Friday, February 01, 2008

Snow storm

The weather is just awful today, so I am working at home. My labs all came in at 9:30 am. An INR is slightly abnormal, so I've just sent a note for my secretary to call the patient and adjust his coumadin dose. She can log in remotely from home if she cannot make it to the office.

My husband is working in our home office as well. He is accessing his office via VPN, as I am. His large database is in Cleveland, but the results for queries are near instantaneous. I guess many large companies are functioning via remote access (the common database is somewhere else), but they have made sure that the pipeline is big enough. We still have a long way to go with SSHA; I heard that there were outages last week in several locations on Ontario, making it impossible for practices to access medical records. I think this would be unacceptable in a business environment (my husband's multinational company could not function); I really don't see why this is acceptable in a medical environment, with people's health at stake. We have been promised good access at the new clinic; we'll have to see if SSHA does come through.

A blood sugar just came in as elevated for another patient, confirming a new diagnosis of diabetes. I've just called the patient to let her know. This lady has other serious health issues, as well as limited English and literacy; I had recently asked our FHT RN Case Manager to see her. The RN Case Manager does not have access to the EMR yet; the referrals are done by fax. I've just notified the Nurse of the lab results by email, without using the patient's name: "recently referred pt -initials- has new dx DM II". Once the RN has access, I will e-message her within the EMR, which is much better. I will probably need to send her an email to let her know that she has a message in the EMR.

It is taking a while to establish all the EMR connections within our team. Each FHN requires its own log-in, and there are two different EMRs to learn. All together, it is complex. I would like it done yesterday, as the benefits are so glaringly obvious, but I know I have to have some patience. We have a bit of IT support for the FHT, but it is limited at present; I am worried about what will happen when all of us move into the big office--will we have enough support to run all these machines and software? I can run my office as our FHN has its own IT person, but I don't know what will happen to the rest of the group. We probably should really start thinking about coordinated IT support.

My resident is now talking about joining me after graduation; I know of several young physicians who have joined EMR/FHN practices recently. I think the current primary care environment is much more attractive for new physicians.

My new partner is functioning well in the EMR environment. After a month and a half, we have worked out most of the initial bugs, and she now has remote access.

She is getting a fair number of old charts from her previous practice: we scan those to the networked external hard drive (I have made a folder for her) after she has seen them. Some of her old charts arrived on CD; we simply drag the file to the external hard drive; the patient can have the CD back immediately if they wish, as the process takes next to no time.

She is getting some lab/DI reports for patients who are not registered in her new practice at my office; we don't know if these patients will transfer here. Rather than starting a new chart, we scan those to a folder; if the patient does come in, we start an electronic record, and the files are then uploaded to the EMR.

She told me that scanning was very slow in her previous office; up to 3 months. It made it very difficult at times to know where results were (on loose paper waiting to scan? in a paper chart? attached to the electronic file?) leading to a lot of wasted time. The reason for the slowness was that scanning was only done in the evening, and the clerk did not have enough time to do everything. This does not work; in my office, scanning takes 1 day, or at the most two. It is really worthwhile investing in a good, fast scanner, and making sure that you have enough personnel to do it properly.

My practice partner is actually talking about converting to EMR! He can't type (using 2 fingers), which will present a problem. I think what would work for him is dictation:

Subjective/Objective
Favorite Notes:

The Subjective/Objective part can be dictated (dragon dictate, other). The Vitals are now often entered ahead of time by my staff. If not, these don't take long to put in.

The medications should be typed in. However, once his list of favourite meds is done, it will only take a few keystrokes to enter, as the rest is auto-filled:

Drug Name



amoxicillin 500 mg Refill: 0
Direction: Take 1 Tab(s) PO TID for 10 Day(s);

The Assessment requires typing the 3 ICD-9 digits (if you know them), or a couple of keystrokes to get the drop down list:


Assessments


ICD - Description

Status

Comments

CPP
-
401 - DISEASES OF THE CIRCULATORY SYSTEM/ESSENTIAL, BENIGN HYPERTENSION


The Plan notes can be dictated as well:

Plan Notes

Favorite Notes:


His CPPs are very organized and legible, we can hire someone to type these in for him. This combination of some typing and some dictating will likely work.

He may not be able to get to the office today. If my secretary can get in, he can call her for results, but otherwise it will be difficult for him to access anything. In Canada, we have snow storms; the EMR certainly makes it easier for us to cope with our weather.

Michelle

2 comments:

g5r1s5 said...

Hi Dr Greiver,

we too in Quebec got problems with our RTSS, same as SSHA in Ontario. If you are outside the walls ( 80 % of GP...), you have a lot of problems: deconnections, slow connections, lots of steps to go inside, frequent provincials bugs.

Not very convenient for busy doctors. Yes, we need security, but we must find a better balance between security and easy accessibility for non-techies, busy clinicians.

In Quebec, there is massive investissement for the DSQ project.
The principal orientations as well as the bases of the reflexion were unfortunately made by high level lawyers and managers. The clinical vision is there so to speak "not very present". the preponderance of the technological persons in charge strongly influence the policy of computer security of the government. the clinical vision should balance this influence so that a better balance is reached. If not, several legislative modifications will have to be carried out when the project controls which is currently in hand will show to them inconsistencies of a vision disconnected from the clinical world. Quebec shows an important delay of medical computerization. I can believe with difficulty that we can treat to the luxury to still take delay in spite of this massive investment. The official medical representatives are little sensitized with the importance to engage of the formal discussions to modify the governmental orientations. There are however the committees RSVP which you must know, that remains however fragmented actions having probably impacts of means of that actions of group. We would have probably much has to learn from Alberta and British Columbia.

Cheers,

√Čric Paradis
Quebec

Michelle Greiver said...

Hi Eric

Health care in Canada is a provincial responsibility, that is what we live with. That is why we are seeing Health IT programs delivered on a provincial basis. This has led to different priorities and different choices depending on which province you live in. An overview of programs was published in a recent Future Practice, at http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Future_Practice/English/2007/June/FP0607_toolkit.pdf

Nova Scotia and BC have chosen an ASP model. I think that this is the better long-term choice (health care data cannot be isolated in small office silos), but it can be fraught with difficulty if not implemented properly. On ASP, the software is managed professionally, but you need the connectivity. As I mentioned, commercial companies are now run through remote access, because they can't work if local data remains isolated. We have seen problems with SSHA in Ontario, and it sounds like you have the same problems in Quebec. Having these organizations isolated from their end-users (clinicians) is a terrible idea. I don't think WalMart would do well if they paid little attention to their customers.

You comment that the culture of Quebec provincial IT is disconnected from clinicians. That is not different from SSHA. If you look at the board of directors, there is not a single physician there http://www.ssha.on.ca/about/bod.asp

As a clinician, it appears to me that these organizations have made security a priority, with service and connectivity of less importance. I recognize the importance of security, but there needs to be a better balance, and more attention to clinicians' needs and requirements.

Michelle