— Julianne Snell, ARNP, OB/GYN, Women's Health
Deanna Tolman, MS, FNP-BC, has been as a nurse practitioner for nearly 10 years in a wide variety of circumstances, ranging from a gastrointestinal specialist office, to family medicine practices, to a national chain of storefront acute care clinics.
Currently earning her Doctor of Nursing Practice from Columbia University, Tolman plans to open her own primary care practice as part of her residency for that program. She needs an affordable Electronic Health Record (EHR) to keep overhead low. Her past experiences with both client-server and web-based EHRs have been a “nightmare,” characterized by awkward interfaces, slow performance, and constant crashes.
At one medical office, Tolman used Amazing Charts for about 18 months. When she started her own house-call practice in 2008, she purchased Amazing Charts, which she used on a laptop in patient’s homes, thus avoiding carrying paper charts in her bag. She loves the program, which made it easy to document a meaningful note during a patient visit, printing out all necessary patient documents, including prescriptions, by the end of the visit. Tolman plans to continue using Amazing Charts in her new “micropractice” outside Denver, CO, starting in August 2010.
When Deanna Tolman first entered nursing school almost 20 years ago, her instructor handed her a blank pad of paper and a pencil to take notes on patients.
“I remember thinking: are they joking? Where are the computers?” she says. “I had been an administrative assistant at law firms using word processing technology for a decade, so I was shocked to see how low-tech the practice of medicine was at that time.”
Since then, Tolman has witnessed the growth of technology in healthcare, frequently with negative results. During her career, she has used four different EHR systems, making her somewhat of an expert on the subject of comparative usability.
The Million Dollar EHR
The first time Tolman encountered an EHR was at a large gastrointestinal specialty practice where she worked for four years.
“I heard their EHR cost the partners over a million dollars, yet most of the physicians hated it,” she says. “It had many checklists and boxes to click, which made it awkward and cumbersome to use when in front of a patient. I usually had to dictate my notes for later entry into the EHR, but that meant many extra hours at the office.
“Because of all the checklists, the EHR could not produce nice-looking referral letters to primary care physicians, and a few of the doctors even threatened to retire over this issue. Eventually, the EHR provider was able to alter the program to get the checklist-oriented EHR to produce decent-looking referral letters, but it took months.”
The Home Grown EHR
Her next job was at a small family medicine practice where a physician had written his own rudimentary EHR. The system allowed her to document patient visits, but notes were still printed and filed away in paper-chart folders to be retrieved at the next visit. “The practice was still paper-based for everything, and the EHR didn’t connect to scheduling, billing, prescribing, or any other critical parts of the business,” Tolman recalls.
The Online Web-based EHRs
At SmartCare, a chain of acute care clinics located inside Wal-Mart stores in the Denver area, Tolman used the web-based EHR, Bond System (now known as Eclipsys/MediNotes). “The Bond EHR was a nightmare – it was slow, awkward, and crashed all the time,” says Tolman. “The EHR suffered from trying to be all things to all people, which resulted in too many buttons and screens just to accomplish the simple tasks associated with a convenient-care clinic visit.”
“It was an online system, which meant that each click moved you to a new browser screen, and sometimes I had to wait as long as 20 seconds for the next window to load, depending on the connection speed and the number of users on-line at the time. It was inherently slow because so many different screens were required to document a note. Plus, the system seemed to crash for several hours every few days.”
While finishing her doctoral degree, Tolman works part-time at The Little Clinic, which bills itself as “Convenient Neighborhood Health Care.” There she uses another web-based EHR: eClinicalWorks.
“ECW is better than Bond, but not a lot better,” she states. “There are still too many bells and whistles for the small clinic environment, way too many clicks to document a note, and too much time wasted waiting for screens to load. As a result, many of my fellow practitioners can't finish a note while seeing the patient. If the note isn’t finished, copies of the documentation can’t be given to the patient to take with them to their primary care provider, and this acts to reduce continuity of care.”
At one point during her career, Tolman spent 18 months at Smoky Hill Family Medicine, a primary care practice with four providers. This is where she first used Amazing Charts EHR software.
“I walked in the first day with 18 patients booked and they handed me an EHR I had never seen before, Amazing Charts,” recalls Tolman. “I started using the program that very day and was able to finish a note by the end of each patient visit.”
Tolman learned to use templates to rapidly document commonly repeated text and then to enhance the note by typing subjectives. “My notes are extensive and detailed, and I love the ability to add free-form text in Amazing Charts. Check-list EHRs like eCW and Bond may seem easier to use on the surface, but it takes much longer to document and notes don’t seem to reflect the full essence of what the patient said or what you thought. Looking back later, the notes from the check-list systems don’t stir my memory the way Amazing Charts does.”
A year after leaving Smoky Hill Family Medicine, Tolman started an old-fashioned house-call practice and purchased her own license for Amazing Charts. She ran Amazing Charts on a laptop and used a mini-printer to print out prescriptions on the spot. Amazing Charts worked great for her. Eventually, Tolman decided to return to school to earn the highest level of degree offered to nurse practitioners: a Doctor of Nursing Practice (DNP).
Tolman is currently residing in New York City and attending Columbia University. After earning her DNP in the spring of 2010, she plans to open a “micro-practice” in her hometown of Aurora, CO. Like many of the providers who practice using this model, she will be alone in the office, with no employees.
She concludes: “I want to do things differently and still make a living. With Amazing Charts, I can run my practice myself, so my overhead is much lower. I can see fewer patients every day, but spend more time with each one. I truly believe Amazing Charts is going to enable more and more nurse practitioners like me to meet the primary care needs of Americans under the new healthcare legislation.”