Friday, January 26, 2007

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 .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 %


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.



Anonymous said...

I was wondering about your thoughts on the benefits / cons of providing your e-mail address to your patients. Specifically what things do you respond to patients about? I would be concerned that patients would send e-mails to book appointments or substitute an office visit for e-mail health advice.

I also wonder what your payments to your EMR company cover. Do they include the cost of installation of hardware, 24/7 support over the phone, installing new terminals, etc.?


Michelle Greiver said...

Emails have not been about booking appointments and the like. People know that they are getting my personal email, so it is treated with consideration. Sometimes it is jut a simple question (I am 40, should I get the HPV vaccine?). Sometimes it is feedback ("I wanted to let you know that your diagnosis of ‘patellofemoral pain’ for my knee was right on – I haven’t had problems since I added to my daily routine the exercises on that print-out you gave me!"). Sometimes it is about a symptom patients are worrying about, and are not sure whether to come in: these can substitute for a visit. I am capitated, so the substitution does not penalize me financially; I think a reasonable approach under FFS is to charge this as an uninsured service.

Our payment to the EMR company include the software, hardware installation, the EMR classes, someone on site for the first half day, 24/7 support. We bought the hardware separately, although we worked with them on what to buy. The fee included some management: they arranged for things like networking; we paid for network drops and the wireless routers. The fee does not include installing new terminals.