Tips and Tricks meeting

We had our Tips and Tricks meeting on Friday, at the company's training room. We all wanted to be there together with computers, so that we could log on remotely to our own practices, and figure out how to improve things. We made the agenda ahead of time, and I ran the session.

Here is the agenda; most of it involves how to be more efficient, based on real world practice conditions:
___________________

Tips and tricks: how to do things faster and better in the EMR

The patient encounter

Using the Summary page as your default

Clinical

Drop down lists to save time

Templates: Rourke, preventive health, smoking cessation

Medications

Rapid prescribing of new drugs

Loading previous drugs and doing repeats quickly

Assessments

How to record them fast

Follow-ups

How to make sure you remember what to do for next visit

Plan

Using drop down lists for speed

Billing

Within the patient encounter; how to make the bill quicker

Preventive services

How to generate your reports (and your bonuses)

Using the Summary page to remind you when a service is due

How to send letters to patients who are overdue

Flowsheets

How to use them.

Programming one

Examples of some: INR, diabetes, depression

Reports

How to generate a Diabetes report

Review of preventive services reports

Scanning old charts

How to get rid of all your paper records (forever).

_______________________

This took about 2.5 hours. It is a good idea to do something like this several months after EMR start-up, as most of us have had a taste of it, but are not using it to its full potential. It has now been 8 months for my group, and I understand it takes an average of 18 months for the EMR to work well. For keeners like me, it is probably 6 months.

I was speaking with a colleague who had been using EMR for 10 years in his 7 physician practice. 2 physicians never went to EMR, so hybrid practices like mine may be more common than people think. It is interesting that he does not scan; paper copies are kept in a paper chart, so there are still duplicate charts after 10 years. He does not feel that he is using the EMR to its full capacity. Nonetheless, he would never go back to paper, and this is something that I hear universally from people that have made the transition.

I found a very active on-line group for my EMR, and have joined it. I have found several useful tips in the messages.

I seem to have a bit more time at the office; I think I am now more efficient because of EMR and so I can do extra things. On Tuesday, I looked at my list of overdue consultations, and found 7 that were very overdue. We faxed a note to the specialists, with the initial consult request and a letter asking their secretary to tick off what happened (pt never showed, pt cancelled, pt seen and report attached etc). Within two hours, 5 reports came back: 2 with consult notes attached, and 3 stating that the patient cancelled or rebooked for a later date.

My preventive services reports are working. I have given flu shots to 109 out of 213 eligible patients (age 65 and over), which is 51.17%. It says that right at the bottom of the report, and tells me what my bonus code is. On Monday, we have our first flu shot clinic, so my report will look better after that. We sent out letters to all the patients. The reports tell me that we have also sent out 35 letters to patients overdue for a mammogram, and 33 to patients overdue for a pap smear. Several of those patients have had the service because of the letter.

I like this organized approach to prevention; because my group has a common remote server, we are looking at doing this as a group once everyone is on-board with the EMR. We can have a group administrator responsible for things like quality audits, reminder letters/phone calls etc. This is very difficult to do if you have single server boxes in individual offices with no sharing of charts. I am becoming very opinionated about this subject as I see how the EMR functions; the single in-office server is OK for large group practices in a single location, but not for distributed small practices like us.

I tried going through VPN at my office on Monday, which was kludgy at best. The SSHA connection came back on, and we switched to that at noon. They tell me that the problem with VPN is my office router, so I have someone coming to install and test a new super-router on Friday. I have a regular Shelob's lair of wires in my back closet, and several boxes with blinking lights. Managing a small office network is not a job for amateurs; it is worth spending a bit of money for extra help at times.

Michelle

Managing waiting times, managing data

We now have a Joint assessment centre to expedite assessments for hip and knee surgery, run in common by the surgery departments of 3 local hospitals. Because the surgery depends on how functionally impaired people are, the assessments are done by a physiotherapist or orthopedic nurse practitioner. This frees up the surgeon's time. The patient can choose the first available surgeon (from 3 hospitals) or a surgeon of their choice--but then they have to wait longer. The Centre opened November 1st.

When I received the announcement, the referral form and letter were scanned into my network. I saw a patient who fit their criteria last week. I printed the letter of introduction and a blank referral for my patient, and a referral for me to fill out. I sent this the same day (with very little hand-written data, it is mostly check-boxes), along with the CPP and a printed copy of my clinical notes indicating what the problem is (which saves having to rewrite the whole thing).

I wish more specialists took this approach, rather than continue to use individual waiting lists.

I am continuing to use the on-line waiting times sites to refer my patients for MRIs, and this has made a difference.

I have to think carefully about what happens to my data. It continues to bother me that so much data needs to be scanned in because it is not integrated with the EMR; this can be a real problem for shared care with a specialist. A local internist sees one of my patients for mild hypertension (I am not sure why). Periodically, he orders blood tests, DI such as bone densities, and changes her meds. In the past, on the paper chart, this was just irritating. In the EMR, it is more of a problem. The blood tests he orders have to be scanned in, and do not show up on electronic summaries (he does not use one of the electronic labs). The changes in meds have to be entered in the CPP instead of just flowing in from my encounter. I have to enter his BP values so they show up on my graphs. It is no longer just irritating, it is now more work (for no better care).

I finally called the specialist and explained why I no longer wanted my patient to see him. I explained that I am using an EMR, and that it is important that the data flow in electronically. He agreed to stop seeing the patient.

I think the primary care EMR will be the core of the eventual Electronic Health Record (EHR) for most patients. When a patient comes back from a hospital, I ask them to tell the institution to send me a report. I show them their EMR, and explain that records get scattered all over the place in our health care system; the only way to ensure information is not lost is to get their data into the EMR.

There are 4 large labs in my area. 3 are electronic and flow into the EMR, and 1 is not. If I get a result from the non-electronic lab, that chart is flagged, so that the patient can be told not to use that lab in the future.

I have now been told that my hospital's software and my EMR will be able to share data, in mid 2007.

I think we can have a say into how the data is managed. We can sometimes direct patients where their data is more likely to follow them.

My group continues to have problems with SSHA (Smart Systems for Health), which is the government agency that provides Internet access for doctors and hospitals. Their lines have been slow at times, and are sometimes unreliable. I had my SSHA internet access cut off on Friday, and I switched to my back-up internet line, which is actually faster. I am not sure government should be in the business of providing Internet access; I may just stay on the back-up line.

Michelle

Guidelines in the EMR

I have been thinking about how to put guidelines in the EMR so that I can use them in practice more effectively. This is a recent review in BMJ : they found that

1. integration with charting
2. computer-based generation of decision support
3. automatic provision of decision support as part of workflow
4. provision at time and location of decision making
5. request documentation of reason for not following recommendation

were associated with more use of the recommendations in practice. Some of these things I can do now, some I can't.

The integration with charting is pretty easy for simple recommendations. For example, I made a template for the GAC recommendations for sinusitis. It has checkboxes for symptoms, and a text box for recommendations (copied and pasted from the website). I had a patient with sinusitis, loaded the template, and showed her the recommendations (no XRs, no antibiotics). These can just be saved to the clinical record, since the amount of writing on the record doesn't really matter anymore. I guess that takes care of point 3 and point 4 as well.

I copied and pasted below a slightly more complicated template I made to help me with the management of patients with chest pain. I used a "history builder", which is where you click on snippets of phrases to put them in the record, then a table, a textbox, and a drop-down list (the table didn't format properly when I copied it for here):

chest pain Updated By:(Michelle Greiver)

chest pain

chest pain

Patient complains of retrosternal chest pain; The pain is worse with exercise or stress; Patient states pain is better with rest or NTG.

number of symptoms 3

Simple Table

	Risk of heart disease
	Age (yrs) Men, 0-1 sympt Women, 0-1 sympt Men, 2 sympt Women, 2 sympt Men, 3 sympt Women, 3 sympt 30-39 4 % 2 % 34 % 12 % 76 % 26 % 40-49 13 % 3 % 51 % 22 % 87 % 55 % 50-59 20 % 7 % 65 % 31 % 93 % 73 % 60-69 27 % 14 % 72 % 51 % 94 % 86 %

Risk of heart disease (%) 76

Test suggestions:

Risk <20%: observe, reduce risk factors Risk 20%-80%: cardiac stress test, unless contraindications Risk >80%: refer, stress test for prognosis, consider angiogram

Test chosen: Cardiac stress test;

I don't really see how the computer can generate automatic decision support in the current EMRs. The decision support tools are all "outside", on the web or on PDAs, and not integrated. Nor does the EMR request a reason for not following recommendations, even if I choose to bypass an alert that a patient is allergic to that medication. I am not sure how well accepted such a request would be.

I think more advanced functions, like context-specific suggestions, will be in EMR ver2. In the meantime, I can use what I already have. I programmed the new Rourke well baby record, using pieces that were in the EMR for the old record. I also pasted the Rourke patient education recommendations to a website. When parents are in, I ask if I can email it to them; they then have access to all the great links from the Rourke. I also printed a copy for a new mom who doesn't use email.

One of my front computers crashed on Tuesday; we had a blue screen with a note to get support. Dell sent a technician to replace the motherboard (didn't work), then the Intel chip and memory (didn't work), and now I think they are going to reload Windows. We are using the laptop as a back-up, so there are still two computers at the front. Some redundancy is good to have.

Michelle

Helping others in my group

One of the benefits of starting EMR as a group, rather than individually, is that we can help each other. At our recent meeting, it was clear to me that I was the furthest along, although others had good ideas. Because the nine of us work in 7 different practice locations, we don't meet all that often; we use email, and recently also the EMR's internal messaging system. We decided to have a "Tips and Tricks" afternoon at the company's training room, and this will be on November 24th.

The plan is for us to log on remotely to our practice EMR during that meeting, so that we can make changes (such as new flow sheets) directly. My group's IT lead physician will help me set an agenda; I will circulate this prior to the meeting to see if there is anything people want to add. We've invited the other FHN's IT lead, so that she can bring things back to her group; her FHN includes one 6 physician group practice and one 3 physician group, so it is not as scattered all over the place as ours.

Some practices are not using the scanner. EMR not only involves software, it also involves learning how to use new (and sometimes unfamiliar) hardware quickly and effectively in a busy office. I did a brief demonstration of how to use the scanner during the meeting; I talked to my staff the next day, and they offered to help as well. Probably the best way to show how we use the EMR is to have a staff member from another office visit my practice on a Friday (since I'm not there Fridays); this happened today.

I have been away at a conference for the past two days. In the evening, before supper, I have been logging on to my practice, and signing off lab work, and scanned reports. I received several messages from my staff, wrote a couple of prescriptions, sent notes to my staff to call patients about their results, and wrote some lab reqs. I also had an email from a patient who was worried about his lung function test; it had been scanned in the EMR, I saw it, and sent him a note that it was normal. One of my patients had received a flu shot at another office in my group; they entered it in the EMR chart, and sent me an internal message to let me know.

This work for my practice took about 45 minutes. I consider going to a conference part of work, so told my staff that I would be logging on daily. It is extra for me, but really does take a load off my practice partner; a big part of covering for another physician is reviewing all the paper that comes in. I am much more efficient at reviewing results for my own patients, because I know them. It is becoming more important for me to let my staff know whether I will be logging on when I am away, and I have to be explicit about this. If I do log on, my partner is only responsible for looking after critical results.

A couple of physicians in my FHN are part of our palliative care group. I wonder if I should ask the nurse coordinator to direct my patients to them when I refer. They would have access to the chart. It would not always be possible to use the EMR during a housecall, since not everyone has high speed internet; they would have to print the CPP ahead of time, and then scan notes in afterwards. However, if there is access, then all the changes are live in the common chart. They could even write a prescription in the EMR during the housecall, and have their secretary print and fax it to the patient's pharmacy (just like I am doing from my conference). I would always be able to know what is happening, and if I made any changes, my colleague would know. Any home care, specialist, or test report that came would be scanned in, and would thus be available to the team. I should talk to my colleagues about this.

Michelle