Thanks to Today's Chiropractic for permission to reproduce this article!
By C.M. Wilkerson, D.C.
In the early 1980s, I sat in front of my office computer, a 286 Hewlett Packard
Vectra desktop model with a 10-gigabyte hard drive. The salesman assured us
we would never need anything bigger or better. The salesman told me many other
things, but I had no idea what he was talking about. I felt like I had been
parachute-dropped into a foreign country, where the citizens spoke pure techno-babble.
It was then that I decided that I had to be technically informed about computers
or else I would be at the total mercy of salespeople. I didnt like this
At any rate, I was fascinated by this Vectra box with a brain, which seemed
to reach out and accomplish tasks. Now, if only I could place this PC in all
my adjusting rooms so I wouldnt have to keep running out to the front
desk. Since then, my goal has been to put a computer in my pocket.
Today, I cant say enough nice things about a Palm handheld computer. I
started with a Palm and still use a Palm. I totally believe in the Palm philosophy
of simple is better. Einstein (1879-1955) said it best: Make things as
simple as possible and no simpler.
In 2002, however, I want more than what a Palm OS can accomplish. I want a computer
in my pocket. The Palm, for all its benefits as a reference tool, does not have
the power of a computer. Having reference material is a good and necessary objective,
but crunching data and viewing the result right on the handheld device, in a
multi-tasking environment, is the front-end foundation of an Electronic Medical
Records (EMR) system.
A System For Documentation
I would like to share how I use a personal digital assistant (PDA), throughout
my day, to chart patient encounters. As a chiropractor, I provide care for musculoskeletal
problems of somatic origin.
Design: My office has a simple peer-to-peer Windows 2000 server that contains
my practice management program, Medical Business Automation (www.mbanet.com).
I use www.eclaims.com for electronic billing. I use MS Office XP Professional
with MS Outlook for communicating with my office staff. I also use a wireless
Access Point on my server that allows me to roam my 2,500-square-foot office
while sharing a broadband DSL connection on my Fujitsu notebook.
Material: I have a mixture of Linksys and D-Links hubs and routers including
a Lucent RG-1000 wireless Access Point, networked to six desktop workstations
running an eclectic collection of 2000 Professional, Windows 98 and one Linux
box. I have nine adjusting rooms, and I use a wireless Fuji pen notebook, when
My PDA of choice is an Ipaq 3850 with 64 MB of RAM and another 128 MB in my
SD memory card. I use a Palm m505 as a backup for reference material and use
programs such as Contacts and ePocrates.
Preparation: The first thing I do every morning, before a patient encounter,
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 (www.epocrates.com) and other reference
material and synchronize my Desktop Outlook 2002 with the desktop overwriting
Then, I head for my 6-ounce forearm/wrist routine (prophylactic for carpal tunnel)
by dropping my Ipaq into its USB cradle. Seamless synchrony takes place automatically
with my settings enabled to synchronize all the files. This dual synchrony setup
(Palm and Ipaq Pocket PC) ensures that my Palm and Pocket PC are symbiotic and
non-parasitic. I love the prudent simplicity of the Palm OS and the power of
the Pocket PC. Both of my handheld units contain the same basic programs, in
While there remains a plethora of Palm applications, my Ipaq provides my personal
panoply. The Pocket PC has all the health-care applications I need and can do
so much more. The Pocket PC OS has a steeper learning curve than the Palm OS,
but so did Windows compared to DOS.
Recording Patient Information
My workday begins by downloading my patients files for the day into my
Ipaq. I use a custom SOAP program, designed for musculoskeletal trauma, called
I use a custom Visual Basic utility on my desktop (part of Digital-Doc) that
reaches across my network and imports my calendar database (an Access .mdb)
file from my practice management system (PMS). The program imports the data
into an Active Sync subdirectory on my Ipaq. This subdirectory is automatically
synchronized with my Ipaq anytime it is placed in the cradle. With the Ipaq
in the cradle, I then open the Options menu on my Digital-Doc software and tap
on Import the Calendar. The entire process of importing 50 patient
files and loading
them into the Digital-Doc software takes less than 10 seconds.
Then, I remove the Ipaq and head for my first patient encounter. If the patient
has not seen the Ipaq, I show it to them. I then ask the patient to physically
touch where it hurts. Asking the patient to touch on their body
where it hurts helps prevent miscommunication. Looking at an image of a body,
I simply tap on the area of chief complaint, the box lights up red, and all
dropdown menus are loaded to match that specific area. All choices for patient
complaints, exams and diagnosis are only pertinent to that same area of the
body. The body part chosen is specifically correlated with the appropriate corresponding
customizable choice. There are no superfluous, irrelevant choices!
I then choose the chief complaint and continue the encounter, asking the patient
about severity, frequency and other aspects. I can cycle through each SOAP screen
in this manner, tapping and picking and choosing. Alternatively, an even quicker
and preferred method is to choose a template based on the anatomical area that
the patient has indicated is the area of their chief complaint. I simply click
on Options, load a template, and save it. 1-2-3 and I am done! I
change only what is different.
At this point, I can read or print the entire note in Pocket Word or save it
and move on to the next patient. The objective portion of the software also
includes a comprehensive customized exam grid (the user can customize it for
their specialty) that can be used for an extensive examination. In my case,
as a chiropractor, the grid is set up for vitals, inspection and palpation,
ROM, orthopedic and neurological exam, medication, X-ray, etc. This grid can
be altered for virtually any health specialty.
Entering a patient history on the fly is quite easy with the combination of
pop-up choices and a transcriber, which saves time and makes it easier to enter
data without typing!
One of the features of this software is a recommended care plan reminder. For
example, I can program it for six visits. When the patient reaches his sixth
visit, the program reminds me. I use this to remind me that a report is due
for third-party re-imbursement, or that the patient should be re-evaluated.
If instructed, the software will remind me of a patients birthday as well.
In addition, I can schedule the patient from the Ipaq with a field that pulls
up a virtual appointment book. This can be helpful when checking your schedule
on the road. On occasion, I will dictate a verbal note, which is also saved
in my chart directories on the Pocket PC for easy retrieval and synchronization.
I can listen to this .wav file on my Ipaq or my desktop computer.
My Ipaq has 64 MB of memory, which allows me to record all my patient encounters
without having to upload the data to my PC in order to make more room. My old
Palm software mandated daily uploads and only the last visit was stored on the
device. I record all my patient visits on my Ipaq, and I only need to archive
them when they are no longer under active care.
I can search all my patient files with a search feature in the Digital-Doc software.
It is extremely important to have all the patient data at my disposal. For example,
if I am looking for a particular test, like an MRI, I can search all my charts
in a second, without having to pull a paper file that is archived in the next
room. The information is in front of me in seconds. Additionally, while out
of the office, I can use this search feature to follow up on a patient by searching
for a specific key word or phrase that I might put in the comments section of
I use a Pocket Anatomy program to show patients images of the area of their
complaint. Showing the patient the muscle or anatomical area that is injured
is a great help in assisting their understanding of their pain. With biomechanical
injuries, part of getting well is understanding what is wrong and how to prevent
recurrence. 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.
The 5-Minute Clinical Consult program is a constant resource, as well as LexiDrugs.
These days, it seems that most people are on one prescription or another, and
it is imperative to know how the medication affects their physiology and symptoms.
Chiropractic care and contraindication to care can often be contingent on a
careful history that records what medications the patient is taking.
HIPAA-oriented password protection is also included the Digital-Doc software
that I use. I set my time for 10 minutes. The device automatically shuts down
in the absence of user-determined use. This feature would prohibit
unwanted users from seeing patient information.
Integrating Office Data
The Digital-Doc has the ability to capture fees due for services when the patient
encounter notes are made. This information can be saved for transfer to the
person posting charges, or to my PMS for electronic billing to www.eclaims.com.
At the end of the day, week or monthor literally, whenever I decideI
can build my charts by date range, for all patients or individual
patients. I can keep them on my Ipaq, which then synchronizes with my desktop
as soon as I drop it into the cradle.
I can print my charts on my Infrared HP 2100 LaserJet or, alternatively, I can
go to my desktop PC and open the charts for printing or editing.
My Digital-Doc software application automatically synchronizes with my desktop
Access .mdb file via Active Sync. From my desktop, I can run Access reports
and queries, sort data and merge with MS Word. I can make changes on the desktop
Access file and then restore to my Pocket PC if desired. It works bidirectionally.
Backup: Presently, I have a dual backup option. I can do it manually via coded
software or automatically with Active Sync. Automatically, my table and data
are backed up with Active Sync as soon as my Ipaq is placed in the cradle. However,
I can also backup my data right from my Pocket PC, via the Options menu of my
Digital-Doc software. This may sound confusing and perhaps redundant, but it
enables me to have a dual backup system in place.
Here is the bottom line for my practice: Mobile computing means less stress
and better patient documentation. This translates to better patient care and
better financial reimbursement. Any SOAP notes, exams or reports (workmens
compensation, personal injury, HMO and insurance) can be generated from any
computer in the office based on what has been done (data input).
I firmly believe that a handheld device is the best, most convenient front-end
adjunct to EMR. However, the front end is only as good as the back end. Application
performance on the Pocket PC is much closer to desktop performance than demonstrated
by any Palm OS application I know.
This may be the reason why companies developing genuinely robust EMRs (not just
reference material), are using the Ce environment instead of the Palm. I think
Palm knows this as well, hence the incipient StrongArm chip change. Multi-tasking
is another big reason. It is a real pleasure to one tap from a drug
database software program to charting software, without having to restart either
Although I dont believe a good handheld application is intended to be
a clone of a desktop application, my point is that the Pocket PC devices have
a much higher potential than what has been demonstrated with the Palm OS.
A Pocket PC can multitask, while a Palm OS cannot. Users can only appreciate
this with applications that take advantage of it. Once I experienced multi-tasking
in an EMR environment, I realized how cumbersome my Palm could be with respect
to opening and closing and going back and forth between different references
and applications. This can become very cumbersome when you have to wade through
program menus from the starting point of the application.
On my 64 MB Ipaq, I have Digital-Doc Trauma Software, JH Antibiotic Guide, Pocket
Anatomy, Washington Manual, LexiDrugs, the Merck Manual, Harrisons Handbook
of Internal Medicine, 5-Minute Clinical Consult, Interact, Archimedes, Patient
Tracker, Pocket Excel, PocketWord, Handbase with multiple medical applications,
VisualCe with custom menus and corresponding Access cdb data file, and the full-text
version of the Bible (a must-have in health).
I also have picture viewer software so that I can cut and paste my own anatomical
and musculoskeletal images to show patients (before and after views). This helps
them understand their progress in restoring their health.
C.M.Wilkerson, D.C., a magna cum laude graduate of Cleveland
Chiropractic College, also has a B.S. degree in neurobiology from the University
of Arizona. He is a member of the California Chiropractic Association and the
College of Sports Medicine. In addition, he founded a health-care software company,
Salubrious Solutions. For more information, e-mail him at firstname.lastname@example.org,
or write to 519 W. Carson St., Suite 101, Carson, CA 90745-2642; call (310)
533-1070; or fax (310) 328-8501.
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