Friday, July 28, 2006

At the four month mark

This was the first month during which I felt very comfortable using the EMR. There was no crisis this month, and computer use is now part of office routine. I am no longer going home later than usual.

I have entered initial prescriptions for almost all of my patients who are on multiple drugs; now it is a matter of renewing the drugs, which is a much faster process (tick the check-box, then print and sign). I have written over 1,000 individual scripts; writing a prescription is very easy now that my list of favourites is populated, as most new scripts auto-fill when I put in the first few letters of the drug.

We have remote access, which is extremely useful. I sometimes take charts home with me so I can enter CPPs later, which means I can have supper with my family. I now have 50% of all charts entered.

The old charts are getting scanned and shredded; large lacunae are appearing in my filing cabinets. Many charts are not getting pulled, because the paper chart no longer exists. I referred a patient recently, and had to add some radiology reports from her old chart; I loaded the pdf file on my Tablet from the hard drive at the front, picked the report that I wanted, printed it, and added it to the consultation request. This is working very well.

I go to the senior's clinic that I run offsite, and access the charts remotely; I usually carry a couple of charts back and forth with me because those patients see me at both the clinic and my office. Those old charts were scanned, and are now getting carried in my Tablet instead.

We are routinely using electronic messaging; the little scraps of paper with notes on them have disappeared. I sometimes use my "to do" list to leave a note for myself instead of using paper.

I found an area in the chart where you can put "follow-up" notes; I will sometimes use that instead of "Plan" in the clinical record. The Follow-up shows up in the summary when I open the chart, and reminds me to do something. For example, when I see a patient with diabetes, I will put a recurring Follow-up called "DM", which recurs every 3 months. This prompts me to look at their diabetic parameters, and is very useful for patients who have other conditions (such as schizophrenia); sometimes the diabetic follow-up gets lost in the middle of taking care of everything else. I also have a Hydrochlothiazide Follow-up, which reminds me to do a potassium after the first month of using this drug. I should program Follow-ups for other drugs, such as potassium and creatinine for ACEIs, so that I don't miss these things.

All the physicians in my group are using the EMR to various degrees, and we have signed off on the document letting OntarioMD know; this will mean that the monthly $600 subsidy will start.

The past month has been much easier than the initial transition period. Now it is a matter of putting in the rest of the CPPs, finishing the scanning, and learning more about the application. I should probably register myself for a booster session.


Thursday, July 20, 2006

Shared Electronic Charts

Having the 9 physicians in my group practice out of 7 different offices gives rise to some interesting possibilities.

I have a patient with borderline hypertension. Her daughter is a Practice Assistant in the office of a colleague in my FHN, and volunteered to periodically check her mom's pressure at her office. My patient consented to have her daughter access her chart and enter weight and BP electronically. So now I have weight and BP entered remotely; I sent an internal electronic message in the EMR telling my patient's daughter how to generate tables and graphs of BP, and I can see those as well. I'll make a flowsheet so that we can follow weight and BP together. The EMR logs and tracks who enters data.

As well, I do shared prenatal care with a colleague. I follow patients until 24 weeks of gestational age, and she takes over after that. This week, I sent an internal message to staff in her office that electronic lab and ultrasound results were available. They were able to view the results on our common electronic chart (no faxing).

Looks like you can both enter data and look at information in a shared electronic chart. Several colleagues in my FHN are in our palliative care group, and a shared chart could be especially useful in this setting. We'll need some good, common sense rules to protect patient privacy while ensuring that people in a patient's circle of care have appropriate access.

A new family medicine resident came to my practice this afternoon. I gave her the spare laptop to use while in my office; it had been configured to access my wireless network and the remote server. We talked about how to use the EMR, and I showed her how to enter clinical notes and prescribe medications. We also discussed how to navigate the EMR-based chart. By the end of the day she started to become more proficient at this, and had done several prescriptions. I think taking over an EMR that is already used in a practice will mean a shorter learning curve.


Friday, July 14, 2006

Remote access

Our remote access is now live. I had to install some extra software on my home computer, and there is an additional password, but it works. It is amazing to be able to see everything, as if I was at the office. I just reviewed all my labs, send a message to my secretary to call the pharmacy with a changed synthroid dose, put this in the patient's CPP, and arranged for a lab req to be mailed to her so she can repeat her TSH in 3 months. From my home.

This will help me when I attend conferences, or if I go on vacation: I can take care of lab tests and messages remotely, to avoid some of the usual mess when I get back to the office. Of course, there will be the temptation to log in while on vacation, which I will not always be able to resist. At least my cottage does not have internet access, so I'm forced to relax there.

It took 3 months to enable this, which reflects the fact that our system is complex, with several security levels (application, hospital, SSHA). It is a trade off: more complex systems need more time to get set up. It would have been simpler and faster if I had a server in my office, with some type of black box to enable remote access. However, long term, I think an "enterprise" set up will serve us better; I have to stop thinking of my practice as a Mom and Pop Shoppe. We need to be interconnected, and connected with the rest of the health care system, and that will mean a professionally managed server, with high level security. Down the line, I can't see this being managed in my own office (plus making sure back-up and upgrades happen as they should).

I have now done about 40% of my CPPs. The student is in mornings, and is now scanning about 30 charts daily; that probably won't be finished by the end of the summer, but he's taught the rest of my staff how to do it, and we'll continue in the Fall.


Friday, July 07, 2006

Paper chase

We have started to scan and destroy old charts. My secretary said that she just can't believe how much paper we have accumulated over the years, all stored in different locations in the office (current charts, charts of patients not seen for over 2 years, deceased, transferred, part 2 of a large chart, seen offsite at the senior's clinic, piled up for pending consult request, or just plain sitting on the doctor's desk). The time and space taken to manage this is huge.

On Tuesday, we scanned the first paper charts to pdf, had a look at several scanned files to make sure they were good, and tested the back-up. We've also been shredding, but I may send some of that to a commercial shredder. We're putting out five large bags daily; my small office has enough shredded paper to confetti at least one medium size parade. It was very strange to see a filing shelf without the usual collection of crammed, dog-eared files.

I saw a new patient yesterday, and he gave me a copy of his old chart (on paper). Eventually, we'll be able to transfer a chart electronically , but I can't imagine this will come anytime soon. I will review his chart, enter the relevant information in my electronic CPP, and the paper will be scanned to pdf just like the rest of the old charts.

The pop up alerts in the EMR came in handy yesterday. I had seen a patient for a check-up; a recent guideline recommends an ultrasound for men between 65 and 75 who have ever smoked, to rule out an abdominal aortic aneurysm. I saw that on my preventive checklist, when signing off the electronic record (but he was already gone), and put in an alert. The patient returned yesterday, the alert popped up when I opened the chart, and he was sent for his ultrasound. I also saw a patient with Hepatitis C; vaccination against hep A and B is recommended, and public health supplies the vaccine for free. When entering her CPP, I had noticed that she had not been tested for A or B antibodies, and put in an alert for myself to do so. She came in yesterday for another reason, and was tested. I should probably run an audit for Hep C when I'm finished with all the CPPs.

I will be away on vacation at the end of August. I will need to figure out how to let my practice partner (who is paper based) look after my patients. We can print the CPPs for him, scan his clinical notes to the chart, and have him review faxes/mail on paper before scanning. I will show him how to find things in the chart as well, and my staff can help. I do not know how he will handle incoming electronic lab results (I will ask), and I don't think he can print consultation requests from the EMR; we'll have to scan those in. Coverage in hybrid practices is more difficult. On the other hand, any of my colleagues in my FHN can have access to the full chart; perhaps, in the future, coverage will be via "virtual" groups like mine, where the physicians may not be all located in the same office, but can all access the information if needed.