Saturday, November 15, 2008

The first year of computerization

I will be presenting a workshop on the first year of computerization at our national family medicine conference, in two weeks. I am doing this with a colleague, Dr Stephen McLaren.

I wanted to do this with someone who is practicing in a different setting, and is using a different EMR system. Whenever I do a workshop or presentation, I find that I learn a lot just through preparation; it was the same here.

My colleague has been using his system for almost ten years. He practices in a large group; I was in a small office of two physicians, and my partner did not wish to implement an EMR at the beginning.

When we started talking about the presentation, I think we assumed that there would be large differences in our implementation. In fact, there were far more similarities than differences. Our goals were the same, and the difficulties we encountered (especially with regards to the problems of external, non electronic data) were similar. The solutions and work arounds we came up with have differences, which fit our individual settings and styles. We even found that the challenges of dealing with our EMR companies were similar.

There are no secrets to a successful implementation; it is the same as any other large scale change: "Plan-Do-Study-Act". The first year is very hard; the rewards (increased efficiency, ability to improve quality) do not come until later, once all the data is in, and the EMR system is used consistently. I believe that there is now enough practical knowledge about what works and what doesn't to make the transition a bit easier, and that's what the workshop is all about.

Our practice team is slowly learning how to use the chart in common. This works best for those of us in the same office: my front staff and my practice RN enter everything in the EMR. We hired a new secretary in September, as well as a high school student for evening relief, and there were no training issues; they used the EMR from the start. Our Family Health Team pharmacist, who usually manages patients off site, came to my office to see a challenging patient with me, and while she was there we discussed flowsheets. I showed her how they worked, and told her that she was welcome to enter data there if she felt that it was relevant to team care; our RN, for example, routinely enters data in the diabetes and depression flowsheets. A few days later, I noticed that the pharmacist had entered information remotely into a chronic pain management flowsheet.

We have had a lot of staff changes with our dietitians and social workers, which has made implementation of a team approach more challenging; these practice team members never had a chance to start the EMR before they left. I received the first clinical message from our new dietitian, as she had a question about a patient she was to see the next day; she is enthusiastic about the technology, which is helpful. While our Family Health Team has not yet discussed where our Allied Health Workers should chart things, I think they should write in the same clinical notes as I do. I don't know if it is necessary for me to review all their notes (likely not); our clinical pharmacist sends me a message to look at her notes when she is done. We should think about whether it is better to do it this way, or better to have the physician sign off, which is what I do with my RN, or have the physician co-sign; this should all be negotiated.

I am currently attending a research conference, NAPCRG. I consider this work, so I told my practice partners that I will be checking in daily for my results. It was very busy before I left, so I did not complete some charts; I needed to go home and pack. I finished my charting from my conference. Remote access makes going to a conference a lot easier to do, and I don't feel like I am burdening my partners too much. Most of the coverage while a physician is away does not involve seeing extra patients, it involves reviewing and managing lab results and other incoming tests and consultations--these can all be done remotely.

My older partner is now six months into EMR implementation, and although he is charting pretty much everything electronically, he is not prescribing. He types the prescription into the clinical notes, and gives patients a hand written script. I asked him if he could prescribe faxed-in refill requests electronically for me while I am away; as of now, he writes "ok" on the faxed request, the secretary calls it in and the paper is then scanned. That is not useful for me, as it does not update my electronic meds. I showed him the process for managing this electronically: the secretary leaves the paper form for him, he loads the patient's chart, checks off the meds, hits the "print" button, then cancels printing. This generates the refill. He then sends an electronic message asking the secretary to call it in, with the phone number.

This process is more tedious for the doctor than writing "ok" on the paper form, but it does preserve the integrity of the data (which is lost with the paper form). I have been strongly discouraging the use of faxed/phoned refills; we have a message on our machine that we do not accept them, and we charge $25 for this service--with exceptions in some circumstances. I do not feel that phone/faxed refills, with no patient contact, represent good care; my patients are always given enough medications to last until the next appointment. There is no quick and easy way to manage phoned refills in the EMR, and there is no clinical necessity for the majority of those--they are often done for convenience.


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