Basically, I use dokuwiki for the underlying system software. Dokuwiki is free wiki software written in PHP . I have it installed on my own server (not an ISP) which uses dynamic DNS . I’m not comfortable with putting patient records on a web server that I don’t completely control and over which I don’t have physical access. I have the basic dokuwiki system running over https and use strong passwords for security. The only people with  passwords are myself and the physician who covers for me in an emergency. Usually, wikis are used for public collaborative projects, but they also work just fine as a personal wiki, too.

For people who’ve never looked under the hood at Wikipedia or the like, the idea is that you can edit the page you’re seeing on the screen by clicking a button. The page you get to after you click is just plain text, decorated with a few extra symbols that tell the wiki software things like you want something to be a heading or an element of a bullet list. So, for example, in Dokuwiki, if you type:

=====20091212=====
This is some *text*,
and here is a list:
 * one
 * two
 * three

you get something that looks like

20091212

This is some text, and here is a list:

• one
• two
• three

when you finish editing the page.

I have a page for each person’s initial evaluation, and a page for each patient’s history, in reverse chronological order, with each visit under a heading so that I can easily look around from visit to visit. Each time a patient comes in, I put a note at the top of his or her page.

Potentially, every single version of the page of the page is available forever. To keep storage space down, I purge old versions about every 3-4 months, but if I totally mess up someone’s note, I can usually restore to a previous version.

I also have a series of journal pages, one for each day of the month, with everyone whom I see that day listed as a hyperlink so that I can see my patients for the whole day at a glance.

If I have to send records, I use the export_xhtml feature of dokuwiki to get a page suitable for printing, print that page to pdf and mail the pdf to whomever wants it.

For prescriptions, I use NationalErx. The interface is pretty lame and cumbersome (it lacks a lot of things that would make it faster and easier to use), but it’s free, so I can’t complain. At the end of the year I can get a big report of every prescription I’ve written for the year, and I just save an electronic copy of the whole thing for my records. I can also generate reports with individual patient rx histories, or reports by drug.

I have a multifunction fax/printer/copier/scanner and I have it set up to save all faxes to files rather than printing them. When I get a lab or the like by fax, I just copy the file to a directory (one per patient) under dokuwiki so that I know where to find all their paperwork. Occasionally, if I get something like psych testing results by regular mail, I’ll just scan the document in, copy the scanned file to the patient’s directory, and shred the original document.

I have a typed evaluation for everyone, but if my handwriting were better, I could probably get away with just keeping scanning in my evaluation worksheet.

With this very simple system, I basically have medical records for my practice that I can access from anywhere on the Internet, and have almost no paper chart for the patient. The only thing I put in a patient’s paper chart is miscellaneous stuff that’s not worth scanning, like requests for refills. (NationalErx tracks that already.)

Since my whole practice is almost paperless, I have an extensive set of procedures which back up all my key files to truecrypt encrypted volumes stored on and off site.

I use Ubuntu on my practice laptop with full disk encryption, including the root filesystem. The entire disk is encrypted, and even if someone steals the laptop, my understanding is that the encryption on the disk is suitable for data at least up to the level of top secret military information, so I think that’s adequate.

Yes, it helps to be computer literate, but I suspect that a $300 computer for the server and about $300 worth of consulting from someone familiar setting up a web server could probably get anyone a paperless EMR that is suitable for a solo or small group psychiatric practice. For me, the only expense was the price of the server, the time to set it up, and the time to keep it backed up.

If you just have paper records, then this issue isn’t problematic-—you use the computer monitor for Skype, and your regular paper notes. However, my record keeping system is on line, and I need to get to it via my browser. (I use dokuwiki, free wiki software that runs on a server at my home. I keep a daily journal on the wiki of patient encounters and each patient has his or her own wiki page. When the patient comes in, I just put a date at the top of his or her wiki page and write my note. Very simple. Very easy to maintain. Every edit is logged and every previous version is kept. This plus nationalerx.com = free online EMR system that works very well for me. Setup time for dokuwiki for someone who knows how to manage a webserver and understands PHP: 10 minutes.)

The obvious way to solve the problem would be to devote half the screen to Skype and the other half to the browser. In Windows, the easy way to do that would be to tile the windows next to each other and go to work. Unfortunately, Skype doesn’t conform to Windows standards and allow you to resize the window are using, so the tiling commands in the operating system don’t help. I haven’t found an alternative to manually sizing the windows and placing them myself, which wastes a minute or so of my time doing something that should work in a second.

Although I wonder if this flaw in Skype has something to do with DirectX, it still seems that it wouldn’t be too much trouble to fix. Obviously, the Skype window, like any other, needs to be a certain size to be useful. On the other hand, it wouldn’t seem to be much more than a few lines of code to make Skype into a good Windows citizen.