Monday, December 24, 2007

Year 2: looking back, looking forward

A year ago, I had just finished entering the last of my CPPs into the EMR. It has now been a year since I have been fully electronic.

This is a log of a routine diabetic visit; I have erased the date and the patient's name:

10:41 AM

View Summary

10:43 AM

Add Encounter

10:43 AM

Add Clinical Notes Templates

10:44 AM

Edit Clinical Notes

10:44 AM

Edit Clinical Notes Templates

10:45 AM

Add Medications

10:45 AM

Add Medications

10:45 AM

Add Medications

10:45 AM

Add Medications

10:46 AM

Add Lab Requisition

10:47 AM

Add Immunization

10:48 AM

Sign off Encounter

I view Summary as my entry screen, by default; this lets me see if there are any outstanding issues for a patient. In this case, she was overdue for her flu shot, which was the first thing I did (the two minutes between Summary and start Encounter). The active medications are auto-loaded into my Encounters, and they are batch printed (that's why they are all stamped on as being at the same time, this is the time they are printed). I sent the patient for an A1C (lab req), and recorded her flu shot. Log lets you get a quick snapshot of how your encounter goes; it doesn't include everything (I also looked at the diabetic flowsheet and the CPP), but it is pretty good.

I keep looking for ways to improve efficiency; the EMR software application is so large and complex that there is still lots to find and use. One of my colleagues was telling me that he feels he uses only about 5% of the functionality; I probably use more, but there is still lots to discover.

My new partner has been using EMR from day 1. I can see that there are some things that are still challenging, such as learning to prescribe more complex drugs (example, gardasil, at 0, 2 months, and 6 months, to be given in physician's office), or doing referral letters. The basic encounter was pretty easy for her to learn. Periodically, we sit down for a few minutes and I show her things. She did not go for EMR training, as it did not seem necessary; she is learning it as she uses it. I will buy a new Windows XP PC for her, because I just can't make Vista connect to my XP network properly. There were a couple of start-up problems: for example, we had to figure out how to make sure that encounters that are started for her by my front staff (they put the vitals in) are sent electronically to her and not to me. Her off-site access does not work; it seems to be a problem with her router blocking the VPN, and that needs to be solved.

She decided that she preferred desktops (wired) as opposed to wireless. Because I have network "drops" in every room, it was very easy to accomodate her. She has her own exam room (the room where paper charts used to be stored), and this now has the desktop with a local printer attached. The printer is the same brand as what I use in the rest of the office, so that we don't have to manage cartridges from different companies. We share an exam room, and she just leaves the laptop in there on the days that she is using it.

Overall, adding a new physician in my office was a lot of paperwork and some extra EMR work (configuring the machines, learning to work with two EMR physicians instead of one), but this is much less than initial EMR start-up, and is manageable. It has not been as difficult as I thought it would be, although there are still things that we need to fix. It helps a lot that my new partner is so easy to talk to, we can solve problems. I expect that, once she gets going, she will be teaching me things.

My son moved out of residence this year, and moved in with two other university students. They have a brief "house meeting" every two weeks, do discuss outstanding issues. He keeps minutes. This is working very well for them; it sounds like a good idea, and I think I will try that with my new partner.

I have been talking to several colleagues about joining me, as I will have a three physician office in the big FHT office; I do not yet have a third partner yet.

While there has been progress, there is still a lot that remains undone. What bothers me the most is the lack of action on the "electronic island"; we are still not connected to the hospital or to outside agencies beyond the labs, there has been no decrease in the incoming data that needs to be scanned, and there has been no progress on decreasing the number of proprietary (non-electronic) outgoing forms. There seems to be lots of talk, but there is no change in my practice.

As an example, we are now being forced to send out proprietary public health forms for Chlamydia urine PCR; up to a month ago, the Ontario lab req was accepted. If you make it more difficult for me to screen for chlamydia, I am less likely to screen (a decrease in quality of care).

There is nothing that a front line clinician like me can do to improve this. Because the health care system is still so fragmented, it is difficult to know who to talk to about these issues, and each problem has to be solved in isolation. We certainly have lots of organizations dedicated to decreasing fragmentation (the LHINs, Canada Health Infoway etc), but I cannot say that their work has percolated down to my practice. Maybe next year.

On the other hand, EMRs are spreading. I have now started the study that I will be writing up as part of my Master's thesis (effect of EMRs on preventive services). We are recruiting colleagues in family practice in my area, and have recently sent out letters of invitation. 26 physicians out of 130 have already replied; of those 15 have or are planning to implement an EMR, and 11 are not planning EMR.

In my own Family Health Team (composed of 6 Family Health Networks), all 40 physicians have or will have EMR by next year. Our Allied Health Professionals are getting EMR training the second week of January. I expect to have more EMR integration at the FHT level next year: by that, I mean that our social workers and dietitians will enter data directly into the EMR. My practice nurse and our clinical pharmacist already do this.

We are getting ready to start renovations on the big FHT office. My own office at the new location will be just over 2,000 sq feet; plans to move in later in 2008 are on track. There was a good article on office planning in a recent issue of Future Practice, by Dr Kendall Noel; just like him, I really like the fact that my patients can see the computer screen--it allows them to participate more in their own care. Almost all of my physicals are now done collaboratively with my patients: I point at what I am looking at on the screen (and I often ask patients age 50 and over if they need their reading glasses--because I'm starting to need those more routinely). It is important that you don't have your back turned to your patient while entering data. It is simpler to do this with wireless because the computer is portable, but the new flat screens make this a lot easier to do with desktops: they take up much less space, and it is easier to place them where they make the most sense.

For the next year, I look forward to planning the big move; this will make my practice fully electronic, as all physicians will be on EMR. I look forward to working as part of a Family Health Team. Now that I have lots of data in, I want to learn to use the capabilities of the EMR to systematically improve care: that will mean doing audits to figure out what patients need, deciding what to do, and using the Team to put our plan into action.

I would like to thank readers of this blog for your company through this journey, and wish everyone a good and peaceful 2008.


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