Dealing with structural and mechanical failures

What a week! I returned to work on Tuesday after the long week-end, only to be greeted by a truly awful smell in my back closet. It turns out that a sewage pipe in the condominium building above my office had leaked. I have been worried about water leaks for a long time because we are at the bottom of a condo. My routers and SOFA (Small Office Firewall Appliance--the blue box that SSHA sends physicians) are located on a shelf in the closet. I don't think they'd appreciate being exposed to a load of crap.

We built a canopy above the equipment several months ago; this saved the day. The building manager sent a plumber and cleaners over pretty quickly. I guess it could have been worse; replacing all the routers would not have been easy. I could be up and running with my back-up internet line and VPN access pretty quickly; the problem would have been the SSHA equipment--it took a long time to arrive when we first ordered it. I wonder if they have expedited delivery for problems like this, where practice continuity is at stake.

My partner was away this week. I saw one of his patients and had to talk to him about further investigations. While talking, I had to flip through the pages to look for an old XR; I could not find it. I am getting used to the organization and speed of the EMR--dealing with a paper chart is becoming frustrating.

We also had a paper-side failure a bit over a month ago: our fax line went dead (I think my office is jinxed). It took Bell three days to come and fix it. Of course, all the XR reports and consult notes come by fax; I think of the fax as the main paper-side (or non-EMR) external communication conduit. One of the issues with fax is that people don't always look at the verification when they send something, to make sure that the fax went through successfully. We notified the hospital, but I'm sure we lost some data.

I order Diagnostic Imaging via the EMR, unless a proprietary form is required (example: MRI). The EMR tracks outstanding DIs. I had a look at those, to make sure that there was nothing that I was truly worried about. While I was at it, I put alerts in the charts of all patients with overdue DIs. A couple of patients have already told me they never went--mostly bone density XRs. I gave them a duplicate of the req. We called the hospital for 3 patients, and they faxed over the results; these would have been lost without EMR tracking.

We had another medication problem this week, for Avandia. I have four patients on this drug. I had a look at the original article, and our clinical pharmacist e-mailed some very helpful information and analysis to my group. I've reproduced the letter that went out to my patients below; I'm getting used to this process! As well, I installed the letter and set up the Avandia mailing list for one of my FHN colleagues in another office, remotely, so I know this can be done. We can think about managing this as a group, with a common letter and mailing, in the future.

Here is the letter:

Dear ....

I am writing you this letter because you have been prescribed a medication called Avandia (or Rosiglitazone) to lower your blood sugar.

A study reviewing the effect of Avandia has just been published; it found that patients taking this drug had a somewhat higher risk of having a heart attack than patients who were not taking the drug. About 4,700 patients would have to take this drug for 6 months to 4 years to cause one extra heart attack. The full study can be accessed at http://content.nejm.org/cgi/content/full/NEJMoa072761

Diseases of the heart and blood vessels are the commonest cause of serious illness and death in people with diabetes; preventing this is a very important part of your care. This is the reason why I prescribe aspirin, cholesterol medications and blood pressure medications.

Because of this report, I am asking you to make an appointment to see me to discuss this drug. Several other medications for blood sugar have been found to be safer; I would like to review your medications with you.

EMR in the waiting room

I have been talking with OntarioMD and my EMR company about establishing on-line patient access to the chart and to my scheduler. Because our server is hosted at the hospital, there are additional security layers. Allowing and managing access is going to be very complicated; there are several organizations involved. I think this is something that may have to wait a bit.

I was told by my EMR company that giving patients access to the scheduler in my waiting room does not present the same logistic problems, and could be done fairly easily. This would be a simple scheduler, with booked spaces greyed out and available spaces blank.

When I look at flow in my office, I often see a little traffic jam at the front. My secretary is busy on the phone, and patients are waiting to book their next appointment. When they book, they can't see my scheduler, and it usually involves some negotiations because my secretary does not know the patient's timetable. Many people book airline flights on line; I don't think booking a medical appointment is going to be all that complicated. If it is done in the office, my staff can help as well.

The EMR company will lend me a PC, and will also give me a one pager for patients. I will put the PC in my waiting room, with the monitor visible to the secretary and to the patient. I will need a pad of paper and some golf pencils so people can write down their appointments. There will need to be some type of patient registration before they can use the scheduler; I'm not sure how that will work yet. We'll try it out and see if it works, sometimes in June. I don't know if there are other offices allowing patient self-booking in the waiting room.

In the future, maybe I can use my waiting room for something more interesting than waiting. Maybe patients can self-check in with a card swipe, and verify their information. If I need a patient to fill out a form (example, a Benign Prostate Hypertrophy questionnaire to see how things are, or a PHQ-9 questionnaire for depression), maybe that can be programmed to pop up when the patient checks in. They can go to another PC in a more private area, and fill that out. Perhaps I could have pre-programmed health information for their health condition for them to look at while they wait. This would also be really good for research; you could have questionnaires administered in the waiting room.

There has been some talk of having several FHT physicians all move to a big office, together with several of the Allied Health Professionals we'll be hiring. I think this type of set-up would work better in a big office.


We have a FHN meeting on May 29th. Several of my colleagues have experienced the same type of hardware/software issues that I have, which involve computers rather than the EMR software itself; at one office, the cleaners accessed the internet at night, and introduced a virus on a PC. We are looking at hiring someone to serve as a "Geek squad", to be on call for these type of issues, and to make sure the computers are properly maintained. We can use group funds for this, but I'm not sure what it will cost; we are going to get a quote.

I have been asked if I get paid by the EMR company for things like giving a tour of my office to colleagues, or for articles that have been published in the press. I talked to them about this pretty early on. I think it is reasonable for people to get paid for their time; what I decided to do instead is to have them deposit the money in a "research fund". I can think of several colleagues who have really good ideas; the fund will not be large enough to support a big research project, but perhaps it can supply a bit of seed money when required--sort of like planting for the future.

Michelle

Having an IT administrator

Managing my office IT continues to require my time. One of my UPS (Uninterruptible Power Supply) devices failed. The computer crashed.

I called the company, and it turns out that the UPS device I bought can only handle one PC, and I had two PCs at the front connected to it. The voltage was too high. They sent me another UPS, and I connected it to the second PC; it works now. I phoned the company to pay for the second unit, but they won't accept that. I have to ship the other unit back, and then reorder a new unit. That makes no sense to me; I am not a travel agent for UPS devices. I'll just wait a bit and see if the company gets upset at me and allows me to pay for the second unit.

I have a bank branch downstairs at work. I wonder whose responsibility it is to deal with this type of issue there; I would bet that it is not the bank manager's. They also seem to have a huge amount of redundancy, certainly more than what I have. They probably have some very good remote IT support; do they have some in-branch support?

We probably need to think about the minimum level of redundancy in each practice; I have written about this before. Maybe we should have one admin person in each group (FHG, FHN, FHT) whose job it is to become familiar with each practice's IT set-up, and to deal with minor but annoying problems. These problems can become major very quickly if they are not dealt with; the physician is often the IT troubleshooter by default, but I don't think we are the best person for this. It would be good to have the IT administrator monitor each PC periodically to make sure that Windows updates are up to date, and that anti-virus programs are working and are scanning periodically. Computers should be restarted periodically. We were told to install IE 7 on every PC, which has not been done at my office. We should probably have the IT person develop some policies about routine PC maintenance.

I am looking at having a PC in the waiting room to let patients book their own appointments. I've noticed that this is a source of back-ups at the front; my secretary is on the phone, and patients are waiting to book their next appointments. The secretary does not know what time is good for the patient, and the patient can't see my schedule and does not know what times are available. This does not seem like the best booking method.

I've found out how to generate some numbers for my practice. I can generate clinical reports in html format, but this just gives me lists of patients (and not how many patients have a condition). I save these reports, and then open them up in Excel. I then use Data, Sort, and it gives me a number. For example:

All active pts in my practice age 20 and over: 987
code 278 (obesity): 226 pts (I code all BMIs of 30 and over as 278)
250 (diabetes): 95 pts
250 AND 278: 43

9.6% of my pts are diabetic
23% are obese
45% of diabetics are obese

Diabetics in my practice are more likely to be obese than non-diabetics.

Michelle

The patient Dashboard: improving communication

I was talking with a colleague who uses a wired EMR. He walks into the exam room, and then quickly logs on. He then sees if there are any alerts or messages for that patient. He told me that this is different from the paper-based system, because the chart was on the door, and he looked at it before going into the room.

I don't do that. I can see when a patient is shown to a room (and which room), because my staff indicates this on the scheduler. I load the chart on my Tablet before I go in, and see the Summary (which I increasingly think of as the chart dashboard). Summary has today's visit and reason, all upcoming booked appointments (so I know if the patient already has an appointment for a full check up in the future), any upcoming recalls (example, colonoscopy due in 8 months), Follow ups that I set during a previous visit (example, 1st script for HCTZ, check potassium), overdue preventive services, and staff messages that have not been archived. I like to see this before I go in. If I need to, I take a quick look at the CPP, I open the encounter and then I go in and greet the patient.

This allows to say hello to my patient instead of to the computer. I can remind my patient to make an appointment for a follow-up abnormal pap if I can see that this has not been booked yet. I remind him or her about overdue preventive tests first, so this is done. We then address the presenting concerns together.

I know that this is not very patient-centered, but it does allow me to remember to do things that are in my patient's best interest more consistently. I think it is possible to do this with a wired system, but you do have to look at the chart before you go in. It may work better with wireless: just open the chart, look, and take it in the room.

I was talking about this to the Team pharmacist: we have to figure out ways to communicate effectively within the Chart-in-common. I referred the first patient to her via emessaging in the EMR; she will see him at the hospital, where she has her office. If she needs to have me see the patient as a follow-up, she will set this in her Encounter. She will assign a Follow-up to me, with a short explanatory note (example: LDL high, Lipitor was increased from 20 to 40). When I load Summary, I'll see it before I go in; I can load her past Encounter if I need to review it ahead of time. She has been practicing with the Dummy patient chart, and I have been looking at that remotely. I think we're ready to go.

We've set the Standing orders according to the toolkit for Medical directives. We are going to start with Diabetes. Here is an example of a Standing order:

In order to optimize care for diabetic patients, the Team has agreed to the following standing orders. These orders conform with the Guideline recommendations from the Canadian Diabetes Association. The CDA has also recommended Team Based care for Diabetics. Goal-based optimization of therapy has been found to improve achievement of diabetic targets (Level I evidence, Gaede et al).

The Team will use a common Electronic Medical Record, with all encounters, medication changes, laboratory requests and results to be entered in the chart. Each Team member will have access as appropriate to their professional roles; all accesses to the chart will be electronically logged.

Standing orders, optimization of dyslipidemia management

The goal for most diabetics is LDL 2.0. The pharmacist will look at the last lipid profile. If the LDL is above goal, AND lipids were done a year ago or less, AND the patient has no contra-indications to increased dosage (SGOT or SGPT is less than twice normal; patient is not complaining of statin-related myalgias), then:

If the patient is on a Statin, the pharmacist is authorized to increase the dose of the statin to a maximum of:

• Rosuvastatin (Crestor): 40 mg PO od
• Atorvastatin (Lipitor): 80 mg PO od
• Simvastatin (Zocor): 80 mg PO od
• Lovastatin (Mevacor): 80 mg PO od
• Pravastatin (Pravachol): 80 mg PO od
• Fluvastatin (Lescol): 80 mg PO od

The pharmacist is authorized to request cholesterol/SGOT retesting, using the physician’s lab requisition (with CK testing at pharmacist discretion, if there is concern about myopathy) for follow up of the changed dosage. The patient will be asked to retest blood a month after medication change, with result forwarded to the patient’s family physician.

The pharmacist is authorized to request lipid profile (total cholesterol, LDL, HDL, triglycerides, total cholesterol: HDL) testing (using the physician’s lab requisition) if this has not been done in the last 12 months, and the patient is not booked to see their family physician for an annual review in the next 3 months.

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If we're going to do Team-based care, we have to have clear, common goals, based on solid evidence. We also have to have really good communication within the team. I think the EMR will help us do that. I wish we could have patient access to the chart; after all, they are at the very center of the Team.

Michelle