Sunday, March 30, 2008

Uncertainty principle

We will be coming to the end of our EMR contract in early 2009. Most contracts in Ontario are signed for three years, because that is how long the subsidy lasts.

Now we have to decide what to do next. Our main options are to stay Local (server at the hospital), or to go ASP (server hosted at the big SSHA box). It is a difficult decision.

We were one of the first large local installations, with 18 physicians at multiple sites, all managed from a single server at the hospital; we own the server. This freed us from having to deal with lab downloads, backup issues, upgrade installation, and all the other server management problems. On the other hand, our server went down recently, and it was not clear who needed to reboot it (the hospital's IT department? The EMR company?) This led to a delay in rebooting the machine, and a loss of service; remote hosting is not without its problems. We are now growing, with additional physicians joining our FHN, as well as all the new Allied Health Professionals. While our server is still adequate to meet our needs, we don't know how long that will last.

Going to ASP (Application Service Provider) would mean moving our data to a fully managed server; the company owns the server, and we just rent space on it. There would be many more physicians also using the same server, so all upgrades happen at once to everyone, and problems are dealt with (or not dealt with) for many of us. We do not know if we can move our data safely to this new server. As well, it may be better for our FHT if all of us were in one large application, so we can share templates and information; I do not know if that is possible.

Because the problem is complicated, we have formed a committee to look into it. Committees are sometimes good: they spread the work (and the blame if needed) around. We'll be looking at the pros and cons of each alternative; just like when choosing EMR software, there are no perfect solutions.

After two years, I think my group has done pretty well. There are now 10 of us in my FHN (and my partner is about to start). We are now at 50% paperless, 40% partial (both paper and EMR), and 10% never started. It is very difficult to come by figures for the "average" implementation; it seems to me that partial implementation is the norm. The National Physician survey shows more family physicians on both paper and EMR (19.4%) than physicians who are paperless (12.3%). It seems to me that about 25% fail to implement, 50% have partial implementation, and 25% are paperless; that is the sense that I am getting from what I have read.

One thing that worries me is what happens when funding stops. For those who never implemented, this is not an issue, they will simply drop the EMR and only pay for billing/scheduling. The physicians who are paperless will not go back to paper. It is those in the middle, who are progressing more slowly, who are at risk; if there is no funding, I think some will abandon the EMR. It seems to me that this may still be a majority of physicians once funding stops.

More uncertainty for us; I thought we were finished with that once we bought the software, but it was just the beginning.


Friday, March 21, 2008

First fruits of the FHT

In my Family Health Team, we are starting to talk about quality of care, and using EMRs to effectively improve care. We have two EMR systems, and perhaps we should switch to one; there is no consensus on this subject as of yet. It is quite apparent now to several of us that the systems are not fundamentally different, and that it is how we use them that makes the difference.

Here are some axioms of EMR implementation that we have developed:

Axiom 1: EMR implementation is far more dependent on us (our Communities of Care) than on the EMR software.

Axiom 2: Improving our care depends on changing our processes to take advantage of the EMR.

Axiom 3: We can accomplish far more as a group than individually.

We have been talking about how to improve our chronic disease management as a group. We are looking at using more flowsheets, reminders, and audits within our practices. All these are certainly possible with EMR systems, but often they are not used; for example, in the Annals of Family Medicine, Closson found that "The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality."

I also think it would be good for us to decide on what kind of diabetic program we would like; for example, we can have a Nurse practitioner do electronic audits, and follow up with patients who have not shown for their appointments, or who are not at goal for their blood pressures or blood sugars. We can develop and use good processes; we can work as a group. I am seeing inklings of this in recent emails.

It is interesting for me to reflect on my group's experience with managing our preventive services. We decided that we were going to use the EMR in a common way for those services across practices (click on the "done" button to indicate that the service was provided). We have one of my staff members as a Project Manager; she is responsible for following up with rostering, and regular mailings to patients. We agreed on the initial processes for entering the information (hire students for data entry over the summer). It took discussion, collaboration, consensus, and on-going work for it to happen. The result is a well-organized program, with tracking and consistent reminders being sent to our patients; in other words, better quality of care. The EMR enabled this, but it was the "human factor" (us) that made it happen, see Axioms 1, 2 and 3. I have talked with colleagues using the same software application, as well as other software applications, and this has often not happened in other practices.

The EMR is a major change; in my Knowledge Translation course, a student put this quote up: "change does not necessarily lead to improvement, but improvement is impossible without change."

We have also started talking about how to code our encounters consistently, to enable future searching for conditions across practices. If we can develop a system that we can agree on, we may then be able to build up a very good picture of what our community's health is like. There is a lot of brain power in this FHT.

My Knowledge Translation course is almost finished; it has been interesting, because so many of the concepts reflect what has happened in my own practice and in my FHN. Much of what we learn and decide to do and change is dependent on what things are like in our own practice, and on discussions with our peers and others (context, facilitation). I would like to start visiting some of my local colleagues at their offices, and see if we can try to figure out together how to do things better with the EMR; a sort of "practical Knowledge Translation" put into action. I'll have to figure out a way to do that.


Friday, March 07, 2008

Wag the dog: of forms and cookies

I am not the only one who thinks these proprietary forms are simply bad care. Here is what a colleague in my on-line EMR support group said:

"I hate the multiple forms we have to use and I have dutifully filled out the exact forms they wanted to make the clerks' lives easier. I now take the stand that if I can increase the completeness of my record and as long as all the clinical info is there I will use the form of my choice and it is up them to convince me otherwise.

However when I talk to them I am very nice and it is amazing what a bribe of cookies can do :) "

I think that perhaps we should form an alliance, and collectively refuse to send or receive proprietary forms. After all, the EMR based forms are typed, are legible, and contain all the needed information. Bring on the cookies!

I am now generating my pap reqs from the EMR; we attach the paper based req on the front, with no information other than the label. The proprietary req says "see attached"; the real information is on the EMR req. I wonder what would happen if we forget the patient label. My public health reqs are now generated from the EMR, which stores the appropriate code; a paper req is clipped to the front, with "see attached".

My practice partner has now decided that he would like a Tablet, so we've ordered one for him. We've also ordered 3 network printers, one for his consult room and one for each of his exam rooms. The total hardware cost to equip a new physician is about $3,500, far less than what it costs to start.

He likes the electronic labs; this is one of the best parts of the EMR. Our community-based labs really have it right; the reports are unbelievably fast and efficient. I probably shouldn't complain so much about pap reqs; I think I'll send my lab a box of cookies, they deserve it. My partner started using the flow sheet for his INRs on the first day; our secretary showed me a message from him to call the patient about the result. He now knows how to use the e-messages and task lists. Paper-based INR sheets are gone as of now.

He seems intrigued by templates; I showed him how to use a Rourke well baby template, and how the EMR remembers the lot number and expiry dates for immunizations. I also showed him how an assessment in the encounter can be simultaneously placed in the CPP, the "write it once, have it go three places" principle of EMR. I will be away for March break next week, and I am hoping he will find some time to play with this. He does some in-patient care at the hospital; there is access to the EMR in the doctors' lounge, and I told him that it would be pretty easy to have it on the floor where he works. He can log on to see his office lab results, and won't have to call our secretary anymore.

I am starting to find more ways to look at my data. For example, there is a place in the EMR that tracks my referrals. In the past 30 days, I've made 8 referrals to social work, 5 referrals to dietitians and 2 to our clinical pharmacist. The total is 15 referrals within the Family Health Team. These represent new things for our health care system, as they would not have existed prior to the FHT. Remote access to our EMR for our FHT Allied Health Professionals has just been enabled, so those referrals will soon start to be generated and recorded within the common e-Chart.

As far as specialist referrals, the most common is Derm, with 6 referrals. Total number of referrals (specialists, programs and allied health): 60 in the past 30 days. 15 / 60, or 25% are within the FHT. This 25% represents the beginning of an integrated system.