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!

Michelle

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.

Michelle

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.

Michelle

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).

Michelle

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.

Michelle

Less chart pulls

Once I have put the Cumulative Patient Profile into the EMR, I mark the front of the chart with a red line. This week, we decided to stop pulling red-lined charts.

We had to figure out how to mark the fact that a patient is in the exam room, since there is no chart on the door. On my scheduler, there is a drop down list beside the patient's name, where you can note that the patient has checked in, is a no show, etc. We added two more items to the list: "room 1", and "room 2". When the patient checks in, the scheduler automatically says "in" once their card has been swiped. When the patient is put in one of my exam rooms, my staff puts "room 1" or "room 2" on the scheduler, and I can see it in my EMR. For now, I put a sticky note with "1" or "2" on the door, but I'm going to buy more professional looking numbers.

I've made templates for the Ottawa knee rule and the Ottawa ankle rule. I don't see why these evidence-based rules can't be incorporated directly into the record; having templates makes it easy. I'm going to make a template for the Wells DVT rule. I've also made a template for the "5 A's" approach to quit smoking (ask, advise, assess, assist, arrange), with a drop down list for the stage of change the patient is at. This is the approach recommended by our Clinical Tobacco Intervention program, and there is a new fee code for doing this. I try to do it anyways, but now I can document it easily as well; I put a note on the template to remind me to bill the new smoking cessation code.

Three pap smears with electronic requisitions came back today from my lab because the requisition was non standard. I sent an email to the lab's IT manager asking him to please send a memo saying that electronically printed reqs are OK. The data on the reqs is the same. I like doing electronic reqs better, because it shows that a pap was done right in the patient record, and I can also track the pap to make sure it comes back. I don't want to go back to paper reqs.

Michelle