Canadian Meds World >> Medical Journal

Acceptance of the personal computer for office use in medical offices has been relatively slow. The reasons for this are probably numerous. However, the most important reason seems to be fear that data will be lost and fear that it will not be cost effective. If you speak to medical secretaries or doctors concerning data security, the most common fear they experience in initial use of a computer system is the fear of losing data when the data are entered and disappear from the screen. Somehow this is associated with the equivalent of putting printed data through a shredder, and hence becomes nonrecoverable. In fact digital data as produced and properly stored by a computer are more secure than print data. These data are also more secure from unauthorized access than print data which one usually sees in folders lining the walls of medical offices.

REQUIREMENTS OF AN OFFICE COMPUTER SYSTEM
User friendly

Every computer system will claim that it is `user friendly’. This implies that it is easy to learn, easy to operate and generally forgiving of any mistakes you make. Very few systems are in fact user friendly, but some are more user friendly than others.

The operating system used by a computer determines in large part the overall appearance and operation of the programs running on it. Operating systems have come and gone in the last 10 years, but the ones that are the most successful today make use of what is known as a graphical user interface (GUI). A computer with a GUI lets you manage and control its operation by manipulating images or icons you see on your computer screen, typically by using a mouse or trackball. Macintosh by Apple and OS/2 by IBM are both GUI operating systems available today. Microsoft is promising a GUI operating system to be called Windows95, but it is not yet available. In the meantime, Microsoft’s Windows 3 software permits you to turn a PC running DOS (an old style command line operating system) into a machine with a GUI.

While the operating system may determine the overall appearance and operation of a program, most of its operation is still determined by its developer. Before you decide on purchasing any computer system you should be sure to see it in operation. Ask for a demonstration and try to use the software yourself. Remember that if you are unable to figure out how to use it during the demonstration then you are probably not going to be able to figure it out after you purchase it and have it installed in your office. Make sure you find out what type of training is required in order to operate the system properly. Remember that lengthy training sessions may just be a sign of a conscientious vendor, but they may also be an attempt by the vendor to compensate for poorly designed software. You should expect the software to be as simple to use as keeping your records on paper.
Input via diverse sources

A complete medical record consists of many different types of data. There are notes written by the physician at the encounter, consultant reports, laboratory results, pathology reports, conversations with patients and other health care providers, illustrations, graphs, radiologic images, and pictures. Automating the collection, entry, storage and retrieval of all of this data can be a challenge.

When you begin looking for a system, make sure that you consider what types of data you will want to manage. Computers are capable of managing all of these data types, but rarely will you find one system which will efficiently and cost effectively manage all of them. Most medical office systems available today simply provide a way for you to manage the textual aspect of the medical record. A few systems are capable of managing sound and pictures as well as text. Generally, though, you will find that systems tend to concentrate on one form of data. When comparing systems for your office, make sure to investigate how it will handle all of the data which you want to manage. Do not be seduced by promises of what the system is being designed to handle in the future. Base your comparison strictly on the present capabilities of each system.
Economics

If you are going to spend thousands of dollars on a computer system you should understand how it is going to help pay for itself and how it is going to help your practice. Some of the economic benefits to computerization are easy to measure and calculate while others are not.

Some of the aspects which are easy to measure are the savings to be gained from not having to buy folders, tabs and paper used in making an actual paper chart. Although individual item costs may be low, over thousands of patients and encounters per year, the materials alone can cost you several thousand dollars per year. Also, as any doctor knows, paper charts take up a lot of room and require lots of expensive cabinets to hold them. Even in a relatively small practice, the filing cabinets and rent for the floor space needed to store the charts can also cost several thousand dollars per year.

Other cost benefits of computerization are not quite so easy to quantify, but are nonetheless equally as significant. First is increased efficiency. A well designed system can help you to reduce the amount of time you actually spend on each encounter. It can also reduce the amount of time your staff spends preparing the patient and documenting the encounter. You can use the extra time in your clinic to do some research, see more patients or simply to reduce the stress level on you and your staff.

The final economic argument for computerization is perhaps the most difficult to quantify — the need to manage a practice which can attract and retain patients. The public is becoming more and more aware of the capabilities of computers. This, coupled with the current trend for reform in health care, means patients are expecting to see computers used extensively in their doctor’s offices. Clinics which take full advantage of available technology and provide a quick, efficient and professional service to their patients will be more likely to attract and retain patients in the future.
Reliable

Once you have your office computerized and things are running smoothly you will want to keep them that way. With all the benefits computers have to offer, they have one serious weakness that must be recognized — they can fail. When your computers are working well you do not give them a second thought, but the minute they fail your entire practice can grind to a halt. If the computer managing all of your data should happen to fail you are suddenly left without access to any of your medical records. This can seem pretty scary, but with the proper precautions it should never happen.

First, make sure that when you design your system you plan for the eventual and unexpected failure of each piece of equipment. You should consider what the consequences would be from each piece of equipment failing and what provisions can be made to compensate for these consequences. For example, you may decide to have an extra computer on hand in case one should fail. Or you could arrange with a local vendor for same day replacement or repair of any failed equipment. Or you may simply decide to work without the failed piece of equipment for two to three weeks while it is being repaired.

Keep in mind that a failed piece of equipment may have repercussions beyond simply the failure of that piece. For example, if the hard disk storing all of your records should fail, replacing it with a new drive will not restore your records. In this scenario you must also have a backup of all of your data to restore onto the new drive. If you have a large database with several thousand records this could take several hours to restore onto a new drive from a backup. You would not be able to use the system for the entire period while the drive is replaced and the data are restored.

The system I am using allows me to keep two copies of my database active at all times (although I am not using this feature at present). This is a technique called mirroring and it is becoming more popular on desktop computer databases. A mirror database is an exact duplicate which is managed by a second computer which duplicates all of the operations of the main computer. If the main computer should fail, switching over to the mirror copy takes several minutes instead of several hours.

Making sure that you always have access to your data may require a little extra expense than you originally anticipated, but it may save you in the long run. You have to make the decision for yourself based on the cost of the extra safeguards of viagra versus the cost of sildenafil and not having access to your system.
Fast

No matter how fast computers are they never seem to be fast enough. This is partly due to the fact that as computers get more powerful software developers find more things to do with that power and thus the software demands more. But many of the complaints about slow computers also relate to the way we work with them.

When you are working on a computer, it generally receives your undivided attention until you have completed the task at hand. That means if you have to wait two or three seconds while it saves a letter and presents a fresh screen you are left sitting and waiting for those three seconds. If you do this repeatedly through the day, every day, it begins to bother you that you have to spend `so much time’ waiting for the computer. If you were doing the same task without a computer you may actually spend more idle time by flipping through papers on your desk, inserting a sheet into the typewriter or some other time consuming task, but at least you seem busy while doing these things. On a computer you simply sit and wait. Just remember that you can never seem to have a computer which is fast enough and be prepared to spend the money to buy a state of the art machine that can outperform multidrug resistance modulators in performance benchmarks.
Components of a system

Every computer system consists of the same basic components. The following components are basic.

Data acquisition: You will need a keyboard to input text and issue commands to the computer. On an IBM-compatible, a keyboard with function keys is a necessity. On a Macintosh, the function keys are rarely, if ever, used.

A scanner is a device which works like a printer in reverse. It allows you to convert images on paper into a form which can be stored on your computer. At the most basic level, a scanner creates a graphic file with a picture of whatever was scanned.

A video camera used in conjunction with a video capture board and software can be used for storing photographs in your computer. The video camera produces a video signal which is fed into the video capture board. The board digitizes the signal and converts it into a form which can be understood by the computer. The video capture software controls the whole process. Many of the new Macintosh computers include video capture (and video output as well) as part of the standard configuration.

You can attach a fax modem to your computer which lets your computer send and receive faxes just like a regular fax machine. The only difference is that you can only send faxes which originate from your computer. If you want to fax a piece of paper then you will also need a scanner to convert the paper into a form understood by the computer.

If your computer has sound input capabilities then a microphone and the appropriate software will allow you to control your computer by voice, dictate into your computer, and store audio notes on your computer. Sound input capabilities are standard on all new Macintosh computers and some configurations also let you control your computer by voice. IBM-compatible computers require an add in board and software. Dictation capabilities are available for both platforms with additional software, but the technology is still somewhat limited in its capabilities.

Data display: Every computer needs a monitor as this is the primary means for the computer to relay information to you. Do not be tempted to forgo a monitor on a computer which will be dedicated to acting as a file or database server. Even these computers need to be controlled by an operator quite regularly and this is impossible without a monitor. A typical monitor will display 640 pixels (dots) horizontally and 480 pixels vertically. With today’s software a colour monitor is essential.

You will require a printer to produce reports and letters. The three main types of printers available are dot matrix printers, ink-jet printers and laser printers.

Dot matrix printers are the oldest technology and also the least expensive, poorest quality and the noisiest. These printers are best used for printing draft documents and lengthy reports since they also have the lowest operating cost per page of all printers. Many people use dot matrix for all of their printing, but be prepared for lots of noise.

Ink-jet printers produce output with nearly the same quality as laser printers. The difference is that ink-jet printers use a liquid ink instead of a dry toner like laser printers. As a result, output from an ink-jet printer is not quite as good as laser output since the ink does get absorbed slightly by the paper. Also, ink-jet printers are usually much slower than laser printers. On the plus side, ink-jet printers are less expensive than laser printers and quieter. Often the only sound made by an ink-jet printer is the sound of the paper feed mechanism used to feed paper through the printer.

Laser printers use the same technology found in most photocopiers. The latest printers print at resolutions of 600 dots per inch and can produce as many as 16 pages per minute. Most offices can get by with something less capable, say 300 dots per inch and 4 pages per minute, although the difference in price between machines with such capabilities may not be very significant. Generally, laser printers are the most expensive printer option, but they do produce the best quality output.

Data storage: Every computer will come with a hard disk. The hard disk stores all of the software needed to operate the computer, including the operating system. With modern computers it is virtually impossible to operate without a hard disk.

Hard disks are the computer’s equivalent of closets and we all know you can never have too much closet space. When you are buying your computer you should consider how much software you want to use on your computer over its lifetime and how much hard disk space each program is going to need. You should then double this estimate.

You should always be sure that you have a considerable amount of unused disk space. This is especially important on the disk which is going to be used to store all of your records. If you ever have any serious problems with your data you may need to replicate all of the data on your hard disk in order to correct the problem.

Do not try to compare hard disk sizes between different types of computers. For example, a PC running Windows should probably have at least 200 Mbytes of hard disk and some would say maybe even 400 or 500 Mbytes. A similar Macintosh computer may be able to run as many programs and do as many things with a 150 Mbyte hard disk.

One last point to keep in mind is that hard disk prices have been dropping. This means you can buy more for less later. You may prefer to buy enough disk space to get you by for two years and then buy another hard disk when you need it. On a Macintosh computer adding more hard disks is simply a matter of plugging a cable into the back of the computer.

Backup: You should definitely have a system for backup. Do not rely on backing up to floppy disks as this is too time consuming and unreliable for your valuable records. Ideally, you should have a system which is automated and does not require any intervention on your part. Also, it should use some sort of replaceable cartridge so that you can rotate cartridges and have several backup copies at all times. One or more backup cartridges can be taken offsite for added protection in the event of a fire or similar catastrophe at your office.

Options available to you include tape, digital audio tape, Syquest drive, and magneto-optical drive. Each technology has its pros and cons including speed, reliability, price and availability. You should consult a knowledgeable vendor in your area for assistance.
MY PERSONAL SETUP

Start from the premise that a system can never be too fast or have too much RAM. Keep in mind that both of these features cost progressively more money, and pick the happy medium for yourself. If your secretary has to wait more than a few seconds for a command to be carried out or the screen to refresh, she will tell you `This machine is too slow. Can’t we do something about it?’, and of course you can if you are willing to spend more money.

Computer systems are divided into hardware and software. Hardware is the computer screen, processor, keyboard and other mechanical items in your system. Software is divided into system software such as DOS, Windows, and Macintosh system software and program software that you develop yourself or purchase from a developer or off the counter.

My system consists of three Macintosh computers and associated software and hardware. One is used as a server where my data are stored and where my main software that I use for my office data base is stored. My secretary has one computer that she uses to enter data, view data, print data, and send and receive faxes. The data that she enters are stored on the server computer. I have a computer in my own office that I also can use to enter, view and print data if I want to. As well I have my computer hooked up to a Sony V701 video Hi8 camera. This allows me to take colour pictures and videos of patients which are also stored on the server computer.

Database software for patient data: This software is the most important software for your office system. It is essential that this software has relational database capabilities. This means that data, eg, a patient’s name, address and health insurance number, need only be entered once, and the software can retrieve this information and use it in many different ways and at different times. If, for example, your secretary is billing on John Doe, she does not need to find his insurance number or address as the system will automatically retrieve it for her if needed. Likewise when writing a letter to the referring physician on John Doe, the referring doctor’s name and address will automatically appear on the letter, sparing her the time of looking up the data as well as typing it in. Properly designed database software will allow you to enter patient clinical data, do scheduling, letter writing, store pictures and scanned in data and also retrieve and display the data in as many different ways as you wish. Data can be sorted or displayed on the basis of age, sex, geographic area, ICD code or any other manner that tickles your fancy.

How it is done: I dictate on a dictating system to my secretary just the same as is done in a noncomputerized office. She then transcribes these data into the computer using her keyboard, the same as if she was using a typewriter. She can view the data on the screen as she works, make corrections and then enter it, whereupon it is sent to the server database. I usually dictate a clinical note on the patient, a letter to a referring physician, and any billing and then go on to the next patient. The secretary enters the data in a similar sequential manner. Once she has transcribed all the data, usually near the end of her day, she will ask the printer to print out all the letters she has entered that day so she can send them out. The data base will then generate all the unprinted letters that she requested based on a specific time interval (eg, date). Sometimes she may wish to send some letters as a fax instead of printing them out and mailing them. The computer software can as easily send them out as a fax as print them out, saving postage and stationary and getting them to their destination quicker. This is especially cost effective if sending information to your local referring doctors as there is no telephone cost incurred in local calls. As well faxes sent out with a computer fax have a much better appearance than ones sent out with standard faxes.

Billing: The program is set up so billing can be sent to private patients by fax or printed bill, or sent to the provincial government as a batch of bills electronically by modem covering a certain time period, usually two weeks. Other paying agencies can also be selected to be sent bills, eg, Workers’ Compensation Board.

Electronic return files are picked up by modem on a routine basis and the billing component of the software automatically reconciles the paid accounts and alerts me to the unpaid or partially paid bills that can then be printed out and revised or accepted.

Data from your hospital mail slot and other doctors: We receive all sorts of data from hospitals in the form of x-ray reports, operating room reports, laboratory reports and letters. Some of these data may come printed on good paper and laser printed. Other pieces of paper may have hand written data on it. These data are scanned into the computer using a Hewlett Packer scanner. If the data are well printed, they are converted into text and stored in the main relational database. If the original data are of poor graphic quality and cannot be converted into text they are still scanned but stored as a graphic file. They can then be viewed just as if they were the original data. The difference between the text file and graphic file is that the graphic file is viewed with a graphics program whereas a textfile is read with word processor software.

Video images: I take pre- and postoperative pictures in my office and store them in a separate database, although they could be stored in the main database. These images can be of variable size, are stored in 24 bit colour and compressed. If the lighting or colour balance is off at the time the picture was taken, I correct it using Adobe Photoshop which is a commercially available image processing program. The images are stored with any number of keywords and the patient’s name so they can be retrieved according to keyword or name. These pictures can be viewed at the same time as I have the patient’s main data file open with their clinical notes.

Video clips taken with the camera can be also be stored. The clips I find useful are pre- and postoperative range of motion for Dupuytren’s contracture or hand trauma cases or to follow the progress of a facial palsy. A video clip confirming the presence of a minor facial weakness before any facial surgery is also of great importance.

Backup system: With all of my records stored on computer I can be sure that I never lose any information. The main server computer has an external magneto-optical (MO) cartridge disk drive which I use for backup and archival purposes.

Data security: A good medical computer system will provide facilities for safeguarding against unauthorized access to the data. A typical approach in computers is to designate groups of users who have access to certain portions of the system then every person using the system is assigned to one or more of these groups. The system I use has groups defined for such tasks as billing, writing letters, accessing medical data and patient scheduling. I can then decide to which groups my staff should belong. Each person using the system can gain access to only those areas for which they have permission. Of course, each user must also be able to specify his own access password. Without the proper password you cannot access the system and even once you have accessed the system you are only permitted to perform functions defined by your group privileges.

ABSTRACT

DJ Classen. Computerization of the plastic surgery office. Can J Plast Surg 1995;3(2):69-73. Computerization of a plastic surgery office presents many challenges. Not the least of these is the diversity of data. Digitization of text, graphics, audio and video data can all be accomplished. Before any purchase of computer hardware or software is undertaken, it is important to know what it is that you want computerization to accomplish.
Informatisation du cabinet de chirurgie esthetique.

Daniel J Classen MD DDS FRCSC
Division of Plastic Surgery, Royal University Hospital, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan