A lot of places are using proprietary and commercial software for chart entry (Newark-Beth Israel, but that was 2 years ago, Duke), and for data retrieval - "Tracemaster" is a great program for places that use it. Tracemaster has 12-Leads scanned in, so you search for the patient, and you can print out on a laser printer. Mt. Sinai has some old system, but it brings up the EKG, and prints it out on real EKG paper.
The Duke system is set up so that you can use a template, which provides all the elements needed for billing (by level). The templates are meager, though, and it is MUCH easier for me to generate a note de novo, but, then, I run the risk of not fulfilling what is needed. There is no good answer. If they call me on the carpet for it, what can I say, but techno-failure?
HHC hospitals in NYC (Bellevue, Jacobi, Elmhurst, that have EM programs) have "HDS", with labs, radiology, and clinic notes that have been entered available.
And the "pièce de resistance" - PACS. As a nuclear med doc told me (a very traditional Jewish guy) - "It's better than chopped liver!" Before PACS, xrays and CT's ran the risk of being lost, and the logistics of mounting films took time. Now, the films are available as soon as they're entered, and places with PACS stations in the ED don't have to bother radiology unless there's a question.
NY-Presbyterian had talked about wireless Palms to send lab data and other info directly to providers in 'real-time', but, I believe, progress has been meager.
