Sunday, April 27, 2008

Taking care of our server

Our server is getting full. This is both a good and a bad thing. We thought we bought plenty of capacity when we first started; however, we are running out of space, after a little over two years.

This reflects the fact that the EMR transition is going fairly well; pretty much everyone is scanning everything in. We are increasingly giving up on paper-based processes. All labs are coming in electronically.

As well, we are now adding five more physicians to our group. Information Technology changes at such a rapid pace that what was considered pretty good two and a half years ago, when we bought our server, is now barely adequate. We now have to add extra capacity, and are working with our EMR company to do so.

When I switched to EMR, I ditched my old computer, which dated from 1996. EMR applications are far more demanding, and you use them constantly. It is a good idea to maintain and update both hardware and software. Some peripherals, like printers will last longer; the computers' hardware and software will likely need upgrading sooner. You also have to think about replacing parts.

For example, a label maker broke recently and we had to replace it. I just ordered a second scanner; I will have to buy a PC to go with it. I bought a new battery for my Tablet, after a year and a half. We broke three shredders when we first started (buy shredders with a replacement warranty).

However, the server is at the heart of your practice. It will need to be upgraded, and eventually replaced. Plan for this, and budget for it; a server that does not meet your needs is dangerous: it will slow you down, and it will eventually fail.

The IT committee for my group is functioning well, and we are meeting regularly; we also talk frequently by email. We have met with OntarioMD and with SSHA, as well as with the head of our hospital's IT department. We are still weighing the risks and benefits of a move to ASP; in Ontario, there are now three large EMR companies on ASP (1 previously approved, and two approvals are pending). We see the finite lifespan of a server happening in front of us, and what server maintenance for a mid-sized group of 23 physicians entails. Going to ASP means renting space on a very large, continuously updated server (not that this is without problems either); doing this would mean completely outsourcing server maintenance and upgrading.

In Ontario, government subsidies for EMRs end after three years. We will be at that mark in 2009. I can see that there are on-going costs; in Alberta, the government has decided to continue to subsidize and support EMRs. Perhaps this is something that Ontario should consider as well.

I have joined the IT committee of the Ontario College of Family Physicians. We are reviewing the key issues impeding the transition to EMR; failure of the system to connect continues to be right at the top of the list. I am increasingly reluctant to forward any proprietary forms. We have a new tri-hospital initiative to expedite colonoscopy after a positive fecal occult blood test; however, the first thing that the program did is send us copies of their proprietary referral form. We discussed this at my hospital's recent family medicine business meeting; programs have to realize that this approach is no longer acceptable. I had a patient with a positive Fecal Occult Blood last week; my first referral was generated in the EMR, with a note requesting a waiver from the form (Je Refuse).

I am now generating public health requisitions within the EMR; the req contains the same information as the proprietary form. I have staplers in every room, and I staple a blank proprietary form behind the real form with four staples so it is strongly attached. There is a Six Sigma Method for improving quality; I call this method the Four Staples Method for patient safety.


Wednesday, April 23, 2008

Summer students

University students are now finishing their last exams. High school students will be out in two months.

Getting some help from students is very common during the transition to EMR; my partner hired two students for data entry. The students are entering the CPP, and my partner then reviews those for accuracy and completeness. Several other physicians in my group did this when we initially started the EMR.

It is not bad to start the EMR transition in the spring; the office is quieter then. As well, you have some idea of what the EMR looks like by the summer, as you hire your student help.

However, CPPs are not the only thing that bright students can help with. Data entry for the preventive services for my group, last summer, was done with student help. It worked, so we discussed a diabetes quality improvement project at our recent FHT meeting, with funds allocated for data entry. There was consensus that we should go ahead. This is the project:

1. Get a list of all diabetics for each practice
2. Verify the list
3. Put in an electronic flowsheet in each practice location
4. Put the flowsheet in every diabetic's e-chart
5. Put in reminders to look at the flowsheet, every 3 months

It looks simple, but it is actually fairly complicated. Not everyone is entering the ICD code for diabetes (250) in the CPP or in encounters. As well, this code is sometimes used for Impaired Fasting Glucose ("pre-diabetes"), or Gestational Diabetes (diabetes only during pregnancy). These patients don't have diabetes. What I will do is get the list of all patients with 250, together with "comments". We often enter a comment like "IFG" if the patient does not qualify for diabetes. If the Diabetes list is poorly populated (I expect about 10% of adults for each practice), I can extract the billing code specific for diabetes.

Once the list looks reasonable, it gets faxed to my colleague's office for review and approval. We proceed with putting in flowsheets only when the list has been approved.

The advantage of electronic flowsheets is that much of the data is automatically populated. Vitals and labs go in automatically; the vitals go in straight from the encounter, and the labs straight from the e-results. I don't have to re-enter this data twice.

However, like everything else, this is not perfect. The labs all use different databases, and patients don't always go to the same company's lab. What I did for my group was meld the databases: in our Enterprise module, there is a place where you can say "this test from lab A is the same as that test from lab B". For some reason, it works very well for two of the three electronic lab companies, and not all that well for the third. It doesn't work at all for paper-based lab results, like the hospital's. When it works, results from any lab just go into the flowsheet.

To get around this problem, I have a cell called "notes" in the flow sheet. I just type the non-electronic tests there. I also give patients a handout with their lab form, with locations and hours of the two preferred lab sites, along with the URLs for lab locations. We do most of my lab tests in my office. We really need to have a common nomenclature for lab tests, as well as a common way to store and transmit lab results electronically; I keep hearing this will happen (OLIS), but I see nothing happening yet at my end (maybe this year?).

There are blank areas in the flowsheet to record other things, such as foot exam and monofilament testing. I ordered some free monofilaments last month from LEAP, and distributed them at our recent FHN meeting.

The students will take the approved lists, and enter a flowsheet in each chart. They will also put in a reminder to look at the flowsheet and check diabetic parameters, every three months. Finally we have a code that we bill every year for managing diabetes and reviewing flowsheets. The students will do a billing list for every physician, and if this works, we will bill this yearly as a group.

I don't yet know what problems I will encounter with this summer student project; I learned a lot from last summer's project, and I think I'll be able to figure out ways to fix things as they happen. Because we all access a common database remotely, all this will be done from my office, with no disruption to any practice; there are some very significant advantages to remote access.

What I hope to achieve is:
-a registry of all diabetics for my whole FHN
-use of flowsheets for every diabetic

My resident is almost finished her two years in my practice, and will be graduating as a full-fledged family physician soon. We will miss her. We get a new resident in July; one of the things that residents have to do is a practice audit; my resident did one for me on my diabetics two years ago. Audits are now a lot faster with EMR; I think I will ask the new resident to audit my practice, and if it is really quick, we'll ask some of my FHN colleagues for permission to remotely audit their practice. We can probably get some very good baseline and on-going data that way. I think I may get to find out if this little diabetes quality improvement project works.

My FHN is growing, and we now have 14 physicians. All three hybrid practices (EMR/paper) in my group are now going to be EMR only, as all practice partners have joined the FHN. We will go from a 12,000 patient base to about 16,000 patients. I expect that we care for about 1200 to 1400 diabetics (there are 89 diabetics in my practice). I think we can use EMR tools to make a real difference in their care, and I plan to have our summer students put in some building blocks to enable this over the next few months.


Sunday, April 13, 2008

EMR housecall

I have now done the first two “EMR housecalls”.

At the first office, I could see that the Tablet was running out of power very quickly. Rechargeable batteries do not last forever; after a year and a half or so, they no longer hold their charge. My colleague has a spare battery, and I asked her to put it in and charge it overnight. I think this must be a common problem for my FHN, as we all bought Tablets at the same time; we have an upcoming FHN meeting, and I will mention this.

My colleague was interested in starting to use the EMR-based lab requisitions. I asked her to tick off what she normally would do at a complete check-up and a check-up for diabetes, and installed those as “lab favourites” while she went to see a patient. When she was between patients, we tested this; I also showed her where the pending lab reqs are kept; sometimes a patient loses the req, and the secretary can print an extra one. This seemed to be a common problem at her office, and the secretary was especially happy to find out how to reprint. I also showed my colleague how the system indicates that lab tests were ordered, as part of the encounter. I showed her how to do her own favourite reqs, and we did one for Fecal Occult Blood testing (a common req due to our new provincial colon cancer program). I configured Diagnostic Imaging reqs for her, and she will now start ordering these electronically.

She wasn’t sure of how to add a patient’s health care number to consultation requests. This was causing difficulties, as her secretary had to enter those manually; I put it in her letter templates and printed an example for her. She was happy with that.

Her scanning system is the same as mine; our FHN admin had shown her secretary what our processes were. I showed her how to use MS Document Imaging to quickly copy a part of the scanned pdf document, then paste it into comments. She practiced this, and I wrote it down for her; it will save her a lot of time.

I installed a shared (networked) folder on the front computer, and made sure it was accessible from the Tablet and from the back computer. I have copied all my handouts and scanned requisitions on a CD, and will give those to her at our upcoming FHN meeting. Her secretary will copy it to the shared folder, so that they can both access it from anywhere.

At the second office, we went over things with three colleagues during lunch. They had thought carefully about what was bothering them. We went over “preferences”, which is where you set how you want the system to work for you. For example, I showed them how to default all the currently active medications in the encounter; this makes it very easy and fast to prescribe, requiring only checking the tick-box, then “Sign and Print”. I also showed them how the system handles “active” and “inactive” medications: there is an “expire by” area on the top of the prescription. My long term prescriptions all have “expire by 1 year”, so they don’t drop off the active list. For short term prescriptions, such as antibiotics or skin creams, the expire by is 1 week (these expiry dates are all saved in favourites, so that I don’t have to remember them). The short term drugs stay in the CPP and show up in new encounters for 1 week and then they’re off. I showed my colleagues additional places where expired medications are kept, as well as rapid methods to remove drugs from the active list. We also went over tricks in prescriptions, such as how to prescribe glucometer strips using three keystrokes.

My colleagues were not sure of how to do sick notes; I showed them how to do a template for letters, and we put a sick note template in. We practiced doing one together on a test patient, which is very simple once the template is in; there is a copy of the note kept in the system. They are now comfortable writing sick notes and letters for massage therapy very quickly. I also suggested that they print the notes at the front desk, so that payment could be managed by the secretary; we put a footer regarding payment at the bottom of the note template.

They use desktop computers, and there is very little desk space in the exam rooms because of the keyboard. I suggested buying some plastic sleeves that could be attached to the walls, some of the paper on the desk can be stored there; as well, a couple of clipboards can be placed in the top sleeve, and these can be used to hold papers to sign prescriptions, or to discuss handouts. There are no printers in the exam rooms, so they walk a lot. Installing a small printer in each room may work; there is space for that.

I think there was considerable enthusiasm by the end of lunch; they had lots of ideas and thoughts about how to improve EMR processes. I was impressed by their rapid grasp of new ideas and their willingness to implement new things.

One of the physicians emailed me with an idea: we could have meetings at the hospital to learn how to better use the EMR. We could use a projector tied to a laptop; one physician would act as a facilitator. Each physician would bring their own laptop and would log on to their own EMR application to try things out.

I think this may work; in fact, I was at a conference for my University Department on Friday. At lunch, a colleague who is using another EMR told me that her group of 22 physicians does exactly that: they hold monthly “EMR learning” meetings, and use exactly the same process. It has helped them a lot. EMR companies do not really offer much broad-based ongoing training, and we really need that.

At the departmental meeting, a physician who had come to visit my office with his whole office team a few months ago came by to say hello. He told me that things were running much more smoothly for him and that he was much happier. It was the processes we outlined that made the difference, although he was the one responsible for implementing them. He was now paperless, and ready to send all his paper charts to the basement.

I think that this type of individualized physician to physician dialogue on EMR is helpful. There is no one better able to say what works and what doesn’t than a physician in his or her own practice. Having a peer who has solved many of the same problems do an EMR housecall is valuable because it adds an extra pair of informed eyes and ears. I don’t expect that everything I suggest will be done; I think each practice is best placed to choose what they would like to implement, when and how. I was asked to do a follow-up housecall in a few months; the problem for me will be managing my time. I just don’t know if there are enough of us around to do this on a wide scale; however, I can see that even a couple of hours will help: each housecall took 1.5 hours.

My practice partner has now chosen May 5th as his EMR start date. Two students are coming by next Thursday morning: they will start entering his CPPs for him. I will give them a bit of training and supervision for the first few entries. My office staff is now booking him very lightly for the month of May; it is important to do that, because he will be much slower at the beginning.


Friday, April 04, 2008

Giving back

I will be giving a seminar at our national family medicine convention (Family Medicine Forum) in Toronto, this November. I put a submission together with my colleague, Dr Stephen McLaren, on "Electronic Medical Records: the first year of computerization". We have invited a Practice Management Consultant from OntarioMD as an additional resource. It should be fun and interesting; we'll really concentrate on the practical aspects of implementation.

I have now just finished my last class of my MSc; I am writing my thesis, much of which is about the transition to EMR. The last course was Thursday mornings, from 9 am to 12 noon; what I have done is left that time slot open for a couple of months. I think I will use the time to put what I have learned --through day to day implementation as well as from my courses-- into practice and give something back to my community: I will go visit some of my colleagues at their office. We have this new Peer to Peer program from Health Infoway, it says that we can offer support on-site; perhaps some of this can fit the PtoP program. I'll see if I can fill my dance card.

My practice partner works at the hospital today. I configured access to the EMR in the doctor's room, on the floor where he works; he told my secretary yesterday that he will be looking at his lab results remotely. He no longer has to call her for results on Fridays. He is now comfortable using our e-messaging system, and is also assigning tasks electronically; he told me that all his INRs are now managed via electronic flow sheets. I printed and gave him my list of medication favourites; he ticked off drugs that he uses often. I entered those in for him, which will give him a head start on prescribing. We practiced entering medications in the CPP, and did a prescription together.

He is approaching the transition with an open mind, and trying things out. He knows that the EMR is not perfect (not even close), but he is also aware of the significant advantages it has over paper records. I think that this is a very sound and very realistic attitude to take. He does have more support than most of my colleagues who are adopting EMRs; I hope that over time, what I am describing will be the norm rather than the exception.

We continue to have issues with medications. For example, a new study showed that one of the cholesterol medications we use (Ezetrol, or ezetimibe) may not be effective: it lowers cholesterol, but may not prevent heart disease. The study may or may not apply to my patients: a search of my EMR today shows me that two patients are taking the drug. I have asked our FHT clinical pharmacist to review the information, and to log in and see if it applies to my patients. She will also prepare a summary for me. I will review that, and draft a letter. Her summary will also be forwarded to my FHN colleagues; thanks to our experience with preventive services, we are familiar with the process of mailing information to patients as a FHN, and not just individually. We will then decide whether such a mailing is needed. We can accomplish far more as a group than individually.