My Team: multidisciplinary care

The New Year will mean more Team-based care for me. A part of it will be the move to the Big Office, but much of it will stem from the on-going development of our Family Health Team: we are now deciding what programs to launch, and how to go about this.

The reason for FHTs is to increase access (more patients rostered, improved access for current patients), to create Teams so that care can be better coordinated, and to increase activities directed at health promotion and disease prevention.

We now have nurses, a RN case coordinator (for tough problems that need system navigation), dietitians, social workers and a clinical pharmacist. We are planning on hiring a clinical psychologist as well. The Social Workers were an immediate hit, and are now so busy that there is a bit of waiting time to see them. We do not have Nurse Practitioners, because there are very few of them, and they’ve all been hired by the other FHTs.

We have a board of directors (mostly family physicians), and an executive director, as well as admin support staff. We have identified several areas that we would like to focus on. Our Allied Health Professionals are getting a full week of in-service training in early January, followed by EMR training the following week.

I’ve been asked to talk about Medical Directives during the in-service training; this is something that we can now start thinking about as a group. Medical Directives allow AHP’s to do delegated act, for patients who fit criteria. For example, I would like to have a directive that will allow my nurse to do a quick strep (or throat swab) for patients who have a positive sore throat score, without asking me for permission first (nurses are not allowed to order diagnostic tests independently). Things like that are easier to do if you use EMR templates; I’ve seen my nurse use the sore throat template correctly several times (it is visible on the EMR Encounter as soon as entered), before I go in to review the history with her; she knows when to do a quick strep, and she has no difficulty in interpreting it correctly. We’ll have to start thinking about what makes sense, and is likely to improve access and quality of care.

There has been some thinking about how to use the EMR; we may go to a centralized booking system for the Allied Health Professionals, accessible remotely. I don’t know how well that will work; I have a feeling several offices will prefer calling rather than logging on to book. We have two EMR systems in our FHT (I heard that in Hamilton they have six!), and some AHPs will work mainly in one system, while others will be assigned to the other. This will be easier for AHPs working inside family practices; I’m not sure how it will work for those assigned to programs.

I have not been actively involved with our FHT board or planning committee, but I am the beneficiary of their work. One physician in particular has been instrumental in bringing this project to fruition, after years of hard work (and lots and lots of meetings for him). It is always like that: there have to be people with vision and dedication to make projects like this happen, and sometimes they are not recognized or rewarded. This is true for some of our EMR pioneers. It is gratifying to see that our provincial government has decided to re-invest in primary care; I think this will pay large dividends.

There will be significant changes related to Team-based care in 2008 for me and my FHT colleagues. I expect that, by the end of the year, my practice will have dramatically changed from what it was as of my first entry in December 2005. Although the upcoming changes may not always be directly related to EMR, IT will be a large component of the final transformation. I am planning to post regular updates on this last part of the journey here.

Michelle

Year 2: looking back, looking forward

A year ago, I had just finished entering the last of my CPPs into the EMR. It has now been a year since I have been fully electronic.

This is a log of a routine diabetic visit; I have erased the date and the patient's name:

	10:41 AM				View Summary
	10:43 AM				Add Encounter
	10:43 AM				Add Clinical Notes Templates
	10:44 AM				Edit Clinical Notes
	10:44 AM				Edit Clinical Notes Templates
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:46 AM				Add Lab Requisition
	10:47 AM				Add Immunization
	10:48 AM				Sign off Encounter

I view Summary as my entry screen, by default; this lets me see if there are any outstanding issues for a patient. In this case, she was overdue for her flu shot, which was the first thing I did (the two minutes between Summary and start Encounter). The active medications are auto-loaded into my Encounters, and they are batch printed (that's why they are all stamped on as being at the same time, this is the time they are printed). I sent the patient for an A1C (lab req), and recorded her flu shot. Log lets you get a quick snapshot of how your encounter goes; it doesn't include everything (I also looked at the diabetic flowsheet and the CPP), but it is pretty good.

I keep looking for ways to improve efficiency; the EMR software application is so large and complex that there is still lots to find and use. One of my colleagues was telling me that he feels he uses only about 5% of the functionality; I probably use more, but there is still lots to discover.

My new partner has been using EMR from day 1. I can see that there are some things that are still challenging, such as learning to prescribe more complex drugs (example, gardasil, at 0, 2 months, and 6 months, to be given in physician's office), or doing referral letters. The basic encounter was pretty easy for her to learn. Periodically, we sit down for a few minutes and I show her things. She did not go for EMR training, as it did not seem necessary; she is learning it as she uses it. I will buy a new Windows XP PC for her, because I just can't make Vista connect to my XP network properly. There were a couple of start-up problems: for example, we had to figure out how to make sure that encounters that are started for her by my front staff (they put the vitals in) are sent electronically to her and not to me. Her off-site access does not work; it seems to be a problem with her router blocking the VPN, and that needs to be solved.

She decided that she preferred desktops (wired) as opposed to wireless. Because I have network "drops" in every room, it was very easy to accomodate her. She has her own exam room (the room where paper charts used to be stored), and this now has the desktop with a local printer attached. The printer is the same brand as what I use in the rest of the office, so that we don't have to manage cartridges from different companies. We share an exam room, and she just leaves the laptop in there on the days that she is using it.

Overall, adding a new physician in my office was a lot of paperwork and some extra EMR work (configuring the machines, learning to work with two EMR physicians instead of one), but this is much less than initial EMR start-up, and is manageable. It has not been as difficult as I thought it would be, although there are still things that we need to fix. It helps a lot that my new partner is so easy to talk to, we can solve problems. I expect that, once she gets going, she will be teaching me things.

My son moved out of residence this year, and moved in with two other university students. They have a brief "house meeting" every two weeks, do discuss outstanding issues. He keeps minutes. This is working very well for them; it sounds like a good idea, and I think I will try that with my new partner.

I have been talking to several colleagues about joining me, as I will have a three physician office in the big FHT office; I do not yet have a third partner yet.

While there has been progress, there is still a lot that remains undone. What bothers me the most is the lack of action on the "electronic island"; we are still not connected to the hospital or to outside agencies beyond the labs, there has been no decrease in the incoming data that needs to be scanned, and there has been no progress on decreasing the number of proprietary (non-electronic) outgoing forms. There seems to be lots of talk, but there is no change in my practice.

As an example, we are now being forced to send out proprietary public health forms for Chlamydia urine PCR; up to a month ago, the Ontario lab req was accepted. If you make it more difficult for me to screen for chlamydia, I am less likely to screen (a decrease in quality of care).

There is nothing that a front line clinician like me can do to improve this. Because the health care system is still so fragmented, it is difficult to know who to talk to about these issues, and each problem has to be solved in isolation. We certainly have lots of organizations dedicated to decreasing fragmentation (the LHINs, Canada Health Infoway etc), but I cannot say that their work has percolated down to my practice. Maybe next year.

On the other hand, EMRs are spreading. I have now started the study that I will be writing up as part of my Master's thesis (effect of EMRs on preventive services). We are recruiting colleagues in family practice in my area, and have recently sent out letters of invitation. 26 physicians out of 130 have already replied; of those 15 have or are planning to implement an EMR, and 11 are not planning EMR.

In my own Family Health Team (composed of 6 Family Health Networks), all 40 physicians have or will have EMR by next year. Our Allied Health Professionals are getting EMR training the second week of January. I expect to have more EMR integration at the FHT level next year: by that, I mean that our social workers and dietitians will enter data directly into the EMR. My practice nurse and our clinical pharmacist already do this.

We are getting ready to start renovations on the big FHT office. My own office at the new location will be just over 2,000 sq feet; plans to move in later in 2008 are on track. There was a good article on office planning in a recent issue of Future Practice, by Dr Kendall Noel; just like him, I really like the fact that my patients can see the computer screen--it allows them to participate more in their own care. Almost all of my physicals are now done collaboratively with my patients: I point at what I am looking at on the screen (and I often ask patients age 50 and over if they need their reading glasses--because I'm starting to need those more routinely). It is important that you don't have your back turned to your patient while entering data. It is simpler to do this with wireless because the computer is portable, but the new flat screens make this a lot easier to do with desktops: they take up much less space, and it is easier to place them where they make the most sense.

For the next year, I look forward to planning the big move; this will make my practice fully electronic, as all physicians will be on EMR. I look forward to working as part of a Family Health Team. Now that I have lots of data in, I want to learn to use the capabilities of the EMR to systematically improve care: that will mean doing audits to figure out what patients need, deciding what to do, and using the Team to put our plan into action.

I would like to thank readers of this blog for your company through this journey, and wish everyone a good and peaceful 2008.

Michelle

Divorce, EMR style

At a recent OntarioMD meeting, several of my colleagues who are early adopters talked about being on their second EMR system. I've also heard from colleagues who are not happy with their system, and my new partner is now on her third EMR system because of changing to new practices.

I think going electronic is a bit like a marriage; you use the darn EMR all the time, sometimes it works and sometimes it drives you crazy. If it drives you crazy enough, then you get a divorce, which is difficult and expensive, but is sometimes necessary. No guarantees on whether the next partner will be any better.

There is no way that the electronic data from my partner's previous practice can get transferred to the new EMR. Her previous office manager is printing the charts of patients who are following her; she has to then re-enter the CPP. We are scanning the old charts that are arriving into the office's external hard drive. This is the current state of affairs.

In Ontario, all approved EMR applications will now have to be portable; in other words, you will be able to transfer data to a new EMR vendor if you switch. This document has what must be portable on page 40 and on. It is a bit difficult for me to understand, but it looks as if most of the CPP, lab and clinical notes are in there. I can't imagine that is will be easy or seamless, since EMRs store things in all kinds of different ways, and in all kinds of different databases. I'd like to see this in action; I think the most important piece will be the CPP.

In my EMR, I now see a Data Export and Data Import piece, so they are getting ready for this.

Having some data that is similar across EMRs is a good idea; perhaps one of the unintended (or maybe intended?) consequences of this initiative is that there will be a common CPP that can be transferred back and forth to hospitals, home care, and specialists when needed.

It is interesting that I have not heard of instances where the divorce was back to paper; the difficulty is with the initial transition to EMR. There is no reversion back to paper, but there is failure to launch EMR.


My Family Health Team is getting ready for the big move; about half of the physicians in the Team will move their practice to the same premises as our Allied Health Professionals. This looks like it will definitely be happening in 2008; I will be moving, along with my new partner and a third physician. Our AHPs will be getting EMR training early in the new year. It will be interesting to see how things get integrated. I've been asked to talk to the FHT Allied Health about medical directives in the new year, so now I have to think about what I would like them to do.

Three of the practices that are moving are now on EMR, and two will be transitioning after the move. On the Master Plan, there is space allocated for high density filing for the non-EMR practices only; I cannot see much wasted chart areas in the EMR practices. I will not be moving any paper charts to the new office; others in my FHN who are moving are now disposing of their paper as well. One physician has moved files to her home, another to a storage company, RSRS (and she is quite happy with the service). I think we are starting to witness the beginning of the end of paper records.

Michelle

Being irritated

We just got a new version of my EMR software. The colours are all different, the layout is somewhat different, my label machine didn't work and I get error messages with some of my bills. We got the new Ontario lab reqs, and I had to reprogram my saved lab favourites. I don't really like new software versions, it seems they never work quite right at the beginning and it takes a while before everything settles down again. Even giants like Microsoft can't quite get it right (Vista is very buggy).

I fixed the label machine; the billing error message is annoying but the bill goes through. I'm getting used to the new layout, and there have been some improvements, such as making the DI and lab areas of the charts easier to access without leaving the encounter. There have been some changes in the prescriptions that I haven't quite figured out yet; on the other hand, one of my FHN colleagues found that the EMR can now print a "non-prescription prescription" when drugs are stopped. That's useful, because I give this note to the patient so they know what has been stopped, and they can pass it on to their pharmacist.

I figure that if I'm irritated, I might as well be an oyster and see if I can make something out of it. I figured out a much faster way to get my lab and DI reqs into the record, which I hadn't seen before. I also followed up on my colleague's comment on the previous post, and now auto-load a pap requisition into the record, so that the pap can be tracked; while I was at it, I emailed the general manager of my lab company to ask him if it would be possible to send him my computer-generated req instead of the proprietary pap form. I sent him an example of a requisition, which is reproduced below. Maybe they'll agree this time.


Some of our lab processes are unnecessarily complicated; for example, a first prenatal exam involves generating a req for prenatal blood work, a second lab req with "IPS, part 1"(Integrated prenatal screening), along with a special Genetics form for the IPS; an Ultrasound req for Nuchal translucency; and a special public health lab form for HIV and other public health labs. That's five forms, plus the handout on IPS that I give patients.

I generated EMR form favourites for the two labs and the US, and they're now clicked into the encounter and batch printed. The special IPS form and the public health form (with my own information pre-entered, and all the public health blood tests pre-checked) are now together as a single file; Adobe Pro lets you put several pdf files together. I also include a letter of explanation that says: "book your ultrasound between 11 and 14 weeks; take the special IPS form, along with the lab requisition that says "IPS I" and the ultrasound requisition to the ultrasound place. The technologist will keep the ultrasound requisition, and write the results in the special IPS form. Take that form and the IPS I lab requisition to the lab on the same day; they will take your blood and keep both forms."

The single file with this letter, the IPS form and the Public Health lab form is then printed. That's one print for the EMR forms, and one print for the rest (instead of 6 load and prints--or having to look for a bunch of forms). Also, I'm much less likely to forget one of the forms, which I've done in the past.


This is my EMR pap req:


Cytopathology Requisition

Dr. Michelle Greiver 212, 5460 Yonge Street North York, ON M2N 6K7

Email: mgreiver@rogers.com http://drgreiver.com Phone: (416) 222-3011 Fax: (416) 221-3097

COPY TO:

---

Lab company

Phone: Fax:

---

Patient: Dummy2, Patient 123 any street Toronto, ON M1M 2M2

Date of Birth: Oct 1, 1947 Phone: (416) 222-2222

---

Date Created:	Dec 7, 2007
Priority: Routine

Tests requested:
Date of LMP:	December 2 2007
	Endocervical

Comments:

PAP SMEAR, LIQUID BASED, using broom. LMP 2 weeks ago. Cervix appears normal Physician OHIP number:

Adding a new physician

A colleague will be joining me in my practice on December 3rd. She has joined my Family Health Network (lots of paperwork), is coming on staff at my hospital (paperwork), will be using my EMR (paperwork) and will be receiving the OntarioMD subsidy (paperwork). I wonder if we could combine all this paper into one giant Sequoia. We also notified the labs so she can start receiving electronic labs from the outset.

I have been thinking about how to make it easier for her to start the EMR. It took a little while to register her properly on the system. I already set up her preferences for her, so that the system works from the beginning; these large systems are highly customizable, but the downside of that is that you have to set things up. When you first start, you don't know much about the options available, and it may not be intuitive. I have a good idea of how things run efficiently, so I put that in and she can always change it later. I've set up things in the EMR like lab favourites (1st prenatal etc) for quick lab ordering, quickfill for DI ordering, physiotherapy reqs, basic form letters, referrals etc. It takes a while to start a new physician, it is more complex than adding staff, a resident, or Allied Health; it is important to try to do it properly.

My secretaries know quite a bit about this, so they will help as well, and my nurse can assist.

She bought new machines, but the Vista system does not seem to see the Window XP machines on my network, so her computers can't access all my scanned documents. I will need to call my IT guy to have a look. In the meantime, I will lend her one of my machines so that things work from the beginning. There is a learning curve for the EMR, and it helps if everything is already set up and if you have some help and advice from the outset. I think one of the things that make the initial transition so hard is that you have to deal with everything at once: the hardware never works properly at first, and the software is terra incognita.

She has been using another software application in the practice she is leaving, and does not like it all that much. I'm not sure what the issues were, probably some combination of process problems and computer issues. I'd like to see if I can do a bit better, but I'm sure there will be glitches. I'm hoping to have everything running smoothly within 6 months, which I think is reasonable, and is certainly shorter than the 18 months that has been quoted for a transition from a full paper-based practice. It will be easier for the next generation of physicians.


I've just had a quick look at my overdue lab reqs: there are nine reports that were done but results were never received, from June to mid-November. We will have to call the lab and request copies. I cannot track paps that have not been received, because the lab will not accept electronically generated reqs (mine will only take their own proprietary form). I scanned the pap req in, and print it as needed, but that makes it non traceable. I have had a patient come back and ask for her pap result, which was missing. We called the lab and had them fax it; I can also look results up on line, but that doesn't help me if I don't know that the report is missing. Whether by fax or online, results do not flow into the EMR: we have to scan in.

I wonder why results go missing, and what can be done about it. We sometimes had paper lab reports delivered to us that belong to a different doctor, which explains missing labs on paper. It is more difficult for me to understand why electronic labs go missing; perhaps a technician miscodes the physician's name when the lab form is received. It is time for bar codes, which my system can do. There should be some way of having labs track missing results systematically, especially for the electronic labs.

Michelle

the structure of the chart

I have now used electronic charts for more than a year and a half. The way I look at the chart has changed substantially, because the chart is now much better organized and it is much easier to find data.

However, I look at my "plain" clinical encounter notes less often. In the past, much of the data was located there; for example, I'd have to search to find previous blood pressures or weights. Now, I click a link or look at my flowsheets.

There has been debate about "the patient's story" in the chart; in the past, that mostly meant ongoing longitudinal data in the encounter notes (legible or not). Now, the story tends to be all over the chart; the data is more easily accessible, but it is also more scattered. Some of it is only accessible in electronic form.

Much of my chronic disease management is captured in my flowsheets; the encounter is a poor format for following chronic diseases. For lab follow-up, I am less likely to write "hemoglobin was 88, now it is 97", because that is clickable in the electronic lab. I do put in assessments in encounters, although this is more likely for in-person encounters (for billing) than for phone conversations. I put in reasoning for treatment or investigations, so I can see what I was thinking. However, I will often not put in "DXA ordered"; the DXA (bone density XR) order is a link within the encounter. If I print the chart, the link will show a DI was ordered, but you will need to access the electronic version to see what it was for. Similarly, my lab requests show up in the encounter as a link, and not as discrete blood tests.

The data is generally richer and more extensive (because much of it flows in automatically), but some of it is standardized because of templates, such as a low back examination or a visit for a cold. My annual check ups also are standardized. This probably reflects an attempt to provide good care for everyone, but it does make the record less individual. I am probably conscious of the fact that there will be patient access at some point in the future (and I fully support this), which may make me a bit more cautious about what I write.

I think we may need to start thinking about "the patient's story" in a less linear manner. I am not saying that the clinical encounter document is not important, but it does seem to me that it is assuming less importance; I look at it less. I'm not sure if that's a good or bad thing.

Michelle

Peer to peer

I have often received requests to visit my practice; I think that there are still so few computerized offices in my area that people want some idea of how the EMR works in a real life setting. I also get requests from physicians who have recently started an EMR, so that they can see how things flow in my office and get ideas for their own practice. I have had visits from people in academia who are interested in the EMR transition.

I recently went to visit Alan Brookstone in BC, and got a chance to tour the recently opened PROOF office. This is a regular medical office, set up for EMR, so that physicians can test hardware and applications in a real setting that mirrors their own practices (waiting room, exam rooms etc). There is demand for this; having something organized and easily available will make it much more accessible.

I don't know if we can get something similar in my area; it will take someone to organize it. In the meantime, I have started passing requests to visit my practice on to OntarioMD. We have the new InfoWay Peer to Peer Network, and it says that one of the things we are supposed to do are "individual demonstrations of Electronic Health Records technology". To me, that means "come see my office". At OntarioMD, we have Practice Management Consultants (PMCs), who help with the process of choosing the EMR and receiving funding. I passed the last request on to my local PMC, and she arranged to meet with the physician's group to discuss things such as the subsidy and what their needs are. Once they are ready, she will then arrange for them to come to my office. I think that this is a much more efficient way to do things, and it also provides my colleagues with much more than a simple visit could.

I wish I could make an organized inventory of work flows that I use. I did not find such a thing, and had to invent many things as I went. I am sure many of my work flows are similar to other physicians'. I was watching my colleague, Dr Stephen McLaren, speak about this subject. The video will take a bit of time to download, but it is well worth the wait. This type of practical, day to day work flow advice is invaluable; maybe we should have some type of document on work flow (paper, or CD or internet based and searchable), with "how to" sections. There are enough power users now that we could have screen shots of different EMR systems so that the document is reasonably vendor neutral; I think it is important to have screen shots so that you can see how it is actually done.

All EMR systems have their strengths and weaknesses. I have been talking to users of other systems, and I am starting to see what those are. It is helpful for us to talk across platforms, because we will then go back to our own vendors and work with them to improve our products. In terms of choosing a system today, my advice is the same as Dr McLaren's: there are enough larger, established products now on the market; do not pick a small vendor--you will be a pioneer, there are no established peer networks for support, and your vendor is more likely to fail.

I am not saying that the cavalry is here to save your implementation; I am saying that there is much more available now than a year and a half ago, when I started. For those of my colleagues at the tipping point of deciding to computerize, your peers who have done it can tell you that the time is now.

Michelle

Reporting my data

OntarioMD has now announced that two new companies have been approved for ASP funding. My EMR software is one of them. This is good news for my group; our contract finishes in a year and a half, and we will be looking at whether we should then transfer to the ASP product. Doing this will mean that our software will be hosted in the SSHA Data warehouse. Other services, such as home care and some public health data, will be hosted there as well. I am sure there will be lots of bugs and difficulties, but this represents the future of health care in this province; it represents the best chance of integrating health care.

I went to the North American Primary Care Research conference last weekend. There was palpable excitement about what is happening with computerization in primary care. There were many presentations dealing with this subject.

As I look at my data over the past year and a half, I can see how valuable it is. Everything possible is going into the EMR now. It bothers me that Diagnostic Imaging reports continue to be reported on paper (despite the fact that DI is highly computerized), and that hospitals are still not connecting. That is unsafe and bad for patient care.

We also continue to receive stacks of paper from the Ministry of Health for our roster lists (list of all patients signed up with a family physician), every three month. These are generated by a computer, is there no way to receive them electronically, and match them with the EMR roster list?

It is now time for us to think about how to give our data back safely, and with full privacy protection. This data can and should be used to improve our health care system. For example, there is much talk about Wait times, and a lot of money is being poured to improve this. I don't really know how good the data is. In my EMR, we routinely collect wait time data as part of everyday care. When I send a patient for Diagnostic Imaging, the requisition is generated in the EMR (with a time stamp). This is the same for a specialist referral. When the specialist's office notifies us of the date, my secretary calls the patient and enters the date into the EMR. When the letter or DI report comes back, it is matched with the req (so we know it has been received), and that date is stamped in as well. I think it is now possible to start reporting on wait times from primary care, which is what is most relevant to patients. I think the public has a right to know, physicians and other health care providers should know, and our government (which funds health care) would want to know. If you don't know there is a problem, it is very difficult to fix it.

I do not think most of my colleagues would have much of a problem with this, provided privacy is strictly safeguarded. I think there is large value for patients as well, with the same caveat. I know I have several colleagues who are thinking the same thing. It is time to get going on this.

One of my colleagues was mentioning the fact that proprietary requisitions seem to be proliferating. Every specialist and hospital program wants their own, usually based on a paper form. This is not the way to go. I generate generic requisitions for DI, and have started generating EMR based reqs for Diabetes education. I simply append their form on the top, with "see attached". That seems to work. Dr Brookstone in BC has managed to get programs in his area to post their reqs on a secure website, but it takes work to make sure this is regularly updated. It is better than what we have here, which is nothing. I think it should be the responsibility of programs to make sure they are accessible when needed. Give up on proprietary forms (health is not proprietary), and make all programs accessible from a common area. Toronto211 is a good example for community and social services, we need something like that for medical programs.

It is time to ensure that the necessary data is there, both for our patients and for our health care system. I can see this is starting to happen now.

Michelle

Back to paper

Due to personal circumstances, my practice partner had to suddenly be away and unavailable from his practice for the past week.

What that meant was that I was looking after two practices, one EMR and one paper-based. This was a somewhat rough way to compare the two systems. The picture above shows what the front of the office looked like after four days, and there were more charts piled up on my partner's desk. He is very meticulous, and wants to look at everything, so nothing got filed away; we must have had well over 150 charts out.

The logistical problems for my staff were tremendous: trying to find a chart to attach a result to quickly became very challenging: labs often send a partial result first, then a final result; this leads to two separate chart searches. My secretaries stacked the charts in alphabetical order, so that there was some chance of finding the right file.

I had trouble finding data in the paper chart. Looking for previous results meant having to thumb through several papers instead of doing a simple search or clicking a checkbox to get a list of results. Labs, consultation notes and Diagnostic Imaging reports were all mixed together. The CPP was up to date, but drug prescriptions were often very hard to follow, as they were in the clinical notes. There was no easy way to refill prescriptions, those had to be written by hand. My partner keeps excellent notes, and has handwriting that is much more legible than mine, but the logistic challenges were still large.

I know that many of my colleagues who have gone to EMR have stated that they would never go back to paper. Having had to go back to paper for a week, I can unequivocally say that no, absolutely not, under no circumstances, and no way would I go back to paper. It doesn't work.

Having said that, EMR does present its own challenges. My resident is on block time (in my office most of the time) and was a great help in the past week. However, her Tablet went on the fritz on our busiest day (Thursday). It suddenly refused to load the EMR software properly. I have a backup laptop for those occasions, but had lent it to my Nurse who takes it to my colleague's office Thursday afternoons. My resident went back to paper (since she was seeing my partner's patients), and my secretary called the EMR company. They had to "remote" into the Tablet (that means they take control of it from a remote location). Apparently, the hosts had disappeared; I don't know what that means, it sounds like something from the hospitality industry. They reintroduced the hosts, and the Tablet was fixed and happy. This took about 45 minutes.

I have been asked what I do when my Tablet crashes. Computers crash, and they usually do so at the worst times. If mine crashes in the middle of a patient encounter, I either leave it to reboot in the room (if I'm doing something else such as examining the patient), or I put in my consult room to reboot and I go take the backup laptop. The backup laptop is left turned on and ready to go; I just log in. You really have to have some redundancy; however, as noted above, even the best laid plans sometimes do go astray.

I do not pretend that EMR systems are free of problems and aggravation (they are not); however, the past week has made it very obvious to me that EMR is far superior to paper. Just try asking your kids to function without the Internet--asking a computerized doc to go back to paper will lead to the same reaction.

Michelle

The Efficient EMR

I am currently in the office three days a week (I am taking a course at the University of Toronto Mondays, and do research projects on Fridays). My roster size is at 1,320 patients and I have about 100 to 150 unrostered patients. That makes a practice of about 1,450 patients.

In my FHN, the average practice is about 1,200 patients. I have a slightly larger than average practice.

If a patient is not too particular about the time of the appointment, they can almost always be fitted in within a few days, and often the next day. The only appointments that are troublesome are full check-ups booked in the morning (so that a patient can get fasting blood work done at my office on the same day). If they can get their blood done prior to the visit, the appointment can be scheduled much sooner; we mail them the requisition along with a list of labs (only ones that do electronic results) and weblinks to lab locations. This is in the Handouts section of my EMR.

The university provides hotspots for students, so I log on to my practice on Mondays; I am usually logged on remotely Fridays as well. I can review results and reports, and assign needed actions to my staff or my practice nurse.

What that tells me is that there is less need for my patients to come in personally for minor problems. If they do need to come in, they can usually be see fairly quickly. Much of this increase in efficiency has been gained by using the capabilities of the EMR (remote access, e-communication), along with having the entire practice work as a team. It helps to have excellent staff. I am starting to see some improvements with my new nurse coming on board, and expect to see more as other Allied Health Professionals join us. My Family Health Team now includes dietitians (I've made several referrals already), and I met our new Social Workers yesterday. The RN and our Clinical Pharmacist already enter data directly into the electronic chart-in-common; the other AHP's will get training; for now, their notes are done on paper and are scanned in.

If I can look after a full roster on reduced hours, this tells me that I may be able to expand my practice if I go back to my regular hours. This is part of the payback for EMR and for adding extra people to primary care. I will have to decide whether I should do more research or see more patients.

I have now taken on a new physician as a partner; she will start in December, and will have an EMR practice from the beginning. We are already starting to keep a list of people wanting to join her practice. I think most of the pain happens during the transition; once an EMR is established (meaning that all the new processes work), it is much easier to add a new member to a practice. I have seen this with my resident. That bodes well for the next generation of physicians, provided that they do not start a paper-based practice.

My nurse will be giving my patients flu shots on a drop-in basis every Monday afternoon, once the shots are available. We will be doing a mail-out to my older patients to notify them of this. We are doing the mailing as a group, just as we did for the other preventive services: the letters are already in everyone's EMR; our FHN admin will print and mail them as soon as we have confirmation that the shots have been delivered to our offices. Several of my colleagues have also decided to have the RN run the flu shot clinic in their office.

It is increasingly difficult for me to remember what it was like to run a paper-based office; I am pretty sure that I would find the inefficiency and lack of communication difficult to tolerate. I no longer believe that paper-record based medical care has a future.

Michelle

Electronic communication in the office

Communication in my office is becoming increasingly electronic. I get 5 to 10 messages from my staff per day (often a patient or a health care worker wanting to talk to me, sometimes a drug refill). Messages are linked to the patient's file (I can just click to access the entire file if needed), and no message gets lost or forgotten anymore. Most of the e-messages I send out are "Actions", or things to do, often stemming from lab results (example, please call patient and tell them that A1C is improved, now at 7.8%; or, INR is 3.8, reduce coumadin to 1 tab daily and repeat INR next wk); typically, there are 5 to 10 of those per day. The "Actions" can be assigned to a group, such as "front staff". This is very helpful if you have several people working at the front; any of my staff can do the requested action, and mark it completed, thus avoiding miscommunication.

I have been assigning complex Actions to my practice nurse, such as discussion of cholesterol results and possible courses of action, or informing a patient about a new diagnosis of impaired fasting glucose. She can often discuss things with my patients over the phone, and she records the phone conversation in the clinical notes; if needed, she will book a patient in to see her. She sends the clinical notes to me for final sign-off when she is done, so I always know what happened.

I use pop-up messaging often as well (Real Popup). This is a small application that pops up in the right lower corner of a PC whenever someone in my office sends an instant message. The message is not part of the EMR. I use this to send a quick note to the front regarding follow-up appointments (example: Mr Smith: DM 3 months). The secretary sees the popup, and gives that patient an appointment marked as "DM", so that the patient automatically gets a weight and BP done when they return, before they are shown to a room. Some of my patients have wondered how the secretary knows what they will be asking for before they even speak! My resident often sends me a popup for a quick question while she is seeing a patient; she also uses this if she wants me to come in and double check something before I see the next patient.

The office environment I have described seems complex, but it works and actually makes the office much less stressful. There is no need to duplicate messages on notes, nothing gets lost, and everything is done. This improved communication is one of the biggest benefits of EMRs.


I have now gone back to signing my prescriptions on my Tablet. So far, I have only had one phone call from a pharmacist inquiring about this, and he was satisfied when informed that it was acceptable practice according to the College of Pharmacists. I think we have progress.

Michelle

Allies

It is difficult to do it all; I have some very valuable allies that have helped with EMR implementation in my group.

One of my secretaries is now working for my FHN as well, as our group admin. She has helped other offices to implement scanning: seven out of the nine of us are now scanning, and one is about to start. She regularly helps other staff with problems, and they are very comfortable contacting her, whereas contacting me would not be as easy for them.

One of my colleagues has stalled with her EMR implementation; she is in a hybrid office as I am, and so gets no help from her practice partner. She has not been able to start encounters, but would like to do so; however, she does not feel confident in her ability to enter data. I have been thinking about how to help, but it is a problem for me as I cannot spare the time to come to her practice and stay with her.

My new Practice Nurse is now getting allocated to various offices by the Family Health Team's Human Resources manager. At a recent FHT meeting, I introduced the RN to my colleague, and talked about having her come to the office. My colleague was very interested; the nurse felt that she would be able to help; the HR manager thought it was a good idea.

The nurse went to the other office yesterday. I lent her my extra laptop for the day, to make sure that there were enough PCs in that office. It helps if both the MD and the RN have access to the EMR at the same time, as each logs on personally, and permissions are different. The nurse can show the MD what she is doing, while the MD is logged on.

When she came back to drop off the laptop at the end of the day, my nurse told me that she had done several annual physicals, and had showed the physician how she entered the data in the preventive services template. She went in for some visits with the physician, and helped to enter things, and my colleague tried several encounters; she also tried a prescription. The nurse entered a diabetic flowsheet for a patient, and showed the physician how data from the Vitals template in the encounter, as well as lab data, flows automatically into the flowsheet. I really think it helps to have someone on-site; the nurse will continue to go there once a week.

While it is not always possible to have a RN to do this, often there are allies who can help. It is worthwhile thinking about some of the untapped resources present in our practices and communities.

I am now at 88% of paps, 89% of mammograms, and 100% of children's vaccinations for my preventive services. My colleagues are telling me that patients are calling in after having received the reminder letters. We are hitting some of the inevitable glitches, such as a patient who had a hysterectomy receiving a pap reminder letter; because we communicate, these problems are getting fixed (for example, telling the secretary how to tag that patient's chart as having had a hysterectomy, so they never get another letter again, and get labeled as ineligible for paps). I figure that we will have most of the problems with the initial mailing, and this will decrease with time; we have had surprisingly few issues.

The draft letters for the flu shot reminders are in, and everyone is deciding on how they will do their flu shots (clinic, RN times etc). We are now talking about holding a common clinic, since the data can be entered from any of our practice sites; I'm not sure there is enough time to organize this, but maybe next year. Our FHN admin has already organized the window envelopes and stamps, and she will mail the letters in October, as soon as we know the shots have arrived. We get a small amount of payment ($6.86) for organizing each reminder; our FHN admin has entered EMR billing lists for the flu shot reminders for each practice based on the mailing lists, and she will auto-bill after the mailing is done.

Michelle

Planning an office layout for EMR

I am currently finalizing the layout for my new office. This will have 3 physicians, at least one family medicine resident, one RN, and one Allied Health Professional. The office is 1,900 sq feet.

I have been thinking about what to change. The exam rooms are 8 x 10 ft, and really do not need much modification. I will have 8 exam rooms (2 per physician, 1 for the RN, 1 for the AHP). I don't know if my new partners will prefer wired or wireless; if they prefer wired, then they will need 1 printer in each room, along with a computer stand (or they can just put the monitor on the desk table). If they prefer wireless, then they just need a stand for the printer.

I will put network "drops" (the RJ45 plugs) in each room, so there will always be a choice. If wireless, then the printers plug into the RJ 45s; this is my current configuration.

I have chosen a common consult room; I think it is very important to be able to talk to each other, especially as the new physicians start practice and EMR. I asked my nurse if she would prefer to have a consult/exam room, or would she want to sit in the common consult room: she definitely prefers to sit with us. I will also have a space for the resident in the common consult room.

When planning a new office, I think it is good to consider workflow issues, as well as people issues such as how you communicate and work with each other. EMR impacts those.

The biggest change will be at the front office. There are no charts, so the front reception area can be a lot smaller. However, my staff does more callbacks, and they need space which is more private than the open reception area. I am planning a separate staff room; we can have lunch there, but it will also have a workstation for callbacks and administrative functions that do not require a secretary to be at the front (example, uploading bills, managing our preventive services etc). I am considering buying a second scanner, so there will be two places to scan: one at the front reception, and one in the back staff room. I will still have two desktop PCs at the front.

I went to the Canada Health InfoWay Peer to Peer meeting last Saturday. I met my colleague, Dr Brookstone, who reports what happened at that meeting , along with several physicians who had been email only until now. It was good to see others who are very passionate about this subject; sometimes you do feel as if you are a voice in the wilderness, although it is getting to be less so. Our provincial bodies (in Ontario, OntarioMD) will work on figuring out how we can help others; I think this will likely mean a contact from one of us when another physician is strongly considering EMR and wishes to talk to a peer (perhaps a site visit, or a phone call to talk about the specifics of deciding to implement EMR), as well as practical help with the early implementation glitches (this worked in my practice, this didn't, here are a couple of things to try).

One of the pharmacists at the meeting told me that signing prescriptions on my Tablet is now acceptable to the College of Pharmacists; I'm going to try that again. The College states that "For a written prescription, the physician's unique signature is required to provide the authorization." The Tablet signature fulfills that criterion.

Michelle

The Diffusion of Innovations

I’ve been reading a very interesting book called “The Diffusion of Innovations”, by Dr Everett Rogers. Much of what I see as currently happening with EMR is accurately reflected in his book. Making a major change like adopting an EMR is very much a social process.

Dr Rogers found that the adoption of an innovation follows an S-shaped curve; he categorized people as Innovators (2.5%), Early Adopters (13.5%), Early Majority (34%), Late Majority (34%) and Laggards (16%). The lower elbow of the S-curve, where adoption starts to take off, is where I think we are now—right in the Early Adopter stage. This means that you may be able to get a critical mass of users now, and the adoption rate then accelerates and becomes self-sustaining (sort of like an atomic chain reaction). It is an interesting stage, because pushing things along here makes the most difference to how fast we adopt EMRs (the “turbocharging effect”).

The process of starting EMR in our practices also has several stages: thinking about it (knowledge); forming an opinion (persuasion); deciding to do it (decision); starting to use it (implementation); continuing to use it and solving problems (confirmation). According to Dr Rogers, people tend to look to their peers when deciding (persuasion and decision stages). Diffusion networks (groups of people talking to each other) are also important at the implementation and confirmation stage, because you always have to re-invent the EMR at least to some degree to fit your local circumstances; we’ve certainly done that in my group (customized templates; implementing the preventive services; getting scanning going; hiring an IT person). It helps to have a group to see how others have solved problems.

Canada Health Infoway is starting a Peer-to-Peer network, together with the provincial e-Health organizations, so they are probably thinking along the same lines. They have targeted the keeners, under various names: “champions”, “super-users”, “peer leaders”—this is the early adopters. Infoway has scheduled the first national meeting next weekend, and it will be interesting to see what they want to do with us (and for us).

My new nurse is now comfortable using the EMR; it did not take long. She starts seeing patients on her own tomorrow. We had several visits where she saw pop-up alerts for patients booked in for other problems, such as a patient with a new diagnosis of diabetes who had not returned for foot examination or urine testing, or a patient who needed to have a MMR vaccination. She is getting good at providing opportunistic preventive care. The clinical pharmacist saw one of my patients at her hospital office last week, and I saw the electronic chart being opened while in my office, which was very strange. My secretary picked up an urgent message from a patient on a Saturday: the pharmacy had not filled one of her medications. She was able to log on to the record remotely, see that the prescription had been ordered (a copy of the script was on the EMR record), and she called the pharmacy to ensure that the prescription was filled correctly. This prevented an important medication error. While Team-based care is possible without EMR, I think it works better with EMR; some of the EMR tools (alerts, reminders, legible records, e-communication) can make collaboration more seamless.

I am looking for new partners for my practice. I have been now contacted by several recently graduated physicians with impressive credentials; I had looked for a new associate a few years ago, with no response. I don’t know whether the interest is due to the EMR or to the benefits of joining a Family Health Team; probably a bit of both. I have noticed that many of the ads seeking to recruit a family physician as an associate mention that the practice is computerized; EMRs are a selling point. All these changes seem to be having an impact, and I am very pleased to personally see that new family physicians are choosing comprehensive care again.

Michelle

DHCP blues

One of my front computers stopped connecting to my network last Thursday; this was kind of bad, because it is connected to the scanner--no scanning. When a computer fails at the office, it is always a bit of a crisis, and someone has to fix it.

In my office, I'm usually the first line of defense (I think every office has one of those, often by default). Most of the time, what I do is reboot the computer, and that often fixes things. This time, it didn't work. Then what you have to do is look to see if you can easily identify the problem; clicking on the "repair" button for the network didn't work.

This is when you call your IT person; every group should identify a professional IT person that they can call (not another physician or their neighbor's teenaged son). He came by that afternoon, and had a look at the machine. He tested the network card, connected the computer directly to the routers and did other things; I can't say exactly what, because I was seeing patients instead of taking care of the problem--which is the way it should be.

He finally identified the issue as a "DHCP server not working; must be replaced". He said that this is bad; he pointed to the router boxes in my IT closet. He assigned a static IP instead of a dynamic IP address to the computer, and said that this would fix it temporarily (whatever that is, it worked and the computer reconnected to the network). This reminds me of being in the garage with the car not working, and the mechanic tells me that the crankshaft is unglued; please just fix it.

Now that the problem was identified, I had to figure out who to call; the boxes in the back belong to SSHA (Smart Systems for Health), and we also go through the EMR company. I sent an email to SSHA, the EMR company, and OntarioMD. My very helpful contact at OntarioMD said to call the SSHA helpline, which is what I did; they took down the information, and gave me a 6 digit number for tracking purposes. On Monday, a new SOFA (Small Office Firewall Appliance), which is the box that had gone bad, arrived by courier. The IT person installed it for me, tested it, and now things are working again.

I am writing this to show the processes I am currently using to deal with IT problems. My computer systems are very complicated, since they involve internal hardware and software, EMR software, and hardware/software managed by an outside agency (SSHA). I am better at dealing with this than at the beginning, but it is still stressful. In order to deal with potential non EMR computer problems, it helps to have:

-a person in the office responsible for low level issues
-an IT person to call in for more difficult problems
-if you have things belonging to an outside agency, have their helpline number and keep the identification number for their hardware (they will ask you for it)

To give you a picture of my office last Thursday, my new nurse was in, my resident was in, my secretary was training a high school student for evening work, and the IT person was working on the broken computer. It was a little crowded and chaotic. There was no way I could work on fixing the computer.


On another note, my group's preventive services project is now finished, and we have mailed letters to all patients who are overdue for paps, mammograms, and 18 months vaccines. It took the students two months to complete the audits for all nine of us, and to enter everything in the EMR. The total cost for the nine of us was $6,500: $4,500 for wages and $2,000 for printing, envelopes and stamps. We mailed 1,433 letters (out of a 12,000 patients roster in my group), so 12% of patients were overdue for one of those services. List maintenance and periodic mail-outs are going to be much easier now that we have the initial audit and computer entry done; our FHN admin person is going to look after this.


Plans are progressing for the big FHT office. A space planner came by my office: although about 15 t FHT physicians will be located there, each group will have their own individual practice space within the large office. Several of the FHT nurses, dieticians, social workers, as well as the FHT admin staff will be also be located there. I have been thinking about how I would like to work; my partner can't move to the big office since he's not part of the FHT, and isn't computerized. I think I would be happiest in a group practice, with two other colleagues. It is time for me to take on some new associates; I will be asking my FHN colleagues for permission to add two new physicians.

There will be no filing cabinets.

Michelle

Practice nurse

Things are progressing for the Family Health Team. We've hired a dietician and several practice nurses. The nurses have been coming to family practices to shadow us.

I have started working with a nurse for the past few days. It is an interesting experience for both of us, since I've never had a nurse in my office, and she comes from an emergency room background.

I asked our FHT physician advisor if I could have a copy of the nursing scope of practice. The advisor is one of my family practice colleagues who has worked for the ministry; he is also a FHT member, and is knowledgeable about these issues. It looks like a nurse can do most things, but can't prescribe.

When our new nurse came in, I registered her in the EMR, and set her Permissions as "Nurse". By default, she is not allowed to prescribe or bill.

I gave her my resident's Tablet, and logged her in. I would come into the exam room, and introduce her. As she shadowed me, she would load a patient's record on the Tablet, so she could see what I was doing as I was doing it. After a couple of days, she had a good idea of the structure of the record, where things are kept, how to access the CPP, how to do an encounter and how to load templates. Patients seemed comfortable with having her in.

Yesterday, she started seeing patients before I came in. The EMR logs who does what, so it keeps her notes under her name. She does not sign off encounters, but instead sends them to me with the heading "Nurse saw patient". I can then modify and complete the record, and sign it off.

The Fall will be hectic for me. I have been doing a part time Masters of Science at the University of Toronto as I'm very interested in the effects of EMR on medical practice and wanted some extra education on policy and research topics. This is my third and final year; I will be taking a course in biostatistics, which will keep me away from my office on Mondays from September to December. I have been trying to figure out how to schedule things so I can still cover my practice, and will be adding extra hours on Tuesday afternoons and some Wednesday mornings. However, I think this will not be enough.

The nurse may be able to help here. I am getting some idea of what she does, and I think she can triage many problems over the phone or through an office visit. I think we will schedule her in on Monday afternoons and Tuesday mornings. She can see patients Monday, and shedule a follow up for those needing to see me urgently (which may not be a majority) on the following day. Having worked in Emerg, she is very comfortable triaging patients who require emergent treatment. She cannot prescribe; if she thinks a prescription is needed (example, positive quick strep), we can collect the pharmacy's phone number and I will authorize the script when I return from my course in the late afternoon. My practice partner is present in the office on Mondays, but I don't want to burden him with this, as he has not joined the FHT and therefore would not benefit from having a nurse; however, he is still there for emergencies.

There are hotspots at the university, and I will also log-on Mondays at lunchtime. While logistically challenging, I think this will work, and is a good opportunity to try interprofessional care in an EMR primary care environment, and to see what roles the practice nurse can take.

My Master's thesis is on the Effect of EMRs on Preventive Services with Pay for Performance Incentives. I recently received some funding for this; I will study two cohorts, one using EMRs and the other one on paper records, to see whether the introduction of EMRs had an additional effect beyond P4P.

Michelle

of Time and EMRs

After almost a year and a half of using an EMR, I think it saves me time. There is no question that it saves a lot of administrative time for my staff: there is no pulling of charts, things don’t get misfiled, and accessing data is a lot faster when patients call for results. That is partially counter-balanced by the need to scan and file non-electronic data, but still accounts for net time-savings.

However, saving physician time is less obvious; I think the EMR can help to save time, but you have to organize yourself to do this. I was away for two weeks, with essentially no Internet access. When I returned, there were 52 labs, 26 Diagnostic Imaging reports, and 58 correspondence reports waiting for me. There were also 10 staff messages. I had budgeted time on the day before I came back to go through everything; it took about four hours to review all the reports, and to send appropriate messages for my staff. The time savings here happened because I was able to review the data by logging in from home instead of having to go to the office. Prior to EMR, I sometimes tried to do this while booking a full complement of patients on my first day back, which was inevitably a disaster.

I do not routinely finish recording patient encounters during or right after I see patients. Much of the numerical data (vital signs) is now entered by my staff before I see the patient. Some of the data, such as a note that a patient is in for a routine diabetic visit or a routine BP visit, is quickly entered using a drop down list as I start the encounter; the reason for that is that it takes only two clicks and does not interfere with the interview. I usually will not load a template, such as an Upper Respirator Infection, when I see the patient, because I don’t want to fill in this data instead of attending to my patient's needs; instead, I’ll use free text to write “URI x 2 days”. The free text reminds me to load and fill the template later. If there are significant abnormal findings, I’ll note those in free text. The templates are especially useful for noting normal findings. I’m not sure I save time; however, my records are more complete.

When I am finished seeing a patient, I’ll often go on to the next patient instead of completing the encounter. I don’t like to make my patients wait, so the visit takes precedence over record completion; I note the abnormal/significant results during or right after the encounter, and the rest waits. The alternative is booking fewer patients so I can finish recording encounters.

Because of this, I have routinely have uncompleted visits at the end of the day. I allot one hour to complete my records, return phone calls, review and file reports, and finish insurance or other forms. The difference with EMR is that I can leave for home if I’m tired and not finished by then, and I don’t lug charts home. I find that it is not as painful to finish completing charts after I have supper with my family. Prior to EMR, I had some charts left for completion for a couple of days (which I know is less than ideal); this no longer occurs. It is unusual for me to have a practice summary showing more than one or two tasks undone at the end of the day; most often, there are none; everything has been done.

The difference here with EMR is the ability to complete tasks more quickly, and to have fewer pending reports. My patients have commented on how fast we get forms back to them.

Electronic lab reports seem to come in overnight, mid-morning and mid afternoon. I’ll review them before I start my office, so that I can send a message to my staff if needed. I’ll review them again at lunch, and before I leave the office in the afternoon. Non-electronic reports get scanned in the afternoon, so I’ll review those at the end of the day. If it is a bit quieter, I’ll do that between patients. Time savings for me stem from the fact that lab results go automatically into flow sheets (no duplication), and from having the ability to look at trends easily. Actually reviewing reports takes the same amount of time; there are no EMR savings there.

Inter-office messaging is much more efficient. For non-urgent message, my staff writes an e-note which is automatically attached to the patient’s chart. A little “M” appears at the bottom of my screen to let me know I have pending messages. I check those periodically, and will often send a note back for my staff to call the patient. We also have pop-up messaging for instant communication, and my secretary can always knock on the exam room door if needed. This has led to quicker turn-around to return messages, and fewer phone calls in the evening for me, as the majority of messages can now be handled by my staff. In order to save time here, you and your staff have to use e-messaging consistently, and you have to work with and trust your staff to return messages appropriately.

I think the conclusion is that we have to work with our EMRs and figure out where they will save us time; this won’t happen by itself. One of the best ways to do this is to find out what our colleagues are doing; I am starting to see some forums for exchanging ideas, such as the new EMR Advisor on our provincial website, OntarioMD.

I can see that if I didn't work on my office procedures when the EMR came in, I was just in for endless frustration. Investing time up front to figure out how to do things better and faster with EMR is definitely worthwhile.

Michelle

Scanning

Scanning continues to be an issue in EMR offices. Electronic lab results have eliminated a great deal of scanning, but DI, consult notes, and various other non-electronic data from the outside (such as forms that patients bring in to be filled) still need to be integrated into the EMR.

In my office, we keep no paper data for patients; as a result, there are 10 to 15 things that need to be scanned in daily. Here is my scanning process:

I have stacked in-boxes beside my scanner. When something comes in, it gets put into one of three boxes: correspondence, DI or lab. Mail comes in the morning. My scanning tech then scans paper from each box to a folder on the PC's desktop called "files to upload"; everything is scanned into pdf format (that gives the clearest picture). She'll do one in-box at a time, and name the file using the patient's last name: example, smith.pdf. When all the in-box has been scanned to the folder, she'll upload all the files to the EMR, and then attach each one to the proper patient. I order things via the EMR, so if there is a consult/DI request pending, that gets matched to the file that was uploaded; the consult/DI then gets taken off my outstanding list (that's how I know a letter was received).

Once an in-box is uploaded and filed, the tech deletes all the files from the folder on the PC desktop. The physical paper gets moved to the lowest in-box, which we call "pending shred". All uploaded files now appear in my Practice summary page as "unfiled", and awaiting my review. At the end of the day, if I'm happy, I take the paper and put it in the "to shred" outbox.

If a file was attached to the wrong patient, I can see that when I load the file; I can take the physical paper from the "pending shred", and put it to re-scan. Alternatively, I can save the file to my desktop, and reattach to the correct patient; I can also print the file, and put it back in the in-box. There is a high level of redundancy to avoid misfiling. We can probably get rid of the "pending shred" box.

The scanning tech will add extra information when attaching the file to each area. For example, there are drop down lists in the Lab area, indicating whether this is an ECG, a histopath report, etc. She can also put in extra comments, such as "insurance form". When there is a "match" with a pending request, the specialist's name or the name of the DI facility automatically appears in the information area. It is a good idea to work with your scanning tech to make sure that the scan is done correctly, and that extra information that is helpful to you is added; things that are done at the front save you time.

We scan everything to pdf; we tried different file formats (jpg, tiff), and pdf was by far the best. I thought about whether to scan to OCR (optical character recognition) so that text was recognized from the outset, and decided against this. The reason for that was that I needed an exact copy of the form, since the original is shredded; OCR is not 100% accurate. If I need to copy part of a note to put into comments (such as the last paragraph in a consult letter), I will use OCR on my tablet. This leaves the original form unchanged. I bought Adobe Pro; I click Document, OCR. The same thing can be done using MS Document Imaging, which comes with MS Office. To use Imaging, load the document, then Print to MS Document Imaging. Use OCR (the little eye) on the resulting file, then copy and paste to comments.

Comments will give you a very quick overview of everything when you load an area in the chart.

Here is an example of a DI area:

Signed Off DI Reports

Date Collected Date Signed Off DI Facility

Dec 30, 2006 Jan 4, 2007 North York Diagno
comments : XR left ankle normal

May 15, 2006 May 18, 2006 Unknown
comments : XR right knee There is slight prominence of the tibia1 spines and there are osteophytes on the patella. The changes are in keeping with early osteoarthritis.


I know that all this seems like a complicated process, but it works, and now it is not even time consuming. It just takes some time to get used to, and to make sure that it goes smoothly. Working with your staff and your scanning tech really helps.

I think it may be helpful for a regulatory college like our College of Physicians and Surgeons to have a look at scanning. We need some ground rules on whether it is OK or not to OCR from the outset, or whether it is preferable to save an exact copy of the incoming material. Perhaps even some rules about acceptable file formats. There seems to be a lot of confusion about the right thing to do, and we need to have some guidance here.

Michelle

Group IT maintenance

Our IT person will be starting our group computer maintenance program this month. This means updating the anti-virus protection if needed, performing manual and utility-based cleaning of the registry, services, files and folders etc (that means making sure all those things work properly), enabling the proper security services, performing internal system checks for overheating and cleanliness (CPU, Hard drive, fans), and cleaning if needed (the insides of computers get dusty and need to be vacuumed sometimes).

He will come to each office to do that. I think it is much better to have a professional come by periodically, rather than leave it as ad hoc for each practice. We decided to pay for this out of group funds. As well, he will be available for each of us as needed (we have needed him several times already), and we pay for that individually.

Our group administrator has now done house calls for almost all the practices, leading to immediate results: scanning started, use of EMR for encounters, improvements in scheduling functions. You need to have someone go to each office to see what the issues are, and to fix them. Many of the issues do not involve IT, but rather changes in work flow processes.

The pharmacist has now scheduled more of my patients; she has seen some off site (with the data entered straight into the EMR), and some at my office. We have a joint appointment for a challenging patient later this month.

We have progress on the Family Health Team's Big Office, with several physicians indicating an interest in moving there; at least two FHNs will move in as a group. It looks increasingly likely that I will move as well. I have informed my partner, and will keep him up to date on the progress of negotiations; I have told my staff as well.

This will give me a chance to think about reconfiguring my office for the EMR. My current exam rooms are 10 ft x 8 ft, and I see no reason to change that; it works. The only difference in going from paper to EMR was that I put in a $50 small stand where the printer sits. There is no paper clutter on the desk, and I don't have all the reqs that used to take up space.

The big difference will be in the front office; that is where the majority of the paper metastasizes. The filing cabinets are there, and much of the paper shuffling happens there. There is now a lot less stuff sitting on the desk at the front; most of that is from my partner's practice. I also need less waiting room area, since patients wait less (flow is better). I don't really need to allocate any space to store handouts (pretty much all the useful ones are available on-line or scanned in); I think I will reduce the amount of space for samples, since I use those less. There will need to be 1 small area to store paper reqs in case of a black-out, that can probably be shared between several offices.

My current front office and waiting room is 16 x 20 ft (320 sq ft); my small lab is 9 x 9 (81 sq ft), for the autoclave and vitals area; each of two exam rooms are 80 sq feet; the consult room is 10 x 9 (90 sq feet). If I practice in a 2 physician "pod", we will need 580 sq feet for the lab, 4 exam rooms and 2 consult rooms. No space needed for chart storage; no front desk space for files: 250 sq feet for front/reception. Without corridor space, that is 830 sq feet. I will also need some room for closets etc. I estimate we could do with 1,000 to 1,100 sq feet for two physicians, with ample space left over. I have 1450 now.

Michelle