Friday, August 18, 2006


Yesterday was my last day at the office for two weeks, and I was covering two practices. Thursdays are my late days, when I see patients into the evening. It was busy. I ended up with 29 charts that needed completion by the end of the day.

Before EMR, I would stay on and complete my charts. I cannot take 29 charts home when going on vacation, because my partner would have no access to them. Yesterday, I just shut my computer, and went home; I was too tired. I finished my charts from home today in about an hour, meaning it took about 2 minutes per file to chart and bill. I don't know if that is faster than on paper, but it was certainly less stressful than staying even later at the office to complete the paperwork.

During patient encounters, I had completed pieces of the record that I would be likely to forget, such as blood pressure measurements or positive findings. As well, all my prescriptions were already recorded, since prescribing and recording happen at the same time. I had volunteered for a study on errors in family practice a few years ago, and found that a common error for me was failing to note a prescription in my record (if I prescribe several repeat medications, and then add a "less important" drug such as cortisone cream, the cortisone cream may not get recorded). This was worse when I was busier. The study found that office processes (such as not finding the chart) were the commonest source of errors, followed by medication errors. With EMR, the risk of lost charts is essentially gone, while the risk of medication errors is lessened (automatic allergy and drug interaction alerts, consistent recording of all drugs in the record, decreased risk of refill errors).

Late Wednesday night, my lab called me regarding a critical result. While I was talking to my patient, I recorded the information on her chart. Remote access to my charts is proving to be truly invaluable.

We tried the automatic blood pressure machine, and really liked it; we are using it consistently for annual check-ups. We decided how to implement staff monitoring of blood pressures for diabetics: at the end of appointments I give my diabetic patients a "ticket" (I have a pad of paper for this on my desk), which says "DM, 3 months". The appointment then gets labeled with a colour assigned to diabetic follow-ups, and when the patient returns, my staff weighs them, takes their BP and enters the information in the EMR before they see me. I guess I'm using this as an example of how processes get thought about and changed at my office.

We should have the rest of my active charts scanned in by the time I return from vacation, in September. I took a back-up DVD home with me, to lock away in my cabinet. In September, we'll start scanning inactive/transferred charts. It is odd for me to think that I can carry my entire practice with me in a couple of DVDs.


Friday, August 11, 2006

Transition's End

It feels like the transition to EMR is coming to an end. We now have over 800 old charts scanned to pdf out of 1250 active rostered patients, and accessing a previous record on my network is very easy (load the folder where the charts are kept, then double click on the file). We have emptied the first filing cabinet and are ready to sell it.

Most of the left over transition work consists of data entry for the CPPs; I am doing most of that from home, via remote access. I do not carry charts home, only CPPs.

My partner is away this week and the next. When I see one of his patients, I use the EMR, because I can record the visit, write a prescription, and bill faster that way. I then print the encounter and put it in his paper chart; it will now be legible for him. I will be away for two weeks after his return. During that time, he will copy me on lab reqs (so that I can get the results electronically); he'll have a quick look at letters and faxes, which will then be scanned in; he'll have access to my old charts on his computer desktop; my staff will print CPPs for him when he sees one of my patients, and the visit notes will then be scanned in. My resident is in a half day per week, and we'll book my patients to see her; she can enter encounters and prescriptions directly in the EMR, and the encounter will be left on my desktop to sign off later. Although it is a little more difficult to arrange vacation coverage in a hybrid practice, it is possible.

I've been printing CPPs for my patients when they come in for their annual physical, and asking them to review the information and to let me know if any corrections are needed. We've also been talking about secure access to charts for patients. My patients are very interested in this. The EMR certainly makes it possible; I think this type of thing can't be too far away. We'll likely need Government help to manage access and security. I would be very happy to take part in such a project.

I still need to figure out how to do electronic Diagnostic Imaging requisitions, and will probably start to use those instead of the paper-based reqs. The electronic lab reqs and pap smear reqs are not ready yet; once they are available, I'll start using them. There is not very much paper-based work that remains in my office; I have to say that I do not miss the paper at all.


Friday, August 04, 2006

The paperless office

I have now entered about 60% of all my CPPs in the EMR; about half of the paper charts for active patients have been scanned in and shredded. We have destroyed three shredders so far, and have now bought a better shredder.

My partner is away for the next two weeks. My secretary pulled a total of four paper charts for me for Tuesday, when I come back from the long weekend; none of the charts needed preparation such as stamping in the date or adding a lab requisition to the front. This was the least amount of work done here for chart pulls.

We have been talking about what to do with the gains in office efficiency once all the paper is gone. I think it is much more interesting for my staff to take on some clinical duties. My filing clerk is a trained lab technician, and does my blood work, pulmonary function tests and Electrocardiograms. Perhaps she can do my allergy injections, so those patients do not have to wait. She can also administer influenza vaccines or other vaccines if needed. I will have to find out what the requirements are.

I have also been thinking of buying an electronic blood pressure monitor, similar to what is used in the hospital. Coincidentally, my resident asked me to participate in a research project run by one of her colleagues: I am getting an electronic BP machine for a week, to find out what I think of it. I don't think it is better for me (compared to the standard mercury-based BP), but it will enable my staff to do BP for me as part of the intake for full check ups. Perhaps we can also do this for diabetic patients, and for hypertensives; I will have to figure out how.

I've been talking with my resident about doing electronic audits; I did an audit a couple of years ago for my diabetic patients, Chart Audits in my practice, and it would be interesting to find out what happened with blood pressures/sugars/cholesterols due to the introduction of the EMR. We had a look at my electronically generated list; she can get the vitals and lab work easily from the EMR. If the lab predates the EMR, the scanned chart is available on my office network. I think the electronic audit will take far less time than the paper-based audit; I wonder if results can be automatically entered in Excel, instead of transcribed.

I've received a note saying that I can log on to the electronic Child Health Network, which will give me access to the shared health record for children. It looks like this has information from hospitals and home care. Two more passwords for me. I also have remote access to my own hospital's database, which contains a partial electronic medical record (in-patient drugs, labs, diagnostic imaging, consult notes). I've used that sometimes to look up hospital results. I've also registered to access my lab results on-line, as a back-up measure if the EMR server fails (example, C.M.L. or MDS). There is also a site where all the pap smear results are kept, Cytobase . We seem to be building several pieces of an overall electronic health record, of which my EMR is part, but it still looks very disconnected. This is a bit like the early days of the internet; there were all these Bulletin Board Systems which were not connected to each other. You had to use separate phone numbers and passwords to log on to each one. Perhaps over time there will be bridges between all the systems, so that the data can follow the patient.

It is a start for an integrated health record, but there is still lots of work to be done.