Phase change

My moving date to the new office is August 22^nd 2009. We are getting very busy with the many details that go into the move.

Informing everyone is very challenging. As soon as the date was set, we sent a letter to all the patients in the three practices in this office. I also periodically update my website (http://drgreiver.com), and we have the date and new address on our answering machine’s message.

We have been informed by eHealth Ontario that the new Internet connection will be ready on time; there will be several family practices, as well as the Family Health Team’s main clinical location (home office for Allied Health Professionals, program managers) all operating from the 7^th floor at 240 Duncan Mill. About half of the physicians in the FHT are moving to the new office; all of us will be using the same EMR software, and all accessing the software remotely; there will be no server on the premises. My husband tells me that these days, many larger companies (including his) are distributed all over the place and no longer have a server with their corporate database on site; his is actually located in Cleveland. If you include all physicians moving in, Allied Health Professionals, support staff, medical students and Residents, we’ll have between 75 and 100 people accessing data remotely at the site. I hope we have a big enough connection for our size.

Our Family Health Team is actually fairly complex; it is composed of six smaller groups of family physicians (Family Health Networks or Family Health Organizations). Some of the groups had already chosen their EMR system before the formation of the FHT, which is why we ended up with two different systems. As well, some groups chose to transfer their software to the new provincial eHealth Ontario ASP server; my group had thought about it, but for reasons detailed earlier, decided to stay on our server at the hospital. Within our server, there are two groups, mine (with 14 physicians) and our sister Family Health Organization with 9 physicians. Even though we use the same server and the same database, we cannot share EMR data across our two groups.

17 colleagues in two different Family Health Organizations decided to go to the eHO ASP model, but as a single data base with shared data; they use the same EMR software as I do.

14 of my colleagues use another EMR software. Four are in one office as part of a FHO, with their server in the office. Ten physicians in a different FHO are dispersed and access a server located in one of the offices.

That makes 6 physician groups, two EMRs, 3 databases using one software application and two databases using a different software application. No wonder our Executive director is getting grey hairs! Even though we are now a mid-sized company as a FHT, our IT infrastructure does not make running programs in common very easy. In retrospect, I guess it may have been better to form Family Health Teams first, and then choose a common EMR and common database for all of us. However, primary care renewal initiatives happened at the same time as the EMR transformation, so things like this were bound to happen. We’re not the only FHT with this issue; a large FHT in Hamilton has 6 different EMRs. Maybe what will happen over time (perhaps a long period of time) is that we’ll eventually join our information in a single database (or maybe two databases, one for each EMR) so that we can actually run and track programs based on our actual data. I can’t imagine any mid-sized corporation not knowing how they are doing, and not having data for forecasting and planning purposes—and yet that is how we operate at the present time.

In any case, we are slowly starting to develop some Data Management skills in my group of 14; part of this is through participation in studies like CPCSSN, where we have a Data Manager to help us, part is through Quality Improvement collaboratives like QIIP. My practice has a Facilitator through QIIP, and she is helping us think about how to organize our data so it makes sense. There is no FHT Data Manager, which is a bit strange considering how much data we have.

For example, having some idea of what percentage of smokers are in our practices is useful if you want to think about planning a program for this. We have 9515 patients with data on smoking; of those, 1964 have been tagged as smokers (20%). I’m sure there are issues with inconsistent data entry, data errors, etc, but at least it is a start. We need to figure out how to identify patients who have no entry on smoking in their chart, and perhaps decide as a group to put a reminder or alert in the chart, so that the next clinician who sees that patient can ask them if they smoke or not.

As you can see, change in ongoing for me, for my practice Team, for my partners, and for our Allied Health Professionals. When I look at this ongoing diary, I guess one way to think about this is as a very slow motion train wreck. However, it does not feel like that to me at all; I prefer to think about it as a slow thaw towards a much more interesting state—ice to water. Phase change.

Reviewing and changing my scanning process

I have changed my scanning process. My EMR company had provided software called "ADM" (or Advanced Document Management) in the past, but I didn't use it. The reason for that was that the quality of the images (they were in jpeg) was poor.

There are two ways to scan data in my EMR:

1. Through the ADM program, which is separate from the EMR, and automates much of the process
   
2. Directly to the EMR, through an upload and attach process in the application

I used the second method; we scan documents as pdf files, save them to a folder on the PC's desktop, and then upload and attach to each patient's file. This is a very laborious process, but the images are very clear. I prefer to have a longer process at the front of the office and to end up with better quality images.

However, I heard from several colleagues that the new ADM program was significantly better; I went to see it, and it was better. Another physician in my group came to my office to have a look at our scanning process (she was using ADM). We had a look at her scans during lunch, and figured out that some of the quality problems were due to the fact that she was not using the right software to open the files. Her scanned files were saved in tiff format; we switched to MS document imaging--it looked better and we could use OCR (Optical Character Recognition) very easily. I had found out how to associate file extensions with different programs because of a home computer problem, so I was able to do the switch for her.

The ADM software does not work out of the box. My IT guy had to install it and to tweak some other files to get it to work properly. However, once that was done, it worked. He showed us how to use it; we started and had to make a couple of changes, but now it works well.

My scanning tech can now scan papers in batches: she puts a whole stack of papers in the scanner, and scans everything into a single file. The program automatically saves it to the right area without the need for naming the file. Once it is in, the ADM software shows her what has been scanned, and she uses it to attach different pages to different patients and different areas of the chart. The software then uploads the file to the right area of the EMR.

I then see it as a tiff file attached to a patient chart in my EMR inbox (separated into lab, DI, correspondence). I can click on the file's link to open it up. Once I see it, I run the OCR process (using the little "eye" icon in MS doc imaging), which is very fast, and then I can highlight what I want and copy and paste it into the "comments" section.

OCR in tiff seems to work better than in pdf--it is easier to highlight the section you want to copy. I find that I am copying more of the letter to the EMR.

This is still problematic. OCR is not perfect, and there are always errors. You have to proofread and correct the text, which takes time. I have a saved copy of the original, so what I do is look for bad errors (numbers being wrong etc), and leave minor problems alone--example: MRI OP BRAIN.

Anything which is OCR'd and copy/pasted is now saved as part of the EMR record (not a scan), and is searchable. If you are parsimonious with what you put in, you end up with a nice summary which is easy to look at (CT chest: granuloma RUL. Echo: Normal). If you put in lots of stuff, it becomes harder to wade through the information or you have to do a text search. If you put everything in via OCR, you don't have to individually load each scanned document when printing a referral or a transfer, but you can end up with a lot of misspelled garbage, and there is no formatting--it is hard to look at.

I'm kind of in between the two. I'll copy the relevant paragraph to the EMR (diagnosis, management suggestions), and leave the rest as a scanned document. When we transfer a chart because a patient is moving to a new family physician, my secretary copies the EMR chart to a CD, but not the scanned documents. I figure the EMR really contains the relevant summaries of everything that is needed. I don't know if I should start including only the EMR summaries instead of the scanned documents when sending referrals; I guess it depends on what the referral is for.

You can see what it took for me to change my process:

• Better software from the EMR company
  
• Seeing for myself that the quality of the images had improved
• Figuring out the file attachment problem (over lunch with a colleague)
• Having a good IT person who could both do the installation for me, and troubleshoot it afterwards
• Training on the new processes and revising how the secretary scans at the front and how the doctor looks at the scan
  

Of course, there were problems in the first couple of days: my scanning tech found the pictures on the screen too difficult to look at (until we figured out where the magnifying glass button was); there were errors in attaching scans (wrong area, wrong patient). My partner has MS Office 2007, and MS document imaging doesn't automatically install itself in that version--I had to go online to figure out how to make it load on his computer. You have to have patience with these new things. Our IT guy also figured out how to make faxes and scans automatically go into the same folder, so now the upload process is fully integrated. It doesn't matter whether the incoming is via fax or via scanner, it all looks the same.

I don't mean to imply that I like scans now; I still think that it is a waste of everyone's time to have to re-digitize documents that were originally produced in digital form. However, the hardware and software is getting better at handling this necessary evil.

Michelle

User group meeting

I went to the annual user group meeting last weekend. I believe that bringing together users is extremely valuable; we shared many tips and tricks on how to use the EMR more efficiently and effectively. We complained a lot, and laughed a lot too. I met several colleagues who were at various stages of implementation; more experienced users were extremely generous in terms of sharing what works for them.

The EMR company's executive team were there; at the end of the meeting, we discussed our "wish list". Some of the requests were:

• Templates that can be exported and shared with others (the #1 request)
• Increased scheduling flexibility for larger groups
• Improved data mining and reporting capabilities
• Better ways of entering and reporting chronic disease management data
• Ongoing training
  

The head programmer demonstrated the new data mining software they are working on; this looks like it fishes data straight out of the database, and should give "power users" a lot of control over what is reported. I can't see having everyone learn database management skills, but several of us are getting more and more interested in seeing what we can do with all the data we are accumulating. Perhaps what will develop in some groups is data expertise (this does not have to be a physician), so that quality improvement projects can be started for entire groups. It will be much easier to do this for groups of physicians rather than for solo physicians. I think the formation of groups in Ontario (Family Health Groups/Networks/Organizations/Teams) is likely to bring benefits in terms of data management capabilities.

The company talked about their plans for "reportable fields". There was a lot of interest around this. As far as I understand it, this is new fields that can be inserted into templates, and that automatically go into into flowsheets, and that can be searched for later.

Altogether, I think this was a valuable meeting to attend, and I plan to attend next year. The EMR is now so central to our practices that it is worth investing time and effort to build and maintain proficiency in it.

Our last two filing cabinets were sold and picked up, and I did a happy dance over the floor space where they used to be; there is now a lot of space at the front. Our moving date to the new office looks like it will be in August (likely August 22nd), and I am trying to get rid of as much paper as possible. We still have some paper handouts, and these are getting tossed out. I'll have a look around and make sure that we are as paper-lite as possible.

The move to the new office is much more complex due to the EMR. eHealth Ontario is overseeing the internet connection in the new office, and we have to make sure that there is overlap (we need to have two SOFAs--Small Office Firewall Appliances) during the transition so that we can continue to function. We are investigating VOIP phones as a group. I have to make sure all the wiring is planned properly and that there is redundancy for the future. I have a small IT closet in the office for all the routers. I started an Excel spreadsheet of all the things we have to do, and this is growing faster than public health swine flu notices.


I took part in the CPCSSN national meeting later in the week. CPCSSN is composed of 9 different sites in Canada, and all sites are reporting anonymous EMR data on five different chronic illnesses: diabetes, hypertension, depression, Chronic Obstructive Lung Disease and osteoarthritis. I am part of the Toronto group, Nortren. There are eight different EMRs involved, so this is a very complex project. It looks like this is feasible, and primary care can be used safely and effectively for chronic disease surveilance. This likely represents an important part of the future of Public Health.

Finally, it upsets me a great deal to read about the problems currently besetting eHealth Ontario. I agree with Dr Brookstone's post, this will be a major distractor for the organization. My group has had multiple difficulties with eHO and its predecessor (SSHA), mainly centered around service provision and communication; however, I completely agree with Allan that this is a large and complex undertaking. The current chair, Dr Hudson, and the previous CEO, Sarah Kramer, have extensive knowledge and experience in this sector; I hope the executive branch of eHO will be able to maintain focus on their priorities. This news release came from our Minister of Health, David Kaplan, today:

"The board reported to me that the current uncertainty surrounding eHealth Ontario threatens to delay initiatives that are crucial to our government's plan to modernize and improve our health care system.

I am acting immediately upon its request to revoke Sarah Kramer's appointment as eHealth Ontario President and Chief Executive Officer. Ron Sapsford, Deputy Minister of Health and Long Term Care, will serve as acting President and Chief Executive Officer of eHealth Ontario until an interim President and CEO can quickly be appointed.

This decision is an important step to restore public confidence in the agency and its mandate of modernizing our health care system."

Michelle

Quality improvement, year 3

Our quality of care for preventive services continues to improve. We have 9,985 eligible services. We provided 87.75% of these services, compared to 73.53% last year, an increase of over 14%. It was interesting, because quality of care went up for every service, for every physician. We also went from 9 physicians to 12. Part of the improvement was better, more consistent data entry by everyone, and part is an actual increase in services; I can't know which is which, but I have no doubt that there is an actual increase in services.

Pap smears went from 74% to 89%; mammograms from 74% to 88%, and influenza vaccinations for the elderly from 71% to 85%.

Our Fecal Occult Blood (FOB) screening program has now started. We were able to extract a list of patients with Colorectal cancer or Inflammatory Bowel Disease for every physician (through ICD codes); these lists were then faxed to each physician for verification. Our data entry person has now entered a code in all Cumulative Patient Profiles to exclude those patients from screening. Every practice knows about the code, so patients newly diagnosed can be excluded in the future.

My colleagues have been good about entering colonoscopies consistently and in the right area of the CPP; we generated lists of all patients with colonoscopies <5>

We will then cross check the remaining patients with the paper lists of FOBT (from lab billing data) that the Ministry of Health recently sent us; we mailed FOBT letters last year as a trial, and this worked, so once all the data entry is done and cross-checked, we'll go ahead with mailing patients overdue for this screen. Our FHN administrator will notify everyone ahead of time, so all practices have time to prepare (order extra FOB kits, make sure that everyone knows to put in a lab req when patients come in to pick up the kit etc); we also email a copy of the letter template to every physician for approval prior to mailing. This will enable us to monitor FOBT from now on and to add FOBT to our regular 3 monthly mailings. I expect this to be completed by July or August, with the first mailing going out then.

Here is the letter to patients:

Dear

Our records show that you are due for a Fecal Occult Blood (FOB) screening test. FOB screening has been found to decrease the risk of dying of cancer of the lower bowel, and should be done every two years.

Please come to the office to pick up your FOB kit. You do not need to make an appointment for this.
If you have had a colonoscopy in the previous 5 years, then you do not require this test. Please inform the office if a colonoscopy has been done.

FOB screening is an important part of keeping you healthy; more information on early detection of lower bowel cancer can be found at http://www.coloncancercheck.ca

As your Family Physician, I appreciate the opportunity to work with you to prevent illnesses and enhance your health.



We are now at 14 physicians in my FHN; we'll add our two new colleagues to the preventive program this summer, which will bring us to just over 15,000 rostered patients. We will also get data auditors to cross check the paper lists to make sure that patients who are rostered on the EMR are shown as rostered on the Ministry lists. We'll do a cross check for patients who already have two letters mailed, to make sure that they have not had an overlooked service. You have to maintain your database, and double check things. As well, during the summer, all patients with two reminder letters and still no response get an extra phone call, as we hire summer staff for this.

We are also getting data entry for our diabetes registry; this adds reminders to look at the flowsheets every 3 months. Several physicians in my group have been looking at overdue reminders, and have called to remind these patients to come in. I thought this was a good idea, so we had a look and found 6 diabetics who had not come in for over 6 months. My secretary called all of them, and four have booked appointments.

As a test, I had data entry done for all my diabetics for last date of retinopathy check (for eyes) and neuropathy (foot exams). I was able to generate a list of overdue retinopaties (>2 yrs)--17 patients--and these are now all getting a reminder letter; as well as overdue foot exams--14 patients--and these now all have an alert in the chart. My nurse saw a diabetic in for another reason, noticed the alert, did a foot exam and marked it as completed. The system now shows me the list with that exam completed, and the date it was done.

I think that our system is slowly maturing, and I have evidence that we are using EMR capabilities to improve quality. I think this is what you should be able to achieve by the third year of EMR.


The last two filing cabinets have now been emptied; all paper charts are gone from the front. I put the filing cabinets on Craigslist yesterday, and sold them today. Paper charts have no place in this clinical setting.

Michelle

Outbreak

We are now in a Category 5 outbreak, with several cases of Swine Flu (H1N1) reported in Ontario.

I went through SARS in 2003; my hospital was at the epicenter of the second wave of the outbreak; I had been on the floor where the first cases were detected. I was quarantined; my practice partner volunteered for the SARS unit of the hospital and he took care of our colleagues and co-workers who were ill. I remember this.

At that time we had no way of rapidly communicating information. Most of us were receiving everything by fax; Public Health and other government agencies had no email lists of physicians. Our hospital department could not reach us (they didn’t have our email addresses either); the physician’s lounge was closed, and we could not pick up reports or information. Our department chiefs went to work and rapidly built up email lists; giving your email is now a routine part of reappointment for hospitals and medical organizations, and the lists have been maintained.

Since I started using the EMR, I have left my email on at all times at the office. I am now receiving updates on the outbreak from Public Health several times a day. My hospital also sends out routine updates and reminders, as does my Family Health Team; so do medical organizations, such as the Ontario College of Family Physicians and the Ontario Medical Association. It is a bit overwhelming at times, as I get the same information from several different sources, but I am updated. Many of my colleagues use a Blackberry. I think the information “push” is now very good, and certainly light years of where we were in 2003.

However, it is still difficult for me to send back information to Public Health. They want us to report the information on cases of suspected swine flu by phone. This is going to be a problem if the numbers surge: they are going to be quickly overwhelmed, just like the last time. I think it would be better to upload via secure web, email, or fax as an alternative. Ideally, I’d like to send the information electronically straight from the EMR, but I know this is not possible because systems for this were never put in place.

I also think we should be able to automatically send some anonymized EMR data straight to public health; I would certainly volunteer to be a sentinel practice for this. Here is what I mean: I would like to automatically upload to Public Health temperature readings from my office (they are in a field in my database) with their associated EMR date and time stamps, linked to the patient’s postal code (only the first half, or Forward Sorting Area, FSA). It would not be difficult to aggregate temperatures and FSAs from several practices; Google does this kind of thing very well. Sort through it and pick out temperatures >38 degrees. You can quickly see the clusters of fever by geographic area. This would require special protection for privacy, but would potentially allow real time tracking of an outbreak in an emergency situation.

I’ve been thinking of the most efficient way to remember what I have to do and to record the data in the EMR; this is through an encounter template. What I did is program a template for my entire FHN (since we are on a common database), which contains all the information sent by Public Health—so we know what to do. As the information changes, I’ll just update the template. I put the phone and fax number of our local public health unit in our common FHN phone book; when I have a suspected case, I’ll load up the template, fill it, and save it to the record. I’ll then start a consult note to Public Health (which automatically contains all the required patient demographic information straight from the record, as well as my name, address, phone number and email), attach the encounter note to the letter, and electronically fax this to Public Health. Then I have a record of what I did, as well as of the fact that it was reported.

Perhaps Public Health could set up a secure email address for reporting, through eHealth Ontario’s ONEMail system. I have access to ONEMail (see previous post), and this would actually be a very good use of that system. Reports emailed within the ONEMail system are completely secure.

Here is the structure of the template; it is very simple. If you have an EMR, you are welcome to reproduce or modify this as you see fit.

• Swine flu (ILI, Influenza Like Illness) template

• Report all cases of Influenza-Like Illness (ILI) with a travel history to Mexico or contact with a case of swine flu in the last 7 days to the public health unit, phone xxx fax yyy
• 
  
• Travel to Mexico in past 7 days? (Y/N)
• 
  
• Contact of swine flu case in past 7 days? (Y/N)
• 
  
• Date of symptom onset:
• 
  
• Outpatient (Y/N)
• 
  
• Upper Respiratory Tract infection? (Y/N) OR
• 
  
• Lower respiratory tract infection? (Y/N)
• 
  
• 
  
• Other Major symptoms such as gastroenteritis?
• 
  
• Temperature:
  
• 
  
• For patients presenting with ILI (Acute onset of fever and new/worse cough or shortness of breath; additional symptoms may include sore throat, arthralgia, myalgia, headache or prostration. In children under 5, gastrointestinal symptoms may also be present.) and a history of travel to Mexico or contact with a confirmed case within 7 days of onset of symptoms, a nasopharyngeal swab can be sent to the Toronto or regional public health laboratory.

Michelle

The three year old EMR

I now have a three year old EMR. I am way past that terribly disruptive newborn period, have dealt with the Terrible Twos, and am starting to reap some nice benefits from a maturing system. The EMR is definitely more responsive and pleasant these days, although it can still throw the occasional tantrum.

I now have three years' worth of data in my system, and am increasingly interested in using this data to improve my quality of care. My practice team went to the Quality Improvement and Innovation Partnership (QIIP) a few weeks ago; there were 50 Family Health Teams represented. My team was able to generate some statistics from our system, but few others could do this. Almost all FHTs are using an EMR, but many are newly computerized; the ability to routinely generate practice-level information (how many diabetics do I have? How many of those are at goal for their cholesterol?) is still very rare—even for those with older systems. It was a little worrisome to see that all this information cannot be put to good use because it cannot be routinely aggregated within practices.

I think that there are a couple of reasons for this

1. EMR systems were initially designed for individual patient care, replicating our paper charts. They are not designed for practice-level audits (which are critical to improving quality)
2. We do not enter data consistently; in other words, we do not have good Data Discipline. If you enter “diabetes” as T2D, NIDDM, DM2 etc, you can’t consistently look for diabetes afterwards. You have to code your diagnoses.

We have to report on a whole series of measures for QIIP, for diabetes, colorectal cancer, and office efficiencies, and I can see that this will present a whole lot of problems for all of us. Perhaps it will make us demand more and better auditing capabilities from our EMR vendors. Perhaps it will make us think more about how we enter data in our EMRs.


I will be moving to a new FHT office designed specifically for the EMR. We have just signed the lease, which is very exciting; construction will start now and I expect to move this summer. We have printed announcements on cards which we are handing out to patients, and we are asking them to regularly check my website, http://drgreiver.com for updates.

We finished scanning my partner’s paper charts into the hard drive at the front, and they have been backed up to two sets of DVDs. He won’t allow my staff to shred the paper; I think many of us still need the old charts for security. I have not allotted any space in the new office for filing cabinets, so the charts will have to go to his basement or to storage when we move; then we’ll finally be paperless. I am selling the last two remaining filing cabinets on Craigslist soon.

The Allied Health Professionals (AHPs) in my office are now using the EMR routinely and consistently for all care. We decided to use eMessages in the EMR instead of faxing referrals; they check the EMR remotely on a very regular basis, and this avoids generating paper. We talked about where to enter data, and our Team’s Social Worker, Dietitian, and Clinical Pharmacist all decided to enter their reports in the Clinical Notes. They sign off when done, and send me a short eMessage linked to the patient’s chart. Both my practice partners agreed to try this system, and are much happier with it; I hear this approach is spreading to other practices in our FHT. If I have a question about a patient, I just send a message; this has greatly enhanced Team communication. For example, I routinely fire off a quick query to our Clinical Pharmacist when I have a question about the best approach for a patient’s medications; she links to and reviews the chart, and sends me back a note along with a link to appropriate on-line resources if needed.

The schedule for the AHPs was being managed centrally at the FHT’s office, using non EMR software. We all decided that it would be better if the schedule was within the EMR and in our office. I made a schedule called “Allied Health Professionals”, and when I need to refer somebody to our Dietitian, they just go to the front and book the appointment with my secretary. The Dietitian can see her own schedule both remotely and when she comes in the office, and she brings up the patient’s eChart directly from Scheduler.

AHPs in other FHT offices must be hearing about this, because I am now regularly being asked to set up them up in the EMR; everybody wants to use the EMR. I don’t mind doing this, because I can do it fast, and I think it is important to do it correctly. Our FHT’s AHPs get their initial training at the EMR company, and then some come by at lunch for a quick orientation and help with initial log in. I think the integration of all Team members will accelerate even more once we are co-located at the FHT office, and can do EMR “lunch and learn”.

My FHN colleagues are doing some very innovative things with their system. Quality Improvement initiatives and good data entry practices seem to be routinely on the agenda at our FHN meetings. For example, one of my colleagues systematically looks for patients who are overdue for their diabetic visits (using the EMR reminder system we set up last summer), and sends them a recall letter. Another physician decided to have her FHT RN recall the overdue patients and manage their visit. I think we are starting to mature as a group, along with our EMR. I updated our FHN diabetes registry (we now have 805 diabetics out of 15,000 patients), and the coding was much better than last year.

My office administrator recently received a letter from a specialist in MS Word, emailed to our office address drgreiveroffice@rogers.com . We talked about what to do with it, and decided to copy and paste the note into “comments” in the incoming correspondence part of the EMR; no printing, no scanning, no OCR, and no OCR-related errors. It is not quite as good as a direct electronic import into the chart like labs, but is so much better than fax; I would really like to use secure email, but the SSHA email system is very impractical so nobody uses it—you have to change your password every six weeks, you can’t have a general office email for people to send things to, it won’t forward a notification that there is something waiting for you. I don’t use it. It looks like it was designed by security experts, with no emphasis on the practical aspects of a communication system. The results are a continuing lack of electronic communication; you get the system you plan for.

Overall, I think things are coming along nicely. There certainly has been a noticeable decrease in EMR-related stress in the past few months; I think our system is now well domesticated, and we can start planning more and better things.

Michelle

The importance of communication

I had a difficult day last week. A patient came in with two reports: one (from a downtown hospital) showing a decreased bone density, and a second (from a different downtown hospital) showing some compressed and fractured vertebrae. This patient needs medication for osteoporosis. The issue for me was that neither of these reports were sent to me, and there was no treatment. The patient was seen at hospital #2 for a different reason; a physician gave her the report and told her "if I was your family physician, I would treat you". The patient handed me both reports. The report from hospital #1 had my name on it, but was never sent to me. The patient's comment was that the system seemed to be failing her. I agree.

Our current College of Physicians and Surgeons magazine talks about the importance of communication; the article discusses two plane crashes that happened because of poor communication between flight crew, cabin crew and flight control. When this happens to planes, there is an investigation, and they figure out what happens and how to prevent it in the future. The CPSO's comment is that "the more complex the system, the more sophisticated the communications"; health care is at least as complex as aviation, if not more.

A problem in health care is that we often don't learn from our mistakes, so we just repeat them. The example above will go unreported, unsolved, and unimproved. We have the technology and the ability to send reports electronically today (my labs come in this way), but I continue to receive most of my reports by fax or mail (or via patients). The reasons why this is happening are multiple:
-other priorities
-lack of money
-lack of time
-the tragedy of the commons (this is an issue that affects everyone, but is no-one's responsibility in particular)

The error above occurred due to multiple systemic factors; however, there is no agency responsible for investigating this or for recommending a better system of communication (send it to me electronically). Each individual hospital has their own individually maintained address book (with all the attendant problems that these duplicate entries entail), and there is no obligation to send reports back to the family physician if he or she didn't order the test. The ordering physician cannot reasonably forward all tests to the family physician. The list of rostered patients (which patients are registered with which family physician) exists at the Ministry of Health, but is in no way tied to any of the hospital's physician address books. The CPSO mandates that we give it an updated list of addresses and contact numbers, but this database is separate as well. We need to make sure that all this information is securely tied together (with all privacy safeguards).

Everyone in my practice team (physicians, nurse, front staff, administrator, social worker, dietitian, clinical pharmacist, residents) is now using the EMR; there is no paper record. We communicate via the record. If there is a problem, I get an electronic message, and it is tracked--and I want to hear about it. I recently had a difficult mental health issue, and my social worker sent me a message remotely, which prompted me to call the patient--the chronological story was recorded in the record.

A physician in my group was not receiving her pap results; I believe that a database error at the lab caused them to be sent to the wrong location, and the other office simply bounced them back to the lab. They were never forwarded. It takes 3 months for us to get our paps back, making it difficult to remember who had the test. Because this physician had decided to generate her pap reqs within the EMR, she was able to generate a list of all pending paps so these could be tracked. We know that the system sometimes fail us and fails our patients; being able to track things in the EMR has a lot of value; you would think that everyone recognizes this, but that is not the case--and sometimes the problem is one of communication.

One of my electronic reqs for Diagnostic Imaging was rejected, because it did not look like the standard paper req. My problem was that I became so upset by this that I was going to make the issue worse by not communicating; I decided to phone instead (after calming down a bit), and they were more than helpful in helping me to resolve this. The problem turned out to be that the person receiving the reqs at the front had not been notified, and found the fonts too small. I can understand this; I'm also a bit past high noon, and can't suture without drugstore glasses anymore. Communication is a two way street; it will take a lot of it to change this system.

This enormous process of change that we are undergoing is a social one. In this system, we function as independant units far too often, and we need to start talking to each other more. The EMR is of incredible value in enabling this type of communication; there is no one in my practice team who would go back to the old way. However, EMRs are still isolated within the whole system, and we continue to have far too few electronic links. Perhaps once we can talk more, we will talk more and better; as the CPSO puts it, "among health-care teams (and in any field), the best communications feature a clarity of roles, a unity of purpose, the ability to not just carry out orders but share ideas, and respect for each other's professionalism and views. That's what will allow any team to take flight."

Ministries and regulatory agencies need to recognize this need for communication, and to enable it. This can't be the responsability of individual teams alone.

Michelle