September 2014 Issue

Electronic Medical Records
By Beth W. Orenstein
Today’s Dietitian
Vol. 16 No. 9 P. 42

Transitioning from paper charts to EMRs can facilitate patient visits and help you run your practice more efficiently.

When Angela Lemond, RDN, CSP, LD, started Lemond Nutrition, her private nutrition practice, in 2008 in Plano, Texas, she used paper charts, but it bothered her that she couldn’t send notes to referring physicians that looked professional. “If I handwrote it, it didn’t seem like it faxed well,” she says. And typing up all her notes and records was labor intensive. “I found myself getting behind in my charting,” she says.

Then, in November 2012, on her way home from her office, Lemond stopped to run an errand and thieves broke into her car, walking off with her laptop and her briefcase in which she had five patient charts she had planned to review that evening. That was the final straw.

Lemond, who already had been investigating what it would take to go electronic with her patient records, decided it was time to make the switch. “I had already been getting pricing and thinking of going that route, and when that happened [the theft], it was done,” she says. Lemond now uses MNT Assistant, an electronic medical record (EMR) program designed for dietitians in private practice that has been available since 2002.

Karen K. Patalano, MBA, RD, LDN, CDE, of Boylston, Massachusetts, who developed the KaiZenRD EMR software for dietitians, tells a similar story. When she started her private nutrition practice in 2003, she was using paper charts. As her practice grew, so did her filing cabinets. “I stuffed them full of charts,” she says. “They were so crammed, I had no more room to get anything in or out.”

By 2010, Patalano knew she had to go electronic, as her documentation was incomplete and illegible, and she had no room for more filing cabinets.
Patalano, who has an MBA in technology management from an engineering school, searched for software for RDs and couldn’t find anything that suited her needs. So she used her expertise in systems management and technology to develop KaiZenRD. The name comes from the Japanese words kai, which means “change,” and zen, which means “for the better.” She started using the EMR program in her nutrition practice four years ago and hasn’t looked back since.

No one knows how many RDs in private practice have converted to EMRs. MNT Assistant has about 100 users, while KaiZenRD signed its 100th client on March 1, exactly two years after its release.

John Gobble, DrPH, RD, LD, CHES, of Clakamas, Oregon, who developed MNT Assistant, is certain the number of dietitians who are using EMRs is growing steadily. “Some people come and go from the profession, so our current users fluctuate, but it’s a growing number,” he says.

Patalano offers free weekly webinars for dietitians interested in learning about and using her EMR program. “I’ve had people come to the webinars from all over the world,” she says.

Like Gobble, Patalano has noticed increased interest in EMRs for private RD practices, such as through her well-attended session at the Pennsylvania Academy of Nutrition and Dietetics’ annual meeting in April. She suspects that as Medicare and third-party payers no longer accept paper claims, the demand for EMRs in nutrition private practices will skyrocket.

No Going Back
Now that they’ve gone paperless, Lemond and Patalano can’t figure out how they ever managed without EMRs. They make housekeeping tasks easier: They can store patients’ vital stats, contact information, insurance, referring doctors, medications, and lab results in one place. EMRs also make it easier to keep notes on patients and what was discussed in sessions.

When Patalano was doing all this by hand, she’d sit down after dinner and spend hours on billing and patient chart management, trying to finish at a reasonable hour because she had to start all over again the next morning. “For every eight hours of seeing patients, I had four more hours of paperwork,” she says, adding that charting electronically is much more efficient. “I got back 50% of my time. I was able to work longer hours on the days I leased an office, resulting in more income and a relaxed dinner with my family.”

One of the biggest time-savers was adding billing to the EMR program, Patalano says. “It creates the bill while you see the patient. All you have to do is upload in a batch at the end of the day, and you don’t have to pay for a biller. It’s really simple.”
Lemond doesn’t use MNT’s billing feature because she has an office manager whose job includes submitting bills, but she says having the patients’ insurance and billing information electronically stored in the charts has simplified the process. “We put all the patients’ billing and insurance information in their electronic charts, and she [the office manager] just goes in and pulls it from there.”

Visits More Productive
RDs using EMRs say the systems also make the time they spend with patients more productive. The programs have nutrition analysis tools dietitians can access while patients discuss diet and health or go over their food log. “As a pediatric dietitian, I can estimate the child’s progress and nutrition needs without having to manually go plot it on a growth chart. You really know quickly the patient’s BMI, and you can input it and track it,” Lemond says.

On Lemond’s recommendation, Gobble added growth charts from the World Health Organization for children aged 2 or younger to the MNT program. “Now you can choose one or the other chart set,” Lemond says.

Patalano designed a feature for KaiZenRD that enables dietitians to develop a relationship with their patients using the built-in nutrition assessment forms. In addition to name, address, and insurance, the forms ask for the patients’ family, medical, and nutrition histories; what medications they’re taking; and why they think they’ve gained or lost weight. “It’s a really nice way to get to know the patient,” she says.

Patalano enters information about what she discusses with her patients directly into the EMR during their visit. She created customizable drop-down lists, so it’s often only a matter of calling up recommendations for a patient note or foods for a meal plan that can be customized for diabetes, an eating disorder, or whatever health issue the patient has. Then it’s just a matter of checking boxes vs. lots of typing, she says. “Some RDs are fearful of that.”

With KaiZenRD, “When the patient gets up off the chair, you’re all done with the patient note, doctor’s note, and the bill,” Patalano says. “That was a huge plus for me. Before, I had to come home to a suitcase full of paper I had to deal with.”
At the end of a patient visit, Patalano can generate a report with a summary of the visit, menus, and instructions and give it to the patient. The reports she gives to her patients and the referring physicians are professional, easy to read, and even have a logo on them. “The patients and doctors are delighted with them,” she says.

If dietitians use SOAP (subjective, objective, assessment, and plan) or ADIME (assessment, diagnosis, intervention, monitoring, and evaluation) notes, they’re available with the EMR as well. Patalano leaves room at the bottom of the patient feedback form where she can type a personal note, such as “Great job on snacking this month” or “Here’s why you need to exercise more.”

Like handwritten notes, EMRs can contain errors, such as when incorrect information is copied and pasted multiple times. It’s important for dietitians to check their work whether it’s on paper or the computer keyboard. Moreover, patient information that’s stored electronically is HIPAA compliant, so patient privacy isn’t a concern, Patalano says.

Because KaiZenRD is a cloud-based program, patient records can be accessed through desktop computers, tablets, and smartphones as long as there’s an Internet connection. Lemond believes that if her patients’ records had been kept electronically when thieves broke into her car, she wouldn’t have had the issue she did. “Some of the files that were stolen were kids’, and we had to tell the moms that some of their information was taken,” she says.

Lemond also was fearful that the break-in would damage the relationships she’d worked so hard to develop with the referring physicians. Fortunately, there weren’t any serious consequences from the theft, she says.

How to Get Started
Gobble says that instituting and using EMRs in a nutrition practice requires some organization. “You have to create templates and a process and stick with it,” he says. But once you have your templates and processes down, “it doesn’t take that much time. It’s just a matter of getting used to it. Once you have it down, ‘boom,’ you do it and it’s not a big deal.”

Lemond believes using EMRs has increased her credibility with referring physicians and makes her practice look professional. And her name and logo are printed on the forms she sends, “so it keeps you in front of them,” she says.

The RDs interviewed here also have been able to easily search their EMRs for material for research studies. “We’re living in the information age, and we’re interested in questions such as, ‘How many people did you see with this condition?’” Gobble says. “It’s easy to do a search if your patient records are electronic.”

Gobble was one of the authors of a study published in The American Journal of Cardiology in 2012 on the effectiveness of a 30-day lifestyle modification program delivered by volunteers for reducing cardiovascular disease risk factors. By searching patients’ EMRs, Gobble and his colleagues collected data on more than 5,000 patients. From the data, they were able to show that volunteers can be valuable social capital in the fight against cardiovascular disease. Their study concluded that “when sourced with appropriate, well-developed materials and programs, volunteers can act as powerful agents of change for health promotion within their community.”

At her presentation for the Pennsylvania Academy, Patalano offered outcomes data from KaiZenRD that showed statistically significant weight loss and an increase in exercise frequency and duration in patients after nutrition counseling by private practice RDs.

Connectivity Issues
Lemond’s only concern about using EMRs and storing them in the cloud involves Internet outages. “If for some reason you can’t get online, that would be a detriment,” she says. Fortunately, most people aren’t without power for long or have lengthy technical glitches, she says.

Kristi King, MPH, RDN, CNSC, LD, a senior pediatric dietitian at Texas Children’s Hospital, which has met the federal mandate for public and private health care providers to use EMRs, sees another possible drawback: “When everything is automated and calculated for you, you could lose the ability to do it in your head if you have to. You could forget how to use certain skills if you’re not practicing them.”
But it’s also good to double-check the computer’s math. “If you do the math, and it comes out differently from the program in the electronic record, it’s going to tell you something.”

Lemond says dietitians in private practice also have to consider the cost of implementing and using EMRs. “You have to justify the cost,” she says, but “I would highly recommend it. It really makes our profession look better and more consistent as a health care provider.”

Patalano’s program, which includes unlimited free billing and support, costs $85 per month. The fee covers the cost of hosting the program, she notes. MNT Assistant runs $49 per month for the first provider in the practice and $29 per month for each additional provider. Ancillary users, such as administrative assistants or bookkeepers, may be added for $19 each per month.

If you’re considering EMRs, you’ll need a program that’s customizable. Both KaiZenRD and MNT Assistant meet this criterion. Patalano and Gobble recommend reviewing your practice’s needs and determining what forms would be most valuable to have in your program and on your website. The developers are willing to work with you to get you set up and teach you how to use their programs.

— Beth W. Orenstein is a freelance health writer living in Northampton, Pennsylvania.

Interested in learning more about electronic records for private nutrition practices?
Contact Karen Patalano at or 508-335-2452. Visit her website at to learn more about her software. You also can contact John Gobble at or 503-746-9134. Or visit his website at