Doctors design a free, downloadable medical record

Its creators say it's good for a primary care practice, although the programmer says it's no substitute for full automation.

By Tyler Chin, AMNews staff. April 8, 2002.

Fed up with how long it took to chase down and manually go through paper charts, physicians at Moses Cone Family Medicine Residency Program decided that they had to find a better way to meet demands for quality improvement and assurance.

So, the Greensboro, N.C., residency program in 1999 designed a miniature electronic medical record that can be downloaded off the Web. It lets physicians automate critical clinical information and more easily conduct quality interventions and audits without having to buy an expensive EMR.

"It's mostly for adult primary care, but any physician could use it for free and modify it," said M. Lee Chambliss, MD, assistant professor at the residency program with Moses Cone Health System and the University of North Carolina at Chapel Hill Dept. of Family Practice. He also is the lead author of an article about the residency program's implementation of the "mini-EMR" in the December 2001 Journal of Family Practice.

Based on the Microsoft Access database program, the mini-EMR is a hybrid of paper and computers. It has an electronic face sheet that captures demographic data, medications and dosages, chronic problems, diagnoses and ICD-9 codes.

Staff print and attach this face sheet to the front of the chart before the patient's visit, giving physicians quicker access to key information, Dr. Chambliss said. The system also alerts physicians when it's time for preventive services, such as mammograms, Pap smears or flu shots.

When doctors dictate their notes, they also add new medications, problems and dates of preventive services. [...]