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Electronic access of records now available by Donna Padgette R.N., MSN Emerald Communications and Training Committee   “Button, button, who’s got the button?”     It may seem like that old children’s game when people from various disciplines need one patient’s record at the same time. Indeed, that might have been the case at the University Diagnostic Center (UDC) when the paper chart was the primary source to obtain information and document care.     The advent of Practice Partner Patient Records has helped make playing the “who’s got the chart?” game much less common in some of MUSC’s outpatient clinics.    Practice Partner is an office-based electronic medical record from Physician Micro Systems Inc. that’s being used in a number of clinics within University Medical Associates, including Adult and Pediatric Primary Care, Pediatric GI, Pediatric Developmental, Pediatric Endocrinology, Carolina Family Care, University Diagnostic Center and Family Medicine.   Unlike the paper chart that can only be in one place at one time, the electronic medical record allows universal access, a primary advantage to a system such as Practice Partner. It links these different physical locations and makes any patient’s record available at once, something not even the fastest courier could accomplish.   Sharon Vendrick, the UDC’s clinical operations coordinator, cites accessibility as one of Practice Partner’s most attractive features. “Efficiency is the key in a busy clinic like ours.”   Vendrick acknowledges that Practice Partner contributes to that efficiency by allowing multiple clinicians to access a record at the same time. A patient visit to the UDC may include encounters with multiple caregivers, and Practice Partner facilitates each professional’s need to review patient information and document care in the patient’s record. The accessibility benefit extends to the ability for on-call personnel to dial in to the system from home to retrieve history on a patient needing attention during off hours.   Practice Partner has the flexibility to accommodate the unique needs of both primary care physicians and specialists, as well as the varied practice preferences that exist among a diverse mix of clinicians.    Its adaptability is exhibited in the capacity to modify how a chart is viewed, as well as how data is entered into a record. If dictation is used to document findings, the patient record can receive input from transcribed notes, placing the note appropriately and updating relevant chart sections. An option when entering data directly into the record is the use of templates, which are pre-designed documents that can be customized for different examinations, patient populations, or individual preferences.   The Pediatric Primary Care clinic uses these templates extensively, which Clinical Coordinator Laura Dobbins Beeks considers the “biggest plus” the clinic receives from the system. The template provides a valuable instrument in the interview, exam and documentation processes, and also assists in verifying that standards of care are upheld, definitely a plus where JCAHO is concerned.      Beeks also notes that the system’s “instant access and info from other areas can expedite patient care.” Clinic staff utilize various components of the system as a patient moves through the clinic, including sections for vital signs, medications, allergies, progress notes, health maintenance status and a problem list. There are features that assist with administrative as well as clinical duties, ranging from one that can generate a letter to send to patients who miss an appointment to another that can produce a growth chart from height and weight data.   Practice Partner receives information from Oversite, a patient scheduling and registration system used in MUSC’s outpatient clinics. The recent interface with the Oacis Data Repository significantly enhances the scope of pertinent data that can be referenced from this single source.   Laboratory results from outpatient encounters as well as radiology results from both inpatient and outpatient encounters are made available through the interface, as are discharge summaries and operative notes. This development greatly promotes continuity of care, and also decreases the amount of time spent to request and obtain inpatient records.      The continuum of care is further supported by Practice Partner’s presence on the 8-East inpatient unit at Medical University Hospital, allowing clinic records to be reviewed when a patient is admitted there. The importance with which JCAHO regards this function in patient care delivery makes these mechanisms another plus at survey time.   The convenience of  readily available information is also a great help to UDC nursing staff who handle patient telephone calls for this large primary care practice.    Vendrick said that the system contributes to timely and effective responses since “what the nurse needs to know is immediately available on every patient.”     A number of such calls involve medications and refills, thus the medication profile feature is a valuable tool. Not only does it list current medications and allergic responses (particularly helpful with patients who are poor historians), it also chronicles the patient’s medication history including ineffective medications. Handling prescription refills is considerably simplified—after reviewing current medications, one touch will renew and print any or all prescriptions.   Practice Partner provides a progressive and innovative approach to meet the ever-changing demands of the outpatient care environment. For further information on Practice Partner, contact Tasia Walsh by e-mail walshta@musc.edu.