Daily Chronicle Special Section - 9/30/07

Dr. Karen Federici uses a laptop computer to access patient information during office visits.

Diane Rapp, Medical Records Director, scans one of the 375,000 pieces of paper that have been put into electronic patient files over the past few months.

Stacks of paper still need to be scanned to complete the conversion to paperless patient files.

Paperless medical record makes hospital more efficient, eliminates storage space, and puts vital information at doctors’ fingertips

Kishwaukee Community Hospital’s Health Information Management Department, better known as Medical Records, is checking into the 21st century. By the time hospital staff moves into the new facility on October 2, all new patient files and most existing patient files will be scanned into a computer application where they will be stored permanently.

Thus, Medical Records will be “paperless”. These patient files will be accessed by physicians, therapists and other health professionals from highly secured computers at the hospital, their home or office.

“KCH is one of a few acute care settings that is going paperless,” says Diane Rapp, Director of Health Information Management. “This will be a huge accomplishment.”

Going paperless makes sense from an efficiency standpoint. Once test results or health assessments are scanned into the system, doctors will have their patient’s information at their fingertips. It is important to note, however, that patient information will still be available only on a “need to know basis”, which protects patient privacy.

When a new patient signs in with patient registration, he fills out the typical forms. Instead of placing those paper forms in a folder and filing them away, they will be scanned into a computer application called FormFast. This application also allows for patient signatures to be captured electronically. Once all the forms are scanned into the system, they are quality checked to ensure accuracy and then shredded.

FormFast also issues a barcode that is unique to each patient. When scanned, the barcode lists the medical record number and account number, and it assigns a numerical value for each type of form (i.e. – physical form, discharge papers). This barcode is also printed on patient wristbands and used for medication verification, a patient safety measure and another way KCH is leading the way in the electronic healthcare environment.

All patient data then comes together to form an electronic patient file, much like the physical file patients are used to seeing. All patient files are then able to be accessed through this computer application, making doctor review easy.

Not only are new patient files being kept electronically, but existing patient files are being scanned into the application as well.

“We started with Laboratory and Radiology orders and worked our way through the various department files, such as Emergency Department and Obstetrics,” says Rapp.

The “scanning” works much like a scanner one might have for a home computer. The scanner reads whatever is on the page, whether it is typewritten words, handwritten words, or photographs.

The hospital’s physical file storage contains files from 2005 until the present. Files prior to 2005 have already been sent out to a permanent storage facility, where they are mostly kept on microfiche. Because of this new technology, the need for physical file storage is considerably diminished. Designers for the new hospital allocated less space for file storage, and instead used this space to expand other patient service areas.

The medical records staff has been hard at work on this task for the past five months, and in that short time has already scanned 375,000 pieces of paper.

Safeguards are in place to ensure this electronic information is not lost. A system backs-up in two places, one on-site and one off-site.

Going forward with this new technology will be a smooth transition. Upon completing patient rounds, all paperwork will be immediately scanned into the system.

Radiology images also electronic

The KCH Radiology Department uses digital media as well. According to department manager Jodi Baker, all radiology equipment made today is digital or has the capacity to produce its results in a digital format. That means the information can also be stored in a digital format.

“To keep all of this information in a controlled, organized environment, we have what is called PACS--Picture Archiving and Communication System,” Baker says. “This system networks all of the imaging modalities, including the reports, distribution of images, burning of CDs or printing of film if needed to take to a physician. The digital images can also be viewed by multiple physicians in multiple locations making consulting and reviewing cases faster and more efficient.”

Doctors access information in their offices

Physicians are also using the “paperless” technology, widely known in the industry as electronic medical records (EMR).

Dr. George Gonnella, internal medicine physician in Sycamore, sees patients with his laptop computer in hand. This allows him to access the patient’s files that may be located in another office. He can also show the patient test results on the computer screen, which can be easier to read, and he can fax prescriptions directly to a pharmacy.

“In essence, a whole file cabinet can fit in my hands,” says Dr. Gonnella. “The EMR (electronic medical record) presents medical notes and data in a neat, legible, orderly manner to share with patients and other medical staff.”

Medical records from outside the physician’s practice can either be faxed directly into the office’s medical records software, or a physical sheet of paper can be scanned.

Tending to patient’s needs can be done outside of the office as well.

“I can review records from any place that there is a DSL connection outside the office, including my home,” says Dr. Gonnella.

Dr. Karen Federici, a family physician in Genoa, also uses electronic medical records in her practice.

“If I get a call in the middle of the night saying a patient is in the Emergency Department, I can access their records on my computer to see what medications they are taking and view their health history,” says Federici. “I don’t have to rely on the patient to provide accurate information.”

She also uses the electronic medical record software to fax prescriptions, or lab or radiology orders. She can also communicate with her office staff via an internal messaging feature.

Dr. Federici says electronic medical records let her staff use their time more efficiently.

“The office staff and nurses don’t have to first find the chart or pull the chart before I can see the patient. It also cuts down on copying and filing,” she says.

The downside to electronic medical records is the learning curve.

“Not only does staff have to get used to doing everything electronically, but they have to learn the software as well,” Dr. Federici says.

Potential additions to a paperless system include physicians entering orders for lab work or radiology directly into the computer system.

“Technology has made tremendous advancements in the healthcare field,” says Rapp. “It only makes sense to embrace these advancements and think toward the future.”