Birth pains and other glitches

My office switches over to the new system for billing/scheduling on Thursday. My colleagues in the FHN have been switching one practice at a time, since last Wednesday. We've encountered some problems.

There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.

I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.

The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.

I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.

I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.

I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.

Michelle

Skinny labels

We had two more training sessions last week. The first one dealt with billing, both to the provincial government and for private bills. The second session dealt with scanning documents and managing security. There is a high level of security with the RSA security fobs (see Glossary) , and we have different passwords for everything (logging in at the office, logging in from home via VPN, logging in to manage security fobs, logging in to server to submit claims to the government). These passwords are proliferating like yeast spores.

Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.

We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.

Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.

We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.

Michelle

Communicating on-line

I've started to communicate with everyone at my office via email. I've also changed my email software to web-based mail, so I can access mail from both home and office.

My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.

The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.

We have now put up signs letting patients know about the change, and asking for their patience.

My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.

Michelle

Evidence-based programming

I've been playing around with the training software at home; I think this will work.

I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).

It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.

I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.

As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.

I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.

I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.

Michelle

Starting to train

We had our first training session today, for four hours. They train 8 people at a time; we all had a computer in front of us, the trainer shows us things via a projector and then we practice. We had a mix of physicians and staff members. There was a very wide range of comfort with computers, from one "super-user" who had already been using the software in another office, to someone who had never used a mouse or email (and was not too thrilled about all this nonsense).

We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.

The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.

We go back in one week for more training. The computers should come in in the next 10 days.

Michelle

Doing things differently

The EMR will allow me to do things differently. How differently will depend on what me and my staff decide to change; it won't happen by itself.

One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:

"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:

I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/

Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."


I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.

One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:

"I use a Hoboware temperature recording device in my vaccine
fridge. It is connected by a USB port to a nearby computer.
It records  temperatures every 30 minutes continually, and
these readings can be downloaded to the computer when desired.
I use one of those cheap temperature displays for looking at,
but nobody needs to write down temperatures.

You can't continually display the temperature over USB because
it sucks the battery too quickly, so we left the cheap
thermometer attached, but nobody needs to write down temperatures
anymore.

I have been doing this for 18 months and it works well. Public
Health here is quite pleased.

You don't need to download the temperatures every day. Once
weekly seems adequate. Glancing at the external temperature when
opening the fridge is good enough for every day."

You can get the Hoboware here. You need the logger, software and cable. Although there is a cost, it will make your staff's life easier because they no longer have to record fridge temperatures twice a day. This is something I will definitely do.

Michelle