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Digital-Doc Software is not for sale
Now using a Tabletpc
instead
Why: Robust charting requires a
desktop PC. The PPC is the middleman and another step. Use a desktop
PC; it's called a TabletPC. Pocketpc are great for snippets of
information, but if you can use a TabletPC, you will save a lot of
time and the end result will be more robust.
November 2001
Introduction:
In
the early 1980s, I sat in front of my solo office computer. It was a
286 HP Vectra Desktop with a 10 Meg 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.
( Remember, this is often how patient’s feel: scared, ignorant and
vulnerable ).
At any rate, I was fascinated by this HP 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 end
user-me, 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 at the point of care or better yet, in my pocket.
What really
fascinates me about computers is perhaps a philosophical oxymoron,
in that something so simple can be so complex and visa versa. With
computers in the health field, we often want to communicate basic elementary information
normally conveyed with voice or handwriting into a series of binary
numbers made up of the two digits 0 and 1 (bits). Taking simple
information or data and manipulating it with queries, sorts and coding is
the complex part, but, the bottom line denominator is just plain and
simple "Communication." The concept (simple-complex) is analogous to looking at the
human body as a whole unit, and again as a tissue sample of a cell under a microscope.
Communication in medicine isn’t the only thing, it is everything. This is
especially true in the health field, where life and death, sickness
and health, can be contingent on communication or lack of it. What could
be more simple or complex than communicating a patient's name and
complaints through the air to a handheld device that resides in a
human's shirt pocket?
I can’t say enough nice things about a Palm. I started with a Palm
in 1996 and still use a Palm. I totally believe in the Palm
philosophy of simple is better. Einstein said it best (1879-1955)
"Make things as simple as possible and no simpler."
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 tool, but crunching data and
viewing the result right on the handheld device, in a multi-tasking
environment is the front end foundation and prerequisite to
Electronic Medical Records (EMR) on a PDA.
Key Words:
Digital-Doc (D2)- Front End software used on Ipaq handheld device
Digital-Doc Desktop (D3)- Backend software used on the Desktop PC,
synergistically works with D2.
Wireless NIC- Network Interface Card that enables radio frequency
transmission
Pocketpc- Operating System by Microsoft also called Ce 3.0
Ipaq- one of many PocketPC handheld computers
Template- memorized data in a soap format
Access Point-Central radio point for wireless network of multiple
workstations
HIPAA Health Insurance Portability and Accountability Act of 1996
PPC- PocketPC
PDA- Personal Digital Assistant
DSL-Digital
Subscriber Line or fast broadband connection
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 Digital-Doc software I
use is presently customized by me, to treat and chart trauma. However, it
is designed to be customized for any health profession with relative
ease, with the use of the "Universal Soap Format."
Design:
My office consists of peer to peer Windows 2000 server that contains
my practice management program called Medical Business Automation .
I use electronic billing. I use MS Office XP
Professional with MS Outlook for communicating with my office
staff. I also utilize a wireless network in conjunction with my
hard wired network LAN. I use Earthlink DSL. ( I also have a wireless
LAN at home with
Linksys, that I am experimenting with to communicate with my office 6 miles away,
using
a small Parabola Satellite tapping into my 802.11 at work).
Material:
I have a mixture of Linksys and D-Links hubs and routers including a
Lucent RG-1000 wireless Access Point 802.11b, networked to 6 desktop
workstations, hardwired with 10/100 NIC cards, running an eclectic collection of 2000 Professional,
Windows XP Pro, Windows 98 and one Linux box. I have 9 treatment rooms in 2500
square feet. I optionally use a
wireless Fuji pen notebook, connected wirelessly to my office DSL.
My present PDA of choice is an Ipaq
3850 with 64 Megs or Ram. I use a sleeve with a wireless
Lucent Orinoco NIC card. I have a 128 meg SD card for my
Skyscape
applications such as 5 minute Clinical Consult, 5m Sports
Consult and 5mOrthopedic Consult and
DrDrugs, A2zDrugs™ & iFacts™, and multiple pictures and
exercises I use for patient education. I use a Palm m505 for
reference material such as ePocrates as well as other
applications not available for the Ce platform. I keep both
units synchronized to my Desktop with Palm's Hotsync and
Microsoft's Active Sync.
Preparation:
The
first thing I do every morning, before going to the office, 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
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 prevention of 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 PocketPC),
ensures that my Palm and PocketPC are symbiotic and non parasitic.
I love the prudent simplicity of the Palm OS and the power of the
PocketPC. Both of my handheld units enjoy the same basic medical
programs, in most cases. While there remains a plethora 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
office workday begins by starting my Desktop Pc and wireless Pen
Fujitsu Notebook and then syncing my Ipaq 3800 with my desktop
PC
computer. By syncing at home and work, both my home and work contacts, calendar
and tasks are always up to date.
Moving from a
PalmV to an IPaq PocketPC was insignificant by size, however, I never thought I
would use the "Brick." (Ipaq+ sleeve). However, this wireless is
just too convenient! I slip on my Ipaq sleeve, with built in
battery, which
houses my wireless Lucent Orinoco card. I start my Digital-Doc
Software (D2) on my Ipaq PocketPC and click the options, setup,
wireless. This enables my Ipaq to keep in constant wireless
synchrony with my Digital-Doc Desktop (D3) software in the main
reception area, approximately 50 feet away. My Ipaq finds the
network and I walk back to my treatment room where a new patient
awaits. My secretary has previously matriculated the patient in the
other room putting in the patient demographics and history. As soon
as she saves the patient on the Digital-Doc Desktop (D3), the patient is
exported wirelessly to my IPaq. I examine the patient, deduce a
diagnosis and remove my Ipaq from my pocket. I
pick the patient's name and then click options, template, put in the
condition (eg Sciatica) and all the soap fields are filled out. 123
and I am done! If there are multiple complaints, I simply enter
another template. I only 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. The soap note is automatically synchronized and
backed up to my server Digital-Doc Desktop (D3). If I want to make
changes to my soaps note, I simply click on the custom editable list
boxes to choose an answer, or simply transcribe the answer in the
text box. Transcriber will convert your handwriting to text. Editing
a patient soap or history on the fly is quite easy with the combination
of pop up choices and
Transcriber
saves time and makes it easier to
enter data without typing! A picture is worth a thousand words, as I
document exactly the anatomical site of the patient's chief complaint. Each picture is stored by
corresponding patient id. X-Rays, MRIs or any picture file can be seen here as
well. On the patient's next visit, the data from the last visit is
copied forward to the chosen date. I only need to change what is
different. All my previous visits, labs, etc. remain on the PPC for
easy retrieval and review with one click of a stylus. Tens of
thousands of patients can be stored on a typical 64 Meg PPC if
desired.
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 symptomatology. All medical professionals must review
drug information regarding indications, contraindications, drug
interactions, adverse drug reactions, and mechanism of action,
allowing the provider to make more informed decisions at the point
of care. Chiropractic treatment and
contraindication to treatment can often be contingent on a careful
history that includes medications being consumed. If you are a
medical doctor, you can write and send prescriptions directly to a
IR capable printer, or wirelessly send your scripts to a shared
network printer, or have your secretary print them from the front
desk since they are transmitted wirelessly at the point of care!
This goes for charts as well.
On
Digital-Doc with the patient open, click on SOAAP Dictate and you
are in the
D2Voice. Dictate what you want. Close when finished
and continue charting. On the desktop PC these wave files are
stored in your My Documents\My PocketPC Documents\dd_dictation
folder. They are conveniently associated with each patient for
auditory retrieval by user.
Messages: My secretary can wirelessly send me custom message
on my PPC,
reminding me that I have a new patient in room 9, or worse, my
wife is on the phone ;-) Messages chime and pop up on my
Iraq's
screen. Messages are saved in a history of chronological
order.
My
Ipaq has 64 Megs of RAM memory and an SD card with 128 Megs more. 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
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, prevention, exercise and dealing with
the biomechanics of living. 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. Dragging and dropping to the
PPC and or memory card is so easy and intuitive, especially if you are familiar
with MS Windows. The pocketpc2002, is in fact an abbreviated version of WindowsXP.
5MCC
is a constant resource as well as DrDrugs, A2zDrugs™ &
iFacts™ for referencing all the drugs and their interactions, 5MSports Consult and
Orthopedic Consult, all from
Skyscape.
I keep these programs on my SD memory card.
Prescriptions/Orders/Instructions: Digital-Doc will allow
a user to write a prescription and print it wirelessly to an
IR printer, or print it to a Shared Network Printer,
or send it to Digital-Doc Desktop (D3) where it can be
cued to fax software for allocation to a pharmacy! . The
doctor has the option of printing the script with the "Chart
Note" or as a stand alone "Prescription Form." The form can be
digitally signed in Pocket Word! D2 sends the RX
script to a print folder on D3 which automatically prints the
script to the attached printer and or fax software. No printer
drivers needed on the PPC! With
PrintPocketCe you
can print directly to IR printer.
RX:
Digitally signed prescriptions can be sent simultaneously to
both the front desk printer and the pharmacy of choice. (PPC
points to default printer and fax software). This method,
serves as "mirrored assurance" that the patients prescription
arrives at the pharmacy, either by fax or patient or both.
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 build charts on the PPC itself
or better yet on the Desktop. I can keep my patients on my PPC which
then synchronizes with D3 wirelessly and automatically.
Alternatively, in the absence of wireless, I
place my PPC in the cradle and tell my desktop to manually sync with
D3.
I can print my charts or Rx from my PPC to my Infrared HP 2100 LaserJet or
alternatively, I can go to D3 on my PC and open the charts for
printing or editing.
Desktop
Digital Doc (D3):
My
Digital-Doc software application automatically synchronizes with
D3 via Active Sync or now wirelessly. From D3, a user can
run Reports, edit demographics and history, batch charts, backup,
send messages, email, etc. as well as extensive
more robust manipulation of the data captured. Reports are
integrated with MS Word.
I can make changes on D3 and then export the changes to my
handheld device. This allows me customize templates and exams and
then send them to my PPC. D2 and D3 works bi-directionally. I can
use Voice Dictation on D3 or scan documents into the program using
third party software applications.
Reports: I can
"Build custom reports" on D3 by inserting custom fields from my
database into a document. This enables me to convey information to
third party payers, other doctors, attorneys etc.
Inactive
Patients: Because
I can have thousands of patients and all their records on my
PocketPC,
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.
I can do this by selective filtering which allows me hide patient
names. Additionally, 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.
A
Word on Charge 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. As I chart, I can tag fees or surgical codes that can be placed on the chart and wirelessly sent
to D3 on the desktop. This simple charge-capture programs lists
the available codes, and you click on the appropriate code. You choose the
appropriate code and you can save and edit the appropriate codes
at your discretion.
Results:
The
bottom line:
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 or RX can be generated from any networked
shared computer in the office, based on what has been done (data
input) on my PocketPC PDA. Soap notes, exams, as well as Workman
Compensation and Personal Injury reports as well as many HMO and
insurance reports can be performed utilizing the synergistic backend
Digital-Doc Desktop (D3).
Comments: 2003
PDAs remain a great
reference tool, but lack the visual real estate and the CPU power to
employ a robust EMR. Hence, I am now using a
TabletPC for
EMR.
With respect to an EMR, I think the PDA will forever be
relegated to a good "reference tool," and at best, be an
adjunct device to a good EMR package that is, " hardware
independent."
Depending on your specialty and
needs, a user could use a PDA in conjunction with a desktop or
Tabletpc application, but using a PDA alone as an EMR is
arguably not viable.
Bio:
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
academic interest in the Central Nervous System. 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. He is married to Mitzy with 4
children, a dog, a cat and a bevy of Desktop and handheld computers. He
rides a Light Speed Titanium road bike or carbon fiber Trek
mountain bike 4 times a week.
His mother, Fran, forced him to play a musical instrument, "The
Keyboard." His mother "Mandated Typing," every summer in the absence of
summer school, which made using a computer a more natural
transition. He is still rebelling, as Handheld PDAs, have no real
keyboard
;-)
Disclosure: Chris Wilkerson is the CEO of Digital-Doc. He has a financial interest in
Digital-Doc Software. Digital-Doc (www.digital-doc.com)
is his business web site. His personal web site is at
http://www.digital-doc.com/C2/index.htm. Dr. Wilkerson is a chiropractor,
who has a full time practice
in Carson California.
C.M.Wilkerson, D.C.
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