Sunday, December 21, 2008

After the upgrade

We are now a week and a half post-upgrade. My stomach acid level is starting to decrease.

As expected, we had some problems with the printers. In my office, my prescriptions wouldn't print from the application. I took screen shots and printed those, then hand signed them.

The problem was due to the Java program. It doesn't work properly with the new version. Java allows me to sign my prescriptions and consult letters on my Tablet. I found that when I disabled this feature, I could print; some pharmacists are going to be happy--I can't sign on the tablet any more.

In order to determine what the problem was, Helpdesk had to remote into my tablet to test things, which took about an hour. I have spare laptops, so I could keep working while this was going on. I told them that I could live without the signature for now; that can be fixed later.

We then had trouble connecting to the EMR on Friday. Everyone assumed it was because of the upgrade, but in fact it was SSHA (now called eHealth Ontario) that had a service breakdown; it took quite a while for our IT guy to determine what the issue was. Late on Friday afternoon, he reported that the issue at SSHA was "flapping vanes" (I have no idea what that is), and that they had resolved it.

By Monday, the system was working again.

I then started to have a look at what is new in the EMR. We have a pretty good method of generating lists of rostered patients meeting different criteria (not previously available). I could more easily generate a list of percentages of elderly patients who have had their flu shots this year; we are currently at 77.9% average for 12 physicians (2,965 eligible patients), with 50% of the physicians having given shots to over 80% of their eligible patients. Last year, we ended up with 71% of patients vaccinated.

We have until the end of January to complete our flu vaccinations, so I expect us to go over 80% as a group.

We mailed letters of invitation once the shots came in; we had our clinics set up, with the help of FHT nurses. In early December, our FHN admin sent a reminder letter to all patients who had not had a shot yet. I think our preventive group project is working well.

The new upgrade includes automatically generated and tracked lists of patients overdue for Fecal Occult Blood screening, similar to the four preventive services (flu, paps, mammos, Kids vaccines) we currently track and manage as a FHN. We previously had to program FOB screens individually. I think I will use the Summer Students to enter the initial data, and then we'll add this service to our current regular mailing, which is done every 3 months.

I will be having a look at the other goodies in the next few weeks, and then will plan an EMR booster for the group in the new year. I think EMR upgrades are all like that; expect some initial glitches, work to solve them, then go on to figure out what is new and how to implement it.

Our FHT clinical pharmacist is currently under-used. I think the problem is that she doesn't come to the different offices on a regular basis, so we don't always think of her. This is a new service in family medicine, so it will take a while to work in; talking to the pharmacist in person is pretty vital to integrating her into the practice.

We negotiated this with our FHT medical director. She agreed to have the clinical pharmacist spend a morning every second week in my practice. I am ready to let her prescribe for my patients, as she has the skills and knowledge to do so. We have worked on medical directives together, and I am ready to sign the document allowing her to prescibe. I will also have to change her EMR permissions with respect to prescription rights. One of the problems that I foresee is that community pharmacists may not be familiar with directives, and may not accept a prescription signed by a clinical pharmacist. What worked in another FHT is having the pharmacist call the prescriptions in after issuing them (but not printing them) in the EMR. We can do that as well, or the FHT pharmacist can assign the call to my front staff electronically. We'll have to practice this in January.

We have applied as a group to QIIP, the Quality Improvement and Innovation Partnership. I will be going with our FHN administrator, my RN, our dietitian, our clinical pharmacist, and perhaps our Social Worker as well. The plan is to use the Team to improve office efficiencies, care for diabetes, and colorectal screening. Although they say an EMR is not a requirement for this, I think it is pretty hard to really implement quality improvement without electronic tools--especially those that allow measurement of quality.


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