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HIT From the Trenches

By Hayward Zwerling; MD

I was in the exam room talking to a patient, who I am treating for hyperthyroidism. The patient complained of profound fatigue, of several months duration. It was unclear if the problem was being addressed by the PCP. While talking to the patient, I reviewed all his labs which were in ComChart EMR. There was nothing obviously wrong.

A True Story – July 07, 2006 

From within the exam room, and while still talking to the patient, I connected to my hospital’s computer and download all his labs which were less than 1 year old. I then had ComChart file the labs into his ComChart chart. I then had ComChart EMR create a chart of all his CBCs by clicking the “Chart … CBC” button in the labs. It was obvious that his hematocrit had dropped precipitously sometime between January and March.

The PC computer I was using had Skype installed (a free program which allows you to make free telephone calls from your computer.) I also have a headset attached to this computer, which I use with Dragon NaturalSpeech Medical. While still in the exam room, and from within ComChart EMR, I clicked the “PCP” button in the patient’s Progress Note and a dialog box popped up and asked “Do you want to go to the Dr. XXX’s Addresses file?” I selected “yes.” I then clicked on the label “private,” which is in front of the physician’s “private” phone number. ComChart opened Skype and connected the call. I spoke with the PCP and I arranged for the patient to see the PCP the following day.

I then click the “orders” button and selected my “anemia work-up” panel. This created a lab order slip which included all the necessary blood tests. I choose the option “Send copy of results to … PCP” and then clicked the button “Fax order slip” to lab.

Contemporaneous Progress Notes

Finally, in front of the patient, I dictated a Progress Note, using Dragon NaturalSpeech 8 Medical. The resultant Progress Note included the chart of the patient’s CBCs. I then selected the PCP as the recipient, and clicked the button “Create queued fax.” In my office, I have one computer which continually sends out the “queued faxes” as soon as they are created. Thus, the PCP had received a copy of the Progress Note and the lab had received the lab order slip even before the patient left my exam room. The entire process occurred within a few minutes.

Assessment

Needless to say, that patient was impressed that my office was able to use technology in order to efficiently advance their healthcare. And, the fact that it all happened in front of the patient, seem to reassure the patient and de-mistify the healthcare delivery process.

Conclusion

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Filed under: Information Technology, Practice Management | Tagged: CBC, ComChart, ComChart eMR, CPC, Dragon Naturally Speaking, EHRs, EMRs, hayward zwerling MD, health 2.0, PC, Skype, SMAC | 2 Comments »