Friday, August 31, 2007

DHCP blues

One of my front computers stopped connecting to my network last Thursday; this was kind of bad, because it is connected to the scanner--no scanning. When a computer fails at the office, it is always a bit of a crisis, and someone has to fix it.

In my office, I'm usually the first line of defense (I think every office has one of those, often by default). Most of the time, what I do is reboot the computer, and that often fixes things. This time, it didn't work. Then what you have to do is look to see if you can easily identify the problem; clicking on the "repair" button for the network didn't work.

This is when you call your IT person; every group should identify a professional IT person that they can call (not another physician or their neighbor's teenaged son). He came by that afternoon, and had a look at the machine. He tested the network card, connected the computer directly to the routers and did other things; I can't say exactly what, because I was seeing patients instead of taking care of the problem--which is the way it should be.

He finally identified the issue as a "DHCP server not working; must be replaced". He said that this is bad; he pointed to the router boxes in my IT closet. He assigned a static IP instead of a dynamic IP address to the computer, and said that this would fix it temporarily (whatever that is, it worked and the computer reconnected to the network). This reminds me of being in the garage with the car not working, and the mechanic tells me that the crankshaft is unglued; please just fix it.

Now that the problem was identified, I had to figure out who to call; the boxes in the back belong to SSHA (Smart Systems for Health), and we also go through the EMR company. I sent an email to SSHA, the EMR company, and OntarioMD. My very helpful contact at OntarioMD said to call the SSHA helpline, which is what I did; they took down the information, and gave me a 6 digit number for tracking purposes. On Monday, a new SOFA (Small Office Firewall Appliance), which is the box that had gone bad, arrived by courier. The IT person installed it for me, tested it, and now things are working again.

I am writing this to show the processes I am currently using to deal with IT problems. My computer systems are very complicated, since they involve internal hardware and software, EMR software, and hardware/software managed by an outside agency (SSHA). I am better at dealing with this than at the beginning, but it is still stressful. In order to deal with potential non EMR computer problems, it helps to have:

-a person in the office responsible for low level issues
-an IT person to call in for more difficult problems
-if you have things belonging to an outside agency, have their helpline number and keep the identification number for their hardware (they will ask you for it)

To give you a picture of my office last Thursday, my new nurse was in, my resident was in, my secretary was training a high school student for evening work, and the IT person was working on the broken computer. It was a little crowded and chaotic. There was no way I could work on fixing the computer.

On another note, my group's preventive services project is now finished, and we have mailed letters to all patients who are overdue for paps, mammograms, and 18 months vaccines. It took the students two months to complete the audits for all nine of us, and to enter everything in the EMR. The total cost for the nine of us was $6,500: $4,500 for wages and $2,000 for printing, envelopes and stamps. We mailed 1,433 letters (out of a 12,000 patients roster in my group), so 12% of patients were overdue for one of those services. List maintenance and periodic mail-outs are going to be much easier now that we have the initial audit and computer entry done; our FHN admin person is going to look after this.

Plans are progressing for the big FHT office. A space planner came by my office: although about 15 t FHT physicians will be located there, each group will have their own individual practice space within the large office. Several of the FHT nurses, dieticians, social workers, as well as the FHT admin staff will be also be located there. I have been thinking about how I would like to work; my partner can't move to the big office since he's not part of the FHT, and isn't computerized. I think I would be happiest in a group practice, with two other colleagues. It is time for me to take on some new associates; I will be asking my FHN colleagues for permission to add two new physicians.

There will be no filing cabinets.


Friday, August 24, 2007

Practice nurse

Things are progressing for the Family Health Team. We've hired a dietician and several practice nurses. The nurses have been coming to family practices to shadow us.

I have started working with a nurse for the past few days. It is an interesting experience for both of us, since I've never had a nurse in my office, and she comes from an emergency room background.

I asked our FHT physician advisor if I could have a copy of the nursing scope of practice. The advisor is one of my family practice colleagues who has worked for the ministry; he is also a FHT member, and is knowledgeable about these issues. It looks like a nurse can do most things, but can't prescribe.

When our new nurse came in, I registered her in the EMR, and set her Permissions as "Nurse". By default, she is not allowed to prescribe or bill.

I gave her my resident's Tablet, and logged her in. I would come into the exam room, and introduce her. As she shadowed me, she would load a patient's record on the Tablet, so she could see what I was doing as I was doing it. After a couple of days, she had a good idea of the structure of the record, where things are kept, how to access the CPP, how to do an encounter and how to load templates. Patients seemed comfortable with having her in.

Yesterday, she started seeing patients before I came in. The EMR logs who does what, so it keeps her notes under her name. She does not sign off encounters, but instead sends them to me with the heading "Nurse saw patient". I can then modify and complete the record, and sign it off.

The Fall will be hectic for me. I have been doing a part time Masters of Science at the University of Toronto as I'm very interested in the effects of EMR on medical practice and wanted some extra education on policy and research topics. This is my third and final year; I will be taking a course in biostatistics, which will keep me away from my office on Mondays from September to December. I have been trying to figure out how to schedule things so I can still cover my practice, and will be adding extra hours on Tuesday afternoons and some Wednesday mornings. However, I think this will not be enough.

The nurse may be able to help here. I am getting some idea of what she does, and I think she can triage many problems over the phone or through an office visit. I think we will schedule her in on Monday afternoons and Tuesday mornings. She can see patients Monday, and shedule a follow up for those needing to see me urgently (which may not be a majority) on the following day. Having worked in Emerg, she is very comfortable triaging patients who require emergent treatment. She cannot prescribe; if she thinks a prescription is needed (example, positive quick strep), we can collect the pharmacy's phone number and I will authorize the script when I return from my course in the late afternoon. My practice partner is present in the office on Mondays, but I don't want to burden him with this, as he has not joined the FHT and therefore would not benefit from having a nurse; however, he is still there for emergencies.

There are hotspots at the university, and I will also log-on Mondays at lunchtime. While logistically challenging, I think this will work, and is a good opportunity to try interprofessional care in an EMR primary care environment, and to see what roles the practice nurse can take.

My Master's thesis is on the Effect of EMRs on Preventive Services with Pay for Performance Incentives. I recently received some funding for this; I will study two cohorts, one using EMRs and the other one on paper records, to see whether the introduction of EMRs had an additional effect beyond P4P.


Friday, August 10, 2007

of Time and EMRs

After almost a year and a half of using an EMR, I think it saves me time. There is no question that it saves a lot of administrative time for my staff: there is no pulling of charts, things don’t get misfiled, and accessing data is a lot faster when patients call for results. That is partially counter-balanced by the need to scan and file non-electronic data, but still accounts for net time-savings.

However, saving physician time is less obvious; I think the EMR can help to save time, but you have to organize yourself to do this. I was away for two weeks, with essentially no Internet access. When I returned, there were 52 labs, 26 Diagnostic Imaging reports, and 58 correspondence reports waiting for me. There were also 10 staff messages. I had budgeted time on the day before I came back to go through everything; it took about four hours to review all the reports, and to send appropriate messages for my staff. The time savings here happened because I was able to review the data by logging in from home instead of having to go to the office. Prior to EMR, I sometimes tried to do this while booking a full complement of patients on my first day back, which was inevitably a disaster.

I do not routinely finish recording patient encounters during or right after I see patients. Much of the numerical data (vital signs) is now entered by my staff before I see the patient. Some of the data, such as a note that a patient is in for a routine diabetic visit or a routine BP visit, is quickly entered using a drop down list as I start the encounter; the reason for that is that it takes only two clicks and does not interfere with the interview. I usually will not load a template, such as an Upper Respirator Infection, when I see the patient, because I don’t want to fill in this data instead of attending to my patient's needs; instead, I’ll use free text to write “URI x 2 days”. The free text reminds me to load and fill the template later. If there are significant abnormal findings, I’ll note those in free text. The templates are especially useful for noting normal findings. I’m not sure I save time; however, my records are more complete.

When I am finished seeing a patient, I’ll often go on to the next patient instead of completing the encounter. I don’t like to make my patients wait, so the visit takes precedence over record completion; I note the abnormal/significant results during or right after the encounter, and the rest waits. The alternative is booking fewer patients so I can finish recording encounters.

Because of this, I have routinely have uncompleted visits at the end of the day. I allot one hour to complete my records, return phone calls, review and file reports, and finish insurance or other forms. The difference with EMR is that I can leave for home if I’m tired and not finished by then, and I don’t lug charts home. I find that it is not as painful to finish completing charts after I have supper with my family. Prior to EMR, I had some charts left for completion for a couple of days (which I know is less than ideal); this no longer occurs. It is unusual for me to have a practice summary showing more than one or two tasks undone at the end of the day; most often, there are none; everything has been done.

The difference here with EMR is the ability to complete tasks more quickly, and to have fewer pending reports. My patients have commented on how fast we get forms back to them.

Electronic lab reports seem to come in overnight, mid-morning and mid afternoon. I’ll review them before I start my office, so that I can send a message to my staff if needed. I’ll review them again at lunch, and before I leave the office in the afternoon. Non-electronic reports get scanned in the afternoon, so I’ll review those at the end of the day. If it is a bit quieter, I’ll do that between patients. Time savings for me stem from the fact that lab results go automatically into flow sheets (no duplication), and from having the ability to look at trends easily. Actually reviewing reports takes the same amount of time; there are no EMR savings there.

Inter-office messaging is much more efficient. For non-urgent message, my staff writes an e-note which is automatically attached to the patient’s chart. A little “M” appears at the bottom of my screen to let me know I have pending messages. I check those periodically, and will often send a note back for my staff to call the patient. We also have pop-up messaging for instant communication, and my secretary can always knock on the exam room door if needed. This has led to quicker turn-around to return messages, and fewer phone calls in the evening for me, as the majority of messages can now be handled by my staff. In order to save time here, you and your staff have to use e-messaging consistently, and you have to work with and trust your staff to return messages appropriately.

I think the conclusion is that we have to work with our EMRs and figure out where they will save us time; this won’t happen by itself. One of the best ways to do this is to find out what our colleagues are doing; I am starting to see some forums for exchanging ideas, such as the new EMR Advisor on our provincial website, OntarioMD.

I can see that if I didn't work on my office procedures when the EMR came in, I was just in for endless frustration. Investing time up front to figure out how to do things better and faster with EMR is definitely worthwhile.