Monday, May 22, 2006

Electronic and paper charts

My electronic charts look different from my paper charts. I think of the paper chart as a book, and the electronic chart as an internet document: paper is linear, while EMR is hyperlinked and searchable. For example, I am always looking at what a patient weighed at their previous check-up, to see if there are any changes. Finding this fairly simple bit of data in a paper chart means flipping through several pages; finding it in the electronic chart means clicking on a link. Paper just does not work very well, because you are trying to track too many disparate bits of data; every chart is a daVinci Code.

I can see how my charts are beginning to get organized. Incoming data from the outside is separated into different areas: scanned labs (EKGs, Pulmonary Function Tests), Diagnostic Imaging reports, consult letters, other correspondence. This is the equivalent of having paper charts with tabbed separators for each section; we never did it for my charts, but it is possible to do this. Electronic lab results are hyperlinked and searchable, and automatically go into the flow sheets I made up; you can't do that in paper charts.

Electronic labs bring up an interesting problem. If my practice partner (who is not using EMR) sees one of my patients while I am away, and orders a lab test under his name, I will not get electronic results. We'll have to manually scan the results into the chart and those will not be linked. I think what I will do is ask him to cc me on the requisition; then he will get a paper copy and I will get an electronic one.

I am going to have similar problems for patients co-managed with specialists, and will likely have to scan results that are not copied to me on the req, or that are not done at one of the 3 electronic lab companies. This will be a problem for diabetes care, because my flow sheets are lab-specific (I guess the lab companies must use each use their own software). As well, my vitals (weight, BMI, BP) are hyperlinked to the flow sheets, and these measures cannot come in electronically from a visit to a specialist. I do not co-manage many diabetics with specialists, because it just introduces more complexity into an already complex problem; this is about to get worse.

This lack of ability to share the chart electronically with specialists will not matter for one-off consultations, such as a referral for gall-bladder surgery. It will matter for longer term shared care. I will have to think about when shared care makes a difference: likely this is for problems I do not see very often, with very complex management issues (MS, rheumathoid arthritis), and not for common problems with clear guidelines (Type II DM, asthma, COPD). My hospital's Diabetes Education Centre is very interested in sharing a piece of the electronic chart; maybe what is going to happen is that part of the primary care chart will be shared with chronic disease programs (diabetes, congestive heart failure, asthma), rather than with an individual specialist.

I did my first electronic chart search last week. The government recently introduced new fees for maintaining a flow sheet for diabetics. I ran a search for all diabetics in my practice; it took less tan 10 minutes to do. I printed the list and gave it to my secretary so she could bill the new code for all those patients. I can see that maintaining a register of patients with chronic conditions is not going to be that difficult with EMR; however, I have to make sure that I enter the condition in the chart consistently. I wonder if there will be more pay-for-quality incentives; EMRs will definitely be useful there.



Scot Mountain said...

Hi Michelle,

One solution to keeping vitals, etc. up to date when they are done in a specialist's office is to create encounters for those visits, even though they were not done in your clinic. Then, the data gets aligned with your emr work flow.

I found when I was using the emr, that I broadened my mental definition of an encounter to encompass quite a few things that occurred outside my office. It is relatively quick to enter the relevant information with a quick note identifying where it came from, and it keeps your records up to date.

Michelle Greiver said...

Thanks Scot, that's a good idea, and I'll do that.

I'm using the encounter to document phone calls to and from patients, and emails (those are really easy, just cut and paste). As well, phone conversations with pharmacists go in there.

I'll have to phone the lab and see what they can do with paper reports from other physicians. Perhaps we can fax/email requests to send those to us electronically.