Saturday, March 31, 2007

One year into implementation: different levels of EMR adoption

April 3rd will mark a year since EMR start-up. I can no longer even imagine practicing with paper-based records.

My FHN group met last week; we took stock of how we are doing. Two of the nine of us are now using the EMR full-time. Two are not using it at all, and really never started, other than for billing/scheduling. The reasons for that include front staff not agreeing to use EMR; not being able to type; not really being ready to change and so not putting in the needed time and effort. We are not making our colleagues feel guilty about this; they will decide to change (or not) at their own pace.

Eight of the nine of us are now receiving lab reports electronically; one never notified the labs and therefore never started. We are still receiving duplicated paper copies of the labs; this is just shredded at my office, I don't even look at it anymore. We have to notify the labs as a group when we are ready to stop the paper reports, and so it looks like this won't happen for a while.

Of the seven EMR users, all are entering CPPs--most of those are now done. Five of us are documenting at least some encounters in the EMR, and four are prescribing electronically. I am the only one who has scanned and shredded all my paper charts; one of my colleagues is scanning a couple of relevant reports in, and then taking the paper chart off-site.

What we decided at the meeting was to have the two consistent users available as a resource to our five colleagues who are still transitioning. We offered to help either at our offices, or at their office, for individual booster sessions. One of my FHN colleagues already came to my office for a couple of hours. I think this will help, but the offer may not continue to be taken up unless I push for it; we just tend to get too busy with day to day practice.

It is interesting that we are comfortable with different stages and speeds of adoption. This is fairly easy in my group, since we practice in different locations; failure to adopt EMR in one office has a minimal effect on the other offices. Even one complete non-adoption in a two physician office (as with my own practice partner) does not have to stop EMR implementation. This must be different when several physicians practice in a single location; there will be more push to implement, and more peer-to-peer support, so perhaps more successes at a year, but also more problems if some physicians are not ready to implement.

Someone in my group said that EMRs are like onions, they have layers. We need to explore these layers at our own pace, with help for the inevitable tears. We're slowly getting there.


Saturday, March 24, 2007

Doing a preventive health exam with EMR

Doing an "annual check-up" has changed with the EMR. I have programmed a template, using the preventive health tables, to make the whole thing easier. The template includes a check-box stating that I have reviewed and updated the CPP, the age/gender appropriate Preventive Table, a review of systems, and a physical examination. This makes recording the exam fast and thorough.

When a patient comes in for their complete check up, my secretary measures their height, weight, blood pressure (using the automated BP machine) and waist circumference. She records this in the EMR, and the patient is then shown to one of the exam rooms, and undresses. My secretary puts the room number in the EMR scheduler, which flags the chart and tells me that they are ready to be seen.

Before going in, I load the chart Summary (which shows me if there are any alerts or preventive services due), and then I come in the room. This gives me a chance to remind them of overdue services first. I then load the CPP, and put the Tablet on the exam table beside the patient; the screen is turned so that they can see it. I point things out as we review them together, and make any needed changes. When this is finished, I print the CPP for the patient. The majority of my patients now have a copy of their CPP, and I expect all patients to eventually have this.

Once we are finished with the CPP, I load the encounter. The BMI is automatically calculated, along with a note stating its range (underweight, ideal, overweight, obese); I show this to the patient. Since we started using the automated BP machine last summer, my patients know what their BP is, because my staff tell them. I then load the preventive health template, and put the Tablet aside to do the exam. I will sometimes glance at the template to make sure that I have done everything.

Once this is finished, I print medications, and then give my patient a verbal summary about their health. To emphasize preventive measures, I print a handout with common recommendations; I modified the handout from the Practice-based Small group's module on prevention. I circle things that I would like them to concentrate on, and then give the handout to the patient. A copy of this handout is reproduced below; I keep it in the handout section of the EMR, it is personalized with the patient's information on top, and the patient's record keeps track of the fact that it was printed. I have already remotely put a copy in the EMR of one of my FHN colleagues.

Then, I come out of the room to let my patient get dressed, and load the lab (usually one of my pre-programmed lab reqs, with additional tests as needed), and I send the req to the front printer. The patient comes to the front, and my lab technologist takes them for bloodwork, ECG, etc. If necessary, I also send a pop-up message to my secretary to book a follow up appointment.

This is very efficient and complete. There was a recent research paper which stated that family physicians would have to spend about 7 hours each working day just to get through all the recommended preventive interventions for their patients. With EMR, this is not true. My preventive health exams are booked for a half hour, and it is rare for them to take longer. The preventive health exam is very structured, and exams are very similar; the EMR can be used to guide the visit. It is worthwhile to think about the process of a visit, and to ensure that EMR tools are used to make the visit as effective and efficient for the patient as possible. Having the patient see their own information and share in building their chart, using a templated checklist at the point of care, giving written, relevant feedback, having your staff help you, and having point of care reminders are all easier to do with EMR than on paper. I have described the process in some detail to outline the changes that have happened in my practice, and to show the improvement in care that can result from the use of EMR tools.

Here is the patient Handout:

Thank you for coming in for your Preventive Health Exam; your health is important. Here are some things that you can do to stay well:

General Safety

• Wear a seat belt when you ride in a car or other motor vehicle

• Wear a helmet when you ride on a bicycle, motorcycle, or all-terrain-vehicle (ATV)

• Have a smoke detector on each floor of your home

• Regularly test each smoke detector

• Do not use alcohol or drugs when you are involved in activities such as driving, boating, cycling, or swimming

Please protect your hearing against excessive noise

If you are over 64 years old:

• Make sure that you do not have hazards (such as loose carpets, exposed extension cords, and stairs with no handrails) in your home that could cause you or someone else to fall or be injured

Dental Hygiene

• Brush your teeth with a fluoride toothpaste daily

• Floss your teeth daily

• See a dentist at least every year

Physical Activity & Exercise

Your daily physical activity should add up to at least 30 to 60 minutes (Include each 5- to

10-minute interval of activity or exercise.)

Pre-Conception Care

If you are planning to be, or could get pregnant, take a folic acid supplement

Potential Risk Behaviours

If you are a smoker:

• Would you like to quit?

• Have you ever tried to quit before?

• Are you interested in medication to help you quit?

• Are you interested in a smoking cessation program to help you quit?

• Do you have a “quit date” in mind?

I am always ready to help you quit; please use the tools (booklet, helpline, medication) available from my office

If you are sexually active, please:

• Take precautions to prevent an unplanned pregnancy

• Always use a condom to protect yourself from sexually transmitted infections (STIs)

• Avoid high-risk sexual behaviour


Please eat the right number of calories (enough to maintain a healthy body weight) every day?

Limit your intake of fat and cholesterol

Emphasize grains (such as cereals,whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet

Take enough calcium and vitamin D for a healthy body and bones

Saturday, March 17, 2007


I was away on vacation this week. This is now the third time that I've been away on holidays since starting the EMR. It was also the first time that the week before vacation was manageable; I think the efficiency is really starting to kick in.

I've noticed that the majority of lab results come in by Saturday; I had 12 labs to look at on Saturday, and only a few results came in afterwards. It is good to keep that in mind if planning to log in while away: the bulk of the work is in the first few days. As for previous vacations, I let everyone know if I will be accessing the EMR. What seems to work best is intermittent access: I don't want to be forced to look at results daily while on vacation, but I don't mind having a look every few days. That means that my partner has a quick look at the incoming data, and only takes care of urgent problems (like abnormal INRs).

Here is what I ask my partner to do while I'm away:

  • Cc me on lab reqs so they go in EMR
  • For incoming lab results:
    • If they are normal, put them in the “to shred” box
    • If they are slightly abnormal, put them in the “to shred” box
    • If they need action, please write on them and then ask staff to put them on my desk after the action is taken
  • For incoming letters/faxes, pls put them in the “to scan” box once you’ve seen them
  • CPPs will be printed for you as needed
  • If you need to see scanned old chart, there is a link on your desktop, double click on the file
  • If you need to see a report on the EMR, go to Patient module, reports, then DI/lab etc.
  • Our family medicine resident can see some of my patients while I’m away
Looking at labs/DI/consult notes is much more efficient if you know the patient and the context. Long consult notes can be left unfiled after a quick look, for more extensive review post vacation. Doing this lightens the load for your partners, and may make going away less difficult.

I am still receiving lab results on paper as well as electronically. Once my group decides we're ready to stop the paper, we have to notify the labs; this must be done as a group. For the past several months, I have not been looking at my paper labs, and they go straight into shredding. I'm not sure what I'll do during vacation once the paper labs stop, since my partner won't have those to look at.

I wonder if this would work for some maternity leaves. I know it has sometimes been difficult to get locums for maternity. It may be possible for one locum to look after several practices via remote access; the physician can decide to come in half a day a week after a couple of months, while doing much of the work remotely during baby's nap (if they nap).

My schedule for Monday does not look horrible; I think the week before and after vacation is much easier to manage this way.


Friday, March 09, 2007

Looking at my data

It has now been almost a full year since I started using the EMR. I am starting to get some good cumulative data for individual patients. I am also learning to search for conditions in my whole practice, by using clinical reports.

This ability to search is essentially not available in paper records, and is a major benefit of EMR. Here is what I can search for:

-diagnostic conditions
-family history

I can also search by gender, and by age ranges. These searches can be combined by using boolean terms (and, or, not). The Report feature is fairly user-friendly, once you've worked with it a couple of times. The search query terms can be saved and reused, and I've used my saved searches to see how I am doing over time.

The Report feature is still limited, since I cannot search for lab results (example, give me all patients with cardiovascular disease AND LDL >2.0), or vital signs (all diabetics with BP>130/80). As well, I get a list of patients, but not the number of patients; I got around that by importing the file into excel and manipulating the data.

This brings up an interesting problem: we can save data to local machines (as I just did). The Hospital for Sick Children was recently severely criticised for losing some personal health data: a researcher took a laptop with patient data home, and the laptop was stolen from his car. Security for the EMR is very tight, especially for remotely hosted applications; however, this does not apply to data downloaded to my Tablet. I put passwords on Excel files, but I don't know if that is enough; I'm not sure what we should do for what is going to be an increasingly common issue. There will need to be a balance between data encryption to protect privacy, and the need to access files. Perhaps we should look at a large purchase of data encryption software for all physicians, rather than leave individuals to fund and buy this individually. I'm pretty sure Sickkids does not make each research buy the software themselves.

In a recent editorial in the New England Journal of Medicine (Performance Measurement in Search of a Path, Dr Hayward, March 1 2007), the author noted that "Perhaps our greatest barrier to developing a worthwhile performance-measurement system is our unwillingness to invest in it." He notes that the Department of Veteran's Affairs, a world leader in quality, does detailed reviews of electronic medical records. I think it is now possible to do this with current EMRs; we need to invest in data reporting, and target priority conditions. What you don't measure, you can't improve.

These are recent reports I've run:

Report Name Date Last Modified Modified By
Age 67 and over Jan 25, 2007 Michelle Greiver
Antidepressant prescriptions Jan 16, 2007 Michelle Greiver
ASA cad Jan 16, 2007 Michelle Greiver
asthma Jan 23, 2007 Michelle Greiver
Bipolar Jan 30, 2007 Michelle Greiver
depression, age 21 and over Mar 9, 2007 Michelle Greiver
Diabetes Feb 17, 2007 Michelle Greiver
diabetic on statin Mar 6, 2007 Michelle Greiver
family history of breast cancer Mar 2, 2007 Michelle Greiver
flu shots Mar 6, 2007 Michelle Greiver
Hypertension age 20 and over Mar 9, 2007 Michelle Greiver
kids shots age 15 Mar 6, 2007 Michelle Greiver
Meningitis Immunization, teens Jan 5, 2007 Michelle Greiver
Patients age 12 and over Jan 8, 2007 Michelle Greiver
Patients with CAD Mar 9, 2007 Michelle Greiver
Schizophrenia Nov 30, 2006 Michelle Greiver
Women age 21 to 72 Mar 9, 2007 Michelle Greiver


Friday, March 02, 2007

The Enterprise module: functioning as a group

I am now beginning to explore the enterprise module. This is the area for group functions, and is one of the most powerful features of the EMR.

I think of "enterprise" functions as things that we should be managing as a group, rather than individually, such as
  • quality improvement projects (example, meeting targets in diabetes; protocols that the whole group agrees on)
  • Shared care, such as prenatal care or palliative care
  • Services that one physician is willing to provide for the group (example, IUD insertion)
  • Allied health professionals attached to the whole group rather than to individual physicians
It is very clear that the majority of family physicians in Ontario practice solo, see the ICES Primary Care Atlas, chapter on Characteristics of Primary Care. This will not change much in the next few years, because it is too difficult to break leases, there are staff issues to consider, etc. However, practicing solo no longer means automatic isolation; my group is now linked through our common EMR.

I have started to use this. A couple of my colleagues wanted a copy of my diabetes flow sheets, and I just installed those on their office application. I helped another colleague remotely with the process of doing consultation letters. I figured out how to access the different schedulers. We have started talking about how to do shared prenatal care across the whole group, and about what would be best practices.

The team pharmacist has started logging on remotely to learn about the application; there were a couple of things that I needed to change in her permissions (the pharmacist profile), and that has been done. These permissions are set for the group so they don't need to be replicated.

My filing cabinets are gone; it is amazing how much space I have at my office. If my partner ever decides to go EMR, we will not need a single filing cabinet for charts. I am now trying to decide if the space should go to a third associate, or whether I should use it for some of the new allied health professionals we will be hiring for our Family Health Team. I am leaning towards the latter; there is still so very little inter-professional health care in Canada that there will be much to learn and invent in small family practices. If, for example, a social worker works out of my office some of the time, his or her schedule is always immediately available to the whole group through the single log-in. Any of our group's support staff can book the appointment and see the location without having to call. I think it will also be interesting for me to have lunch-time conversations whith whoever we hire.

This, in my mind, is what lies beyond the EMR transition: EMR ver2 can let us do as a group what we cannot achieve individually.