Many physicians today are interested in electronic medical records (EMRs) but have been discouraged from adopting them because of their high cost. Full EMR systems can be extremely expensive, but you don't have to convert to a completely paperless practice to enjoy the benefits of using computers in patient care. I've equipped two exam rooms with hardware and software for “point-of-care” computerization (computerized documentation in the patient's presence) for less than $5,000 — an investment that looks particularly wise when compared with dictation expenses, which can climb to $2,000 a month per physician in some practices. With prices for some desktop computers currently less than $1,000 each, the time to consider a partial EMR system is now.

What are the benefits of a system like mine? It enables me to generate legible, consistent progress notes while maintaining problem and medication lists. It gives me the ability to hand patients personalized instruction sheets before they leave the office. It improves the efficiency of my visits with patients who need to have forms completed related to workers' compensation cases or occupational physicals by greatly reducing the paperwork burden of these highly repetitious forms. I also believe that my time is valuable. By spending less of it on documentation, I have more to spend on caring for patients.

To make a system like this work, you need not be in practice on your own; you need only an entrepreneurial spirit (and a few thousand dollars). I'm employed by a health system that isn't yet embracing computerized records, but I'm making it work with minimal software and hardware support, and a system that I set up and continue to maintain while carrying a full patient load. Here's how — and why you may want to, as well.

Putting the pieces together

My health system wasn't interested in investing the money for point-of-care computers. But given the affordability of desktop computers, computer-networking hardware and EMR software, I decided to see what I could accomplish with off-the-shelf solutions.

First, after making several false starts, I found an EMR program that met my needs: SOAPware from Docs Inc. (See “Resources.”) It was developed by a family physician and has been on the market for more than four years. I chose it because it looks like a chart on screen, it lets me record repetitive clinical information, such as diagnoses and medication lists, for use in generating future reports and progress notes and to change that information as needed, and it's reasonably priced ($300 for a single-physician license). In addition, you can run the software on a peer-to-peer network like mine (a computer system with several connected desktop computers) at no extra cost.

To facilitate report generation during patient visits, I found reasonably priced hardware and software that lets me feed a paper form through a scanner (a device similar to a fax machine) and complete it on the computer screen, in front of the patient. This “form-typer” software is part of PaperPort Deluxe 5.1 software package, which came with the scanner I use, Visioneer's PaperPort. My scanner is no longer manufactured, but version 6.0 of PaperPort Deluxe is available, and it's compatible with many easy-to-use flatbed scanners.

I also had to secure the computers and the networking hardware. Although my health system wasn't ready to implement EMRs on a wide scale, my employer did provide me with two desktop computers. I purchased a third for my administrative office so I could easily back up all the files each day (I can access the database from all three computers). The scanner and a printer also are housed in this area.

Finally, I had to put the system together physically. Creating my network wasn't terribly difficult, as it turned out. Desktop computers with Windows 95 or 98 operating systems include software that lets individual computers share information. I opened the networking icon found in the Windows 95 and 98 control panel and consulted the help it provided. For each computer, I bought and installed a network card, which enables the computer to be connected to the network. I also bought wires to connect the computers and a device called a hub, into which the wires from each computer are plugged. Making the connections was easy; the ends click into the computers and the hub like oversized telephone connectors. In fact, I was able to install all of this myself because my office has false ceilings through which I could feed the wires.

Configuring the software so the computers could talk to one another was a little more difficult but manageable, especially with the aid of one of the many “how-to” books on the market. (For more information on building a network, see “A do-it-yourself computer network” and “Resources.”)

I chose desktop computers over laptops for the exam rooms for several reasons. When they need service, laptops often must be sent back to the manufacturer, which lengthens repair time and makes it more expensive. Furthermore, I've found that in a network environment in which computers must remain on all the time in order to be connected instantaneously, desktops come out of suspend mode more quickly. They also break down less. I know there are exceptions to these generalizations about laptop performance, but you also must consider the cost differences. If my health system hadn't provided the two desktop PCs, I could have purchased two for the price of one laptop. While I prefer desktop systems, I have wired several other exam rooms that we use less frequently to accommodate a laptop when needed.

Benefits

So how does my system help me provide excellent care more efficiently? With my chronic-care patients, using EMRs gives both me and my patients better access to the information we need. I generate clear, legible notes for each encounter without going through the dictation process. Each chart has an up-to-date, typed list of active problems, medications, allergies, inactive problems and family and social history. This information is available instantly to form a new note — no re-typing required. For the patients, the system enables me to create individualized handouts detailing their diagnoses and medication lists, generally by making only a few modifications to standard templates. Each handout also includes my plans and directions for testing and the patient's follow-up appointment date.

The system also has greatly improved the efficiency of my episodic-care visits. Using the scanner, I've created a form for commercial drivers-license physicals, with the “normal” responses and my office address already entered. Abnormal and fill-in responses, such as urinalysis reports and the patient's name, are entered in the exam room during the visit. With a couple of keystrokes, a perfectly legible form appears from the printer. Workers' compensation reports are completed the same way. As a result of standardizing these reports and filling them out on the computer, requests from insurers for more information — formerly a daily occurrence — now happen about once a month. Generally the insurers are satisfied with receiving a copy of the encounter note, which we simply print from the electronic chart.

Intentional limitations

For now, I've decided not to involve the staff in using my EMR system. This allows me to tailor the system to my own preferences, to guarantee the system's security and to blend in with the style of the other physicians in the office, who use dictation. From the staff 's perspective, I'm essentially generating a “dictated” report for immediate chart insertion: I print all generated reports at the time of care (although sometimes I make later updates to the problem list in the EMR). In other words, both the paper chart and the computer store the information needed for the next visit.

Although voice-recognition technology seems to be the hot topic in computer-supported patient care, I've restricted my system to keyboard-based data entry. For me, with a patient present, dictating is more difficult than keyboard-based data entry.

Who pays?

If you, as a salaried physician, want to set up a system like this, who pays for it? The answer, for me, has been sharing the burden. I've found that a hospital or health system is more likely to be willing to provide hardware, which can be used in many different settings, than software. If you're willing to make a small outlay of your own resources for the software, you may be able to convince your employer to find you a few desktop computers even if you wouldn't be able to convince management to buy a high-end system costing $10,000 or more per physician. Pointing out the relatively high cost of dictation may help you to make your case. Also, keep in mind that you don't have to buy everything at one time. You can start with a single desktop, build your network once you've acquired a second computer, and then add more capability as time and funding permit.

I've found that a decent software package and low-cost desktop computer network are as helpful to me as a good stethoscope. It may be cobbled together, but my system gives me and my patients the information we need when we need it, and it does a good job of report generation, cutting down repetitious work. With the low-cost hardware and software available today, any physician should be able to do this — and enjoy its benefits for patient care.