December 2003 Bulletin

Benefits of a ‘totally electronic office’

Research your options

By A. Herbert Alexander, MD

Technology is already available that will allow willing ortho- paedic surgeons to incorporate computed radiography (CR), electronic medical records (EMR) and computed practice management into their practices. I will refer to this as the totally electronic office (TEO) rather than the paperless office because the TEO also encompasses computed radiography. To help you better understand how a TEO can benefit your practice, I will describe the functionality in my TEO.

Many practices have already computerized their billing and appointment schedules. Our practice also has our patients check in and enter their demographics into a software program that handles the practice management. We still enter this information manually—but there are touch screens and systems available that let the patient directly enter this kind of information.
Another option allows the patient to enter the information on a special form that is scanned and automatically populates the database. Once this information is entered in the practice management software, the demographics are shared automatically with two other software programs. The first is my EMR; the second is the database list used by my CR system. Patients are then escorted to an exam room where the nurse does a preliminary interview and enters information such as chief complaint, history of present illness and review of symptoms, family history and past medical history on a computer workstation located in each exam room.

Necessary X-rays are done with a conventional machine. However, instead of a film plate, we use a special CR plate that is read on a CR digital image reader. The images are then transmitted within seconds to the exam room from which the patient came and displayed on the monitor.
At this point, I can manipulate the image by changing the contrast, brightness or magnification. I can also template for total joint arthroplasty, draw angles, Cobb angles, measure distances or annotate the image with text.
Afterwards, I record my findings in the EMR and formulate a diagnosis and treatment plan. From this information—and with a few mouse clicks—prescriptions are printed, notes to employers or schools generated, physical therapy prescriptions printed, and a consultation letter prepared. The consultation letter is faxed directly to the referring physician without ever generating a paper copy. With another mouse click, the EMR transmits the CPT codes to the practice manager software.

Benefits of TEO
Since converting my practice to TEO, I have experienced direct and indirect benefits. X-rays and medical records are never lost and always available. My office staff shares in the joy of not dealing with constant manipulation and handling of charts and paper transcriptions. Retakes of X-ray images are almost unheard of and X-ray imaging is no longer a bottleneck. We require no physical storage space for X-rays and charts. My EMR is accessible from any computer with an Internet connection. I can see all my patients’ X-rays from home. I can also transmit their films to the hospital and receive hospital films without involving courier services.

Again, a film is never lost and an unlimited number of physicians can be looking at the same film images at an unlimited number of different locations. I do not have to buy film jackets, film processing chemicals, film or a dark room. With my EMR, my patient notes are complete when the patient leaves my office and are immediately available to all who might need them. I spend no time at the end of the day dictating charts or signing off yesterday’s charts. I have no transcription costs. Finally, compliance with the Healthcare Insurance Portability and Accountability Act is assured with nearly all up-to-date EMR products.

A few negatives
There are some negative issues related to the TEO. Computer phobia will prevent some orthopaedists from ever attempting this change. Large practices with a tremendous number of charts and X-ray files face special conversion issues because they will have to maintain both paper charts and X-ray files for a while. These practices must decide whether or not they should convert old paper charts and X-rays to digital.

However, there are reasonable ways to do this. The ideal way to go TEO with none of these issues is when entering or starting a new practice. My advice to graduating residents or orthopaedic surgeons about to start their own practices is that they establish a TEO from the onset.

If the TEO is something you wish to consider, there are some important matters to explore. Integration of all systems is key. It does not make sense to have a TEO unless the practice manager, EMR and CR software can all share the demographic data. There are numerous different EMRs on the market. Select one that will work for you.

Important EMR and CR features
Important features of an EMR include: Rx [prescription] writer, consult letter generator, phone message manager, ability to use free text or template, voice recognition, patient information handout generator, scanning capability, report acquisition and management, drawing module, spell checker, E & M Coder and drug interaction checker.

There are fewer digital X-ray systems available. One must select either computed radiography or digital radiography. Digital radiography is a technology where the X-ray image is directly generated on a receiving module without first exposing a plate of any kind. Unfortunately, the price tag on this is too high for the average orthopaedic practice to consider. Most established practices would probably move to CR, so that they can continue to use their current X-ray equipment. Though different CR companies have different hardware, the most important consideration here is the software that comes with the system. On a day-to-day basis, an orthopaedic surgeon will interface and manipulate the software to look at images. The hardware or the CR reader is less important; I suspect the average orthopaedic surgeon does not know the brand of his X-ray machine or film processor.

My recommendation is to obtain CR software that is specifically designed for orthopaedic practices. Radiologist-designed software—though usually much more expensive and designed for hospital systems—in my experience, is far inferior to the orthopaedic-designed imaging software I use in my office. One might choose to continue with the office’s current practice management software. However, if it is not compatible with the EMR or CR systems, it will be necessary to change.

Impediments to converting to TEO
Cost might be one of the major impediments to converting to the TEO. However, there is an expensive way to do this and an inexpensive way. Some EMRs may cost as much as $50,000 or more and some as little as $300 per ortho- paedic surgeon. Just because it is expensive, does not mean that the EMR is good. From first-hand experience, I have made similar observations regarding practice manager software and CR systems.

In summary, I have only scratched the surface on the important issues of the TEO. If this is something you are interested in pursuing, seek the help of a trusted computer consultant or someone who has already made the conversion.

A. Herbert Alexander, MD, is president of Alexander Orthopaedics and chief of staff at St. Luke’s Wood River Medical Center in Ketchum, Idaho. He is also the associate editor-in-chief of The American Journal of Orthopedics and chairman of the AAOS Internet Communications Committee. He can be reached at (208) 727-0005 or via e-mail at

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