On Aug. 14, internal medicine specialist Anthony Fiorillo saw three patients at Shadyside Hospital during morning rounds, then 13 more at the Oakland office of Solano, Kokales Internal Medicine and Associates during the afternoon.

Patient-wise, it was a relatively light load for Dr. Fiorillo, 54, who splits his week between clinical care and overseeing a UPMC team implementing electronic health records in the office setting. During hospital rounds, which begin at 6:30 and end about 9, he sees as many as 10 to 13 patients. On his busiest days in the office, he sees 20 people between the hours of 10 a.m. and 5 p.m. His practice schedules 20-minute visits, five minutes more than most practices, and the affable doctor admits he has a habit of going even longer than that with his patients and thus gets behind.

Paper-wise, it's never a light load.

Dr. Fiorillo said a study done last year with 10 physicians in the practice found they received 4,000 pieces of paper relating to patients in a single week.

"That included patient correspondence, physician correspondence, lab tests, radiology tests, insurance requests," he said. "We found when we did the study there was a lot of redundancy ... we probably only needed to receive 20 percent of that because we already had access to information being passed to us.

"I bring that review up just to point out what a primary care physician receives, how inundated he is with requests for information," he added.

"That's 400 pages a week per doctor for a five-day period."

It's an old story -- and one not limited to doctors. Dr. Fiorillo said that President Ronald Reagan's secretary of Health and Human Services proposed in 1985 a standard single-billing form he hoped all insurance companies would accept. The reason: The U.S. health system would save $5 billion a year in administrative costs.

It is no wonder then, Dr. Fiorillo said, "that a common complaint of doctors is 'you're turning me into a clerical worker.' "

Dr. Fiorillo's own desk bore witness to the complaint when he arrived Aug. 14. On it, next to a computer that he uses as much as possible, was a 2- to 3-inch pile of papers. He also needed to fill out a form connected to home care he had prescribed for one of the patients he saw that morning at Shadyside.

"She needs these papers filled out to get some home-care needs -- oxygen, a bedside toilet, home-care nursing," he said. "Any time you have a nurse enter a home and do anything, any care, I have to sign off on all of it. Outside home care is very, very common, but there's a lot of paper for a single visit."

Sometimes multiple-page forms, like those for occupational therapy, have to be signed on every page. If they're papers that can be scanned into and sent by computer, he uses a stamp of his name. Others he has to physically sign.

"This is from Jefferson [Regional Medical Center]," Dr. Fiorillo said of another paper on his pile. "If we had an integrated [computer] system, we'd be able to send it to my in-basket and I'd read it, sign it and it'd be contained within the patient record."

At one point, he shook his head and smiled. "You have to tell me when to stop," he said, but his enthusiastic campaigning for electronic records is contagious.

At 10:20, he got a break from the paperwork with the arrival of his first Oakland patient. The patient asked to be identified only as Jerry, 70, of Westmoreland County.

Jerry said he told Dr. Fiorillo his heart beats harder at times, so the physician has ordered him to wear a heart monitor for 30 days. The patient also reported that Dr. Fiorillo told him losing 10 pounds wouldn't hurt.

Later, Dr. Fiorillo said that during appointments, he jots brief notes about the patient on his computer, using a template he has developed. After every three patients he then composes longer, more formal notes on each of them.

"I have been practicing in a time when documentation of care has evolved from simple short notes on paper to structured electronic notes on the computer," he said. When he joined the practice in 1992, the doctors did notes on 2-by-5 index cards "on which you could jot two or three things: 'patient looks ill, suspect bronchitis, amoxycillin.' By today's standards that would not fly."

Insurance companies look at doctor's notes and require a lot more information to see if content matches the billing, he said. Specialists who see his patients also require more content.

For those reasons, Dr. Fiorillo said, the best time to create a note is within the first couple hours after the patient visit. Otherwise, "the details slip away and so much in medicine, especially internal medicine, we're looking for patterns in health, patterns in disease. If you forget those nuances you may miss those patterns, so it really is important."

Nevertheless, he knows doctors who do all their notes at night and one who does his Thursday and Friday notes on Sunday.

The next patient is Dominic, 81, of Plum, who has been accompanied by his wife to the appointment, a four-month checkup.

"He said I'm doing good, I'm doing great," Dominic said afterward.

No wonder: Dominic is a model senior patient. Slim but fit, he goes with his wife to a gym for a senior citizens' workout program three times a week. They lift weights and do exercises for balance. They even do Zumba -- dance aerobics with a Latin beat.

Though his patients see a kindly hands-on physician, Dr. Fiorillo continues to evaluate new ways computers can help in the delivery of care.

For example, every physician now has a national Provider Identification Number that is issued by the federal government and required for prescribing narcotics. It also can be used, if desired and if the necessary computer interface has been installed, to electronically order from a drugstore any prescription except narcotics, which must be printed out on water-marked paper and sent to the patient.

"We've been e-prescribing for about 18 months," after UPMC tested the system with a few practices over three or four years, Dr. Fiorillo said.

"The FDA and Medicare are what are driving all electronic health records and that's a good thing because at least they're willing to set some standards."

Lillian Walter of Mt. Lebanon, who had just celebrated her 77th birthday the previous day, was Dr. Fiorillo's next patient. It was her regular checkup and included taking her blood pressure and vital signs. Earlier, in another room of the office, she also had an EKG.

"He asked how I'm feeling," she said. "He's very wonderful to talk to. That's always the case. He loves when someone asks him a question."

Nowadays, some of those questions come by computer. The practice is encouraging patients to register for electronic data transfer. A reference to the system as "e-mail" sparks a quick correction.

"It's not really an e-mail," Dr. Fiorillo said. "It's actually a secure messaging system where the patients send me messages in the context of their chart."

Today, for example, he said a patient reported continuing back pain; Dr. Fiorillo probably will recommend surgery. Another wondered why the surgeon he saw for a colonoscopy told him to have another in five years rather than 10.

"It's variable," he said, when asked how many e-mails he and his colleagues deal with daily. Looking into the various colleagues' files, he sees one doctor with only 12 in his basket; another has 87. Dr. Fiorillo has 25, half of which are from the previous day.

Michael Malley, 69, a personal property appraiser from Regent Square, had come in to see Dr. Fiorillo for a six-month checkup.

"I have a little high blood pressure," Mr. Malley said. "I feel pretty good. I take one pill a day.

"I've known him long enough to ask about the family. It's nice to have a doctor you have confidence in and know he'll care for you.

"I've had other doctors for other issues where I felt I was part of a factory."

That's just not Dr. Fiorillo's style, whether he's dealing with patients, reporters or employees.

"He's very easy-going, a nice guy, personable," said Alice Sutton, executive secretary in his electronic health records office.

He'll need that affability in heading doctors' conversion to the electronic records. He said it's going to be a "hard sell for physicians. They really struggle. They have to change their work flow and at times do extra work. Eventually, after a year, they'll be back to being time-neutral, but they'll say 'Where's my gain?' "

There's an improvement in legibility -- no more unreadable physician's scribble. There's also "decision support," such as when the computer finds associations like drug interactions or allergies and informs the doctor.

The quality of care will improve, Dr. Fiorillo predicted.

"The gain is the patient's safety."

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