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.


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