Sunday, February 04, 2007

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.


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