For the past 15 years, our office has been on a mission to become totally paperless, and we have achieved this goal. Electronic medical records (EMRs) are currently a hot topic, with many vendors entering the arena. But back in the day, practice management software companies were slow to keep pace with cutting-edge technologies. MS DOS-based software remained the only available option years after the introduction of Microsoft's Windows operating systems.

It's hard to imagine today that my simple request for an electronic appointment scheduler was disparaged as a "pie-in-the-sky" feature that no office would want. Our appointment book was so heavily laden with White Out that it would crack as you turned the pages. This pushed me to purchase an off-the-shelf appointment scheduler. It proved to be a sizeable improvement in function and convenience. The success of our makeshift electronic appointment book set us on a firm course to convert more office tasks.

Our practice started to crawl by using the computer to maintain simple demographic data and perform patient recall. Today, the computer is our most essential piece of office equipment and we could not practice without it. (see "The Role of the Computer," left, for functions served by our computer).

I'll show you why you should go paperless too.

Bring it into the exam room

Originally, our test room had a single, stand-alone computer dedicated to the perimeter and topographer also in that room. Printing test results was slow, costly and added more paper to the patient file. These instruments came with high-tech software that included impressive presentations, but all I had to show the patient in the exam room was the paper printout — much less impressive.

My solution: I set up a simple network so I could access the testing room computer from my exam room while the patient was in the chair. Bringing the computer into the exam room created a windfall of new uses for my computer. I can now:

• input and review exam findings
• retrieve prior examination data
• display diagnostic test results
• create PowerPoint presentations for patients about their disorder and treatment options
• retrieve family-member records
• generate electronic routing slip
• view electronic PDR
• write refractive and pharmaceutical prescriptions.

Now that I am "connected," I am able to release the full potential of my practice management software. If you speak to a computer professional, they will say you need an expert to set up an office network. I'm no professional and I'm telling you, it's child's play.

Location, location, location

Now — how many computers do you need, and where do you put them? These are potential hot spots for the placement of computer workstations: Exam rooms, the doctor's private office, tech station, business office, front desk, optical and the lab. However, all of these locations are not indispensable. The front desk is the location for all primary functions and is thereby essential. You can expand slowly as you incorporate additional features and modules of your practice software. As a guide, everywhere you need a telephone is probably a good place for a computer workstation. Adding stations as your demand grows is easy, especially with wireless connections.

Manage those documents

A patient record is much more than a collection of exam forms. Thus, making records paperless takes more than just computerizing exams. Documents such as letters, reports, co-management forms, record release forms, insurance cards, new patient registration, HIPAA statements, duty to warn, informed consent and plenty more, fill our patient folders to the bursting point.

Scanners provide an easy solution by creating a link between written and electronic documentation. These devices are inexpensive, simple to install and enable us to translate all of our paper documents into a digital format. Many practice management systems allow paper documents to be scanned directly into the patient's electronic file. Loose papers are organized by date, category and name. You can then quickly search within these categories for documents within a patient's file.

Hopefully, in the near future, practice management software will allow us to store blank forms that can be filled out electronically, bypassing the paper to scanner steps. This ability could save thousands of dollars annually in printing costs.

Last but not least: EMRs

One final point completes my argument for going paperless. Our optical and contact lens records had been computerized for some time before we attempted exams. We held off because available EMRs took longer to complete, offered limited options and made freehand drawing difficult. They more resembled typical data files rather than the familiar exam forms optometrists are accustomed to. Adding a digitizing pen tablet to my computer made working with my EMR truly practical.

Pen tablets plug into any computer and allow you to write, draw or type within your electronic medical record. I can navigate through the record faster than my mouse and can draw on anatomical eye charts within the record. I've even added handwriting recognition software to my pen tablet. It's like writing on paper energized by the power of the computer.

Staff utilization

Every phone call and office visit necessitates a trip to the file cabinet. I've calculated the labor expenditure devoted to filing and record retrieval (including misplaced files). This adds up to one half of a single employee's work load. This is not only a huge hidden cost that doctors normally do not place under scrutiny, but there's also a missed potential to utilize this staff member for other important office responsibilities.

Getting the staff on board is essential. A hatred for filing is universal, so you're guaranteed to have their full cooperation. With a little extra staff training and proper setup of the software, exam forms can be prepared at the front desk. Having the staff pre-fill the reason for visit, chief complaint, history and refractive information (taken from the patient entrance form and auto-lensometer) speeds up the examination.

The patient record is ready and on screen when I enter the exam room. Data entered from within the exam room automatically generates spectacle and contact lens orders as needed. Our optician adds frame and lens information at the optical computer, which we can later view from our lab workstation. The staff loves this because they no longer have to write up optical forms.

Easing into paperless

At first, the staff had concerns about converting existing records and the extra work it would involve. We decided to transition to EMRs by using the old paper files in conjunction with the new electronic records. The alternative is to scan paper records into each patient's file as they return for care. The staff was relieved that I chose the former approach.

We also found that paper files rob a practice of productivity. What do you do when Mrs. Smith is in the chair and asks about her mom's last exam? I used to have my receptionist pull mom's file and bring it to the exam room. Now I just open the record on screen where I can review past exams, visual fields, retinal photos and her next scheduled appointment. I don't have to take my receptionist away from what she was doing, nor do I waste time waiting for her to pull the file.

Lay to rest legal fears

Worried about operating paperless in the event of an audit or malpractice suit? Don't be. Even attorneys have gone to electronic record storage. Global financial institutions conduct electronic transactions and it's ludicrous to exclude healthcare. The spotlight on medical error prevention will eventually shift the standard of care to require computerized record maintenance.

Illegibility and improper documentation are safeguarded by an EMR, which protects both the doctor and patient.

At the completion of my examination, I "lock" the patient's exam record so that no one can alter it in any way. Prior office visits are easily reviewed on a read-only basis to prevent tampering. EMRs track the level of care provided during the visit and direct me to code the exam appropriately. This prevents under- or over-billing to shield the doctor in the event of an audit.

Don't fight it

The world around us is turning digital.  Business is wireless and paperless, setting new standards for efficiency.  This is the direction our practices must move in to keep competitive and viable.

Dr. Kreda practices in a primary care setting in Lauderhill, Fla. He's a frequent lecturer and author. You can contact him at eyerx@peoplepc.com.