table is ported over to my desktop as an access table. I realize this sounds a little confusing and perhaps redundant. It is redundant, but analogous to a Raid hard drive, it enables me to have a dual backup in place.
Inactive Patients:
Because I can have thousands of patients and all their records in my pocket, I need a method of archiving the inactive patients when no longer under active treatment. This is not mandatory, but does free up room in an ever increasing table, as well as speeds up searches. Every 3-6 months or at my discretion, I will run a query that finds pre-designated fields that correspond to inactive patients. These patients are then tagged for archive to the hard drive of my PC.
Results:
The bottom line for me:Mobile digital computing means better organization, more free time, less stress and better patient documentation. This translates to better patient care and better financial re-imbursement. Any SOAaP notes or reports can be generated from any computer in the office based on what has been done (data input), i.e.: notes, exams, Workman Compensation and Personal Injury reports as well as many HMO and insurance reports.
Comment:
The beauty of the program that I use is that it is customized by me. The underlying table can be used by any specialty. Only the menus need to be changed. The program was designed that way. A universal table, that only needs cosmetic surgery to work for any medical profession.
I firmly believe that a handheld device is the best, most convenient front end adjunct to an EMR. However, the front end is only as good as the backend. This is another subject entirely. Application performance on the Pocket PC is much closer to desktop performance than demonstrated by any Palm OS application known to me. I "think" this is a reason why companies developing genuinely robust EMRs (not just reference material), are using the CE environment instead of the Palm. I think Palm knows this as well, hence the incipient ARM chip change. Multi-tasking is another big reason. It is a real pleasure to "one tap" from a drug database software program to charting software, without having to restart either application.
While I don't believe a good handheld application is intended to be a clone of a desktop application, my point is that the Pocket PC devices have a much higher potential than what has been demonstrated with the Palm OS.
A Pocket PC can multitask and a Palm OS can not. Users can only appreciate this with applications that take advantage of it. Once I experienced multi-tasking in an EMR environment, I realized how cumbersome my Palm could be with respect to opening and closing and going back and forth between different references and applications. This can become very cumbersome when you have to wade through program menus from the starting point of the application.
On my 64 meg iPaq I have Digital-Doc Trauma Software, JH Anti-Biotic Guide, Pocket Anatomy, Washington Manual, LexiDrugs, the Merck Manual, Harrisons Handbook of Internal Medicine, 5 Minute Clinical Consult, Interact, Archimedes, Patient Tracker, Pocket Excel, PocketWord, Handbase with multiple medical applications, VisualCE with custom menus and corresponding Access.cdb data file, the full text version of the Bible, a must have in health ;) picture viewer software so I can cut and paste my own anatomical and musculoskeletal pictures and photos to show patients,(e.g. pictures of a patients before and after- great for wound analysis etc.).
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Dr. Wilkerson graduated from the University of Arizona in 1973, with a B.S.degree in Neurobiology. While in graduate school, he met a Chiropractor on a ski lift in the White Mountains of Arizona. They talked, and Dr. Wilkerson saw an opportunity to help others, as well as continue his academics. He ended up leaving graduate school in Arizona and going to California. He attended Cleveland Chiropractic College for four more years of education, graduating Magna Cum Laude. He maintains a practice in Carson California. His website is www.digital-doc.com.