This image above shows an example of automated data capture with the EMR; I am now tracking data on my visits for several different diagnoses. I can see that my annual check ups are stable, visits for common colds have seasonal patterns, and that I have changed my practice towards more chronic disease management and away from the treatment of acute, minor conditions.
The chart above is for the number of visits billed for hypertension; these are clearly declining. This is interesting to me, because it reflects the outcome of a number of changes I have made in my management of hypertension.
I use an automated BP machine in my practice; my staff do the BP readings, not me. I think the quality of BP readings in my office has improved as a result. Patients come in every 6 months if their BP is stable, consistent with current evidence. If BP reading is above goal, they are asked to drop by on a Friday (I am not in the office that day) to obtain an additional BP reading from the machine. These visits are not billed. I see the result remotely, and can send a message to obtain one more reading if needed, or to ask my secretary to book an appointment for medication optimization.
I also use home BP machines much more often. I have two loaner machines in my office.
The end result is good BP control, but fewer visits with the physician (see graph above). I don't think that routine BP measurement is a good use of my time, but I have switched from Fee for Service to a capitated payment system; this rewards efficiency instead of service intensity--there are pros and cons to that.
I can look at my data and plan further improvements because I now have "Well-Tempered charts". What I mean by that is that I have tried to enter good data, and to enter it consistently so that I can search it later. It was a learning process for me; I knew that my data would not be very good in the first year, and would then improve. I now enter "250" (diabetes) only when the patient is diabetic, and not when Impaired fasting glucose (or "pre-diabetes") is present. If I think the patient has angina, but I'm not sure, I will code the diagnosis as 785 (chest pain not yet diagnosed), comment "possible angina"; I code for angina, 413, only once I have the diagnosis. When I search my records, I now know that my diagnoses are highly specific (finding a code for diabetes means that the patient is truly diabetic). The searches may be less sensitive (may miss some diabetics), because some of my patients with pre-diabetes actually have the disease but have not been diagnosed yet.
This coding schema in my brain applies to important chronic conditions, because I really do want to identify patients with on-going problems that I want to manage better. I am less careful with minor conditions, such as colds; I may identify a cold as laryngitis or acute bronchitis (when they get an antibiotic).
Even though the EMR system allows me to use free text for conditions, I have limited this. I think trying to search for "DM II", "diabetes", "T2D" etc has far less value that coding the problem properly--even if you never misspell the condition.
Every prescription is entered in the EMR database; I avoid "free text" prescriptions whenever possible. Once I built my list of drug favourites, prescribing through the Multum database became much faster. All phone repeats are entered as prescriptions. I can now search through my prescriptions with a great deal of reliability.
Entering data is a pain; getting data out is the real gain. We need to think about the minimal requirements for the Well-Tempered chart, and I have outlined what I did above. I think coding correctly for about 10 common chronic conditions (DM, HT, depression, Asthma, COPD to start with) is a good start. Using the EMR to prescribe is helpful. Switching to labs that provide electronic results is a very good idea. None of this is terribly difficult, but it does take some effort to learn how to do it, and some discipline to enter data consistently.
JS Bach showed us that well thought out, orderly musical compositions are pleasing to the ear. I think we can learn from the Master, and apply his principles to the content of our records.