Tuesday, January 31, 2006

Networking my office

The network installer came on January 27th, a Friday. It is not a good idea to install on a Monday, as those days are too busy.

I had to choose between a wired and wireless network. I've heard various opinions on problems with safety, speed and stability of wireless. It is difficult to know, as the technology changes so fast. It seems to me that wireless is a reasonable option now; security can be properly configured if done by a professional. In any case, having a tablet means having a wireless network, since the tablet is portable.

I ended up choosing to have both. Each wired "drop" (or plug in the wall that connects to your network) costs $150. This is a one time capital cost, it would be difficult for me to arrange for someone to come in to do a single line through the ceiling. I ended up having wired network connections (or RJ45 outlets) in every examining room, at the front, and beside my scale. I will also have a wireless router.

Another way to think about this is to have wired connections for all desktops computers (ie, the front computers for your staff), and wireless for the tablet. I also put in an extra RJ45 outlet in the front for the credit/debit card pinpad; you can have those run through the broadband connection, instead of tying up your phone line. Two companies that supply pinpads are Moneris and Paymentech.

I am thinking of buying some network printers. These are not expensive anymore. They can use the network cable (Ethernet) instead of USB, and I'll put one in each exam room. Then I can use my tablet to access my network wirelessly, and print prescriptions and handouts in the room.

Our contract includes some nice desktop computers, with extensive warranties. It is good to get those for "mission critical" areas, for example for your front staff. If that computer breaks down, you want it fixed, fast. As well, the tablet includes a very good warranty. I will probably buy some inexpensive eMachines in the future for less critical areas, for example, where the scales and vaccine fridge are, so that weights and fridge temperatures can be recorded. Perhaps I can find a thermometer with software that automatically sends the temperature to the computer.

I also work at a satellite office, in a residence for seniors, once a week. I had the network installer put a network connection there as well. The building's front office has broadband (which they're letting me use), and I can access my server via VPN. I won't have to trudge charts back and forth from my office anymore.

Our first training session will be February 8th.


Monday, January 30, 2006

Choosing training and go live dates

We held a meeting in December to confirm hardware choices, and to decide on training dates. The training schedule was complex, as there were 7 offices, 9 physicians, and support staff; training sessions are from 9 am to 1 pm or from 2 pm to 6 pm. We had picked our preferred dates, as well as preferred "go live" dates, and emailed them to the company as well as to our It lead ahead of time. At the meeting, we confirmed the dates (with a bit of bargaining around).

"Go live" day for me is Thursday March 2nd, 2006. On that day, we will stop using my old billing program, and will switch to the new billing and scheduling software. I blocked off half of my appointments. We will be getting a trainer at the office from 9 am to 1 pm.

We have two training sessions of 4 hours each scheduled for my staff, and for me and my partner in February. We will learn billing, private invoices, reconciliation and scheduling. We also have an extra 3 hour session to learn how to manage the RSA security fobs. These are small key fobs that you carry around; they display a random number, and you enter that along with your password. There is one for every physician, and one for each staff member (we also got one extra one, in case someone forgets to bring theirs to the office). These are included in the purchase price, and they provide very good security. The company will also teach us about the electronic lab interface (we will switch from paper to electronic data for labs), and how to manage scanned documents.

We had completed all the paperwork for OntarioMD, and received the initial subsidy of $4,500.

The next step will be to set up the network.


Sunday, January 22, 2006

Thinking about how to convert my data from paper to electronic

I had been thinking about how to convert from paper-based data to computer-based data. I found these resources to be very helpful:
  • Computerization and going paperless in Canadian primary care, a book by Dr. Nicola Shaw, which I bought from the CMA's website
  • Implementing an electronic medical record in your practice, available here. The "rapid but cautious" article by Dr. Mark Dermer is especially useful
As well, there is the Physician's Guide to implementing electronic medical records (free for CMA members)

Dr. Dermer suggests converting during quieter office times; Fall is not a good time, as we are especially busy due to flu shots. During the summer, everyone is away, so that is not a good time either. We are going to train in February, and start using the EMR in March.

Scanning all my old charts is not going to be very useful. You can't easily search the scanned images, and it would be a lot of work. Dr. Dermer suggests thinking of charts as "volume 1" (paper), and "volume 2"(EMR), which makes a lot of sense to me. I will be entering my Cumulative Patient Profile (CPP), which is the summary report at the front of the chart into the EMR, and almost nothing else. All new lab results and other reports will go into the EMR after the start date.

I had been thinking about hiring someone to enter the CPP on the computer, but have decided to do it myself. It is the most important part of the chart, and needs to be done properly and reliably. I have made sure that my CPPs are well organized, which will help with data entry.

The IT trainer from myNightingale had asked me for a test diskette with data from my old billing program. He needed to test it to see if transferring demographic data (patient names, dates of birth, addresses, health card numbers etc) would work. I was able to give him that, and he said we should have no problem with this data. Scheduling and billing data are more of a problem; they cannot be transferred. We will print the schedule and manually transfer it to the new system, but I'm not sure what we will do with billing yet. The trainer told me that he will get a "final cut", which is the demographic data on the last day we use the old system, and transfer it to the new system so it is ready for "go live day".


Wednesday, January 18, 2006

Choosing hardware

My practice partner decided he wasn't quite ready for EMR. However, he agreed to switch to the new system for billing and scheduling, as our current system was over 10 years old, and was DOS based. We would therefore have a hybrid office, but with a single billing and scheduling system; having two computer systems would have been very difficult for our front staff.

I made a point of trying to keep everyone at my office as up to date as possible. This is a big change, and it helps if people know what is happening.

My group held one more meeting in October, and we decided to sign the contract. We met the company's IT trainers, and we set up dates for them to visit each practice. Our FHN lead reminded everyone to send in the SSHA and EDT applications. We discussed the cost of the server (shared with the other FHN); this is approximately $1,500 per physician. We started to think about hardware: we had a choice between a wired network with desktop PCs (or "workstations") in each room, and a wireless network with tablet PCs for the physicians. Please see the glossary for a definition of Tablet PC.

We each gave a check for the software to our FHN lead physician, to deposit in our group account. The contract is for the entire group, so the FHN pays for the software, not each individual physician.

The two IT trainers came to my office a week later. They spoke with my staff and me, and had a look at my practice's physical layout. I thought I would prefer to have two workstations at the front desk (as I have two staff members there), and a tablet PC for myself. I use a Palm PDA very often, and had gone to FutureShop to try the Tablet PC: it felt like a large PDA, and I thought I'd be comfortable with this method of data entry. My partner chose one desktop PC for his consultation room, and did not need any computers in his exam rooms. I wanted a printer in each room (to print prescriptions, because electronic transmission of prescriptions is not allowed, and to print handouts). Printers are very inexpensive, and can be plugged into the Tablet as needed. The trainers had a look at my existing computers and equipment; most of it was very outdated, and little could be salvaged.

Once everyone had a site visit, the company asked us to email them our thoughts about the hardware we needed. For my practice, this was:
  • 2 workstations for the front, 1 for my partner
  • 1 tablet PC for me
  • 1 network printer for the front
  • 4 printers
  • 1 card swiper
  • 2 label printers
  • 1 scanner
Our IT lead set up a meeting in December with the Project Manager assigned to us, to go over our hardware choices, and set up the training schedules.


Sunday, January 15, 2006

Signing the contract and thinking about implementation

We were getting to the final nuts and bolts of the contract. Our IT lead had kept us informed via email. At the meeting, we went over a couple of points on the contract offer, with the regional manager from myNightingale; it looked like we were going to sign.

We went over the Scope of Work document, which we each had to fill. Most of what we had to write in there was impossible for us to understand. Our IT lead had asked the OntarioMD specialist what we needed to write in, and just dictated this at the meeting. That is the only way this document is going to get completed.

We were also thinking about implementation. The company had emailed us a description of how they were planning to implement:

  1. workflow analysis: they send people to each office. They talk to the physicians and staff and find out what happens in the office
  2. training and implementation plan: this tells us how we will do
  • billing,
  • scheduling,
  • training for staff (course is mostly standardized, but can be customized--although I'm not sure how exactly this can be customized)
  • EMR training for physicians
  • IT assessment for practices and the hospital (what machines go in, wiring, etc)
  • decide on wired or wireless network
3. buy and install the hardware
4. start training
  • 2 sessions on practice management (billing, scheduling)
  • 2 sessions on EMR
  • each session is 4 hours
The hardware needs to go in at least a month before you "go live" (start using the software). This is to make sure it is properly installed and tested. Training needs to happen after hardware is installed, and shortly before going live. We each have an on-site trainer from the company for the first half day that we go live to help out. They suggest booking lightly for the first week.

We were going to start using the billing and scheduling (or "practice management") software first. Then, we were going to go back for the two EMR training sessions, and have the physicians start using the EMR a month after the staff starts. This is called a "staged implementation".

We now had to go back to our practices and talk to our non-FHN partners, as they needed to decide if they were going to use the same software. It was October.


Saturday, January 14, 2006

Getting SSHA broadband in the office

After some prodding from our IT lead physician, we sent the documents to SSHA so we could each get a broadband connection. My office received an ADSL connection; SSHA shipped me a DSL modem, as well as a Small Office Firewall Appliance (SOFA). The SOFA is about the same size as the modem, and provides additional security. Instructions on how to connect the whole thing came with the shipment; the modem connects to the phone jack, and the SOFA connects to the modem. If you need help, there is a 1-800 number to call.

My internet connection did not work. After an hour of being connected, the modem started to smoke and smell bad, and then shut off. My OntarioMD IT transition specialist put me in touch with someone at SSHA, and they sent me a second modem. Perhaps the problem was that I have two phone lines at the office, so I bought a line splitter; putting DSL over a dedicated phone line (such as a fax line) is a better idea. The second modem fried as well, shortly after installation--a critical hardware failure.

SSHA then told me that they would install cable internet. This came about three weeks later. You have to make sure that you contact SSHA well ahead of time, as it takes time for the installation, as well as time to solve problems. The cable internet connection now works.

Some physicians in our group (including me) had never switched to Electronic Data Transmission (EDT) to submit billings, and were still using diskettes. We had to send in a form to the Ministry to switch to EDT. The two forms are on the Ministry of Health's website, Form 1 and Form 2.

Our IT lead physician was proceeding with the contract negotiations. OntarioMD told us that they would release the first installment of the subsidy ($4,500 per physician) once they had our Letter of Intent, Vendor Contract Declaration, and Scope of Work. The OntarioMD IT specialist will help with the forms; the first two are done for the group, and the last is done by each physician (we did it together at one of our meetings).

The cost over 3 years for software and hardware was going to be approximately $30,000 (depending on how many computers in the office etc), fairly close to the subsidy. The greatest costs are hardware, training, and support, not software.

Our IT lead called a meeting so we could decide on next steps.


Wednesday, January 11, 2006

Choosing an EMR company: we decide

We decided to have a demonstration at the company's head office. All of us got together one July evening, with some of our staff, and tried the software. At the end, it seemed pretty clear that we were going to go with myNightingale.

Now came the hard work of negotiating a deal, and a Service Level Agreement (SLA). The SLA is a separate document outlining support and maintenance (such as what happens in case of catastrophic failure, how fast the company responds to requests, etc). Documents relating to the SLA can be found here, under "Contract Negotiations", and here, under "Systems Management Guidelines". Our IT lead started on this, and had some help from a lawyer. It helps if your group has a bit of money in reserve to pay for this. The FHN receives some money each month for being on-call, and we hold this in a common account. We used this to pay the lawyer, and to reimburse the IT lead physician for the time she put in. You don't have to have a lawyer review the software agreement or the SLA, but there is a lot of fine print. It is worthwhile doing.

Because of the fact that we are in 7 different offices, we decided to go with a "Configuration 3" set-up (for an explanation of configurations, please see the glossary). This means that we have a server (or main computer) at the hospital, with all of us accessing our data via broadband. There are some advantages to doing this: we contract with the hospital's IT department to do regular back-up and maintenance, and they keep a copy of all data off site (they do this as part of their regular hospital back-up procedures, so there are already processes set up for this). The EMR company works with the hospital to maintain and upgrade the server as needed. We no longer have to worry about back-up management, or database software issues.

The other FHN wanted to do this as well, and we agreed to share one single server, which cut the cost of the server hardware in half. If more FHNs decided to join us in the future, or if more physicians join our FHN, there is ample room on the server to accomodate them (this is called scalability).

The head of the hospital's IT agreed to have the server in the hospital. Having the hospital work with us is very helpful; perhaps having our server inside the hospital will help us to share our data. If a patient is in the Emergency room, or is admitted, appropriate data from their community-based chart should be available inside the hospital. Conversely, when a patient is discharged, I should have access to their hospital data.

We had to solve the problem of having non-FHN physicians on the server as well. If a physician has data on a different server, you have to log out and log back in to see their patients. That would not work very well in my office, where I am a FHN member, and my partner is not; my staff would have to continually log out and log in to switch between us. We had to get permission from OntarioMD to have non FHN physicians on our server, which they granted.

We were now ready for final negotiations. It was September.


Sunday, January 08, 2006

Choosing an EMR company: unexpected difficulties

Our IT lead physician arranged a meeting for our group with the OntarioMD IT transition specialist assigned to us. Each FHN has access to a transition specialist to help with the process and the (often very complicated) forms we have to do.

Our transition specialist told us how the subsidy program works, and showed us a power point presentation about the program. She explained what the different configurations for the server are.

Our FHN has some problems. There are 9 of us, working in 7 different offices. Three of us work in a two physician practice with a non-FHN partner. We did not know how the EMR would work in this case.

The transition specialist explained that the non-FHN partners would not be eligible for the IT subsidy. The FHN negotiates as a whole, so there is only one IT contract for the whole group. Our non-FHN partners would not be negotiating with us, and we each would have to make separate agreements with them. This introduced the possibility that some practices would have a mix of physicians using and not using EMRs.

We knew about the other FHNs decision on software; our IT lead wanted to explore a few more options before deciding on a demonstration, and we agreed to do this.

We were also told to apply now for free broadband access from SSHA, as it takes from 2 to 4 months for them to install this. We were given forms to fill and fax back to SSHA. The forms include authorization for both cable and ADSL (over phone line) broadband, and you have to fill out both. SSHA decides which one should go in your office. At the same time, we were also given forms to fill for the rVPN (remote Virtual Private Network); this enables access to the practice software from other places (for example, home or cottage). I have put a link to a glossary on the right side if you find all these acronyms to be confusing.


Friday, January 06, 2006

Choosing an EMR company: getting consensus

The lead physician for the other FHN had chosen myNightingale as the preferred EMR. She arranged for a demonstration at their head office for her group, and invited several physicians from my group to attend.

A physician in our area had been using the product for a couple of years, and was very happy with it. He came to the demonstration to show how he was using it in his office. Having local colleagues who are already using EMRs may help, as they are familiar with the products, and will often have good ideas for implmentation.

We tried the software in the company's boardroom for several hours, and had lots of questions. There did not seem to be any obvious critical problems. It seems to me that the demonstration should be the last step; it is not a good way of making an initial decision (it is too brief, and you miss too many important points). It is a good way of getting consensus for a product, and to make sure there are no major problems.

It looked like the other FHN was going to purchase this software. We now had to decide whether it was right for our group as well.


Tuesday, January 03, 2006

Choosing an EMR company

The decision to choose EMR software is not easy. There are many vendors out there, different pricing levels, and different levels of support. OntarioMD supplies vendor assessment tools. This is includes an extensive checklist that can be used to compare vendors.

The problem was that most physicians in our group (including me) were either too busy or not sufficiently interested. There is another FHN in my area, and we were looking at what they would choose, because it would likely influence our decision. Each FHN decided on one physician to lead the IT effort. If you do not have such a "champion", the EMR effort is unlikely to get very far. The IT leads spearheaded the process, and compared several companies. Several of us had favourites, based on what our friends were using or what we had seen before.

In May, the other FHN's lead was ready to make a decision; she had three top companies, but considered one to be best suited to our circumstances.

I have not been able to find literature to tell me what the "best" EMR is. In fact, I found a study showing physician satisfaction and dissatisfaction with several different software applications. It may depend on how "sold" you are, and how often you use it.

The next step was to be a live demonstration.


Monday, January 02, 2006

The decision to start an EMR: funding from the government

As part of primary care renewal, the government committed to helping to implement and pay for EMRs for family physicians. The following is a brief overview of how this was done.

In October 2001, the ePhysician Project (ePP) was created by the Ontario government and the Ontario Medical Association to choose IT software for family practices opting for primary care renewal. The two parties agreed that the government would provide a $150 million contribution towards EMRs, to be administered by OntarioMD (a wholly owned subsidiary of the OMA).

OntarioMD provides IT transition support to family physicians, administers the IT subsidy, and operates a website accessible to all Ontario physicians. Broadband access is provided free of charge by the Ontario Smart Systems for Health Agency. The subsidy is $28,600, paid over 3 years ($4,500 initially, $2,500 when 600 patients have been entered, and $600/month for 36 months). Because the $150 million was tied to primary care renewal, only family physicians participating in non-Fee for Service models are eligible.

Software companies had to go through the ePP certification process to be eligible for a subsidy. 13 companies were initially certified (list). The certification documents can be found here. One company's product (GE Centricity) was chosen as an ASP model.

The problems that arose out of this were:
  • not all family physicians are eligible
  • there are too many companies to choose from, this is confusing for individual physicians
  • some software vendors are upset with the tendering process used to choose the ASP
Family Health Network physicians were notified in January 2005 that the subsidy process was in place. We could now start investigating the different certified EMRs.


The decision to start an EMR: background information

I have wanted to computerize my records for a long time. However, like most of my colleagues, I have been reluctant to do so.

The major issues, as outlined in a recent Canadian Medical Association Journal have been cost, worries about long term reliability of the software companies, and lack of connectivity with other parts of our health care system. There is no question that EMRs are good for patients and good for the system. The rewards for physicians are less obvious.

Family medicine has been changing recently in Ontario. The government has been promoting "primary care renewal", and has been actively trying to change how we practice and how we are paid. One of the models is the "Family Health Network", in which you form a group with at least 5 of your colleagues, and agree to share call. The payment is a blended system; most of the funding is by capitation (a set amount of money per patient, depending on their age and sex), with some incentives (for example, for meeting targets for influenza vaccinations, patients age 65 and over), and a small amount of Fee for Service payment.

The FHN contract also includes help to implement EMRs (financial and support from a transition team). That was one of the main reasons for me to join a FHN. At the time we signed the contract (2003), my FHN did not know exactly what the support entailed; however, we knew that it was coming. This helped with financial concerns. We also knew that the government was in the process of certifying software companies.

The next step was to come in February 2005.