Computerized Medical Records: The "I.T. Should Be" Observations

Definition

Computerized medical records must be unalterable for legal sufficiency, and should be based on a relational database, where a single medical record entry drives multiple retrieval systems from a problem list, starting with client concern(s), and includes atypical fourteen-system PE findings, deferred or waived needs, and assessments of atypical conditions; inventory adjustments; invoicing; and prescription management. The system must "enforce" standards of care, which must drive treatment plans, and the software should be able to drive the fee schedule, based on time-linked procedures, compensation, overhead, and profit margin needs.

Reality

The above does not yet exist, but each year hardware and software capabilities are coming closer. If this relational database system really existed, we could do the following query. Although it may require multiple queries to get the classifications delineated, the original input would be from the single entry progress notes:

Retrieve all bi-lateral canine otitis externa cases seen in the past eight months, compare treatment results and return rates for those treated with (1) Panalog^®, (2) Tresaderm^®, (3) Mitox^®, or (4) Otomax^®, and show the average total cost and average client transaction income associated with each treatment modality.

POMR

The "Problem Oriented Medical Record" (POMR) format is the accepted level of competency in veterinary medical records. Any veterinary software program that purports to be a medical record system must support the healthcare delivery program, not vice versa. The POMR is based on four elements: Subjective (History), Objective (Exam), Assessment (what are we treating), and Plan (here is what we can do). Thus, the terminology "S-O-A-P" or "H-E-A-P" is used, when talking about appropriate medical record annotations. The assessment of H-E-A-P or S-O-A-P has many forms, each meaning something slightly different in a court of law:

 A = assessment. This is what the above H-E or S-O means to me.

 dx = tentative diagnosis, which is the most probable cause.

 ddx = differential diagnosis. These are all the possible causes of the signs we are seeing.

 R/O = rule out. The treatment plan below will either rule out the signs, or this best-guess disease, or rule out the treatment.

Observation: from the above discussion, it is evident that forensically, R/O is the safest, and is, in fact, the only one that has not yet been litigated to the detriment of the healthcare provider.

Problems

The POMR is base on identifying problems. But in reality, many times the veterinarian treats based on probabilities (empirical treatment), rather than use diagnostics. Any veterinary software system that requires a final diagnosis for entry onto the master problem list must therefore be suspect. Client concern is an essential problem list entry (pain, puking, pooping, peeing, cough, limping, drainage, smells, etc.). More importantly, today we are treating "wellness", not problems!

Building The Successful Veterinary Practice: Programs & Procedures, as well as the VCI® Signature Series Monograph Medical Records for Quality & Continuity of Care provides a foundation for this concept, with forms and formats. Please review these resources for any questions you may have.

 Depending on the diagnostic ability of the practice, about ten to fifty percent of the cases return unresolved, which requires a change in therapy. As such, each assessment (R/O, dx, ddx, etc.) needs to be numbered and documented in a master problem list, if its to be followed up at a later date.

 An assessment that is "open" is not open. It only means symptomatic care (empirical treatment) is being offered. Ensure that the medical logic is stated clearly!

 On follow-up, the problem number can preclude reiteration of the S-O-A and H-E-A portion of the medical record entry and allows the provider to go directly to the new/revised/modified treatment plan.

 Some academics and computer programmers often try to have "major" and "minor" problem lists. In client relations this is dumb, as well as inappropriate. Either the problem/concern needs to be followed or it does not. The problem/concern may be chronic or acute, yet the master problem list is for the next healthcare team member/provider to pick up the conversation with the client and the care of the patient.

 Wellness surveillance may elevate genetic predispositions to problems, and as such, has a major followup and sequential nursing surveillance need, such as nurse-specific clipboard tracking.

Rationale

While the computer has become the primary client relations tool, the medical record needs to be the cornerstone of the continuity of patient care, whether it is done by computer or on paper. The invoicing, reminders, and client education efforts (pet parent training), while critical to the business of veterinary practice, are secondary to the healthcare delivery requirements. As such, there are certain critical elements of information required to be written, legibly, in the progress notes of the medical records. Please review Section 1, AAHA Standards for the Accreditation of Veterinary Hospitals regarding.

 Patient-specific medical records (client-patient).

 Date of presentation.

 Client concerns (chief complaint) at presentation.

 Abnormal history and physical exam findings always include:

 Physical exam is by system, usually twelve to fourteen, and normal or abnormal is required for each system. Best systems default at "Abnormal" or "Not Examined", so assessment entry is actually mandated.

 T-P-R-BP is documented.

 Pre-emptive pain scoring is required (one through ten).

 Sequential weight with body condition score (BCS).

 Dental grade (0-4+).

 Assessment of problem(s) (dx, ddx, A, R/O, etc.)

 Pre-anesthetic risk assessment at any admission (one to five).

 Doctor's treatment plan.

 Client's acceptance, waiver, or deferral of each element.

 Diagnostics conducted with results.

 Medication/prescriptions, with full SIG.

 Problem list review for resolutions.

 Return/recheck/reminder/recall expectations.

Discussion

The above information could be streamlined, but liability would increase with deletion of critical information. The goal is not to enter the least data possible, but rather to ensure prompts and formats, which accelerate the keystroke requirements for entering the essential medical information. The client concern allows/drives the examination protocol and diagnostic tests. For most effective continuity of care, the software critical path would be:

Please note that the above "critical path" is only a basic "skeleton", without muscle, organs, or skin. The "rest of the story" is at the end of this appendix, as a full system checklist, but here is what should happen at a presentation or consultation (body condition score deviation causes defaults to care levels) leading to an admission (pre-anesthetic risk level causes defaults to care levels):

 If there is a notepad or note tablet, a handwritten mobile computer device, the above should appear automatically as the default. This default checklist system provides a positive form of wellness or operational "protocol", as required by the expanded 2003 AAHA Standards for Hospital Accreditation. These default "protocol checklists" must be interactive, with server and progress notes to ensure chronological record. Signature consent forms and diagrams could ".tif" into file, as long as the chronological nature of progress notes is maintained. The newer software versions can read multiple handwriting styles on the same electronic tablet/notepad, rather than only one style of handwriting per tablet, as originally offered.

 In the past, integration of "expected protocols" has been minimal. This should happen from the assessment, directly into the plan, and require default professional explanation when deviations occur.

 Dr. Scott Campbell developed a FoxPro-based protocol system early in the development of Banfield, then Cornerstone has played with various "informational" programs over the years, and in more recent times, some of the electronic "notepad hype" has offered a self-guided level of personal protocol opinion.

 In the RxWorks program, now available in sixteen countries, including the USA, everything is progress note driven, so medical record entries, rather than invoice entries like traditional USA programs, drive the problem list, as the lack of a service (deferral or waiver) can automatically cascade to the problem list.

 I would prefer a search link be provided from the assessment to an established reference for treatment protocols, such as www.vin.com (Veterinary Information Network) or even Larry Tilley's The 5-minute Veterinary Consult: Canine & Feline, which would download automatically into the plan.

 The newer Windows^®-based systems have direct download of diagnostic results from the optical scanner or diagnostic machine into the patient record, and it becomes retrievable in many formats, including colored graphics and merged files with photos and client instructions.

 Imaging can be linked to medical records now by DICOM systems.

 The case assessment drives the treatment plan and dispensing actions. The followup expectations, as well as client waiver's, deferrals, and acceptances, must be reflected in the official veterinary medical agreements made with the steward of the animal for the healthcare treatment for the patient.

 Prescription refills must be overt decisions at the initial treatment, so when a medication is written in the plan, a full SIG, including refill authority, should become a system-tracked action.

 Any hospital admission MUST be an overt action, preferably with pre-anaesthetic risk assessment level, consent forms, and prognosis prompts.

 Before the end of this decade, ALL of this will most likely be driven from a touch screen consultation room computer station.

 Do not accept less, and demand the Windows® upgrades from your vendor. Be ready to change computer vendors, if they cling to the past.

 The veterinary computer and software systems are changing so fast that some reputable vendors have actually developed a three-year plan for total conversion of all veterinary users to Windows®.

EDP theory

The "electronic data processing" programmers usually do it backwards. The first goal should be to meet the healthcare delivery standards of the veterinary profession, working within the framework of established quality criteria, such as the AAHA Hospital Standards for Accreditation. Automation goals of most vendors are focused on the money. They start at the end of the process, the invoice. In fact, most traditional veterinary computer systems in the USA are not much more than cash register programs linked to word processing, with a mail merge capability.

 It is very interesting to note that a "practice management software" should be able to complete the basic business formula, "Income - Expense = Net", yet no existing veterinary software system can do this alone.

 If a software programmer understood veterinary healthcare delivery, everything would be driven from the progress notes, so there would be no multiple-entry requirements to meet the AAHA Standards. We only know of one system that is working from the progress notes as the source document for its software system.

 If the veterinary practice owner(s) would have put standards of care and continuity of care before the invoice importance, the existing software vendors would have become bankrupt long ago.

 As stated initially, a truly relational medical record database could: Retrieve all bi-lateral canine otitis externa cases seen in the past eight months; compare treatment results and return rates for those treated with (1) Panalog^® , (2) Tresaderm^®, (3) Mitox^®, or (4) Otomax^®; and show the average total cost and average client transaction income associated with each treatment modality. This search-and-sort capability does not exist with the current PC-powered hardware systems, and will even grind a mini-mainframe, like the AS400, to a halt.

Our traditional veterinary software systems are not that difficult to establish, they are just over-priced. For example, the Access Bible^®, costs less than $70, has the "Mountaineer Veterinary Clinic" as its demonstration disc, and in about seven days, a savvy computer geek could have a full veterinary software system, plus the proprietary rights.

Look closely, at this point in time, as we only know of two veterinary software systems that have any ability to merge income data with expense data to drive a balance sheet and profit and loss statement, the two minimum EDP reports of any business.

Common software problems abound in veterinary medicine, since the corporate programmers appear to believe that driving the invoice, and spinning off mail merge reminders, are the primary reasons for veterinary software. Look at the following elements (shortfalls) taken from our consulting experiences with common veterinary software systems, and see why we want something more for our consulting partners:

1.  Musculoskeletal is most often presented as pathology or trauma, but has often been confused with primary locomotion describers in various program(s).

2.  Circulatory is more than a pulse rate, mucous membranes, or capillary refill rates, but some vendors have made it only a cardiac evaluation by the describers available.

3.  Respiratory starts at the nares and has a "normal rate", but is often restricted to the lungs by the computer template describers.

4.  Digestive is the center of an anatomical donut, but signs, such as vomiting, have often been entered in the computer describers, as well as appetite (diet) and bladder (urogenital). Dental grades should be in a separate tracking system.

5.  Genitourinary (urogenital) is the genital and urinary apparatus, but "behavior" has been shown as describers by some computer programs.

6.  Eyes (unilateral or bilateral) most often have a discharge, are inflamed, or itch. These signs are usually missing from describers in programs.

7.  Ears, like eyes, come in R and L and often need to go beyond the computer describers, to include common conditions like itchy, inflamed, excessive hair, etc.

8.  Neural is "reflex" and "consciousness", but not generally "behavior", although some computer describers indicated to the contrary. Why would gait (a reflex) be musculoskeletal and housebreaking (behavior) be urogenital, while behavior disposition is neural?

9.  Lymph nodes are found in other areas than the neck, although some programmers seem to have missed this fact.

10.  Mucous membranes are usually evaluated in the eye and mouth, so why list them in multiple other body systems?

11.  General appearance shows as "Bar, except for...", which confuses any tracking. This is a great place to log the BCS, if the system can track it as consecutive weights.

Disclaimer: I am not picking on any one computer vendor. Practices need something a bit more innovative and creative than what we have traditionally been provided. If you want to attract the quality patients to your "new system", stay on paper, until the computer database becomes relational (see below).

Factoids: Sure hope you are becoming unhappy and dissatisfied about now. Regardless, please remember that software vendors do not set medical record standards. Also please accept the fact that the industry medical record standards are set by AAHA and the universities. They are modified by the AVMA trust agents, who settle medical record litigation out of court. Our courts have provided us with many forensic precedents that further alter legal sufficiency of medical records, and are usually ignored in veterinary medicine for the wrong reasons.

Precaution: If a software vendor wants to sell you hardware at elevated prices above market, and uses the excuse that they cannot be accountable for the software performance unless they sell the hardware, run, do not walk, away from that vendor!

"The I.T. Should be" System Assessment: Rubber to the Road Time

Now that the importance of consistent standards of care and replicable physical exam protocols are understood, the practice team may feel they are ready to go software shopping, but they still may not know what to look for with each vendor's systems, or each fast-talking sales presentation:

 First Rule: Carry your "need" list and do not let the individual vendor distract you from your quest. You may also have a "want list", but that is for non-essential elements of the software program.

 Second Rule: Look how entries are made, versus what is visually presented, or what is tracked (the screen pictures), when assessing the computer vendor's presentation.

 Third Rule: Graphics, bells, and whistles are nice, but they don't give you critical medical or business management information. The user-friendliness is critical for staff replication on any given day in the practice.

 Fourth Rule: Before any commitment to purchase, you must talk with people who have been using the system and who are not on the vendor's payroll.

 Fifth Rule: Never sign a "boiler plate" software purchase contract. Negotiate best price for on-site trainer time and/or training modules concurrent with hardware and software module negotiations. Also never sign any contract until your attorney agrees that it is the best deal for you.

Use the following activities list to ask software vendors to demonstrate their "integrated system" capabilities. The better vendors will provide an on-site demonstration, with a "loaner" or "demonstration CD-ROM", to allow better team experimentation with their product. Always keep track of the number of times a vendor says the practice "must modify their procedures to use the software as designed/offered". This "number of times" is an indicator of each system's shortfalls, for those aspects not easily tailored to the practice needs. The key elements include:

 General medical records/treatment

 It is essential that the "critical path" reflected earlier, progress note driven system, is the foundation of the software system. Anything other than that will be the demise of "adequate medical records".

 A veterinary software "practice management system" must meet the basic business documentation rule, which is "Income - Expense = Net".

 Anything other than that will be the demise of generally accepted accounting principles (GAAP) and any resemblance to a business system used for management.

 A simple system of quickly creating medical records that are superior, more structured, and as complete as any written record. Preferably a system that provides an easy, "point-and-click", "typing-free" method. Includes access to:

 Presenting signs (client concerns)

 New or existing client.

 New or existing patient, plus other pet screen for household.

 New or existing sign/concern.

 Ancillary wellness needs (vaccines, heart worm, FeLV, etc.)*

 History

 Examination (+/- diagnostic testing) *

 Case assessment. What are we going to treat for?

 Supplemental testing needs*

 Automatic filing of testing reports into medical record*

 Medications (full SIG)* and treatments*

 Dispensing*/prescribing action (full SIG)

 Automatic inventory adjustments.

 Client education.

 Next visit expectation, including telephone and mail expectations.
* Denotes a potential invoicing linkage requirement.

 As shown earlier, default checklists should be able to be linked to key entries, such as body condition score other than 5, pre-anesthetic risk level at admission, positive lab finding, any dental grade other than 0, etc. This default checklist system provides a positive form of wellness or operational "protocol", as required by the expanded 2003 AAHA Standards for Hospital Accreditation.

 Accurately records all elements of a patient's visit to the practice, and makes paperless even the most minute details, such as recording the reason for the patient's visit, as "written" in the appointment by your front desk staff, and then making that information available to you in the consultation room, surgery suite, or treatment room.

 All S-O-A-P, H-E-A-P, and other exam functions are reduced to point-and-click. Even complex paragraphs and procedure summaries may be digitally-stored for easy retrieval.

 Rx dosing is automated, using a nationally published formulary. Procedures, full SIG, and medications are automatically transferred to the invoice, and authority for refills with quantities is automatically listed.

 Invoicing is allowed at multiple sites, with multiple cash drawers, with individual close-out summaries and transfers at shift breaks.

 Fully integrated word processor

 No need to export to MS Word^® or WordPerfect^®.

 Integrated Draw^® program allows free-form drawing on pictures and scanned images, such as dental arrays, etc. For example, a user can graphically place an "X" on a tooth to represent an extraction, and the bill will automatically be updated for the charges.

 Multi-level password protection and clear identification of any user accessing/touching the medical records.

 Digital white board

 Daily treatment scheduling for hospitalized patients, with automatic updating of medical information and charges for treatments.

 Location tracking (cage, run, or service) of animal, while on inpatient status.

 Prioritization for list of patients, with specific treatments needing to be done for the day with rapid, point-and-click, on-screen entry.

 Create treatment days with quantity and frequency of treatment and instructions, and then duplicate this over several days.

 Daily treatment screen (digital white board) allows user to enter initials for done treatments, which are then transferred to the progress notes, as well as the invoice, hopefully with a single key stroke.

 Integrated "Ready To Go" time promised to client, with discharge instructions (D.I.) completion time, including prescription completed and ready cross-link.

 Patient medical standards of care (easily tailored to the practice)

 Wellness standards, as well as treatment protocols, are supported as defaults. This requires that Internet and respected veterinary text CD-ROM sources are easily importable.

 "Standards of Care" function allows you to set up an automated "compliance" measurement systems based on progress note entries, or can be used manually.

 This standard of care module would also allow tracking of "compliance" for any period for individual providers, patients, or global practice analysis.

 Beyond standards of care analysis, this template and tracking tool should help your team in increase client awareness for recommended or needed procedures by allowing easy access to results of pet parenting programs (see below).

 Capability to link "Assessments" with Internet or XML protocol sources, with "drop-down" into the "Plan", with variance tracking capabilities.

 Pet parenting program communications

 Client communication preference linked export for popular web-based, fax, or snail-mail reminders, newsletters, health alerts, etc.

 Integrated client education systems, which allow targeted sends by patient age, species, disease syndrome, or other healthcare parameter.

 Client profiling for tailored "calls to action", following general information distribution.

 Linked marketing for internal promotions. For example, informational newsletter or health alert three to four weeks before "call to action" (reminder) card.

 Capability to link "Client Education" with Internet or XML information sources, with "drop-down" into the "Discharge Plan", with variance tracking capabilities.

 Reminders

 At least four levels of practice-tailored, long-term, wellness, and recheck reminders for due and overdue healthcare.

 Euthanasia, departure health certificates, reports of loss/death, or with patient record transfer, system automatically adjusts/curtails the reminder program for that patient.

 Totally easily tailored messaging, without jargon. Never links FVRCP, BUN, BSC 7, or other medical record notes directly to message content. Driven by the progress note three Rs.

 Tracks reminder compliance by specific message and/or need

 Allows different delivery client communication methods for types of situations, such as puppy and kitten series have e-mail or voice recall reminder action, while dermatology may need a fax with a picture or diagram.

 Overdue short-term reminders will prompt user at daily startup.

 Automatically generated thank you letters for client referrals and for new clients.

 Call-backs, alerted at daily startup, and printed lists by attending nurse or specific provider.

 A/R post-dated checks, alerted at daily startup, for deposit.

 Automatic linkage to pet parenting communication program.

 Boarding and respite care functions

 Drives husbandry surveillance check-list, with compatibility to Title 9, CFR, for each species being supported.

 User-definable boarding/respite care occupancy by cage types.

 User-defined hospitalization levels of care for respite care patients.

 Set up boarding availability by cage type and location, such as "small-ward A", "large - suite B", "cat condos #6", etc.

 Allows for overbooking override, as well as two animals in a cage.

 Prints and tracks post-guest report cards, reports of stay, sequential status graphs (see below), and similar client information discharge messages.

 Sequential status graphing

 Categorized charting system will graph values for patients by date/time for any value, including glucose curve, BUN, weight, etc.

 Notes may be added manually or from internal information library and added to client handouts or instruction sheet.

 Powerful tool for the medical record and/or client education.

 Healthcare plans (please, never "estimates")

 Create and categorize healthcare plans with high/low, quantity/price ranges.

 Easily create/modify/use healthcare plans from within an open medical record.

 Print personalized healthcare plans with expirations.

 Stored or converted healthcare plans are archived.

 Prescriptions

 Ensures and provides operations and system surveillance checklist is driven by Title 16, CFR, as well as Title 21 for controlled substances.

 Automated Rx medication dosing calculated based on current patient weight, using standard one line or multi-line custom prescriptions templates.

 Rx dosing is automated. Procedures and medications are automatically transferred to the invoice from progress notes "Plan".

 Authority and quantities for refills are automatically listed.

 Refill action automatically deducts from balance remaining, AND annotates dispensing action(s) into the progress notes.

 Point of sale

 All invoice/return lines entered by on-screen list/sub-lists, avoiding the use of codes.

 Invoicing by client or quick walk, in OTC cash sale.

 Automatic inventory management.

 Reminders, upcoming appointments, and linked notes, printable on invoice or supplemental sheet with patient picture.

 Ability to block any line item discount, as well as automated discount levels (multiple levels) for clients and/or patients, plus manual adjustments to the bottom line of the invoice, which is trackable by provider.

 Split payment, for any number of payment types.

 Invoice lines tracked by veterinarian and support staff.

 Non-medical notes (multi-user mail) may be attached to invoices.

 End-of-day reports, as full-day and split-day, plus sorted by pay method.

 Sale summary reports for any period by date, pay method, doctor, transaction type, and sales journal.

 Bank deposits with credit card discounts, if applicable.

 Sales journal export. User's choice by category or by line item.

 Purchase entry by vendor, with viewing of previous costs and markups, allows immediate new price entry.

 Minimum charges, dispensing fees, surcharges, pharmacy, and add-on charges supported.

 Inventory management

 Historical and seasonal stocking levels.

 Expiring drug tracking, with start-up alerts.

 On-hand and warning levels.

 Unlimited number of vendors per item.

 Reports may be printed by vendor, by inventory, and price lists.

 Low stock tracking and purchase order.

 Year-end inventory reports.

 Controlled substance system, with multi-level password system, for both central pharmacy bulk storage and end-user "unit dose" usage.

 Prompts "Initial" and "Biennial" wall-to-wall audits of controlled substances, in accordance with Title 21, CFR.

 Professional referrals

 Allows "referred by" or "referred to" tagged to any medical record.

 May be based on the referring hospital, or any number of doctors per referring hospital.

 Print referral letters, including the procedures done and results, using integrated word processor.

 Print letters for open or closed medical record or batch print letters for all closed medical records for a period.

 Client management

 Owner/co-owner information, including home and work contact numbers.

 An ability to communicate by e-mail or text message, including automatic linkages with patient reminder needs, as well as pet parent education sends. For example, the night before surgery, "Please remember, no food after midnight," by SMS/text messaging.

 Automatically links new clients to "Thank you for allowing us to serve you and your pet" letters.

 Tracks number and type of referrals.

 Automatically links referrals to "Thank you for the referral" letters.

 Identifies preferred contact methods of pet parenting updates and communications on pet needs, and automatically links it with messages.

 Display client financial history, revenue-spending analysis, individually and within chronologically selected period.

 Tracks post-dated checks.

 Tracks discount groups and coupons.

 Quick search by client phone, last name, co-owner, file number, and custom search.

 Automatic discounting can be set up separately for clients and/or patients, based on percentages or a five-level system for such groups as senior citizen, staff, wellness plan, fraternal, law enforcement, etc., as well as Good Samaritan activities.

 Identifies client clusters in catchment area, and changes within the clusters, over chronological period(s).

 Patient management

 Master problem list with create and resolve date, with visual indicators.

 Complete patient information, including pet picture capture.

 Date of birth direct entry or estimated by age given in weeks, months, or years.

 Complete user-defined breed list related to species chosen.

 Detailed patient history and graphical entries.

 On screen visual indication of overdue or soon due for patients.

 For past due services, a default capability for W-D-A-X entry before the patient leaves practice.

 Track current rabies tags, as well as all previous tags, with automatic cross-check between inventory and certificates.

 Change of owner.

 Transfer of patient history records.

 Built in forms and certificates of health, spay/neuter, dental charts.

 Hospitalization/surgery/boarding/euthanasia consent forms, according to AVMA guidelines and other client healthcare authorizations.

 Quick search by pet number, current tag, previous tag, master problem, tattoo number, pet chip ID, and custom search criteria.

 Appointment scheduling

 Variable length appointments easily established and accessed, within any portion of scheduler, for outpatient, inpatient, surgery, respite care, grooming, boarding, etc.

 Appointment scheduling fully integrated within clients and patients.

 Multi-tasking, multi-vet, multi-room, multi-function, drag and drop.

 View by date, by rooms, by vets, single vet, and type of appointment

 Color-coded and user-defined.

 Time-alert system, color-coded, for delayed client service.

 Direct access to appointments from medical record, client, pet and reminders.

 Information (medical/educational) management

 Computerized library, with keyword searches.

 User-modifiable dose calculator.

 Veterinarian information, including digitized signature.

 Customizable master problem lists.

 Integrated label writer.

 Internet access to protocol sources, such as www.vin.com, XML reference linkages, etc.

 Archiving, purging, and retrieving records

 Records may be printed, or saved to disk as a text file, before purging and retrieving at a later date.

 Archival definitions include client groups, patient groups, invoice/discount groups, purchase groups, vendor groups, individual clients, and patients.

 History records

 Complete computerized medical records, including master problem lists, S-O-A-P, POMR, and systemic approach, using lists/sub-lists with the "point-and-click" system.

 Prescription labels automatically generated from history or customizable.

 Unlimited pages of progress notes possible for each medical record.

 Automatically linked and manual reminders with history entry.

 History records listed by consultation/waiting room, hospital admission, boarding, respite care, lab/pick-up, medications, grooming, as well as followup lists.

 Customizable, user-defined searches, using powerful query editor, with saved search definitions.

 Quick searches on master problem lists by system.

 Searches linkable to prescriptions and/or return rates.

 Detailed logs

 Anesthetic/surgery.

 Radiology/imaging.

 Laboratory.

 Dentistry.

 Control drugs.

 "Want" lists, such as inventory, office supplies, maintenance and janitorial, etc.

 Linked from progress notes, default for when assessments are required.

 Revenue analysis and statistics

 Revenue reports may be generated by profit center (user-defined), veterinarian, transactions, cash sales or both.

 System automatically linkable to VCI® Signature Series Monograph Profit Center Monograph, with charts and graphs printed without extra steps.

 Custom searches by treatment, income per procedure, and cost of procedure treatment.

 Income-to-expense ratios by line item.

 Sales per FTE staff member, by chronological period.

 Sales per FTE doctor, by chronological period.

 View or print reports for any period by

 Total clients, patients, medical records, transactions, and codes.

 Pets per household, totalled by species, with percent.

 All clients, rather than new clients and percentages.

 All patients, rather than new patients and percentages.

 How clients decided to come to your practice.

 Pharmacy sales to diagnostic sales ratio by doctor.

 Financial transactions in period, such as total, minimum/maximum, average. etc.

 Percentage of pets vaccinated, surgeries, lab, imaging, dentals.

 Return rates for clients and/or pets.

 Value of client, rather than value of pet per chronological period.

Reality Statement As of January 2007, we know of no single software system that can do everything listed above. Concurrently, there are software systems that can do some of the above, and at least one system that can do each of the above elements listed. We do know of three "Progress Note" driven systems, which have been or are being developed, and with the advent of the notepad tablets, more that are approaching the above levels every day. Please keep your fingers crossed that one day, more veterinary software systems will be focused on medical records, standards of care, and continuity of care, as primary issues. We are!

Consider

The hierarchy of data, as proposed by most computer vendors, ignores the critical path described above, and skips around most of the above key elements of information. They focus on the invoicing, which is the last element a medical record should drive or address. Veterinarians, who want to retain their active licensure in practice, cannot skip these steps. Assessments must be linked to the master problem list, even if it might be just a commitment to treat symptomatically, for continuity of care. In situations where the client waives or defers the diagnostic plan, which the medical records must reflect accurately, increased surveillance must be initiated.

In the "New Visit" template, ensure it is user-friendly. Most veterinarians examine an animal from nose to tail and from the outside inward:

A. The typical exam includes:

1.  Well-discussed history with husbandry history

2.  Temperature, pulse, respiration rate

3.  Sequential weight with body condition score (BCS)

4.  Preemptive pain score

5.  Coat and skin

6.  Eyes

7.  Ears

8.  Nose and throat

9.  Mouth, teeth, with dental grade, and gums

10.  Legs and paws, with TNT need

11.  Lymph nodes

12.  Heart

13.  Lungs

14.  Abdomen

15.  Gastrointestinal

16.  Urogenital

17.  Anal sacs

18.  Diet

19.  Vaccines

20.  Heart worm and FeLV

21.  Fecal

22.  External parasites

23.  Behavior

B. Concurrent with any admission to inpatient, the veterinary software system should ensure, by default if desired:

1.  Overt reason for admission.

2.  Pre-anesthetic risk assessment score (level)

3.  Prognosis, as related to client

4.  Consent authorization, signed by client.

5.  Ready-to-go and next contact time, as promised to client

6.  Endo- and ectoparasite describers.

7.  Status of preventive medications, as well as accurate listing of current medications

8.  Updates of prognosis, TTO events, and other continuity of care requirements

C. Some of the emerging Windows®-based "veterinary" computer software systems are now offering:

1.  Ultrasound download directly into the patient record, with a "visual organ screen" offered as pre-surgical procedure.

2.  Video ophthalmoscopes, endoscopes, and episcopes recorded directly into the patient record, with matched pictures provided at recheck.

3.  Lead 2 Screening ECG, for less than $20 with Biolog, Heska, etc., with direct feed into the patient's medical record, and/or a physical exam digital ECG system, with contact electrodes, which will download an ECG with every outpatient physical, now defined as "doctor's consultation". It is no longer called "exam" or "office call".

4.  Fiber-endoscopes, with video processor and light source, to allow direct recording of highly graphical photo observations into the patients' medical records.

5.  Video vet-scopes, which allow the provider to perform a dental exam, ear exam, biopsies, irrigation, suction, foreign material removal, or similar procedure, while under constant EDP visualization, which is automatically stored in the patient's record.

6.  Bar coding control of inventory, blood bank resources, equipment, and other important assets.

7.  Integrated time clock to payroll system, with other human resource management factors, such as accrued personal time.

8.  Easily tailored appointment schedules for specialists, boarding, grooming, as well as the routine clinical functions.

9.  Relational database search capabilities of medical records, likely in a series of single question eliminators or groupings, which can be programmed and searched by on-site staff, by client location, diagnostic code, master problem list, species, age, therapy regiment, or similar practice-specific variables.

10.  Simplified download capabilities of income data to common spreadsheets for comparison with associated "line item" expense data for the same period.

11.  Voice and handwriting identification and transcription are improving dynamically and dramatically every day.

12.  Automatic uplink capabilities for Internet access, including veterinary information networks, systems, and libraries is concurrently increasing.

13.  Easy links to proven protocol systems, such as Tilley's Five-minute Consult, VIN, etc.

Consultant's Wish As an international consultant, I would like to obtain key management numbers directly from the computer, without causing the practice to transcribe. I'd like a software vendor to facilitate reporting of key elements of information from the practices EOM software summary to the practice's consultant via Internet. Computer software vendors should be able to extract practice data and establish true benchmarks, showing any user where they sit, as compared to similar demographic and staffed practices, and what the variables are between the top fifteen percent of the market and the practice in question. The best veterinary software should have easily tailored EOM reports that can be quickly designed and summarized, so major printouts are not required to get the key management factors extracted and assessed.

Hospital flow and hardware/software

Of major importance in hospital flow, and in the hardware and software selected, will be that it must assist the hospital staff and doctors in ensuring:

1.  Client flow, which promotes, enhances, and simplifies a practice's vision of client, patient, record and staff flow from check-in to check out.

2.  Client value, which creates, enhances, validates, and substantiates the value of all the hospital's services and products in the minds of the client.

All flow in the hospital will be systematic, standardized, constant, and repeatable to the best of the staff's ability. The software and hardware setup must emphasize client convenience, education, and service in the same repeatable way as Rolls Royce^® repeats the client message of special service of a quality product, so the pet parents expect and receive the same service every time they visit the hospital.

The flow of clients is envisioned as follows:

First: The new or returning client will call to make an appointment. The phone room attendant, separate from the greeter up front in the waiting area, will answer the phone to make the appointment. There must be a potential for web site self-appointing, if the practice deems it appropriate. The client relations specialist will enter all the information into the computer.

Important >> The software must be highly interactive, by prompting the computer user to ask the client scripted questions, or request additional medical history, based on pre-determined species-specific, age-specific, and/or breed-specific information, as the owner relays patient information.

The software must be able to recognize certain important parts of the history taken over the phone, and provide scripted information for the phone operator to give to the owner. For example, "OK. I see Fluffy has become a young adult. Our profession now knows that since a dog ages five to seven years for every human year, twice-a-year life cycle consultations are needed. We offer an age-dependent, yet comprehensive, wellness package, which tests for early kidney disease, heart disease, and other body systems. Our nurses can discuss that with you when you come in." or "I see Fluffy has been here before for an ear infection. "How is she doing?" or "I see this is a recheck appointment for Fluffy. Please bring in all medications that Fluffy is currently taking." or "I see "Flapper" the parakeet is coming in for his first exam. Please remember to bring the cage with you.

The software system will generate e-mail reminders to the client, print out a schedule of appointment confirmation calls for the day prior, or feed into an automatic call service that is currently on the market. The software system will generate welcome letters for new clients.

Second: On arrival for the appointment, a clock starts tracking client wait time. The owner will be escorted into the consult/exam room, where the clock automatically resets. The OPNT can take a modified history of the client concern, perform an asymmetry examination, and record all atypical observations on a swing arm notebook computer, including TPR, dental grade, body condition score, blood pressure (PetMap), Lead II ECG, and asymmetry exam abnormals, all against a twelve to fourteen system PE template programmed into the software. We prefer an additional monitor (minimum 19 inches) to be built into the wall, placed at eye level, near the client's side of the room. Based on the presenting problem the pet has, the OPNT will either:

1.  Place a short educational DVD into the room's separate, wall-mounted, large screen LCD-TV for client viewing, with the appropriate treatment/procedural information. For example, if an owner is here for bird behavior problems, then the tech will put a DVD regarding behavior. If it's a routine yearly exam or a new client, the owner will see a behind-the-scenes presentation on the hospital's services. If there's a dental problem picked up by the technician, the owner will see a short DVD on proper dental care and the treatments for periodontal disease offered at the clinic.

2.  Sync into an Internet streaming video.

The program must also be able to recognize certain buzz words in the history taking that prompt the OPNT to go through certain protocols and force the clients into "yes and no" responses. For example, if the nurse notices dirty ears on an initial physical exam, the computer will generate a pop-up, asking if the owner has ear cleaner at home. If not, at the end of the doctor's exam, but before the client makes a followup appointment while in the room, a pop­up question will appear as to whether the owner wants ear cleaner to go home. If yes, it will be added to the invoice automatically. Prices of the product /service offered will also pop up, when the question appears.

Third: When the doctor comes into the room to do a full consultation PE, concurrently the OPNT acts as a transcriptionist, typing the results of the exam and doctor's discussion of patients needs with the client.

Alternatively, the doctor could carry a PC tablet into the room, when they get fast enough, pull up all the owner and pet's information, which the OPNT previously typed prior to the doctor's arrival in the room.

Note: There would, therefore, need to be communication between the notebook/PC on which the technician recorded the information, and the tablet.

During the consultation, the doctor could add personal notes, by writing on the tablet, which would have handwriting recognition software. The separate nineteen-inch LCD built into the wall is for client education, while waiting for the doctor to come into the room, learning about the practice's boarding services, of nurses taking radiographs, etc. The LCD will need to have a volume and on-off control easily accessible near the screen.

The software system will need several templates and medical diagrams available on the tablet, on which one can hand draw information. Concurrently, the graphics are shown on the PC nineteen-inch LCD monitor, which the provider can pull up on the tablet screen and draw on to illustrate key points, then printed remotely and wirelessly in color for the owner to take home.

For example, if the dog has a corneal ulcer, pull up a pre-drawn picture on the tablet screen, take a stylus, and draw the location of the ulcer on the tablet. This is actually a medical record necessity, separate from client education efforts, so some form of metrics must be attached to help identify lesions. The provider can then send that image to the printer in the pharmacy, back lab area, or the front greeter area, so the owner can take the image home to show the family. At the same time, the image will be saved to the patient's file.

Other scenarios >> In the case of discharging a pet that has a dental procedure done with digital radiographs taken before and after the procedure, and during the discharge, we want to be able to upload and send a copy of the digital radiograph to the consultation room large LCD monitor. The digital radiograph was taken in the treatment area and saved to a laptop attached to the digital radiograph machine. The pet parent can see what the before and after shots look like. Staff will be taking digital pictures of the teeth before cleaning and after. We want to easily pull up these before and after pictures on the large LCD monitor to show owners the value of practice services, as well as print them on the go home instructions for dental hygiene and dental nutrition, which is about seven to ten days post-discharge, with a courtesy nursing followup consult.

A trinocular microscope, with a camera attachment, will be in the lab where still shots of bacteria/mites/parasites, etc., can be taken. It also will have the ability to take live-feed shots. We need to be able to send these live-feed shots to any consultation room LCD monitor. The same goes for the panotic ophthalmoscope, vet scope, and other imaging devices we will utilize. We also want the ability to take these digital still shots and bring them up in real time on the LCD monitor in the room.

For clarification, when stating "large-screen LCD monitors", the LCD monitor size needs to be appropriate for the room size. Use judgment as to what is the appropriate size for each consult room, as the nineteen-inch mentioned above was a guesstimate. Each room is a different size. Also, the placement of the LCD large-screen monitor for client education, and the swing arm notebook for the provider, will be important, since there will be animals in the room, some of which are big, and some of which fly (birds). The equipment you pick must be consistent with large animals and beaked animals, so that they cannot destroy or otherwise come in harmful contact with the equipment. Therefore, height off the floor and distance from the exam table will be important.

Software on the tablet with diagrams, and all the capabilities of the software on the tablet, should be as is on the PC.

Other software requirements/questions

 Medical records-driven?

 S-O-A-P or H-E-A-P format?

 Able to print out take-home directions directly from medical records and without opening a new window to a different screen or section of the program?

 Hold pictures of patients anatomy/teeth/masses removed, before and after, in record?

 The medical records power the invoices?

 Holds "canned" invoices, with the ability to make changes if doctor deems necessary?

 Rooms labeled by species and size, and, therefore, make appointments according to patient needs, not doctor needs?

 Easy to learn by new employees?

 Updates? How often? Cost?

 Tech Support? Hours? Free?

 List of meds on computer? Automatic alerts on over-dosage? Interactions?

 Compatible with tablet?

 Pricing by number of stations?

 Wireless compatible? Has this actually been done by hospitals successfully? Can send information to printers anywhere in hospital?

 Instantaneous updates via any station in hospital? For example, can appointments be made and all stations instantly updated? Can appointments be made on-line and all stations be updated automatically?

 Generate reminders by keying in on specific information once and having the computer remind of when those reminders need to be printed out? For example, blood work on all hyperthyroid cats in database every six months.

 Generate separate nurse and doctor call-backs daily of animals seen the previous day, generated by practice-specific set parameters?

 Who services the hardware in the catchment area?

 Can we schedule in-hospital information backups, without interfering with other stations, such as without having to shut them down? Inventory control according to specific ordering rules set forth by AAHA?

 Download onto same spreadsheet, such as QuickBooks®, for compatible comparisons to an older version of the AAHA chart of accounts?

 List of questions for OPNTs to ask in room? Standards of care scripts for OPNTs and phone operators taking and making appointments?

 Can it be used with software that prints out informational, credit card-like cards on their pets for clients to take home, as well as postcards to be sent in mail as reminders?

 Track flow within the hospital from reception area to consultation rooms to treatment area, etc.?

 Is there the ability for the software to do more once the "general stuff" beyond "basic software"?