Saturday, December 30, 2006

At the nine month mark: a new year, a new beginning

I have just finished the last CPP. It took me nine month to enter almost 1,500 CPPs into the EMR; sometimes I got bogged down, when things were very busy, and didn't do any for a while. That's about 166 CPPs per month, on average. Done!!!!

During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.

Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.

My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.

One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.

In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.

There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.

It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.

There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.

I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.



Anonymous said...


Great to hear about the end of your CPP entry! Now that this transition phase is over, will you be ending your blog posting? As a dedicated reader I hope that you will continue to post your thoughts. My office and I have learned a lot through your posts. Thanks for blazing a trail for us. What challenges do you foresee in the coming months for your EMR?

Michelle Greiver said...

Thank you, I appreciate your comments. I will continue, as I see this as an ongoing process. The main part of the transition is finished, but not EMR development.

The biggest challenges will be trying to build bridges from the "electronic island". This will be not only to others in health care (hospitals, pharmacies, home care, specialists), but also between different EMR applications in primary care. I would also like to see patient access to their own records. That is medium to long term, and most of it is out of my hands.

Challenges for me in the short term will be learning how to look at my data now that I have some, and trying to figure out what to do with what I find. As well, I still have a lot more to learn about the application; these are large and complex programs. Now that the transition is over, it is tempting to become complacent, and leave things as is.