Paperless!

On Monday, we scanned and shredded the very last paper file in my practice. My secretary made one last DVD back-up, and that's it. We filled 20 gigabytes of hard drive; I now see external hard drives with 500 gigs, so storage is not an issue for any practice. Next week, I am taking my staff out to celebrate.

I found a buyer for all my filing cabinets, and they are gone as of next Monday.

It is interesting for me to look back at this diary; a year ago at this time, we were just about to switch over to the new system for billing and scheduling.

My husband went to see a specialist a few days ago. He came home and told me that there was a wall of paper files behind the secretary; the specialist wrote everything by hand, and also gave him a prescription scribbled on a little piece of paper. When he went back to the front to make an appointment, the secretary was on the phone with a patient, and was flipping back and forth in a paper book to try to find where the appointment was (which took a while).

While this is the current "normal" in health care, and is not too far removed from my practice of only a year ago, it does not have to be thus. We now have the tools to do better.

I had a couple of computer experts from a company called DM Link in the office today. This is something new that SSHA (the Ontario Government agency charged with connecting the health care system) has set up. I think one of the issues in small practices is that we are not IT experts, and can't configure or maintain these systems by ourselves. The EMR companies are mainly concerned with software, not hardware. The computer guys went around and made sure that all my computers had anti-virus working properly and that Windows updates were up to date (they said that this was a problem in a lot of offices). They also did an inventory and put labels on my routers so that I would know what things are. They wrote down my system configuration, and will send me a hard copy so I know what I have and how it works. They had a look at my routers, and made sure that the UPS device was properly set up so that power would not be interrupted in the event of an outage. I had a couple of questions, and they answered those as well; they even set up my printers to work faster.

This type of housecall is very helpful. Having some professional help and review from people who know what they are doing, and have a checklist to make sure everything works will likely save a lot of grief down the road. The whole thing took about two hours. SSHA has come in for a lot of (deserved) criticism in the recent past; however, this undertaking looks like the right approach.

Michelle

Working with your EMR company

After 10 months, I have a fairly good idea of how to work with the EMR company. My most common contact with the helpdesk is by email; if I can't get a good answer, I contact the helpdesk manager. Phone calls to helpdesk are rare, because I find this inefficient; it is more useful for things that are urgent or that are not getting resolved by email.

Some things are more of a "wish list", and I know that I may or may not get them. They get sent to the development team. As an example, I use "profiles", with the assessment ICD, medication and follow up preprogrammed (cystitis-595, Septra DS bid x 3 days, push fluids); I would like to have a bill pre-programmed as well. I think if there are lots of physicians asking for the same thing, it is more likely to happen. The on-line group that I belong to is monitored (we sometimes have a reply from someone at the company), so ideas from there likely percolate to development. We are getting an upgrade at the end of the month, so I'll find out then about the extra things.

My husband works in the coatings industry; they use a very large company for their corporate database, SAP. He tells me that despite millions spent on implementation, there are still problems, and upgrades are very expensive. His company also bought a colour computer to help with color matches; it took a year to get that working properly, and several sister companies never did get theirs working.

It is still not clear to me what the critical elements are for a successful transition. In the Compete study in Hamilton, 25% of physicians abandoned the EMR at the end of 3 years, and there were still 22 chart pulls per day after 18 months. I think there are also transition problems in South Western Ontario, at the DELPHI project. These projects provided a lot of support and help. It is unrealistic to expect 100% adoption (or to have everything working within half an hour); it looks like the major issue is the management of all the changes, and surviving the turbulence. There are other physicians like me who have managed the change, I wonder if we could help our colleagues. Some of the information will be company-specific, but some can be translated across all EMRs.

The EMR provided an unexpected finding for me this week. When managing depression, I have an alert in the chart for my staff to print a PHQ-9 questionnaire before I see the patient. Often, patients don't return for follow-up. A couple of days ago, I saw a lady for a sore shoulder, and she handed me a PHQ. She was seen for depression 6 months ago, but did not return for follow-up visits and did not get treated. Her alert remained in the chart, and so a questionnaire was printed for her when she came in. Her PHQ is now completely normal--she got a better job and fired the bad boyfriend. Now I wonder what the natural history of depression in primary care is; perhaps I'll get to find out a bit about what it is in my practice.

I am finding some creative uses for the EMR. I have put information on the home BP machine that I recommend in my list of prescription favourites, so now it prints as a prescription. Maybe I should do an exercise prescription next.

I guess with EMR,
You can't always get what you want,
But if you try sometimes you just might find
You get what you need

Michelle

The non-EMR physician in a wired office

My practice partner seems to be happier. There was a lot of disruption during the EMR implementation, almost none of which benefited him personally. I think he tolerated this because he knew it was important to me. I was pretty careful with the financial aspect; I showed him everything, we agreed on the extra amount that I would put in for common computer expenses (such as networking), and if I had a bill that was clearly EMR related, I paid for it myself. The disruption is now over, and the office is running smoothly again (although with a split personality).

He still does not want to go EMR. He does not type fast, and is not all that comfortable with computing. Even with an office that is now fully configured for EMR, he just can't see making that step; I think the change is just too big. It is sometimes difficult for him to see my patients when I'm away, because he can't easily navigate an electronic chart. My staff helps, by printing CPPs for him. He knows where CPPs are, and knows how to look at encounters. I try to help by managing my lab and reports remotely when possible.

The resident in my practice spends half her time with him, and half with me, so that some of her patients are on paper, and some on EMR. We put alerts in the demographics so that the secretary knows whether to pull a paper chart for her. It is creaky, but it works for now.

I wonder what will happen as more parts of the system and more physicians go electronic. There may be a time when labs no longer issue paper reports, perhaps as a cost saving measure. At a family medicine meeting yesterday, almost half of the physicians put up their hands when asked if they were looking to computerize soon. My hospital will be going to Computerized Physician Order Entry this year. Their PACS Diagnostic Imaging system is working well--it is probably not a very big step to integrate the report with the EMR. Plans to link our community-based EMR with the hospital system are proceeding apace. I think we're just about to move past the early adopter phase.

It really is a different way of working. Here I am, writing this from home, with my email and my practice both loaded up on my computer. A specialist just called me a few minutes ago to discuss a difficult case; I had all the data in front of me--and I'm getting used to practicing this way.

And, of course, those of us who have successfully transitioned become IT enthusiasts. I wonder if my partner is becoming tired of hearing about EMR this and EMR that; living with a true believer is not a peaceful thing.

Michelle

Life after the transition

I sometimes look at one of my scanned non-electronic old charts, and I have trouble believing that I practiced that way for 20 years. Even though I tried to be organized, the record is still scattered (all the diagnostic imaging, consult letters, and lab reports are mixed together). I used flow sheets for diabetes and INR management, but nothing else. Trying to follow on-going vitals like BP or weight meant laboriously looking through the clinical record. I had to calculate every BMI myself with a PDA. I sometimes forgot to record medications, especially skin creams. Doing audits for quality of care was possible, but time-consuming.

Now, things work. Because I have e-messaging in the EMR, and pop-up messaging for instant communication, I seldom need to come to the front, and can just alternate between my two exam rooms. I often return calls between seeing patients (because I have more time) instead of having the calls pile up at the end of the day. Sometimes I do not need to phone personally; I just send an e-message to my secretary, and she handles the return call. I sometimes go to the front just because I like talking to my staff.

I have been told that my transition was faster than that of most of my colleagues. Many things went right in my practice. My staff helped me; they often came up with suggestions, and were willing to try new things and to help me fix things that didn’t go right at fist. I was very committed to doing this, and was willing to put in time and money. I knew I would have initial problems (although I did not know what they would be), and was determined to solve as many things as I could, as quickly as I could. I knew just enough about IT, and could learn enough as I went along to be able to fix most things fairly quickly. The fact that my partner did not go along was disconcerting at first, but may have helped me: I did not have to spend much time helping him, and could concentrate on my own practice. Perhaps a definite “no” at the beginning is better than a half-hearted “yes”, although this may not always be possible with government funding (they fund entire groups, which must all agree to go EMR with the same software, rather than individual physicians).

One of the most helpful things was scanning and shredding the old charts. This accelerated the transition, as going back was no longer possible (there were no charts), and it made the use of EMR the default in practice. This is not for the faint of heart; we began scanning 3 months after EMR start-up. It does immediately reduce chart pulls, and demonstrates the efficiency of IT on a daily basis. The cost was minimal; hiring a summer student to do this is worth it.

I keep being asked if I am happy with my software, because many of my colleagues are now looking to computerize. This is a loaded question: the current market is crowded and competitive; what I answer may influence some people. It is impossible for me to judge other EMR applications because I don’t use them, and thus I can’t compare them to what I have. What I will say is that I use the software I have daily, for almost everything I do in practice, and that I like it. I will not say that it is better or worse than other applications.

One of the things that I like is that it does coding for diagnoses well. This was not a selling point for any EMR; I don’t remember it even being mentioned at the beginning. When I read Dr Nicola Shaw’s book, Computerization in Canadian Primary Care, one of her key points (repeated several times) was “learn to code”; I can’t say I paid any attention at the time.

When I enter a diagnosis at the end of an encounter, putting in the code directly in the code field (example, 401) is faster than entering most words, like “hypertension”. Sometimes I don’t remember the code, and I have to use the drop-down list to help me choose one. For example, for cancers I start to type “neop”, and all the cancer names drop down, with their ICD number in front: I pick the relevant one. ICD organizes the cancers by body systems, so all the digestive cancers are numbered consecutively from mouth to anus. After a while, you know where things are.

Sometimes I can’t find what I’m looking for, then I have to go look at the paper list of ICD codes I have from the Ontario Medical Association. I have a copy on my desk, and a scanned copy in my computer. This is the slowest method. After a while, I learned some of the common things, like 307 for a tension headache, or that ADHD is called “Hyperkinetic disorder” in the ICD drop-down.

A benefit of coding is that the ICD number flows directly into my bill (code once, use many times) and I can look for things in my EMR; every previous MI is coded as 410. As the government moves towards more pay-for-performance, we’ll need to identify and keep registers of patients with certain conditions. Using free text for diagnoses will make that difficult; free text for on-going medical conditions in the CPP is especially bad.

In the near future, we’ll start using primary care EMR data for health care system planning (because the data will be there, in usable, electronic form). We need to know how many people with diabetes there are, how many people with congestive heart failure etc, and what is happening with them. The free text diagnoses will not be good for that; it is much easier to look for all 401 than for all HT, HTN, hypertension, high BP, incr BP etc etc. Free text diagnoses are a relic of paper records; all EMRs should make diagnostic coding the default, and make it as easy to do as possible. If you are thinking of buying a system, ask your vendor to demonstrate this; it will not happen unless we ask for it.

Michelle