Saturday, December 30, 2006

At the nine month mark: a new year, a new beginning

I have just finished the last CPP. It took me nine month to enter almost 1,500 CPPs into the EMR; sometimes I got bogged down, when things were very busy, and didn't do any for a while. That's about 166 CPPs per month, on average. Done!!!!

During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.

Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.

My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.

One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.

In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.

There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.

It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.

There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.

I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.


Friday, December 15, 2006

Insurance companies

I dislike insurance companies. At times, it seems like their purpose is to make family physicians' lives miserable by inundating us with time consuming, difficult to fill, paper forms (multi-axial diagnoses; precise time of return to work; lenthy functional enquiries; detailed descriptions of amount of weight that a patient is able to lift; repeated requests for the same data, etc). I have noticed that, for the past several years, they are refusing to pay for the forms they request. Often, the request is urgent, detracting from patient care.

I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.

I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.

What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.

The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.

Fat chance.


Friday, December 08, 2006

Working as part of a team

The EMR is allowing me to think about working as a part of a team.

My resident did a chart audit of my diabetic patients using remote access to the EMR. It did not take her that long for 70 patients, because the data was in the flowsheets, but I would like to have automated audits in the future. The results are not bad; (2003 audit results are in brackets):

% meeting targets (July 2003 results)
BP <140/90=83% (65%)
BP <130/80=66%
LDL <2.6=63% (50%)
LDL <2.0=40%
HbA1c <8.4=81% (74%)
HbA1c <7.0=48%

There is a new clinical pharmacist in our family medicine teaching unit at my hospital. She can do consultations for our patients who need extra help with their meds. What I was thinking of doing is identifying patients from the audit who need intensification of their meds (sugar, bp, lipids) and referring them to her.

Because I am paperless, I will not do this as a paper based referral. I will give the clinical pharmacist access to my EMR as a team member, just like my resident has. Because I don't know exactly what the scope of practice for a pharmacist is, I will configure the EMR permissions together with her. The EMR has detailed permissions (permission to view, permission to sign off, permission to prescribe etc, for each part of the EMR); we will need to discuss this on set up so that she has appropriate permissions, not more and not less than needed. I figure that, as the family physician, I am the custodian of the primary care record (I don't want to call it a chart, it is becoming increasingly different from a paper chart); therefore I need to think about who can and should have access and input for this record. The "pharmacist" profile, once set, is then available to my whole group. I have an extra RSA security fob for the pharmacist, and this will log and identify her for every chart access just like every member of the team.

Once this is set up, we will mail letters to the identified patients to let them know that the pharmacist may be contacting them. She can access their chart remotely from anywhere with internet access, and call to set up an appointment anywhere convenient; it does not have to be at my office. When she sees the pt, she will be accessing their EMR chart live, and she can enter information directly in their clinical record, live. That is, it is a fully shared chart, with remote access. If we continue, she can also access the chart later for monitoring and callback. The EMR has detailed audit capabilities, so I am able to find out what each team member is doing, and who accesses the chart. If the patient needs to see me for follow-up, the pharmacist has access to my schedule, and can book the appointment.

She is coming to my office Thursday; we'll give it a try.


Sunday, December 03, 2006

Efficient and effective processes

I had a flu clinic last Monday, and will be having another one on December 11. Here is the process for the clinic: I set up a separate schedule, called "flu shot clinic", with appointments at 5 minute intervals. When patients came in, my secretary swiped their card, and entered them in the flu clinic schedule. She then sent them to the back area, where I was standing next to the vaccine fridge, and I gave them their shot. When she had time, she opened their electronic chart, clicked the button that enters the flu shot in my preventive list, and then entered the full flu shot (the lot number and dosage are pre-set in the EMR, there was no need for her to reenter the same information every time). When the clinic was finished, I changed my pre-set billing code to G591 (the Ontario code for influenza vaccination), clicked the button to auto-bill the entire schedule, clicked send, and it was done. We were finished within 5 minutes of the clinic closing. There were no charts pulled or put back. My preventive services list was automatically updated.

The EMR allows for very efficient processes, with a high degree of automation for things that are repetitive. However, this doesn't happen by itself; you have to figure out how to make the EMR work for you.

As another example, I bought an Automated BP machine (the BP Tru) in the summer. My staff is trained on it and they know how to use it. If I get a patient that requires additional BP readings (perhaps because their last BP was above 140/90), I will often ask them to come on a Friday. I am not in the office Friday. My secretary takes their BP using the BP Tru, and enters the average reading (which the machine produces out of several BP readings) in the EMR. I see it remotely, and will send back a message if needed. The current guidelines say that if office BP is between 140/90 and 160/100, you need 4 to 5 visits to diagnose HT. I can get several visits done pretty easily this way. I also use home BP (Lifesource monitor) extensively. I also use the Friday BP visits for diabetic BP slightly above 130/80, for verification. The EMR generates lists and graphs of Blood pressures, so it is easy to follow them. Having my staff help me, and using automated electronic equipment and EMR has improved my quality of care.

My secretary tells me that I won't have a single paper chart belonging to me in the office by 2007. We are currently scanning the Inactive Patient charts, and that is the last of it. I will put 4 filing cabinets for sale on Craigslist over the holidays. I was trying to figure out how much we pay for the space for these: each filing cabinet is 1.5 ft x 3 ft. I have an exam room that is not usable because of filing cabinets, that is 9 ft x 9 ft. I also have to figure out some space to walk around the cabinets. In addition, I no longer store handouts or chart aids (they are scanned into the computer, or accessed from the Internet). This must be about 150 sq feet for my office; at $30 rent per sq foot in my area, that is $4,500 per year for paper storage. I wonder what an office designed with no paper from the start would look like.

Interestingly, I seem to be going through more paper since starting the EMR. However, I look at it as "good paper". For example, when a patient is in for their annual physical, they are usually sitting on the exam table. I have the Tablet sitting beside them, with the screen turned so they can see it. I load the CPP, and point to it as I talk, to verify the information. When that is finished, the last step is for me to say: "I will print a copy for you to have on hand, in case you need to use it". That is now routine. As well, I'll often print a copy of the flowsheet for diabetic patients, so they can see how their results compare with recommended results. I am certainly printing lots of handouts, such as calcium/vitamin D recommendations during full checkups. The storage cost for Good Paper is essentially nil, because they are just blank sheets ordered from the office supply store as needed.


Sunday, November 26, 2006

Tips and Tricks meeting

We had our Tips and Tricks meeting on Friday, at the company's training room. We all wanted to be there together with computers, so that we could log on remotely to our own practices, and figure out how to improve things. We made the agenda ahead of time, and I ran the session.

Here is the agenda; most of it involves how to be more efficient, based on real world practice conditions:

Tips and tricks: how to do things faster and better in the EMR

The patient encounter

Using the Summary page as your default


Drop down lists to save time

Templates: Rourke, preventive health, smoking cessation


Rapid prescribing of new drugs

Loading previous drugs and doing repeats quickly


How to record them fast


How to make sure you remember what to do for next visit


Using drop down lists for speed


Within the patient encounter; how to make the bill quicker

Preventive services

How to generate your reports (and your bonuses)

Using the Summary page to remind you when a service is due

How to send letters to patients who are overdue


How to use them.

Programming one

Examples of some: INR, diabetes, depression


How to generate a Diabetes report

Review of preventive services reports

Scanning old charts

How to get rid of all your paper records (forever).


This took about 2.5 hours. It is a good idea to do something like this several months after EMR start-up, as most of us have had a taste of it, but are not using it to its full potential. It has now been 8 months for my group, and I understand it takes an average of 18 months for the EMR to work well. For keeners like me, it is probably 6 months.

I was speaking with a colleague who had been using EMR for 10 years in his 7 physician practice. 2 physicians never went to EMR, so hybrid practices like mine may be more common than people think. It is interesting that he does not scan; paper copies are kept in a paper chart, so there are still duplicate charts after 10 years. He does not feel that he is using the EMR to its full capacity. Nonetheless, he would never go back to paper, and this is something that I hear universally from people that have made the transition.

I found a very active on-line group for my EMR, and have joined it. I have found several useful tips in the messages.

I seem to have a bit more time at the office; I think I am now more efficient because of EMR and so I can do extra things. On Tuesday, I looked at my list of overdue consultations, and found 7 that were very overdue. We faxed a note to the specialists, with the initial consult request and a letter asking their secretary to tick off what happened (pt never showed, pt cancelled, pt seen and report attached etc). Within two hours, 5 reports came back: 2 with consult notes attached, and 3 stating that the patient cancelled or rebooked for a later date.

My preventive services reports are working. I have given flu shots to 109 out of 213 eligible patients (age 65 and over), which is 51.17%. It says that right at the bottom of the report, and tells me what my bonus code is. On Monday, we have our first flu shot clinic, so my report will look better after that. We sent out letters to all the patients. The reports tell me that we have also sent out 35 letters to patients overdue for a mammogram, and 33 to patients overdue for a pap smear. Several of those patients have had the service because of the letter.

I like this organized approach to prevention; because my group has a common remote server, we are looking at doing this as a group once everyone is on-board with the EMR. We can have a group administrator responsible for things like quality audits, reminder letters/phone calls etc. This is very difficult to do if you have single server boxes in individual offices with no sharing of charts. I am becoming very opinionated about this subject as I see how the EMR functions; the single in-office server is OK for large group practices in a single location, but not for distributed small practices like us.

I tried going through VPN at my office on Monday, which was kludgy at best. The SSHA connection came back on, and we switched to that at noon. They tell me that the problem with VPN is my office router, so I have someone coming to install and test a new super-router on Friday. I have a regular Shelob's lair of wires in my back closet, and several boxes with blinking lights. Managing a small office network is not a job for amateurs; it is worth spending a bit of money for extra help at times.


Sunday, November 19, 2006

Managing waiting times, managing data

We now have a Joint assessment centre to expedite assessments for hip and knee surgery, run in common by the surgery departments of 3 local hospitals. Because the surgery depends on how functionally impaired people are, the assessments are done by a physiotherapist or orthopedic nurse practitioner. This frees up the surgeon's time. The patient can choose the first available surgeon (from 3 hospitals) or a surgeon of their choice--but then they have to wait longer. The Centre opened November 1st.

When I received the announcement, the referral form and letter were scanned into my network. I saw a patient who fit their criteria last week. I printed the letter of introduction and a blank referral for my patient, and a referral for me to fill out. I sent this the same day (with very little hand-written data, it is mostly check-boxes), along with the CPP and a printed copy of my clinical notes indicating what the problem is (which saves having to rewrite the whole thing).

I wish more specialists took this approach, rather than continue to use individual waiting lists.

I am continuing to use the on-line waiting times sites to refer my patients for MRIs, and this has made a difference.

I have to think carefully about what happens to my data. It continues to bother me that so much data needs to be scanned in because it is not integrated with the EMR; this can be a real problem for shared care with a specialist. A local internist sees one of my patients for mild hypertension (I am not sure why). Periodically, he orders blood tests, DI such as bone densities, and changes her meds. In the past, on the paper chart, this was just irritating. In the EMR, it is more of a problem. The blood tests he orders have to be scanned in, and do not show up on electronic summaries (he does not use one of the electronic labs). The changes in meds have to be entered in the CPP instead of just flowing in from my encounter. I have to enter his BP values so they show up on my graphs. It is no longer just irritating, it is now more work (for no better care).

I finally called the specialist and explained why I no longer wanted my patient to see him. I explained that I am using an EMR, and that it is important that the data flow in electronically. He agreed to stop seeing the patient.

I think the primary care EMR will be the core of the eventual Electronic Health Record (EHR) for most patients. When a patient comes back from a hospital, I ask them to tell the institution to send me a report. I show them their EMR, and explain that records get scattered all over the place in our health care system; the only way to ensure information is not lost is to get their data into the EMR.

There are 4 large labs in my area. 3 are electronic and flow into the EMR, and 1 is not. If I get a result from the non-electronic lab, that chart is flagged, so that the patient can be told not to use that lab in the future.

I have now been told that my hospital's software and my EMR will be able to share data, in mid 2007.

I think we can have a say into how the data is managed. We can sometimes direct patients where their data is more likely to follow them.

My group continues to have problems with SSHA (Smart Systems for Health), which is the government agency that provides Internet access for doctors and hospitals. Their lines have been slow at times, and are sometimes unreliable. I had my SSHA internet access cut off on Friday, and I switched to my back-up internet line, which is actually faster. I am not sure government should be in the business of providing Internet access; I may just stay on the back-up line.


Friday, November 10, 2006

Guidelines in the EMR

I have been thinking about how to put guidelines in the EMR so that I can use them in practice more effectively. This is a recent review in BMJ : they found that
  1. integration with charting
  2. computer-based generation of decision support
  3. automatic provision of decision support as part of workflow
  4. provision at time and location of decision making
  5. request documentation of reason for not following recommendation
were associated with more use of the recommendations in practice. Some of these things I can do now, some I can't.

The integration with charting is pretty easy for simple recommendations. For example, I made a template for the GAC recommendations for sinusitis. It has checkboxes for symptoms, and a text box for recommendations (copied and pasted from the website). I had a patient with sinusitis, loaded the template, and showed her the recommendations (no XRs, no antibiotics). These can just be saved to the clinical record, since the amount of writing on the record doesn't really matter anymore. I guess that takes care of point 3 and point 4 as well.

I copied and pasted below a slightly more complicated template I made to help me with the management of patients with chest pain. I used a "history builder", which is where you click on snippets of phrases to put them in the record, then a table, a textbox, and a drop-down list (the table didn't format properly when I copied it for here):

chest pain Updated By:(Michelle Greiver)

chest pain
chest pain Patient complains of retrosternal chest pain; The pain is worse with exercise or stress; Patient states pain is better with rest or NTG.
number of symptoms 3
Simple Table

Risk of heart disease

Age (yrs) Men, 0-1 sympt Women, 0-1 sympt Men, 2 sympt Women, 2 sympt Men, 3 sympt Women, 3 sympt
30-39 4 % 2 % 34 % 12 % 76 % 26 %
40-49 13 % 3 % 51 % 22 % 87 % 55 %
50-59 20 % 7 % 65 % 31 % 93 % 73 %
60-69 27 % 14 % 72 % 51 % 94 % 86 %

Risk of heart disease (%) 76
Test suggestions:
Risk <20%: observe, reduce risk factors
Risk 20%-80%: cardiac stress test, unless contraindications
Risk >80%: refer, stress test for prognosis, consider angiogram
Test chosen: Cardiac stress test;

I don't really see how the computer can generate automatic decision support in the current EMRs. The decision support tools are all "outside", on the web or on PDAs, and not integrated. Nor does the EMR request a reason for not following recommendations, even if I choose to bypass an alert that a patient is allergic to that medication. I am not sure how well accepted such a request would be.

I think more advanced functions, like context-specific suggestions, will be in EMR ver2. In the meantime, I can use what I already have. I programmed the new Rourke well baby record, using pieces that were in the EMR for the old record. I also pasted the Rourke patient education recommendations to a website. When parents are in, I ask if I can email it to them; they then have access to all the great links from the Rourke. I also printed a copy for a new mom who doesn't use email.

One of my front computers crashed on Tuesday; we had a blue screen with a note to get support. Dell sent a technician to replace the motherboard (didn't work), then the Intel chip and memory (didn't work), and now I think they are going to reload Windows. We are using the laptop as a back-up, so there are still two computers at the front. Some redundancy is good to have.


Friday, November 03, 2006

Helping others in my group

One of the benefits of starting EMR as a group, rather than individually, is that we can help each other. At our recent meeting, it was clear to me that I was the furthest along, although others had good ideas. Because the nine of us work in 7 different practice locations, we don't meet all that often; we use email, and recently also the EMR's internal messaging system. We decided to have a "Tips and Tricks" afternoon at the company's training room, and this will be on November 24th.

The plan is for us to log on remotely to our practice EMR during that meeting, so that we can make changes (such as new flow sheets) directly. My group's IT lead physician will help me set an agenda; I will circulate this prior to the meeting to see if there is anything people want to add. We've invited the other FHN's IT lead, so that she can bring things back to her group; her FHN includes one 6 physician group practice and one 3 physician group, so it is not as scattered all over the place as ours.

Some practices are not using the scanner. EMR not only involves software, it also involves learning how to use new (and sometimes unfamiliar) hardware quickly and effectively in a busy office. I did a brief demonstration of how to use the scanner during the meeting; I talked to my staff the next day, and they offered to help as well. Probably the best way to show how we use the EMR is to have a staff member from another office visit my practice on a Friday (since I'm not there Fridays); this happened today.

I have been away at a conference for the past two days. In the evening, before supper, I have been logging on to my practice, and signing off lab work, and scanned reports. I received several messages from my staff, wrote a couple of prescriptions, sent notes to my staff to call patients about their results, and wrote some lab reqs. I also had an email from a patient who was worried about his lung function test; it had been scanned in the EMR, I saw it, and sent him a note that it was normal. One of my patients had received a flu shot at another office in my group; they entered it in the EMR chart, and sent me an internal message to let me know.

This work for my practice took about 45 minutes. I consider going to a conference part of work, so told my staff that I would be logging on daily. It is extra for me, but really does take a load off my practice partner; a big part of covering for another physician is reviewing all the paper that comes in. I am much more efficient at reviewing results for my own patients, because I know them. It is becoming more important for me to let my staff know whether I will be logging on when I am away, and I have to be explicit about this. If I do log on, my partner is only responsible for looking after critical results.

A couple of physicians in my FHN are part of our palliative care group. I wonder if I should ask the nurse coordinator to direct my patients to them when I refer. They would have access to the chart. It would not always be possible to use the EMR during a housecall, since not everyone has high speed internet; they would have to print the CPP ahead of time, and then scan notes in afterwards. However, if there is access, then all the changes are live in the common chart. They could even write a prescription in the EMR during the housecall, and have their secretary print and fax it to the patient's pharmacy (just like I am doing from my conference). I would always be able to know what is happening, and if I made any changes, my colleague would know. Any home care, specialist, or test report that came would be scanned in, and would thus be available to the team. I should talk to my colleagues about this.


Friday, October 27, 2006

Managing Flu shots with the EMR

Computers are good at making lists of things. As of October 1st, my EMR automatically generated a list of patients age 65 and over, since they are due for a flu shot. I have two lists
  1. a Report list, which shows how many patients I have that are 65 and over, how many received a flu shot, and the percentage who have been vaccinated
  2. a Letters to send list; this shows me the list of everyone who has not been vaccinated so I can generate a personalized letter for them. The list has buttons that you click on to generate letters
I wrote a letter inviting my patients to come in for the shot. We run two flu shot clinics in the evening, and the letter also includes the date and time for those. We bought window envelopes; the letters get folded so that the address shows in the window, so that we don't have to print labels.

When a patient gets a flu shot, I have a button that I click on in my Summary sheet. That removes the patient from the Letters to send list, and marks them as vaccinated in the report. Then I start the encounter; in it, I click on the drop down list for vaccines, and click on "influenza". I've preprogrammed information on lot number, expiry date, and route of administration, so that all gets automatically recorded. If the lot number changes, I can update the saved information.

If a patient gets a flu shot outside of my office, I just click on the button in my Summary sheet.

The vaccines are late this year. I've had to defer the clinics; we'll have one on November 27th, for high risk patients, and one on December 11th for everyone. I've posted this all over my office, and put it on my website. I've been telling people to look at my website to find out when the clinics are.

I was talking with my staff: after 6 months of use, we now have very little that is still managed outside of the EMR. All clinical notes, prescriptions, phone calls and inter-office messages are recorded in the EMR. Requisitions (DI and lab) are now generated in the EMR, with the exception of pap reqs (my lab has still not authorized this), public health reqs, and some specialized reqs (Diabetes education, MRIs). All letters and consult notes are in the EMR. Everything that comes in is scanned and then shredded.

I figured out how to upload faxes without printing and then scanning. What we do is view the fax, then click File, Print, Print to pdf. That transforms the fax into a nice, very legible pdf file, which is then saved to the "charts to upload" folder on the desktop. It is then uploaded to the patient chart along with the scanned files, which are saved into the same folder. I taught my scanning tech how to do it, and we have had no problems.

An 18 page old chart came by fax. Rather than printing it to paper, we saved it as a pdf file to the external hard drive where all my old charts are kept.

My friend at IBM told me to download a copy of Adobe Reader, and archive it. That way, I can make sure my files are readable in the future. I saved a copy to DVD.

My scanner sent a message that it needed a new pin roller; this is something that you replace after 100,000 pages. I guess we scanned that many. We're now scanning all the files of deceased patients. I think by the time this is over, I'll manage with a single filing shelf.

We had a meeting for my group of physicians last Tuesday. I think I've gone the furthest; most people have entered CPPs, some are prescribing in the EMR. We're going to go to Nightingale's computer training room at the end of November to share tips and tricks. We're starting to receive the montly EMR subsidy from OntarioMD, which is $600 per month for 3 years. I've also received a $2,500 bonus for entering over 600 CPPs.

My own family physician has retired. I will be going to one of the physicians in my group, for two reasons. That person is an excellent family doctor; as well, my chart will be on our server, so that I can access my own data. I've already entered my demographics, my CPP, and uploaded a couple of reports. I'm healthy now, so accessing my data is not that important; however, if I get sick, I want to know what is happening to me. I've made it so that I can.


Saturday, October 14, 2006

Lights out

Thursday was a terrible day. Our server went down at 2:30; then a transformer blew, and the electricity went out for my street at 3:30, for the rest of the day.

With no electricity, I could not even access my old charts, which are stored on my external hard drive. The data on those is already a couple of months old, but at least there is some information there. This is a risk of going fully paperless: if there is a major power interruption, I am stuck.

Having been through a couple of server problems earlier on, I had some idea of what to do: jot brief notes on paper; only give prescriptions that are not recurring (such as antibiotics), or recurring prescriptions for patients who were on only one medication and knew what it was (such as birth control pills). All complex renewals to be faxed to the pharmacy once the system was working again. It was difficult to function: people were asking me what the result of their tests were, and I could not tell them. None of my fancy recall systems were working: I had no flowsheets for a diabetic that came in; I could not remember exactly why I had asked an elderly patient with multiple problems and cognitive impairment to come in (and neither could he). I ended up rescheduling some appointments.

I work late on Thursdays; without access to the scheduler, we had no way to even call patients to ask them not to come if they were booked after sunset. My secretary brought some flashlights. One of my exam rooms has a window and faces West, so I saw patients there while there was still light.

The server came back on at 6:30 pm (which was of no use to me at the office, without electricity). I went home after seeing my last patient in the dark, and completed my charts remotely. I left for a conference the next day.

My group is very unhappy with this server interruption. We will be meeting with the company to discuss what happened: service interruptions can come from the hospital, from SSHA (which provides our internet access), and from the server itself. Since start-up, we have had interruptions caused by all three. Having a centrally managed server has advantages (managed backups, managed security, centralized upgrades, ability to securely share patient data between several providers), but also introduces complexity to the system. Along with this complexity come multiple possible failure points. I think my group is an early adopter of an enterprise-level system; down the line, it is probably the right way to go, but this week it just felt like a lot of birthing pains.


Saturday, October 07, 2006

Tracking patients, tracking reports

The EMR allows tracking of several things. I've already mentioned tracking of lab results, which is not perfect, but is much better than what I had before (nothing). It tracks DI reports, and also consultation requests. I have three folders for tracking requests to the outside (lab, DI, consults).

I had a look at my consultation requests folder recently. The largest number are for derm referrals (I probably over-use this); Second was for ENT. When I send a consult, I can put in a "date expected" in a drop down field; if the date is exceeded, the request is highlighted in red. One of my patients had a rather serious medical problem, and no report was received. We sent in a note to the specialist, and they told us that she had cancelled. This lady comes in fairly often, so I will ask her what she would like to do. When a report is received, I click off "received"; in the future, perhaps we can do audits to see what actual times between referral and report are.

There are therefore a couple of advantages to this
  1. you can get a sense of what your referral pattern is like
  2. you can track patients to see what happened
  3. you may be able to get a sense of waiting times. That might be useful for wait time management for our health care system in the future
I also track "follow-ups" in my office. When someone needs a follow up (1st rx for HCTZ: needs K+; 1st rx for ACEI: needs K+, creatinine; etc), this shows up in my Summary screen when I load up the chart, to remind me. However, it also shows up as a list of Follow-ups, so I can see which ones were missed. A common miss seems to be the follow up for depression therapy, after a patient was given a first script for a SSRI. They don't book the follow up appointment with my secretary when they come out, and they don't come back. Guilt and hopelessness are features of depression, so it is no wonder this happens. Right now, I don't have the resources to do something about this; however, once we have the FHT going, I wonder if it might not be good to assign a mental health worker to phone these people. Same thing for people who have missed more than one of the recurring DM follow-ups.

There are problems with doing this, such as how much is the physician's responsibility and how much is the patient's. Tracking does make recalls for chronic disease management possible; we already do it for preventive services, such as influenza or pap smears. We'll have to decide how much is possible to do, which problems to target, and how to do it.


Friday, September 29, 2006

Distributed information

My Tablet is back from the repair shop. The problem was that a small cable was getting caught when I twisted and closed the screen. They replaced it, but it took a whole week.

While the machine was getting its vasectomy reversal, I was using the backup laptop. What was interesting was that most of the functions that I use no longer reside inside my machine, so it wasn't as bad as I thought. Of course, the EMR isn't even in my office. My scanned old charts are on a networked external hard drive. The scanned paper requisitions (public health, Diabetes Education referral etc) are on the front machine. I still had some trouble, because my payroll program and Quicken (which I use for the practice's bookkeeping) are on the Tablet. These are backed up to a USB key, but I would have had to reinstall the programs on another PC. I guess the information is getting distributed to all kinds of different places; the laptops or PCs used to access the data do not actually hold that data inside. This is what they mean by "thin clients".

I received a report for someone who is another doctor's patient; her physician is part of my group. What I did is I scanned the report and uploaded it directly to the patient's chart. I sent a brief message so that the other office would be aware of what I did; I received a message from my colleague saying that the report was there, and it was no problem. I guess we can scan and upload from any office for any patient in this group.

This is interesting, because the government recently approved our application to become a "Family Health Team", or FHT. What that means is that we get some extra money to hire other health care workers, such as social workers or mental health workers, for our group. They will need to have remote access to the EMR as well; that way they can see and enter information directly into the patient's chart. We'll have to figure out what type of access each person can have. The location where the patient is seen no longer really matters, since access to the chart can be from anywhere.

I don't know yet how this will function, or who exactly we need to hire. I think it may help to have the occasional face to face team meetings, but I'm not sure how much of that we need. I find I work quite well with our home care coordinators or our Regional Geriatric Program, and contact is mostly over the phone. I have a feeling much of the communication will be over the internal EMR email, which is much more efficient. We'll probably get together if we decide to plan a new program, like an asthma clinic for patients identified as needing group education; otherwise, I don't really think I want more meetings, I have enough of those already. I think the key to this team approach will be the Distributed EMR.


Friday, September 22, 2006

Electronic lab requisitions

I've started using electronic lab requisitions, and electronic Diagnostic Imaging requisitions. The lab reqs replicate the look of the paper Ontario lab requisitions, but the patient information is pre-filled. I had to think about that one, because if that's all there was, there is really no advantage to having electronic lab reqs; in fact, it is faster to just pick a blank req from my pile, tick off the couple of lab tests that I want, and have my secretary put on a label.

However, I found that I could pre-fill a series of lab tests, giving me a list of "favourite" lab forms. I made a series of them: full check up for diabetics, full check up for hypertensives, full check up for people age 40 and over, Methotrexate blood work, first prenatal exam. That is akin to standing orders, and will save me time; it will also increase quality, because now I can't forget to do a microalb/creat ratio for diabetics. I can add additional tests to each req if needed, but I have all the basics covered.

If I generate a lab req electronically, there is a record of what I ordered in the patient encounter; when the results come in, they match against the requisition, so I can see if they were received. However, the match is against the entire req; that is, individual results do not reconcile (the system can't see if the TSH I ordered was done, but it does see whether a batch of lab tests for that requisition came in). That probably stems from the fact that the req is a replica of a paper-based process; individual tests are not coded electronically.

All public health forms (such as HIV or viral studies) are paper-based, and require their own paper requisitions. I have stamped the forms and scanned them in to my system to be printed as needed. All public health results come in on paper only and have to be scanned in. I know public health is very underfunded, but it seems to me that this is one area that would really benefit from better information systems, especially if we have another crisis.

I have a couple of favourite DI reqs, such as bone density requisitions for my hospital, and CXR for the local facility. Saving time in EMRs often comes from automating things that are done repeatedly.

It is interesting being connected. Last week, a patient came in because of a delay: she likely has severe OA of her knee, and she's in her early 50s. The surgeon won't see her until she has a MRI; however, there is a long waiting list for MRIs at my hospital because of high demand. Her MRI isn't until late November, so her ortho appointment was delayed until January; she's in pain. I loaded up the Ontario wait time website, which I've put on my EMR's list of internal websites, and we found a nearby facility with a median wait of only 12 days. I asked my patient to call them, and find out how to refer; a referral sheet came the next day and we faxed it over.

Eventually, I would prefer to send everything electronically (lab reqs, DI, prescriptions, public health, referrals), much like I do my banking. We're still a long way from this.


Friday, September 15, 2006


My Tablet failed. It is still usable, but when I flip the screen and shut it to turn it into a slate, the screen goes dark just as it is about to be shut. I phoned IBM; we have an extended 3 year warranty, but it does not include on-site service. They sent me a box so I can ship the Tablet to them. I'm not going to do that; I don't know how soon it will come back.

This brings me to the issue of redundancy. What do you do if some of your hardware or software fails? It was hard to plan well for that at the beginning of EMR, because I was too busy just keeping my head above water. Now that things are smoother, I have managed to put in some safety valves.

I do not know of any manual that outlines exactly what we should plan for; perhaps practices are too individual for that. I figure that it is good to identify things that you can't do without, the so called "mission criticals", and plan for what happens if they did fail. In any case, here is what I have done in my practice.


Practice data is the most "mission critical" thing there is. In my FHN, we have the server at the hospital, so they back it up nightly (as part of their routine back-up systems for the whole hospital's IT), and keep a spare copy at a second hospital site. The data has been validated, which means that they've looked at it to make sure that the copy is good. If the server fails, the most we can lose is a day's data. We had server failures early on in the project, so we know what to do if that happens: write notes on paper and scan into the EMR later; do prescription refills when the system is working again. Things are much more stable now, but if there is a problem, we know what to do.

There is also local data. The scanned charts in my external hard drive have been backed up to 2 DVDs, 1 copy at my office and 1 at home. As new charts get added from the inactive files, we back them up to DVDs weekly. The local data on my Tablet (patient handouts, clinical cheat notes, reports from committees I sit on, etc) gets backed up to an external hard drive at my home (sometimes).

Internet connection

I have a back-up internet connection to access the server via VPN in case SSHA fails. That required paying someone from Nightingale to come and do it properly; the office network is sufficiently complicated that I cannot manage this myself.


I have a spare laptop to use in case my Tablet really breaks; I carry it around, it can get dropped. The laptop is used by my resident a half day a week, so I know it is properly configured and ready to go. When not in use, it is attached to a laptop lock beside the vaccine fridge.

The Tablet has a stylus to write on its screen; I use the stylus instead of a mouse. These are always getting misplaced; I have two spares, 1 in each exam room.

There are two desktop PCs at the front. If one fails, we can still function, and can use the laptop temporarily.

As far as the screen problem on my Tablet, IBM gave me the name of several local companies that they use. I am responsible for the cost of the "housecall" (about $95/hour) if I choose to have someone come to my office, and they will pay for the repair. I phoned around, and there is a very reputable company close to where I live. They told me that if I bring the Tablet to them, there is no extra charge. That's what I will do.


Friday, September 08, 2006

Having a resident in an EMR practice

After five months of use, the EMR is starting to pay significant dividends. We had no chart pulls this week; my practice is now paperless. All the old charts of active patients have been scanned and shredded, and we have now started scanning charts of inactive and transferred patients. I had to look at an old chart from home today, and just clicked on the file from the backup DVD of my practice; there it was. Amazing.

My desk was completely clear at the end of the week, despite having been away for two weeks, and I have no backlog. I feel as if I'm bragging!

My resident has now been given remote access to the EMR. I have taken on a few new patients recently; they have been specifically assigned to her, so she can build a "mini-practice" while working under supervision. She is only in my office one half day every week, so we were talking about how she can manage lab tests for her patients, because these are coming back before the week is up. We decided to do this: I will look at all results as they come in, and will deal with all urgent reports (such as INRs). She will log on remotely periodically. If results are abnormal, but not urgent, she will deal with them as she sees the result, and put a note in the EMR. She cannot sign off on lab reports, so I will always see the comments. We will use the internal messaging in the EMR to communicate about patients, because this is much more secure than email. This remote lab review would work very well for a family physician who has a very part-time practice. I have a "dummy patient"chart that my resident can use to practice, so she can see how templates and other more advanced aspect of the EMR work.

I printed and scanned a diabetic flow sheet so that you can see what it looks like in practice. Lab results and vitals go in automatically, and I enter the last four items manually; notes and meds are also for manual entry as required. Flow sheets are customizable, so you can put in the parameters you need. I have made flow sheets for diabetes, for asthma, for depression, for INR management, and for BP/wt loss. I'll probably make more; they are especially useful for chronic disease management.

No way I'd ever go back to paper.


Tuesday, September 05, 2006

Back to reality

I am back from vacation, and my office is getting very busy after the summer hiatus.

During my absence, my (non-EMR) partner looked after my patients. He had some problems, as he could not see CPPs or previous encounters on the EMR, so my staff had to print a lot of things for him. I looked at the Permissions in my System Set up module, and realized that I could have given him access to read-only forms of my CPPs and encounters. I'll know better for next time.

My resident saw several of my patients, and entered the data for me to sign off later (which I did remotely).

I had been away for two weeks; I told my staff that I would have no access to the Internet for the first week, but that I would access the EMR the second week. My partner still looked after urgent lab result, and saw patients that needed to come in. However, I could deal with most incoming lab/reports remotely, and sent several messages to my staff. It was about 3 hours of work over the week.

When I came back this morning, after a two week absence, I had about 45 minutes of work (mainly forms to fill out). There were no stacks of charts and papers to review.

There are pros and cons of doing things this way during vacation. You have to be willing to give up some of your vacation time. You cannot deal with more urgent things remotely, unless you commit to logging on daily, which is not always possible or even desirable during vacation. On the other hand, there is much less chaos and pressure when you come back, as most things have been taken care of and filed away.

We received two record transfer requests while I was away. We printed the chart from the EMR, using the "print whole chart" feature; the CPP and encounters were printed very quickly, but it did not print the scanned documents (these are not OCR'd and pasted in the record, so you have to load them to see them). It looks like you still have to load scanned material to print individually, so printing a whole chart is not as quick as I expected. However, the old paper chart is now a pdf document, and that simply gets transferred to a CD ROM to mail out--size of chart no longer matters.

I do the bookkeeping for my practice (on Quicken). I have now registered for on-line business banking, and did my first electronic reconciliation today (much faster and easier). I plan to switch to on-line payments as much as possible. I think having an EMR has made me think of what other paperwork I can reduce.


Friday, August 18, 2006


Yesterday was my last day at the office for two weeks, and I was covering two practices. Thursdays are my late days, when I see patients into the evening. It was busy. I ended up with 29 charts that needed completion by the end of the day.

Before EMR, I would stay on and complete my charts. I cannot take 29 charts home when going on vacation, because my partner would have no access to them. Yesterday, I just shut my computer, and went home; I was too tired. I finished my charts from home today in about an hour, meaning it took about 2 minutes per file to chart and bill. I don't know if that is faster than on paper, but it was certainly less stressful than staying even later at the office to complete the paperwork.

During patient encounters, I had completed pieces of the record that I would be likely to forget, such as blood pressure measurements or positive findings. As well, all my prescriptions were already recorded, since prescribing and recording happen at the same time. I had volunteered for a study on errors in family practice a few years ago, and found that a common error for me was failing to note a prescription in my record (if I prescribe several repeat medications, and then add a "less important" drug such as cortisone cream, the cortisone cream may not get recorded). This was worse when I was busier. The study found that office processes (such as not finding the chart) were the commonest source of errors, followed by medication errors. With EMR, the risk of lost charts is essentially gone, while the risk of medication errors is lessened (automatic allergy and drug interaction alerts, consistent recording of all drugs in the record, decreased risk of refill errors).

Late Wednesday night, my lab called me regarding a critical result. While I was talking to my patient, I recorded the information on her chart. Remote access to my charts is proving to be truly invaluable.

We tried the automatic blood pressure machine, and really liked it; we are using it consistently for annual check-ups. We decided how to implement staff monitoring of blood pressures for diabetics: at the end of appointments I give my diabetic patients a "ticket" (I have a pad of paper for this on my desk), which says "DM, 3 months". The appointment then gets labeled with a colour assigned to diabetic follow-ups, and when the patient returns, my staff weighs them, takes their BP and enters the information in the EMR before they see me. I guess I'm using this as an example of how processes get thought about and changed at my office.

We should have the rest of my active charts scanned in by the time I return from vacation, in September. I took a back-up DVD home with me, to lock away in my cabinet. In September, we'll start scanning inactive/transferred charts. It is odd for me to think that I can carry my entire practice with me in a couple of DVDs.


Friday, August 11, 2006

Transition's End

It feels like the transition to EMR is coming to an end. We now have over 800 old charts scanned to pdf out of 1250 active rostered patients, and accessing a previous record on my network is very easy (load the folder where the charts are kept, then double click on the file). We have emptied the first filing cabinet and are ready to sell it.

Most of the left over transition work consists of data entry for the CPPs; I am doing most of that from home, via remote access. I do not carry charts home, only CPPs.

My partner is away this week and the next. When I see one of his patients, I use the EMR, because I can record the visit, write a prescription, and bill faster that way. I then print the encounter and put it in his paper chart; it will now be legible for him. I will be away for two weeks after his return. During that time, he will copy me on lab reqs (so that I can get the results electronically); he'll have a quick look at letters and faxes, which will then be scanned in; he'll have access to my old charts on his computer desktop; my staff will print CPPs for him when he sees one of my patients, and the visit notes will then be scanned in. My resident is in a half day per week, and we'll book my patients to see her; she can enter encounters and prescriptions directly in the EMR, and the encounter will be left on my desktop to sign off later. Although it is a little more difficult to arrange vacation coverage in a hybrid practice, it is possible.

I've been printing CPPs for my patients when they come in for their annual physical, and asking them to review the information and to let me know if any corrections are needed. We've also been talking about secure access to charts for patients. My patients are very interested in this. The EMR certainly makes it possible; I think this type of thing can't be too far away. We'll likely need Government help to manage access and security. I would be very happy to take part in such a project.

I still need to figure out how to do electronic Diagnostic Imaging requisitions, and will probably start to use those instead of the paper-based reqs. The electronic lab reqs and pap smear reqs are not ready yet; once they are available, I'll start using them. There is not very much paper-based work that remains in my office; I have to say that I do not miss the paper at all.


Friday, August 04, 2006

The paperless office

I have now entered about 60% of all my CPPs in the EMR; about half of the paper charts for active patients have been scanned in and shredded. We have destroyed three shredders so far, and have now bought a better shredder.

My partner is away for the next two weeks. My secretary pulled a total of four paper charts for me for Tuesday, when I come back from the long weekend; none of the charts needed preparation such as stamping in the date or adding a lab requisition to the front. This was the least amount of work done here for chart pulls.

We have been talking about what to do with the gains in office efficiency once all the paper is gone. I think it is much more interesting for my staff to take on some clinical duties. My filing clerk is a trained lab technician, and does my blood work, pulmonary function tests and Electrocardiograms. Perhaps she can do my allergy injections, so those patients do not have to wait. She can also administer influenza vaccines or other vaccines if needed. I will have to find out what the requirements are.

I have also been thinking of buying an electronic blood pressure monitor, similar to what is used in the hospital. Coincidentally, my resident asked me to participate in a research project run by one of her colleagues: I am getting an electronic BP machine for a week, to find out what I think of it. I don't think it is better for me (compared to the standard mercury-based BP), but it will enable my staff to do BP for me as part of the intake for full check ups. Perhaps we can also do this for diabetic patients, and for hypertensives; I will have to figure out how.

I've been talking with my resident about doing electronic audits; I did an audit a couple of years ago for my diabetic patients, Chart Audits in my practice, and it would be interesting to find out what happened with blood pressures/sugars/cholesterols due to the introduction of the EMR. We had a look at my electronically generated list; she can get the vitals and lab work easily from the EMR. If the lab predates the EMR, the scanned chart is available on my office network. I think the electronic audit will take far less time than the paper-based audit; I wonder if results can be automatically entered in Excel, instead of transcribed.

I've received a note saying that I can log on to the electronic Child Health Network, which will give me access to the shared health record for children. It looks like this has information from hospitals and home care. Two more passwords for me. I also have remote access to my own hospital's database, which contains a partial electronic medical record (in-patient drugs, labs, diagnostic imaging, consult notes). I've used that sometimes to look up hospital results. I've also registered to access my lab results on-line, as a back-up measure if the EMR server fails (example, C.M.L. or MDS). There is also a site where all the pap smear results are kept, Cytobase . We seem to be building several pieces of an overall electronic health record, of which my EMR is part, but it still looks very disconnected. This is a bit like the early days of the internet; there were all these Bulletin Board Systems which were not connected to each other. You had to use separate phone numbers and passwords to log on to each one. Perhaps over time there will be bridges between all the systems, so that the data can follow the patient.

It is a start for an integrated health record, but there is still lots of work to be done.


Friday, July 28, 2006

At the four month mark

This was the first month during which I felt very comfortable using the EMR. There was no crisis this month, and computer use is now part of office routine. I am no longer going home later than usual.

I have entered initial prescriptions for almost all of my patients who are on multiple drugs; now it is a matter of renewing the drugs, which is a much faster process (tick the check-box, then print and sign). I have written over 1,000 individual scripts; writing a prescription is very easy now that my list of favourites is populated, as most new scripts auto-fill when I put in the first few letters of the drug.

We have remote access, which is extremely useful. I sometimes take charts home with me so I can enter CPPs later, which means I can have supper with my family. I now have 50% of all charts entered.

The old charts are getting scanned and shredded; large lacunae are appearing in my filing cabinets. Many charts are not getting pulled, because the paper chart no longer exists. I referred a patient recently, and had to add some radiology reports from her old chart; I loaded the pdf file on my Tablet from the hard drive at the front, picked the report that I wanted, printed it, and added it to the consultation request. This is working very well.

I go to the senior's clinic that I run offsite, and access the charts remotely; I usually carry a couple of charts back and forth with me because those patients see me at both the clinic and my office. Those old charts were scanned, and are now getting carried in my Tablet instead.

We are routinely using electronic messaging; the little scraps of paper with notes on them have disappeared. I sometimes use my "to do" list to leave a note for myself instead of using paper.

I found an area in the chart where you can put "follow-up" notes; I will sometimes use that instead of "Plan" in the clinical record. The Follow-up shows up in the summary when I open the chart, and reminds me to do something. For example, when I see a patient with diabetes, I will put a recurring Follow-up called "DM", which recurs every 3 months. This prompts me to look at their diabetic parameters, and is very useful for patients who have other conditions (such as schizophrenia); sometimes the diabetic follow-up gets lost in the middle of taking care of everything else. I also have a Hydrochlothiazide Follow-up, which reminds me to do a potassium after the first month of using this drug. I should program Follow-ups for other drugs, such as potassium and creatinine for ACEIs, so that I don't miss these things.

All the physicians in my group are using the EMR to various degrees, and we have signed off on the document letting OntarioMD know; this will mean that the monthly $600 subsidy will start.

The past month has been much easier than the initial transition period. Now it is a matter of putting in the rest of the CPPs, finishing the scanning, and learning more about the application. I should probably register myself for a booster session.


Thursday, July 20, 2006

Shared Electronic Charts

Having the 9 physicians in my group practice out of 7 different offices gives rise to some interesting possibilities.

I have a patient with borderline hypertension. Her daughter is a Practice Assistant in the office of a colleague in my FHN, and volunteered to periodically check her mom's pressure at her office. My patient consented to have her daughter access her chart and enter weight and BP electronically. So now I have weight and BP entered remotely; I sent an internal electronic message in the EMR telling my patient's daughter how to generate tables and graphs of BP, and I can see those as well. I'll make a flowsheet so that we can follow weight and BP together. The EMR logs and tracks who enters data.

As well, I do shared prenatal care with a colleague. I follow patients until 24 weeks of gestational age, and she takes over after that. This week, I sent an internal message to staff in her office that electronic lab and ultrasound results were available. They were able to view the results on our common electronic chart (no faxing).

Looks like you can both enter data and look at information in a shared electronic chart. Several colleagues in my FHN are in our palliative care group, and a shared chart could be especially useful in this setting. We'll need some good, common sense rules to protect patient privacy while ensuring that people in a patient's circle of care have appropriate access.

A new family medicine resident came to my practice this afternoon. I gave her the spare laptop to use while in my office; it had been configured to access my wireless network and the remote server. We talked about how to use the EMR, and I showed her how to enter clinical notes and prescribe medications. We also discussed how to navigate the EMR-based chart. By the end of the day she started to become more proficient at this, and had done several prescriptions. I think taking over an EMR that is already used in a practice will mean a shorter learning curve.


Friday, July 14, 2006

Remote access

Our remote access is now live. I had to install some extra software on my home computer, and there is an additional password, but it works. It is amazing to be able to see everything, as if I was at the office. I just reviewed all my labs, send a message to my secretary to call the pharmacy with a changed synthroid dose, put this in the patient's CPP, and arranged for a lab req to be mailed to her so she can repeat her TSH in 3 months. From my home.

This will help me when I attend conferences, or if I go on vacation: I can take care of lab tests and messages remotely, to avoid some of the usual mess when I get back to the office. Of course, there will be the temptation to log in while on vacation, which I will not always be able to resist. At least my cottage does not have internet access, so I'm forced to relax there.

It took 3 months to enable this, which reflects the fact that our system is complex, with several security levels (application, hospital, SSHA). It is a trade off: more complex systems need more time to get set up. It would have been simpler and faster if I had a server in my office, with some type of black box to enable remote access. However, long term, I think an "enterprise" set up will serve us better; I have to stop thinking of my practice as a Mom and Pop Shoppe. We need to be interconnected, and connected with the rest of the health care system, and that will mean a professionally managed server, with high level security. Down the line, I can't see this being managed in my own office (plus making sure back-up and upgrades happen as they should).

I have now done about 40% of my CPPs. The student is in mornings, and is now scanning about 30 charts daily; that probably won't be finished by the end of the summer, but he's taught the rest of my staff how to do it, and we'll continue in the Fall.


Friday, July 07, 2006

Paper chase

We have started to scan and destroy old charts. My secretary said that she just can't believe how much paper we have accumulated over the years, all stored in different locations in the office (current charts, charts of patients not seen for over 2 years, deceased, transferred, part 2 of a large chart, seen offsite at the senior's clinic, piled up for pending consult request, or just plain sitting on the doctor's desk). The time and space taken to manage this is huge.

On Tuesday, we scanned the first paper charts to pdf, had a look at several scanned files to make sure they were good, and tested the back-up. We've also been shredding, but I may send some of that to a commercial shredder. We're putting out five large bags daily; my small office has enough shredded paper to confetti at least one medium size parade. It was very strange to see a filing shelf without the usual collection of crammed, dog-eared files.

I saw a new patient yesterday, and he gave me a copy of his old chart (on paper). Eventually, we'll be able to transfer a chart electronically , but I can't imagine this will come anytime soon. I will review his chart, enter the relevant information in my electronic CPP, and the paper will be scanned to pdf just like the rest of the old charts.

The pop up alerts in the EMR came in handy yesterday. I had seen a patient for a check-up; a recent guideline recommends an ultrasound for men between 65 and 75 who have ever smoked, to rule out an abdominal aortic aneurysm. I saw that on my preventive checklist, when signing off the electronic record (but he was already gone), and put in an alert. The patient returned yesterday, the alert popped up when I opened the chart, and he was sent for his ultrasound. I also saw a patient with Hepatitis C; vaccination against hep A and B is recommended, and public health supplies the vaccine for free. When entering her CPP, I had noticed that she had not been tested for A or B antibodies, and put in an alert for myself to do so. She came in yesterday for another reason, and was tested. I should probably run an audit for Hep C when I'm finished with all the CPPs.

I will be away on vacation at the end of August. I will need to figure out how to let my practice partner (who is paper based) look after my patients. We can print the CPPs for him, scan his clinical notes to the chart, and have him review faxes/mail on paper before scanning. I will show him how to find things in the chart as well, and my staff can help. I do not know how he will handle incoming electronic lab results (I will ask), and I don't think he can print consultation requests from the EMR; we'll have to scan those in. Coverage in hybrid practices is more difficult. On the other hand, any of my colleagues in my FHN can have access to the full chart; perhaps, in the future, coverage will be via "virtual" groups like mine, where the physicians may not be all located in the same office, but can all access the information if needed.


Thursday, June 29, 2006

Organizing the CPP

I don't think we called the helpdesk at all this week. Things are definitely going more smoothly.

I am reviewing previously entered CPPs when I see patients, and correcting earlier mistakes. I am now systematically entering CPPs from my alphabetical list of rostered patients; I am about 30% done. I see about 10% of my patients without any paper charts being pulled at all; we are still often pulling charts that have been marked as "EMR".

There are different ways to organize a CPP. The way I've organized mine is:

  1. current, ongoing health conditions (diabetes, asthma, hypertension etc). These are all coded in 3 digit ICD 9, for easy searchability
  2. allergies (drug, non drug); coded from the drug reference software
  3. social history (smoking, alcohol, marital status etc)
  4. family history; all coded in 3 digit ICD 9
  5. past medical history. This is free text, and thus not easily searchable, but easy to enter. It contains previous operations; previous limited medical problems (eg, gastritis); previous antibody results (rubella Ab, varicella status, hep A/B Ab); date of last previous screening tests (pap, mammo, DXA, FOB); date of last full check up
  6. procedures (structured), with date and result: gastroscopies, colonoscopies, hysterectomies, previous breast cancer. The last 3 are to help me with preventive audits, the gastroscopy is because I can never find it in the paper chart
  7. immunizations
  8. alerts
  9. labs (entered directly via a button in the electronic lab result, eg: pap, FOB, Hep B Ab, others). The free text Past Medical History area is only for old paps and FOBs. All new ones go in the CPP lab area.
  10. flowsheets
  11. Framingham cardiac risk score
  12. referrals (entered directly from the EMR referral)

I have been told that my templates can be put on the general server; I will ask Nightingale to transfer the preventive health templates, the sore throat score, the small smoking cessation template, and the Ottawa ankle and knee rules.

On Tuesday, we start scanning all the old charts. Happy Canada day, everyone!


Friday, June 23, 2006

At the three month mark

It was an interesting week. It started very badly, and ended well.

On Monday morning, I came to the office to find out that there was no internet access at all. SSHA had upgraded their system over the week-end, and it all crashed on Monday. Luckily, I have a back-up internet line. However, I found out that it does not work with the SSHA router (the SOFA, Small Office Firewall Appliance). No dice. I will need to get a separate router, and will have to access the server via the SSHA VPN (virtual Private Network). I seem to be learning to talk computer. We don't have the SSHA VPN yet, and were told that there are still technical problems holding it up at the hospital server; they are working on it.

It is worthwhile making sure the back-up systems work; that is good to say in theory, but in practice I have been so busy managing the EMR start-up that there just wasn't time for that. I think I'll do it now, though.

We went back to paper for the morning, just like the previous time. Patients were very understanding (we couldn't book appointments, test results were not available etc). I think pretty much everyone has experienced computer problems at some point in time. We were back on-line in early afternoon.

An SSHA analyst had a look at my line again, and contacted me. He said that it will be much better by today, as he will make sure it becomes faster. I phoned my secretary a couple of hours ago, and she said there was a noticeable difference.

I am just about at the three month mark. A couple of patients who have recurring appointments every three months came in this week, giving me a chance to look back at their chart to see what I did at the very beginning. I had to fix a couple of things, especially with medications (I put expiry dates on continuing meds, some of the dosages were odd etc). One of my diabetic patients told me that I had forgotten to do her annual foot exam and monofilament testing, so I did it now and put it in the EMR diabetic flow sheet. My quality of care went down at the beginning, because I was figuring out all these new things; I also think you can expect to have less than perfect records as you learn.

I am now having more good days than bad (except for Monday). Practice flow seems to have stabilized, and efficiency is back to normal, but not yet better. It seems to me that the first three months are the hardest, as everything has to change at once. I probably should have booked more lightly for a bit longer. This is not something to do in the middle of flu shot season!

I am now entering CPPs much more quickly; I am pulling charts in alphabetical order at lunch, and after the office. I'm about 25% done. I figured that I could do my pap, children's vaccination, and mammogram audits at the same time, since I'm looking at all the charts anyways. I found a button on the EMR chart summary that reminds me to do a pap or mammogram. When I hit the button, I can enter the date of the last pap or mammo; then the alert does not pop up again for two years. At the same time, I also started using the area that generates reminder letters for patients who are overdue, and have sent out several letters (pretty easy to do, 1 click for the letter, then 1 click to print). Once I record the date of the pap/mammo on the summary button, the patient's name disappears from my overdue list, and I don't generate a letter.

As we continue to use the system, sometimes we would like to have things added. For example, when my secretary makes an appointments with a specialist, she now enters the date in the application, so we can keep track of this. However, there is no area to record the time of the appointment. I emailed Nightingale, and received a reply that they will put this on their list of enhancement requests. That's how programming changes happen: if there is something you need or would like, you send a request to the company, and if enough people ask for it, it gets programmed for the next upgrade. I think the process must be fairly similar for other vendors.

A family came in, and mom asked me to look at her son (who did not have an appointment). It was very easy to just pull up the file on my Tablet (and quickly make sure he was up to date on his vaccinations). That's a definite improvement over paper.

In summary, the first three months are probably the most disruptive, because of all the changes. Try to plan for change where you can, and take the time to solve problems as they happen. If possible, book lightly, and do it during a quieter time at the office. Expect delays with various things, like lab, VPN etc. Talk with your staff a lot, it is just as challenging for them as it is for you. Doing it as a group is a good idea, because you can talk to your colleagues when problems happen (or just for moral support), you can split various tasks, and you can share ideas. Use the helpdesk often, that's what they're there for; encourage your staff to use them as well. There will be extra stress, so take a bit of a vacation in the middle if possible. Above all, don't let the inevitable problems and difficulties discourage you; the ladders do outweigh the snakes.

I think I'm now at the end of the beginning for this project. On to the second half of the transition period.


Sunday, June 18, 2006

Handling scanned documents

Last week was very good. Everything worked, and I even entered all the CPPs ahead of time for two days. I was completely paperless those days, which gave me a taste of what my office will be like in three to four months. I like it.

I got a call from someone who works in technical services at SSHA. He said that the inconsistent speed was because the wiring in my area is very old; we have copper wires. They are working with Bell to try to improve this, and may be able to give me some work-arounds.

A colleague was asking me about how scanned documents are handled in the EMR, so I will give a brief overview here. There are two types of scanned documents:
  1. the old chart
  2. new incoming documents (Diagnostic imaging reports, consult letters etc)
1. It is not useful to have the old chart scanned as part of the EMR. You would have to classify each piece of it (is this report filed as DI? Is this a consult letter? etc) which is very time consuming. What we will be doing over the summer is scanning each old chart as a single pdf document (the scanner does 25 pages per minute, or 50 pages if you scan both front and back). Each scanned chart will get a file name (last name, first name). Those charts will be then be saved to an external hard drive, which will be attached to one of my computers and shared across the network. If security is a concern, you can assign a password to the files. I will also back up the whole thing to a DVD, which will be kept offsite.

You can load the pdf file from the network if you need to look at the old chart; also, pdf files are searchable.

For files of deceased/transferred patients, there is no need to keep them on the network, because I will not need to look at them. They will be put on a DVD (locked away at the office), with a copy on a second DVD, kept offsite. DVDs cost about $1 each.

I have hired a student to do my scanning this summer. The reason to scan the old charts is that then the paper is gone forever from your office, and the cost of ongoing storage is zero; also, with a back-up to DVD, you can never lose your charts to an office fire.

2. All new incoming paper/fax documents are scanned to the EMR. They can be classified in the chart as DI, consult notes, lab, ER notes etc. My filing clerk does this when she scans and uploads documents. She also adds extra information, such as the name of the specialist, or the type of DI. When I look at the file, I may put in a comment, for example "XR normal". Then I have a good overall summary of all DIs for this patient in a single area of the chart.

Loading the scanned document so you can look at it takes time; I try to put the useful information in my comments area so I don't need to bring up the whole document. This is usually very brief (example, for a derm consult: Dx acne rosacea, Rx metrogel). If I need to copy a bigger piece of the report for the comments, then I use OCR (optical character recognition). There are various ways to do OCR; what I do is send the scanned report to Microsoft Document Imaging (file, print, MS Document Imaging), then I hit the OCR button, then copy and paste to comments.

I also had to decide what to do with various pieces of paper that can't be efficiently scanned to the EMR, for example, ongoing allergy shot records, or 2 step TB tests (4 visits) for hospital volunteers. The allergy records are now kept in the box with the allergy serum, and not with the chart. I will scan that in when the allergy series for that year is completed. For the 2 step TB, I give the form back to the patient; it is their responsibility to bring it back each time they come in. We scan the report when it is completely filled in.


Tuesday, June 13, 2006

Plugging away

I spoke with the pharmacist across the road from my office. He gets inspected periodically; if the inspector sees a script signed electronically, that can lead to trouble for him. At the College of Physicians and Surgeons, they told me that this policy comes from the College of Pharmacists. This is not something I can change for now, nor do I want to cause problems for pharmacists. I am now printing and signing my prescriptions in blue pen.

My lab and my EMR company have been talking with each other; the pap requisitions will be reprogrammed soon so that they conform to the Ontario Laboratory Accreditation program. It looks like that problem is about to be solved through cooperation, which is good to see.

I have found access speed to be inconsistent. Sometimes it is OK, and at times, it feels like data is coming through an eyedropper. The government told us they can upgrade our internet lines, so I applied for an upgrade. I received a new line, and a new modem, which the people from SSHA installed. However, I had to connect this to my network myself, and I had no idea how to do this. Trying to connect wires by myself did not work. It took the better part of an hour last Thursday morning, on the phone with the SSHA helpdesk, to figure out what to do (something to do with IP config). Then all my printers went off line; this did not get fixed until late afternoon. The new line is not faster, but I understand that they are working on this.

These are complex systems, and problems will happen; I sometimes miss the simplicity of paper. I still think EMR is the way to go, but I was not happy that day.

I found out that if I print a handout from an internet site accessed within the EMR, this is tracked in the patient encounter. I like that; I print a lot of handouts (from my own website, from the College of family physicians of Canada, from the AAFP website). Now I can see in the record that I gave the patient a handout. I can also see if I generated a cytology req; pretty soon, I'll have the rest of the reqs as well. I've also started printing some XR requisitions. I am beginning to see how this can capture and track a large part of my process of care. I don't know if it will make those processes better, but at least I'll have a chance to look at what I am doing.

I have been talking with a colleague about joining us; she is thinking about starting a new practice. If this works out, she will start paperless from day 1. I have a student coming in two weeks to start scanning all my old charts, which we will then shred. This will free up space, allowing us to take on an extra physician (but only a paperless one).


Tuesday, June 06, 2006

Interacting with others in the health care system

The lab called me to ask why I was sending these non-standard pap requisitions. I am continuing to send the computer-generated reqs, with the data circled in red, and a note asking them to please accept this paper. They said that the size of the paper is different, and it is also a different thickness, so this will present filing and tracking problems for them; also, the technologists are not used to seeing the data presented in this way.

We had a nice conversation. I explained that having the pap reqs printed from my computer avoids mislabeling with the wrong patient info (it is done right from the patient encounter, no sending to the front for a label). The pap is tracked from my system, so I can make sure I receive it. As well, I use the tracking for my preventive bonuses (I get a bonus if 80% of women age 35 to 69 in my practice have had a pap in the last two years - pay for quality).

I think the lab will start to see a lot more computer-generated requisitions; it might be good to start planning for it now, while it is just a trickle. They seemed receptive to that argument, so we'll see what happens.

I received an email from a patient, commenting on the fact that the pharmacist told her he'd have to call my office regarding the prescription I signed on the Tablet. We had talked about it at the office, and she thought it was silly as well. Maybe I'll email my College representative to see if he can help; if introducing EMRs is deemed to be important for patient care (as Canada Health Infoway says), then our regulatory agencies can do their part to help.

I have been thinking about coding my diagnoses. If I want to do audits in my practice, I have to enter diagnoses consistently. I can't call a UTI a bladder infection one day, and cystitis the next. Right now, I am entering diagnoses as 3 digit ICD 9 codes. We send bills to the government using the ICD9 codes for diagnosis, so at least I know some of the numbers. I know that Health Infoway is thinking about having everyone use SNOMED, so that different computers (hospitals, home care, physicians) can share data, but there is no way I can learn and use this in practice. It's just too busy. Maybe there is some way they can translate ICD9 into SNOMED.

I am using a flow sheet to track depression. It was surprisingly easy to program. I enter the PHQ9 score, the Quality of Life score from the bottom of the PHQ9, the meds, and comments. I have an alert on the EMR asking my staff to print and give the questionnaire to my patient to fill in the waiting room, so I get the result right away. I referred a patient who had been on several antidepressants (with no change in the score) to the psych intake program at my hospital, along with a printout of the flowsheet. I think this will give the consultant an organized summary of what happened.

I will be taking on a family medicine resident for the first time, starting this July. She will be working with me and my practice partner, and so will see both an electronic and a paper-chart practice. She'll also see the transition to EMR; I think it will be interesting for her.