A Typical Day of Wireless Charting

 

A Typical Day of Wireless 802.11b Charting
November 2001



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).

 


Click to enlarge

Summary: November 2001

I never thought I would go for wireless on a miniscule screen 3.5 " but getting data in "real time" as opposed to syncing on a desktop is very nice. For example, a new patient can be matriculated on a computer in the other room and show up instantly,  with virtually no delay on my Ipaq, with all the pertinent demographics and a message as to what room the patient is in. I can then chart the patient and send that updated information back to the front desk computer software, print it or fax it all from my handheld.

My Ipaq 3800 has a Silver Orinoco card in my sleeve. The sleeve comes with a built in battery.  The sleeve and Ipaq together constitute the infamous "Brick."  At home, I have a Linksys Access Point (BEFW11S4) with shared DSL. At work I have a Lucent RG1000 Access Point with shared DSL. Both are 802.11b. I use both setups seamlessly changing my network setting defaults for work and home on my Ipaq PPC. This multiple setup could easily work for multiple offices and or hospital.

I can wirelessly synchronize, store/backup and print charts (prescriptions) to shared printers and fax software over the network and send my charts to my server's D3 for more robust data manipulation, such as reports and batch printing etc. Changes that take place on D2 or D3 are shared bidirectional and all performed wirelessly!

In other words,
I can print from the handheld using the server printer (s) and send faxes to the pharmacy right from my handheld PDA!  I can enter charts on my PPC and they automatically refresh on the desktop for the front desk or anyone on the network! New patients and desktop entered notes appear on the intended handheld!

Hardware:

1. Access Point $200-500
2. PC or CF NIC card for each PocketPC $75-100
3. Sleeve or slot for PC card ($150 for Ipaq sleeve, other handhelds may have built in slot).
 


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.