Sunday, April 22, 2007

Improving quality of care

I spent Friday afternoon with a colleague at the EMR company’s headquarter. We were invited to discuss future directions for the Reporting functions of the EMR. By Reporting, I mean the ability to look at data for an entire practice, or even a group of practices.

There are many things you can produce a report for. It is much better to look for data entered in fields (consistent entry), rather than free text. We can already generate clinical reports for diagnoses, immunizations, medications and family history. We talked about adding lab results, vitals (temperatures, blood pressures, BMIs), as well as social history items such as smoking, alcohol use, marital status, allergies, etc. We also discussed automated reporting, that is, reports generated automatically on a periodic basis (every month, every 3 months).

To me, the ability to look at this data is vital to quality improvement; you can’t improve what you can’t measure. Quality in health care is measured by many things; one of the things that I want to look at is our processes. For example, the large Veteran’s Administration reengineering project in the US used EMRs, chart audits, and disease management programs to improve their quality. They improved many processes, such as preventive services (mammograms, flu shots etc), monitoring for chronic diseases (lab tests for diabetes), meeting evidence-based goals for chronic diseases (140/90 for hypertension etc).

It is not difficult to find evidence-based processes in primary care; I think we will pick select processes and start working on them. The first processes will be those with incentives. Then, processes with strong evidence of reductions in the risk of illness or death; good examples are found in the UK’s list of incentives, and deal with chronic illnesses such as diabetes. As well, we can pick preventive services that do not have incentives, but which are recommended by the US or Canadian Task Forces.

Once we decide which processes we want to improve, we then have to decide what to do about them, and how to do it. There are several ways to improve things, such as point of care alerts, proactive patients notification based on whole practice audits, and Chronic Disease Management programs.

We already have pre-programmed point of care alerts for services that have incentives, as well as self-programmed alerts for overdue services (tetanus shot more than 10 years ago). My Summary page is loaded as a default when the patient comes in; if there is a service overdue, that is the first thing I see. My patients must be getting tired of getting a Fecal Occult Blood kit (bowel cancer screen) handed to them: if you are 50 to 75, you will get the FOB kit, rather than an antibiotic, when you come in for your cold.

Patient notification by mail is already happening in my practice; we send letters if someone is overdue for one of the services with incentives. I can do more of this; I would like to use email in the future.

Chronic Disease Management programs are interesting. That is where someone is responsible for overseeing quality for a whole program (example, diabetes). This is not something I can do at a single practice level.

We are now becoming a Family Health Team. That means we will be hiring Allied Health Professionals, such as Pharmacists, Nurse Practitioners, and Social Workers, to work with us. I think the CDM program will be managed by Allied Health; we can designate one person as responsible for on-going audits, monitoring, targeted recalls, and perhaps even setting up group education and patient self-care programs, for one or several conditions, depending on the number of patients and the complexity of the program.

Because the EMR contains an integrated chart-in-common, what one team member enters in the chart is available to the other members of the primary care team who have the appropriate permissions.

The FHT has not been set up yet. However, as I mentioned previously, we already have a clinical pharmacist as part of our Academic Unit. The first electronic audit of diabetes care has already been done in my practice, by my resident. The Pharmacist has remote access to the chart-in-common, with defined permissions. I am now working with her to define standing orders: for example, if blood pressure is above 130/80, the pharmacist is authorized to increase current hypertensive medications up to a maximum of (here we put the list of possible meds and maximum doses). We have identified patients with at least two out of three parameters that are out of range (BP, LDL cholesterol, A1C). She will recall them for lifestyle counseling and medication optimization, with the changes recorded directly in the chart-in-common, whether she sees them at the hospital or in my office. If needed, she will send me an electronic message inside the EMR. Team-based care is currently recommended by the Canadian Diabetes Association’s Clinical Practice Guidelines, and it is now becoming a reality.

I view this as a pilot for CDM programs for the FHT. We will have a chance to work out the bugs on a small scale. The EMR company will program the ability to Report across several practices, so we can see how we are doing as a group, and track progress.

Once this is set up, I would like to start tracking patient outcomes as well; for example, what is the rate of heart attacks (code 410) in patients with diabetes (code 250)? That will tell us whether the changes we have made are truly making a difference to our patients’ health, but it will come after the changes in process.

We will have a problem in my FHT: there are several FHN groups that have joined, and although the majority uses the same application as my FHN does, one of the small FHNs already uses a different EMR application, and cannot change (it is very difficult to change EMRs). We will have to program the audit and tracking to work on the second platform as well. It will be difficult for the CDM lead to learn to work with two different programs. We may need to have separate CDM planning and personnel for the small group. This is not ideal; each FHT should consider using a single EMR application if at all possible.

To my mind, the ability to track quality improvement projects and protocols across several practices is one of the things that lie beyond EMR implementation. Implementation is not quite Blood, Sweat and Tears (there is no blood), but it is tough. Once it is done, though, then the bonus parts come into play; the Veteran's Administration program has shown what can be done: they have gone from poor quality to outperforming the rest of the US. We can do the same.


Friday, April 13, 2007


I've been asked how I do housecalls with EMR. I did a housecall on Wednesday.

I review the chart before going. I print the CPP (which has the patient's date of birth, health card number, address and phone number on top). I take that to the housecall; it helps to have the address, I don't have to copy it from the chart.

During the housecall, I may make a brief note on paper; when I get back to the office, I document the visit in the EMR. For simple prescriptions, I give the patient a written script (entered in the EMR later); for more complicated prescriptions, I ask for the pharmacy number; I print from the EMR to fax it in later. I have an ethernet cable in my laptop bag, in case there is internet access where I am going.

On Wednesday's housecall, I had to call an ambulance. It was good to be able to give the ambulance attendants a printed CPP with all the information on it. It would be better if the CPP was securely available on-line when needed, but this can't be done yet.

I found out from a colleague that I can stop the paper lab reports; this does not have to be done as a group. It was was surprisingly easy to do--just two emails and a faxed letter.

I continue to be amazed at the satisfaction that I am getting from the paper Bgone process, and others are telling me the same thing. My consultation room is uncluttered, and my exam rooms are much neater. When drug reps come in, I no longer accept pads of patient handouts; I will take a single page if it looks interesting, and will scan it in later if it is really useful. The reps now manage the sample cupboard, they put the drugs in the cupboard (and never on the counter). A rep came in on Tuesday carrying two cases of enormously over-packaged samples; this was promptly rejected. My practice team is much more conscious of office space usage, and I think I feel more Green.

I've put patient instructions on my saved favourite DI reqs, so that these are always printed along with the req. As well, our Total Joint Assessment Centre has specific requirements for knee and hip XRs; I've saved those as a favourite DI req, so I know that the appropriate XR will automatically be done in the future. I've emailed samples of electronically generated Diabetes Education Centre reqs and MRI reqs to both centres, and have asked if I can use those instead of the scanned standard reqs. If I generate those electronically, they are part of the chart, all the demographics are automatically entered, there is no bad handwriting, and the referral can be tracked. They will have a look and let me know; there is a good relationship between the hospital and family physicians, so things like this often happen.

Very good


Wednesday, April 04, 2007

Drug recall

We had a drug recall this week, for Zelnorm , a drug used for constipation in irritable bowel syndrome. Zelnorm was linked to an increased risk of heart attacks and strokes.

When I received the fax from the manufacturer, I ran a search for all patients on this drug. I also know how to put in alerts, and generate a mail-out. This wasn't difficult to do, as I've done it several times for preventive services. I sent out a "how to" email to my FHN colleagues, and also posted it on my on-line discussion group.

Zelnorm is not a drug used for many patients in family practice. It was good that the first drug recall with the EMR was small and manageable. I can see that the process works; it will work for a large recall, such as Vioxx, but the number of letters will be considerable. We should be be figuring out the role of the big pharmaceutical companies, they really should bear the costs of this targeted notification if one of their products is at fault. It may be time for our political organizations to get involved, ahead of time; this is certainly not the last time there will be a drug recall.

I found out that my application is part of the hospital's network, since the server is inside the hospital. This is interesting; I tried accessing my office from one the PCs in the doctor's lounge, which works. I think this is potentially very useful for members of my group who do OB, in-patient care or palliative care; they can access the EMR from any computer in the hospital.

On another note, I had an interesting discussion with a colleague on what exactly is meant by the EMR "dashboard", which is really a question about how information is presented. I think as a dashboard as an overall view of the information (like a car's dash). There are different ways of presenting that (and not one size will fit all).

I figure that there is a trade-off between a simple dashboard, which will be easy to learn, and a complex dash, which is more useful later on, but is harder to learn. Good programming will present the dash in a way that will shorten the learning curve, while preserving some complexity. A car is an example of a fairly intuitive dash, with some complexity; the fact that it is so prevalent in our society has made good engineering ubiquitous. You have a very short learning curve when buying or renting a new car, because of the similarities in dashboard construction. When you need more complexity, example, commercial airplane, the amount of training increases. Once you have used the dashboard for a while, the amount of unconscious processing increases dramatically; I can take in a lot when I look at the front page in my EMR, but this didn't happen at the beginning.

The Dashboard for individual patients, rather than practice level, would follow similar guidelines (simplicity vs learning curve; choosing the most important info to present, not too much, not too little; navigation issues). It is an interesting interface between the computer and human psychology; a Steve Jobs should get involved in EMRs--his elegance and flair for design would help.