Friday, April 28, 2006

Looking back at the first month

It is now four weeks since I switched over to EMR. For the past week, I have felt very comfortable using the Tablet routinely for everything; the EMR is now becoming an integrated part of my practice. What works for me is carrying the computer around in Tablet mode, and opening it as a laptop in the exam room. I like typing better than writing, and I don't see why I should store my bad handwriting in the computer. I type during part of the patient encounter as I am listening to my patients. Some of my clinical notes are starting to get completed during or right after the encounter, and I plan to get more of them done that way.

One of my colleagues said that his notes became much better once he switched to EMR: the usual scribbled information looked very scanty when typed, so notes became much more complete. Templates can also put a lot of information in the record very quickly.

What happens during the encounter is that I start typing in the clinical notes section. If there is a problem that needs a template (for example, a cold), then I load and fill the template. Other issues continue being written in the clinical notes section. It splits up the subjective/objective part into several sections, but seems to work.

I've made a template for my abdominal examination (Abdomen soft, bowel sounds normal, no hepato/splenomegaly, no masses, no tenderness). If there is something abnormal, I just uncheck the check box and write comments. Templates are really good for automating things that you do over and over again, and for documenting groups of normal findings.

The ability to look at sequential results for electronic labs is interesting. I had a patient with a mild anemia, who had another blood count done two weeks later. I clicked on the check box beside her hemoglobin, then clicked on the tab for "tabular results", and showed her that her hemoglobin was 107 two weeks ago, and 112 two days ago. This is much better than leafing through paper lab results. The software also does graphs; you click on the "graph" button. This is very useful for on-going conditions, such as A1C's for diabetics, or INRs.

I had a look at the scanner that I bought. It can scan documents into Adobe Acrobat pdf format. It also can do "duplex" scanning, which means that it takes a picture of the front and the back of a page at the same time. You can put 50 pages in the automatic document feeder, and it scans 25 pages a minute (or 50 pages if you do front and back at the same time). I tried that for some of my clinical notes, and the pictures are really clear and sharp. This is very interesting, because it means that archiving charts of my transferred or deceased patients is not going to be all that difficult or take all that long. I will get the clinical notes scanned in duplex, and the lab forms/consult letters in simplex (one side of the paper only). We'll call the files something like Doe, Jane clinical notes, and Doe, Jane labs; I'll hire a student in the summer to do this. I'll put the files on CD ROM disks, and keep two copies, one locked at the office, and one locked offsite. You can search for things easily within pdf documents, so this is useful for data retrieval. If this works well, then I'll scan and archive paper charts of active patients, once I've fully transferred to EMR. Maybe I can then sell my filing cabinets on eBay. I wonder what I'll do with all that freed office space.


Monday, April 24, 2006

Scanning and working with electronic faxes

We are still having difficulties with electronic faxes. The faxes come into a fax folder on the computer; they get transferred to the scanning software on the desktop. The filing clerk then has a look at them on the scanning console, files them electronically (both under the patient's name, and as a category--diagnostic imaging, consultation note etc), and uploads the report to the EMR.

At least that is what is supposed to happen. We're not quite sure where the faxes actually go; sometimes faxes stay in the fax folder, and sometimes they appear both in the fax folder and in the scanning console software. I found reports for several patients attached to a single patient this morning, so this was uploaded incorrectly. Clearly, the software is problematic and we're having trouble with this process.

Our IT lead has talked to the company, and they told us that a software fix is on the way. As well, I have to minimize the risk of misfiles from scans or faxes. If something is electronically misfiled, it is going to be very hard to trace.

What we decided to do is to print all faxes for now. I will look at them without chart pulls, to make sure that I've personally seen them, and will initial them. We have a "to scan" box, where I will then put the printed faxes. Once scanned, the print will be put into a "pending shred" box. I'll have a look at that box every few days, and if I'm satisfied that I've seen the report electronically and that it is OK, then I'll transfer to the "ready to shred" box. Then and only then will they be shredded.

We found that it is too difficult for my secretary to scan and upload while answering the phones and doing several other things; that is likely to lead to misfiling. What we decided is to leave scanning for the filing clerk, who will do nothing but take care of scans and electronic faxes when she first comes in in the afternoon. I can see that it will be difficult for the clerk to decide what is "DI", what is "cytopathology", etc, so she can allocate the scans properly. I will spend some time reviewing that with her, and explaining it. If that is done properly, it will be easier for me to find things in the electronic chart's sections, but this will not happen by itself. For scans, like for faxes, I told her to put everything that she has scanned into the "pending shred" box; it will only be shredded once I've reviewed it and transferred it to the shred box.

Sometimes patients have documents that need to be copied to the chart, with the original returned to the patient right away. I thought that this could be scanned, but the problem is the scan has to be filed, which is hard to do if my secretary is very busy. What she will do is just photocopy the document, and put the copy in the "to scan" box for later scanning. If, however, it is quiet(er), then my secretary will scan and file it on the spot.

This whole decision process happened this morning, during Monday morning madness (phones ringing incessantly, patients checking in and out). Sometimes you really do have to solve problems on the spot.

I expect the whole fax/scan issue to settle down eventually; however, I want back-up systems until I'm sure we've got the whole thing right. You have to figure out how to minimize the possibility of errors while all your office processes are changing--not that easy to do on a Monday morning.


Wednesday, April 19, 2006

Electronic lab results

My lab results came in electronically today. When I looked at my practice summary page this afternoon, there was a message saying that 147 labs were waiting for my review. The lab system sends the reports directly to the patient's chart. They also automatically flag abnormal results.

When I clicked the link to the lab results, all the results were there in two lists: abnormal (alphabetically by patient last name), and normal (same). The lab sent me all my results since March 23rd, which is why there were so many. To access each lab report, I clicked on the patient's name in the list, and the report came up, with abnormal tests highlighted. There is a section where you can make comments (I just put a "N" if the abnormality was irrelevant). You can print the whole report, or a subsection to give to the patient. You can also forward a note to your staff (for example, call the patient to let her know that the results were normal). When done, one click files the lab into the electronic chart.

Reviewing all these results and filing them electronically took me about 20 minutes (I'd already seen them before). My secretary would not have been happy if she had to pull 147 charts, put the results on the front, and then file the charts away again. I told my staff not to pull charts for lab results anymore, starting tomorrow. They will just give me the paper lab results unfiled; I want to make sure that there are no problems with the electronic results. If the two match, then the paper reports will be shredded. In a little while, I'll ask the lab not to send me paper reports anymore. The system checks for results every two hours; I'll have faster updates than through the current courier system.

I now have several patients who do not have any paper charts. Some are new patients; all new patients have electronic charts only. One new patient transferred from another practice with a bulky old paper chart; we scanned a couple of recent results and relevant consultations into the EMR. The rest went to the back room as a chart #2. Newborn babies do not have paper charts either: we scan the bit of paper we have, and the rest is electronic. The EMR generates percentiles for height, weight and head circumference automatically when I enter the numbers in, and the growth charts are also done automatically.

I'm getting more comfortable with doing some typing in the exam room. I'm a fairly good touch typist, so I can type while looking at and listening to patients.

I bought a docking station for the Tablet. I have a full keyboard and a mouse attached to the station; it also recharges the Tablet while it is docked. I leave it docked at lunch, and when I am finished seeing patients; I find that billing is much faster with the numeric keypad on a full keyboard.

My group is meeting on May 2nd. One of the things we will be discussing is remote access via VPN (see glossary); we don't have this yet, but it is supposed to happen sometimes in May.


Sunday, April 16, 2006

Having a bad day

Last Wednesday was a bad day. I could not look at my scanned documents (a phone call to helpdesk), then I had trouble accessing the server and finally could not access it at all (another call to helpdesk). The Passover Seder was that night and I had to leave on time; I was also short of patience and very irritated. My lab is still not coming in, and I will be sending off another email to the lab company to remind them to start sending electronic reports. Some scanned images are printing as landscape instead of portrait, with nicely elongated letters. My Tablet crashed.

I also got a phone call from a patient asking why her glyburide was changed to bid. Her pharmacist noticed and called her. It is very easy to choose "bid" from the drop down list instead of "od". This was for one of the first prescriptions I wrote, on March 23rd. I apologized, and explained why this happened. It is challenging for me to transfer every single prescription to the EMR, and I am now very paranoid and very careful about re-reading what I print. As I was talking to her, I updated the glyburide order on the chart; at least I know that I cannot make that mistake when I refill her medications.

I have to remind myself to expect problems, especially at start-up. Every time I install a new program on my home PC I have glitches, and EMRs are so much more complex. This is where having support really helps; if you don't have this, days like last Wednesday can turn from bad heartburn to major disaster. Most of the time, when I call the helpdesk, they can help me; sometimes they take my computer over remotely and fix the problem. I also get screenshots emailed to me, so I know what to do the next time. Sometimes the person at the helpdesk can't help me right away, and then I get a "ticket", which is a number that they use to track my query. I get an email or a phone call sometime later. The "ticket" seems to be for annoying but not critical problems.

Problem solving is also much easier if you are part of a group. Our IT lead is not shy about making her views known (you go girl), and I've just received an emailed copy of her communication about the landscape printing problem; it is the same at her office. We all have similar hardware and software, so you can see pretty quickly what is a local problem in one office and what is a software glitch that needs to be fixed for the whole group.

I survived; Thursday was a better day, and then I was off for the long week-end.


Tuesday, April 11, 2006

Unbound medicine

I've been wireless for two days now, and using the EMR with patients. I had a look at what my colleague, Dr. Brookstone, said about using the EMR in the examination room, and adopted the recommendations. The pamphlet that Dr. Brookstone's site links to is worth looking at.

I start the patient file in the EMR before I go in the room; that way I can say hello to my patient instead of fiddling with the computer. I keep the computer in Tablet mode , so that it looks like a clipboard, and it gets carried in that way together with the paper chart. Before EMR, I did not take very many notes during the encounter (other than numbers, such as blood pressure, because I was likely to forget those). After EMR, this has not changed. I figured out how to enter numbers quickly in the vital signs area using the tablet pen; this replicates writing the number in the chart. I've shown several patients their data on the EMR by picking the tablet up and holding it like a clipboard. My patient sits on the examining table, and we look at it together. This works. One of my patients had come in for an asthma exacerbation last week, and I entered her new peak flow yesterday, and showed the two readings to her as a graph; I think it helped her to see that. She's buying a peak flow meter.

I asked several patients what they thought of this, and had rather positive comments. When I did not ask, no patient commented on the computer being present. When I am not using the tablet in the exam room, it lies on my desk just like a chart would.

I sometimes convert it to laptop mode, when I need the keyboard. This is typically to enter medications; typing is faster than entering with the pen. I tell my patients that it will take a bit longer than usual for me to write the script, as I am learning to use the new system. I expect that doing refills will be faster with pen entry, since you just need to click on the drug's checkbox and hit the "refill" button. I also use the laptop mode to quickly look up handouts and print them.

We used the scanner for the first time yesterday, and got stuck. We had forgotten one of the steps. Another call to the helpdesk; nothing ever works perfectly the first time, and you have to expect glitches. Today, it was no problem. We talked about when to scan, and decided that my filing clerk would take care of this. It is hard for a medical secretary to scan and upload in the middle of phone calls and greeting patients. We made an inbox where all the documents to be scanned and shredded are placed, to be done when the clerk comes in. The faxes are all coming in electronically as well; my clerk will also manage this: some will be printed (for my partner), some deleted (junk faxes), and some uploaded to the patient file.

When my IT trainer was in on Friday, I gave him my home laptop to configure for my office system. I was worried about dropping and breaking the Tablet, and being stuck without a computer. I bought a laptop lock, and am leaving the laptop turned on, beside the vaccine fridge. Now my staff have an extra data entry area, and I can unhook the laptop and use it in case I drop the Tablet. I also have medical students in from time to time, and that is going to be their computer.

I started using the EMR without patients for a week and a half, because my wireless was not set up. By the time I took it in the exam room, I was familiar with basic navigation, and had less problems with finding my way around while trying to listen to patients. This was due to serendipity, but it is not a bad way to do it. You have to be comfortable with excusing yourself from the room to load the encounter and write prescriptions, for a week or two.


Friday, April 07, 2006

Looking back at the first week

I've finished my first week after switching to EMR. Since coming back from March break vacation 3 weeks ago, I've logged more hours than usual at the office, probably 1 to 2 additional hours every evening. One reason for this was the post-vacation backlog, but the EMR implementation has been a major factor. I am trying to customize the software to work best for my practice, I have been charting in the EMR, and I am trying to enter at least 2 or 3 Cumulative Patient Profiles every day. There is always the temptation to play with the software, which I've given into way too often.

This Thursday, much to my surprise, I finished at my usual time. My charts were all written up, all my phone calls and letters were done, and I got away 1 hour after seeing my last patient. I can't imagine that this is going to continue, but it was good to see that it was possible.

I'm starting to learn little tricks like using the tab key to switch between fields, instead of the mouse (tabbing is much quicker if you are using a keyboard). I've started to make a template for the preventive health exam.

There is an area in the software that keeps track of pending consultation requests. When I write a consultation request, the software asks me to put in a date to check for the report. I put in "one day" for one of the requests (this was just for a derm consult for acne, but I wanted to see what it looked like). If it is overdue, it is highlighted in red, and is very obvious. Once the report comes in, you can click on the "received" button, and it goes off your list. Most of my requests are for 3 months from the date sent, but I wonder if I should make this longer; I don't usually know what the specialist's waiting list is like. This "pending report" list may be a problem for me to manage; sometimes patients don't go, and I'll have to be very rigorous about taking pending requests off when the report comes in. I already have 19 requests on the list.

I heard from my regular lab. It looks like my lab reports will start to come in electronically next week. I also received a note from the Ministry of Health: it looks like they're finally giving up on the old style lab requisitions, which have carbon copies (bad for privacy protection), and have to be tractor-fed into a dot-matrix printer. The new lab requisitions are printed sheets; EMR software applications should be able to print them straight from a patient's chart, so that the physician's information and the patient's demographic data is automatically entered into the requisition. That will avoid having to print labels for requisitions. As well, I'll be able to track which lab tests are overdue, since the software will be able to match incoming lab with ordered lab. I may have some trouble with that; patients often don't go for tests, and I have large volumes of results. Wading through pending lab data may not be possible.

Today, we had two people from Nightingale in the office, to do the last parts of hardware and training. They installed and configured the scanner, and did some additional training on how to use it. It scans much faster than my photocopier copies. The scanned copy is kept on the computer, and can be filed electronically at any time; if a patient needs their paper back, my secretary will be able to scan quickly, let the patient leave, and upload to the chart later. I can see that, in the future, printing copies of the chart for transfers, legal reports or insurance reports will be much less of a hassle. I think I will still be somewhat selective about scanning old charts, because the scan is just a picture: it is not searchable. This is good for storage only, which is not very useful if you want to find something in a very large file. We do EKGs and PFTs in my office, and those will be scanned into the file; there is a comment field in the EMR, and I will enter comments electronically rather that writing them on the report, so that I do not have to load the whole picture to look at what I wrote.

Electronic faxing was also configured. All faxes will now come into a computer, so we can upload them directly into a patient's chart without having to scan. We can delete junk faxes without having to print them; we can send outgoing faxes either from the computer or from my fax machine.

I now have 3 patient charts that are electronic only. These are relatively new patients to my practice; we scanned the 2 or 3 papers that I have for them, and I entered the Cumulative Patient Profile directly into the EMR. I put an alert into the patient demographic area saying that the record is EMR only, so that my secretaries don't waste their time looking for a paper chart.

The wireless router is now installed and ready to go. On Monday, I start taking my Tablet into the exam room.


Monday, April 03, 2006


Today was the day that I officially switch to EMR. I am definitely getting faster at entering clinical encounters, to the point that I may have tipped over to being faster on the computer. My staff is now entering all heights and weights in the EMR; I have figured out how to have the "vitals" template (which includes height, weight, BP, Heart rate, Peak Flow) pre-loaded into each clinical encounter, so accessing it from that area is a single click. Phone calls are recorded in the computer. I have been notified by one of the labs that they will now be sending me results electronically; however, that is not the lab that I use the most often, so electronic lab reporting is not happening yet.

We are all trying to figure out how to decrease paper as much as possible. The chart for the second patient I saw today could not be located; that is one thing that won't be happening any more.

I have more letter templates, such as a transfer of information request. I have the referral letter process down pat. I have now written over 100 prescriptions, and my "favourite drugs" list is getting to be very useful. It is interesting that the EMR software numbers my prescriptions sequentially, so I know how many scripts I write each week. I can see that I'll be able to search easily for drugs. I get a prescription profile each January from IMS, which is a company that buys information on physicians' prescriptions from pharmacies and resells this to pharmaceutical companies and others. Those IMS summaries never looked very accurate to me, but now, I'll know.

My staff has "read only" access to clinical data in the chart; a patient had lost a prescription and my secretary was able to access that for the pharmacist from the electronic chart. We are getting used to finding out where things are in the EMR.

I can see that I will need to start building templates for XR facilities that I use most often, so I can print XR requests from the computer. I am sure that most places will not mind if I don't use their forms--it is probably more important that the information is clear, complete and legible. My information and the patient's information will automatically be generated on the diagnostic imaging requisition, along with the CPP if needed. I'll get rid of all those paper pads.

I've been trying to figure out how to get information from my tablet as efficiently as from my Palm. The EMR does not have good clinical calculators or decision support (the only one I found is Framingham for heart disease prediction). I'll still need to use outside software for that. The PDA is really good for quick decision help (for example, Medrules) and quick calculations (like MedMath). I found something that I think will work for me at the CMA website, InfoRetriever. It is at, click on the "clinical resources" tab, then "InfoPoems clinical tools" on the tab on the left, then "InfoRetriever". It is very good for decision help (for example, the sore throat score), but not very useful for calculations, like creatinine clearance, because chemistries are in mg/dl (US values) not umol/l, which is what we use in Canada. I can use the decision help program to look up things, but will have to enter the result manually into the EMR. I wonder if that kind of thing can be integrated in the EMR, so I can load the rule straight into the patient record.

All in all, not a bad start.


Sunday, April 02, 2006

How good will my data be?

I spent the past two days at a conference organized by my University's department of Family Medicine. There was certainly a lot of interest in EMRs; it will now be possible to contribute data for large studies. If (God forbid) we ever do get an influenza pandemic, it will be incredibly useful to be able to track things like patient temperatures directly from the charts in family medicine. I remember how helpless and out of touch I felt during the SARS crisis, and I hope better communication will help if there is a next time; SARS killed a family doctor.

The researchers will have to be very careful with protecting patient and physician confidentiality. I have done a bit of research in family medicine, and probably should think about how to use the EMR for that.

The EMRs are customizable, which is good because this lets you put in the data in a way that fits you best. On the other hand, everyone will enter data in somewhat different ways, so the charts will all look different. As well, there is some "free text", which is where you can enter things in any way you like. The free text is the easiest way to enter information, but will probably make it more difficult to search for things in the future. There will need to be some balance between "hard-set" entries, where you have to put in data in a certain way (so that you can do audits for things that interest you and to improve your practice), and ease of entry. A tricky proposition.

Maybe we should think at some point about making records more similar across many practices, so that we can share data more easily (for example, transferring a chart to another family physician, sending data to a specialist, to Diabetes education or to a hospital). I know that Canada Health Infoway is working on common standards (HL-7). It would be good if there was a common standard: if an EMR company goes under, the patient data is too valuable to allow it to be lost. A common standard may help to transfer the information into a different platform.

Perhaps, in the meantime, groups of physicians using the same software application can decide to record things in similar ways. I don't know how easy this would be (probably very hard), or how exactly it would be done. Maybe physicians who are interested could get some help with that.