The following article appeared in The News Herald on Wednesday, January 16, 2002.

Surgeon automates charting, spends more time with patients

by Brontie Runkle

Ask any doctor or nurse what eats up most of the time they could be spending with their patients, and you will hear "documentation" said again and again.

Every procedure done for the patient must be charted. The patient's physical exam must be documented. Medical history must not only be taken, but written down as well. Vital signs must not only be noted, but noted on paper.

Dr. William Cloud, a local general surgeon, has eliminated dictation and hand-written notes with "MD Logic," a form of electronic patient charting that uses touch screens.

The result? "It allows me to spend more time face-to-face with my patients," Cloud said.

It used to be that after examining a patient, the doctor would shuffle off to the dictation room to dictate the history and physical into a little machine. That evening, a medical trascriptionist would pick up the tape and type up a report, which would be added to the patient's chart the next morning. As the need arose, orders and progress notes would be scribbled in a semi-legible scrawl. In any case, patients are not well-served by a chart that takes a day to be updated and orders that are difficult to read.

"We've been looking for something like this for a long time," Cloud said. "I spend no time dictating between patients. I track them through the touch screens. It takes about one-and-a-half minutes. Patients don't have to wait on me."

He demonstrated with a workup of an imaginary patient named "John Belushi." In the demonstration, Belushi is visiting the office for abdominal pain. Cloud spent the next minute touching screens on his little laptop computer with a small stylus, inputting temperature, weight, a review of the physical, past medical history, medical tests, diagnosis and treatment plan, which for Belushi, would include gallbladder surgery. Within 90 seconds, the entire history and physical was legibly printed and on the chart.

Cloud also is able to send a report back to a patient's primary care physician almost immediately in what he calls "real-time documentation."

"You avoid the turnaround time that transcription requires. They've got a hard-copy record by the end of that day," said Cloud, who added that his handwriting is "awful."

The MD Logic system protects doctors' offices from Medicare fraud, keeping them legal by generating the correct code for each Medicare patient.

The system will soon be adding the chore of prescription-writing to its repertoire.

"They (MD Logic) have been really good about incorporating our feedback into the program," Cloud said. The program is updated every few months to include recommendations of the physicians who actually use the system on a daily basis.

Electronic charting ahs been something of a holy grail for the medical community, which has gotten more and more bogged down with documenting every facet of their patients' care. Each fact is usually documented in more than one place on the chart, and not just for medical reasons, but for legal ones as well. However, may professionals have been reluctant to become dependent on a single computerized system. What if the system wen down? What if data were lost?

Cloud says his system works around these problems by backing up all the doctor's work.

"Everything we've done here today is at MD Logic in Atlanta," he said, adding that patient confidentiality is maintained by requiring passwords to access the system.

For more information on MD Logic, contact Steven Klein at (704) 553-1210 or smklein@mdlogic.com or visit the web site at www.mdlogic.com.