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:
|Asthma flowsheet||Flow sheet for management of asthma|
|INR||Flowsheet for INR|
|Weight loss, BP|
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.