Wednesday, July 16, 2008

Power outage

We had another power outage last week, this time for over an hour. It is hard to keep working when the power is out; however, my back-up systems worked.

My routers are plugged into an Uninterruptible Power Supply (UPS) box; if the power goes out, the UPS battery takes over. The two front computers are also on UPS. The Tablets are battery powered. The UPS battery only gives you a half hour of power; we have to shut down the front computers after a short while. However, the routers use so little power that they can function for quite a while, so access to our remote server was not interrupted.

The fact that we still had computers working gave my secretary access to the scheduler; she was able to call several patients to let them know that the power was off, and some appointments were rescheduled. Our phone system was down (the phones are dependant on electricity), so we used cel phones.

We were still able to see patients, to some degree. Only two of the five exam rooms have windows, so me and my practice partner were down to one room each. Although all the Tablets worked, none of the printers did, so I could not print lab reqs, prescriptions or handouts. I have frequently emailed handouts to patients, so I just switched to email for this. I left some prescriptions in the chart (issued, but not printed), and asked the patients to call in their pharmacy numbers later; I sent this as a “to do” to my secretary. I had a pharmacy fax number on file, so I emailed that prescription via Internet fax; fax via the phone line didn’t work (our fax machine and fax box are electricity-dependant), but I could use my Internet fax, which did work. For the lab reqs, we used blank forms and my lab tech had to copy the patient information by hand.

It is not fun to work without power, but it can be done in an EMR office; as in a paper based office, you are limited to where there is available light, and many things (especially peripherals like printers and labelers) don’t work. You need to have the critical components (routers, your server if you are on a local system, at least 1 front computer) plugged into UPS devices; for offices using desktops only, it may be worthwhile considering having a laptop in the office to take over from desktops. You will also need 1 wireless router, and make sure that it is plugged into a UPS. I can see that offices in remote areas (or even not so remote, like my cottage, which has chronic power outages) also need to have a generator as back-up.

We had a group EMR learning session in the evening, later that day. My FHN lead had arranged for a room and projector at our hospital. Because the server is at the hospital, I can plug my Tablet into a network jack and have access to the EMR from anywhere within the institution.

Space and equipment to set up a Booster learning session may be a problem. Some groups have access to their own boardroom, with computers. Some, such as my group, don’t have access to this (we are a collective of small, independent offices). The Boardroom approach is best, I think, because everyone can log in to their EMR during the session and follow along. However, the simple setup with just a room and projector, worked well; I think most groups may be able to get that from the local hospital. You have to make sure that you can log-in to the EMR. Failing that, see if you can get a demo CD ROM of the application from your vendor; you can set the demo version up on the laptop attached to the projector.

I had done individual visits to each of my FHN colleagues in May, so I was familiar with the questions that they had. Several problems had been solved while I was on-site. A group training session is a bit less useful (all of us are at different stages of implementation), but is more efficient; individual visits are hard to arrange. I am very familiar with small group educational sessions, because I have been a facilitator for my own Practice Based Small Group for over 10 years; I think this is a fairly effective way to learn things. There is no question that we need on-going training, and that this is not well provided through the EMR companies, if done at all; the lack of on-going education is something I’ve heard from colleagues using several different EMR systems. We do get the initial training at start-up, but afterwards, education is very haphazard.

We spent about an hour and a half at our small group booster session, going over several things. If you would like to see the basic layout of the session, it is below; some of it is specific to the EMR we use, some is likely generalizable to most EMRs.

Booster session July 8, 2008


  • Basics: using quick fill in encounters: start typing the name of a favourite drug, and the rest auto-fills. If there are several dosages (example, amoxil), pick your dose from the drop down list (amox susp 125 tid x 10 d; amox 500 tid x 10 d)
  • Expiry date: that is what makes it stay on or go off your CPP
    • Short for short term drugs
    • Longer (eg, 1 yr or more) for long term drugs

  • Discontinuing or modifying drugs in the encounter: double click on the Medications tab, then pick Update or Discontinue.

  • How to check drug interactions before you prescribe: click on the checkbox for the drugs you want, and then click the “interactions” button on top.

  • Hx button: check on what happened to your drugs; you get a quick history of what you did (changed dose; stopped drug because of adverse rxn; drug no longer needed etc)

  • CPP, Archived to see previous drugs, or double click on Medications in Encounter

Lab bundles and diabetes

  • Using bundled labs: all the recommended annual lab tests are saved in the “diabetes” lab, which everyone now has. Double click on the requisitions tab, click on the checkbox for the “diabetes” lab, then Sign and Print. If you want to add more tests, click on the blue link for the lab test, Open, and then add extra tests. Save, Sign and Print
  • If you have a lab that you would like to re-use (example, annual check-up, female), click on the “save as favourite” checkbox.

Practice functions

  • Dashboard, My practice: click on the MyPractice tab to see how many of your patients are overdue for preventive services
  • Dashboard, My Settings: use that to change your overall preferences
  • Adding tracked diagnoses to Dashboard: Use MySettings, MyPractice to pick what you would like to track (example, how many diabetic visits you have per month, and per year); this is updated daily, overnight
  • Checking your overdue preventive services list: go from MyPractice, click on the blue link for your service and it will bring you directly to your list of overdue patients


  • Code long term conditions through Assessments in Encounters or in your CPP. **Do not use free text for Assessments in CPP, these cannot be used reliably for registers or for tracking**
  • Do not code if you are not sure (example, better to code 786—respiratory problem not yet diagnosed-- than 493 for asthma, if you are not sure the patient has asthma); when you go to Reports to pick out your conditions, you only want to see patients who actually have asthma.

Thursday, July 03, 2008

Lost in Transition: why residents use EMR and the rest of us don't

A large US survey of EMR adoption was published today in the New England Journal of Medicine. It found that "fully functional EMRs" exist in only 4% of practices.

Welcome to medicine in the 21st century: information starvation in the midst of data plenty.

It is still too hard to implement an EMR, and full implementation continues to be the exception instead of the norm. In the NEJM article, younger physicians were more likely to adopt (same as for the Canadian National Physician Survey); perhaps it will be the next generation of physicians who will practice in an electronic office, and not us.

We have two residents who started today in my practice: one starting with my new partner, and another one starting with me and my "old" partner, who is away this week. The new residents will be with us for two years; most of the time, they are in the practice for a half day a week.

Here is what it took to get the residents set-up: a computer for them, a registration in the EMR with permissions set at the Resident level, a log-on ID and a security FOB. I bought a Tablet for residents two years ago, as my department recognized that this was needed for teaching practices, and funded an extra computer for learners. I know how to set up all the basic log-in, so it did not take long, but it still needs to be done by someone (either a physician or a clinic manager). There is extra work for EMR set-up, which does not exist for paper-based practices.

My new resident came at lunch time, and my clinic manager oriented him to the practice; she gave him his security FOB. We logged him on to the resident Tablet, and he set up his PIN. I set his basic chart preferences to make sure that they were the same as mine; I don't know if I have the "ideal" preferences set-up, but it seems to work for me, and I'll be showing him how to use the software.

My resident followed me for the rest of the afternoon. I showed him how to load encounters and CPPs. He took his Tablet in, so that there were two computers in the exam room. He saw how I was using my Tablet, which helped give him a sense of how the EMR works and can be used in a patient encounter. He could also load screens on his Tablet during the encounter, since he had the same electronic chart open as me, but on his own machine.

He saw me touch type while talking to patients, write prescriptions, do a consultation letter while in the exam room, look data up in various areas of the chart (CPP, DI, labs, flowsheets), order labs and Diagnostic Imaging electronically, respond to pop-up alerts and other care reminders, and use e-messaging and Office Actions sent to staff. While he was there, an electronic message came in from our clinical pharmacist via remote access from another site; she had reviewed a problematic case for me and sent some suggestions in the patient's chart. She had also emailed me a relevant article via regular email.

My resident had never been in an office using EMR. He will only use EMR while working with me; there is no choice, since there are no paper charts. I spent at least as much time teaching him the EMR as discussing clinical matters. I don't think that's bad for the first day, since his care will depend on his familiarity with the chart.

On the other hand, he has access to all my saved favourite drugs, all my batched labs, all the CPPs are in the EMR, and drugs automatically go into the encounter. There is also a lot of knowledge in the office about what to do when computer problems happen.

I simply cannot imagine that he will be willing to revert to paper after two years here. Many of our residency teachers affiliated with my hospital have now switched, or are in the process of switching to EMR. We have 8 academic Family Health Teams in Toronto, and these are the teachers of family medicine. Although not all have implemented, three now have (including our FHT); all units have either bought or are considering buying EMRs. I don't know if EMRs are more common in practices that teach, but this is worth exploring. I think many teachers are modeling EMR use for our new physicians.

We get new residents every two years. While one resident will be exposed to the initial pain of transition, the next one will see the EMR at a later stage.

I think many residents will use EMR during their training, and will then start working in practices that have computerized. The rest of us will have far more difficulties.

My practice partner is away this week. He decided to spend the week at home, and use some of his time to catch up with his work. I sent him aan EMR message about whether he wanted me to look at his results during his week off, and he emailed me back (in the EMR, via remote) that he would take care of them. He is now used to looking at the EMR via remote access, and can see all his labs and scanned reports. A student started entering his CPPs as of yesterday. Remote may well be one of the most useful features of the EMR for him.