Communicating electronically

In my practice, we now frequently talk electronically. One advantage is that messages are archived in the patient's chart. For example:

Oct 18, 2006

to: staff

Greiver, Michelle

Call pt re results

A1C above goal (8.5%, should be 7% or less). blood sugar not controlled. pls make appointment Completion Notes:'pt informed will call for app'

This is very efficient. Patients are now routinely informed of important follow-up results that are normal, which didn't happen in the past. Several patients have said that they really appreciated the information.

I recently installed a small pop-up program for instant messaging inside the office, Realpopup http://www.download .com/RealPopup/ 3000-2085_ 4-10367875. html. This was suggested by a colleague in my on-line users group, Dr Paul Hasson; the program is small and free. I used to give patients a note to present at the front if they needed follow-up, example "DM, 3 months". Now I just send a pop-up to the front, and the note never gets lost or forgotten. Yesterday, my secretary sent me a pop-up that there was a pharmacy on the phone, line 1, so I just went and got it. This is good for small, instant messages that don't need to be archived to the EMR.

Email with patients is becoming a bit more frequent; this month, there were 8 messages. I recently wrote an article about emailing patients; in the EMR, recording the email involves cutting and pasting it into an encounter (easier and more complete than recording a phone call).

While email is not secure, this does not seem to be a problem for most patients. One of my patients lives in the Far East, and needed his chart (he has complex medical problems). The chart had been scanned into pdf. I told him that I could mail it, or email it to him if he preferred, provided he was aware of the low security and gave me permission. We had communicated previously by email, and identification was not an issue here. He asked me to email it, and we sent a 200 page file electronically that day.

Another patient needed a back to work form emailed; I had to print the note for my signature (I don't have an uploaded signature), we scanned and emailed.

I have secure email via SSHA's ONEmail system; however, it periodically needs a new password, I don't look at it very often, and it won't forward a message to let me know that there is mail for me. I don't know anyone who uses it, because it is not very useful right now. It will probably be good for secure messaging between health care providers, but not for patients since the information goes outside of the system.

I probably should think about setting up an "office" email address for general enquiries; perhaps this should be through SSHA.

I connected the second PC at the front to the fax line (I used a line splitter). Now we can fax from both PCs. If there is a simple fax (a single pdf file, or a lab result from the EMR), my staff can fax straight from the computer, by using the "print, fax" command. No paper is printed.

I found out that I can copy and paste all the decision tools from MedCalc on the EMR. MedCalc is free on the OntarioMD site. I used the PDA version very often, but with this one, you do the calculation on-line, and the result is transferred to text or xml format, to copy into the EMR clinical record. Here is an example of what an atrial fib risk calculation looks like on the clinical notes:


"Decision Tool: Atrial Fibrillation Five Year Risk of Stroke or Death

Age: 60 (4 points)
Systolic Blood Pressure: 120-139 (1 point)
0 points for: Diabetes: No
0 points for: Smoker: No
6 points for: Prior MI or CHF: Yes
0 points for: Significant murmur: No
0 points for: LVH on EKG: No

Total Score = 11 points
Result Interpretation: 11 points : 20 %

References:

Wang TJ, Massaro JM, Levy D, et. al., A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study, JAMA, 2003 Aug 27;290(8):1049-56, PubMed ID number: 12941677"


It looks like it is possible to integrate a great variety of clinical prediction rules fairly quickly into EMR at the point of care. I think I'll try that in practice.

Michelle

Having fun with the EMR

Now that the transition is essentially over, the EMR is not just efficient, it is also fun. Everything is always done; everything is tracked; there is little to no loose paper flying around

My secretary was commenting on how efficient we have become. There was a call from a specialist's office, as they needed copies of some Diagnostic Imaging reports for one of my patients, from October. It took her under 30 seconds to load the chart, locate the reports, and fax them over, all without leaving her desk. Because of the enormous gains in efficiency, they have time to do more call backs to patients about test results. As a result, my staff are becoming much more knowlegeable about tests; I no longer put in normal ranges for fasting sugar when I send an e-note to call a patient, because they know this. They are becoming more like clinical assistants.

I am starting to use a lot of flowsheets; I have found that this is the best way to correlate several things (BP and medication changes; Asthma exacerbations; CHF: weight, eGFR, medications). This is a list of my current flowsheets:

Active Flowsheets:

	Flowsheet Name	Description
	Asthma flowsheet	Flow sheet for management of asthma
	BP
	CHF flowsheet
	COPD
	Depression flowsheet
	diabetic flow
	INR	Flowsheet for INR
	Osteoporosis
	TSH
	Weight loss, BP

I have figured out how to make results from several different labs mesh together, so that they go into one common flowsheet.

I have also made a couple of "history builders"; these are a type of template where you click on a link, and a series of phrases comes up, which you then save to the record. This is the builder called "normal neurological exam":

"Pupils are equal and reactive to light and accomodation. Fundi are grossly normal, with no papilledema. Cranial nerves II-XII are intact. Neck is supple. Motor examination reveals normal gait and normal strength bilaterally. Reflexes are equal bilaterally and within normal limits. Sensory examination is normal with respect to touch."

If there is something abnormal, you can always change it before saving. It saves a lot of typing. I have a two part Builder for BCP counseling; the first link is if I did STI counseling, and the second is for discussion of BCP benefits and side effects.

I probably should do one to document discussion of Steroid side effects. This is good for anything where there is standard counseling.

I had a look at my activity log; I've reproduced a bit of it below, without patient identification. This gives me a pretty good idea of what I am doing during my day.

	9:47 AM	Greiver, Michelle			Edit Encounter
	9:51 AM	Greiver, Michelle			Add Medications
	9:52 AM	Greiver, Michelle			Add Lab Requisition
	9:54 AM	Greiver, Michelle			Add Clinical Notes Subjective/Objective
	9:54 AM	Greiver, Michelle			Add Assessment
	9:54 AM	Greiver, Michelle			Edit Plan Notes
	9:54 AM	Greiver, Michelle			Sign off Encounter

I have my email loaded, which can be distracting at times. However, it does make sending links like the BP Action Plan from the Heart and Stroke Foundation, or the excellent self-care depression booklet very easy to do. I have the links inside the EMR, load them up, ask for permission from my patient, and then copy/paste the URL into an email to my patients. This is a really great way to extend the education done at the office; the EMR tracks the fact that a link was sent.

Some abnormal blood results came in for one of my resident's patient. I sent her an email to please log on to the EMR and have a look at the results. She had a look, and emailed me a very appropriate management plan. I am still responsible for the patient's care, and will manage any urgent reports, but this gives my resident the ability to look after her own patients even if she is only here one half day a week. Continuity of care in residency is now a reality. My group is talking about adding a nurse practitioner, since we are becoming a Family Health Team. Team based care can involve the same processes me and my resident are now using.

I know that the transition to EMR is challenging, having been there. However, now that I am paperless, I have found that the EMR is making my practice more fun, more efficient, and definitely more interesting. And I still expect more.

Michelle

Managing my hardware

I am starting to own a lot of hardware and software.

EMR is so important to my local residency program that preceptors are offered a subsidy if they buy a laptop for the use of medical students/residents. I just bought an extra Tablet. I am very happy with my Tablet, and I think it is a good idea for my resident to have access to one; it will likely be a very common form of medical data entry.

The new Tablet arrived recently. I then realised that I didn't know how to access my wireless network--it is not a simple home network, there are a lot of security features. That meant an email to the EMR company. I also had to put my printers on the Tablet (they are accessed wirelessly via IP ports), and I had to configure access to the server. This is a lot of work, so I ended up sending the Tablet to the helpdesk. They did tell me how to access my wireless, and I will keep this information.

One of my FHN colleagues has a folder with all the passwords, and a list of all the printers and computers in her office. This is a good idea, I think I will do the same. I think it is still better to have someone else do the work of setting up a new computer, but it is wise to keep all that information safe someplace. I probably know a bit too much about networking for my own good (that is, just enough to get into trouble); I know how to fix an IP port for a printer, because I've had printers change their IP address.

I think many offices will end up with at least one person very familiar with common IT problems, mostly through experience, so many things will be fixed quickly on site once the transition is over. I have an office manual, which is updated periodically; I have started to put EMR information in there, and I will add information on common problems. I think that, as we move towards a Family Health Team, or group practice, it would be good to assign one staff person to be a resource for the entire group; maybe we should give him or her a blackberry.

I have started taking digital photos to put in the EMR; I had an extra camera at home, which I brought to the office. The Tablet has a SD card slot, so I can just remove the memory chip from the camera and put it straight into the computer. I then attach the picture to the patient file.

Because I carry the Tablet with me all the time, it is becoming highly customized for my needs. I have found that I access some extra information within the EMR (example: templates), some on the internet (example: CDC travel advice), and some locally on my Tablet (example: "cheat notes" for common conditions). I have stopped using my PDA at the office, since I can access everything on the Internet; I use the on-line version of ePocrates. The PDA is backed up to the Tablet, so I have access to my phonebook and calendar on my desktop. I needed a Gestational calculator, so I downloaded one from Medical Algorithms and made a couple of changes, such as a field for "today's date", and changing from a standard Excel file to a template, so it can be reused. The Gestational template is at http://ca.briefcase.yahoo.com/mgreiver@rogers.com, click on Shared, and you will see the file to download. I have it in a folder on my desktop, and just save data for each pregnant patient as an Excel file in the folder; because of the "Today" field, the gestational age is automatically calculated when the patient is seen. I print the excel if referring a patient for prenatal care.

Finally, I have been told that some of my templates will now be shared with my colleagues. Once they are shared, I can no longer modify them. The templates include the age-based preventive health tables; this was the tables on paper records, and this is what they look like on EMR (click on preventive health in the shared folder; it is a big file because of all the screenshots, and will take about 20 secs to download). The last screenshot shows what the template looks like when saved to the patient record.

I bought a temperature logger for my fridge. My filing cabinets are now advertised on Craigslist.

Michelle

The cost of EMR

My cost to start the EMR was approximately $30,000, half for software and half for hardware. This is comparable to buying a new car (not a SUV), but does not depreciate as quickly. There are additional costs to the EMR, such as my upgraded VPN router (which cost $1,000 for parts and labour); as well, I have a backup internet line, at $500 per year. I have not had significant additional hardware costs beyond the router; however, I do expect to put in additional things, such as an automatic temperature logger for my fridge vaccine (about $100 for sensor and kit). The cost for scanning and shredding my charts was $300 for hardware (DVD reader, external hard drive), and about $1200 in labour costs for a student. My staff continued to scan and shred after the summer, during quieter office times, and I have a student coming in the evening to do this. Total labour costs to completely get rid of old paper charts are in the $1500 to $2000 range.

Once our 3 year EMR contract runs out, I expect yearly support and maintenance costs to be in the order of $3,000 per year.

It is difficult for me to say whether this makes business sense without government subsidies. There is a cost to continuing to carry paper records: The approximately $4500 in yearly rental costs taken up by filing cabinets and papers; the cost of the cabinets themselves (my 6 drawer end-file cabinets cost $1,054 each, new); the time for staff to manage the paper; the cost of inefficiency (lost files etc).

As well, there is the cost of managing preventive services on paper. The maximum incentive payment for reaching targets for five preventive services in Ontario is $11,000 per year. Doing this on paper is very difficult; either the physician or their staff has to do the audits, or it has to be contracted out to a private company for a fee. I understand that there is a company that does this; I have heard that the cost per physician is anywhere from $800 to $3,000 per year. Now that I have finished doing my CPPs, the EMR keeps track of preventive services for me. It generates a list of patients overdue, to print letters; I expect to look at the list about once a month--I may now assign this task to one of my staff. The letters are personalized and are very easy to print; a copy is automatically kept in the patient's record. I expect to see more pay-for-performance incentives in the future.

Private bills are much easier to manage with EMR. I print things like notes for massage therapy or sick notes at the front printer, where the patient collects and pays for the note at the same time. We have a PinPad at the front, so people can pay by credit or debit card. As well, the notes are all templated, and are much easier to generate than with paper records. A copy of the note is always and automatically generated in the electronic record; there is no longer any need to photocopy for the file.

Many of my colleagues are now contracting out block billing and private bills to outside companies. I contracted out block billing in the past, at an annual cost of approximately $2500. I have to figure out how to do the block billing, but the private bills are certainly done more easily and efficiently in the EMR.

Having said all that, I strongly believe that government subsidies are needed to kickstart the EMR process. In Ontario, there was a recent lottery, where physicians in FHGs (Family Health Groups, receiving fee-for-service payment) could apply to receive the $28,600 subsidy. They allocated $15 million to this initiative; 2100 physicians out of the 4,000 FHG physicians applied. If a physician gets funded and already has an EMR (provided it is from one of the approved companies), the funding is still given, provided the EMR continues.

There is now lots of physician interest. The initial cost continues to be a barrier, and governments can certainly do a lot to address this. However, I think a reasonable business case can now be made for EMR, if the ongoing cost of paper is taken into account. Additionally, it appears that if there is funding down the line, this funding will be retroactive.

Michelle