Upgrading the office hardware

My tablet is now 3 1/2 years old; that's old for a computer!  It is still working well, but I expect it to have an increasing number of problems over the next few months.  It is time to get a new machine.

The other computers I initially bought are all desktops, and are functioning well; I bought pretty solid Dell business machines.  These two computers are used at the front, and are limited to business functions only.  One computer has the scanner and fax machine attached to it, and our IT manager added some extra memory a few months ago.  I have a second scanner attached to a newer computer in the staff room, and a second fax machine in the staff room in case of failure--we have had to learn to plan for redundancy over the years.  It looks like we can get a number of extra years out of the two computers at the front, although they will eventually fail and have to be replaced.

As we grew, I added more machines.  I tried to keep the new PCs the same (all Dells, all Windows XP), so that maintenance would be easier (same look and feel, same software).  There are now six desktops, four Tablets, three laptops and a Netbook in the office.  We have two scanners, two fax machines, and four labelers.  We have twelve printers; nobody has to walk very far to get a printed document.  Everyone has ready access to computers.  All this is for a (paperless) three physician office.

I talked to our IT manager before buying the new Tablet.  I have to decide what operating system to buy (XP vs Windows 7), and which machine.  I use the Tablet every single day; I decided to upgrade to as much RAM (4 MB) and to as fast a processor as they had available.  I added three years of on-site warranty. My IT manager recommended that I downgrade to Windows XP, so that the machine would be fully compatible with the rest of my office network, and I have done this.

I will have to start thinking about what to do to upgrade the entire office, as our machines age.  This is becoming a more complex issue due to the number of machines we have.  My colleagues in our Family Health Organization will have the same issue, as we all bought our hardware at the same time.  We should probably  put this on the agenda at one of our IT committee meetings.

As you can see, we have more IT help and organization than when we first started.  We have an IT committee, composed of two representatives from each of the two Family Health Organizations on our server and our IT manager.  Our IT manager oversees the functioning and daily maintenance of our common server, and recommends server upgrades as needed.  Because all FHO offices have similar hardware and software, our IT manager is able to provide some support for in-office issues over the phone (as he is now very familiar with what is in the offices), and we are experiencing far fewer hardware failures than in the first two years. 

We are also starting to have a bit more IT structure for our Family Health Team (which is composed of six different Family Health Organizations).  The FHT has an IT manager to oversee issues for the administrative office, as well as for the new FHT Allied Health clinical offices; this office was used for our H1N1 vaccination clinic, and is now slated to open later this month. It is two doors down from my office.  There are a lot of computers there as well.

Last week, my eHealth Ontario internet connection was failing:  it started to run more slowly, and would intermittently disconnect.  The problem was isolated to the SOFA (Small Office Firewall Appliance), which is the router supplied by eHO.  The SOFAs for all the practices here are now in the phone room of our floor, and the FHT's IT manager looks after problems for that equipment.  He disconnected the malfunctioning SOFA and plugged my office into another office's SOFA as a temporary measure (worked well), and then notified eHO.  They shipped another router by the next day, and we were back in business.  Frankly, I like this managed approach much better than the old panic attacks at my office.  Support makes a big difference; working as part of a larger group of practices helps; having an organization behind you is good.

We are starting to enlist the help of our patients.  I received an email from a patient asking if we had a "preferred lab" in her area of the city.  We are making a concerted effort to direct patients away from non-electronic labs: we have handouts on lab locations, and we call the patient if we get a lab result on paper (they get asked to avoid that facility in the future).  A patient with a complex health condition said that she takes the printed CPP I give her to all the different specialists, because it helps them keep track of her overall health; she is very picky about making sure that I update the CPP properly, and we do this together.  She can see that most of the specialists do not use computerized records.  Another patient was furious about the fact that the hospital never sent me anything, despite the fact that she gave them directions to forward the information to her family doctor.  She is going to complain to her Member of Parliament about the facility's lack of abilitiy to send her data electronically.  Maybe we can partner with our patients to push for interconnectivity; after all, it is their health and their quality of care that is affected by the fact that their data does not follow them.  Disconnected care is bad care.

Michelle

H1N1 vaccination clinic and EMR

Our H1N1 vaccination clinics are now running at full capacity, five afternoons a week. All Family Health Team physicians have volunteered to staff the clinics. Family Health Team RNs have been withdrawn from their regular duties in our offices, and are staffing the vaccination clinics.

We are running this at a single location for all 53 physicians in the FHT, and this was all organized in a few days. We are currently vaccinating high risk patients in our FHT. The clinic has one administrator, three nurses and two physicians. We vaccinate about 360 people in 3 ½ hours.

The clinic is two doors down from my office, and I see the line up in the corridor when I poke my head out the door. The waiting time is about 40 minutes, and nobody has to wait outside in the cold. Patients getting vaccinated are in a different location than those coming in to see their family physician for the flu, so this approach limits viral transmission. We have had very good feedback on our clinic from patients getting vaccinated.

The vaccination team holds a debriefing session at the end of each clinic. They review their processes, identify bottlenecks, and quickly implement changes.

We use the EMR to record data, because otherwise we would have to keep enormous amounts of personal information on paper (the consent forms, the name of each patient getting the vaccine, their ages, gender, and risk category). The FHT, as an organization, does not have a mandate to hold personal information, nor do we have storage facilities for this at our central FHT office. In Ontario, all patient data has to be kept for a minimum of ten years; for children, until they are 28 years of age.

The first issue that we ran into is that we do not have an integrated EMR for all FHT physicians. There are two EMR software applications being used; the larger one, which my group uses, is split into three databases (or enterprises), one for 14 physicians, one for 9 physicians and one for 20 physicians. The physical location of the offices does not matter for data entry, as it is all done remotely—we log in to a server located off site. The other EMR, serving 10 physicians, uses software on servers located in individual offices, so there are actually a larger number of individual databases for fewer offices. You have to have a different log on for each database, and you have to establish remote access.

In a FHT-wide program, especially where speed is key, you cannot have multiple different log-ins. What I mean by that, is you can’t have Mr Smith, who is in Dr A’s practice, having demographic data and H1N1 immunization entered in Dr A’s database, then Mrs Jones, in Dr B’s practice, comes, and the clerk has to enter demographic data by logging into a different database etc. It doesn’t work because it is too complicated, is too much additional work, and slows things down too much.

We decided that all data entry was going to be done in the 20 physician database. Here is the process:

1. the patient checks in, the clerk swipes the health card
2. if the patient is already in the current database, the system recognizes this and automatically registers the patient. If not, then the swiped card automatically adds data to the EMR (name, date of birth, health card number, gender), and the patient is entered as new
3. patients are sequentially added by the software to the schedule, so that the clerk can see who is next in line when calling patients in.
4. The clerk gives the patients the screening form, and the patient waits until called in to see the nurse.
5. When checking in, the nurse reviews the data; an encounter is opened, which contains the screening questions as checkboxes, all defaulted to no (most patients are all “no”). If there is a “yes”, the nurse changes that, and notifies the physician
6. The patient signs the consent electronically on a signature pad, and this is saved to the EMR.
7. The physician sees the patient and gives him or her the H1N1 vaccine. Lot numbers and dosages are pre-set as defaults. The dosage is changed if this is a pediatric injection.
8. The encounter, screen, consent, signature, and vaccination are all electronically saved in the EMR.
9. The patient goes to wait for 15 minutes in our post vaccination room, which has chairs and a television. They are given a paper to inform their family physician of the vaccination. If there are any reactions, these can be entered in the correct field of the EMR, so that the data can be extracted later.

The first day that we had the clinic, the waiting time was longer. The rate-limiting step was the screening; the initial EMR screening template used drop down lists, so all information had to be individually entered, which slowed things down. Once it was changed to checkboxes defaulted to “no” for all screening questions, this was much faster. The change was implemented at the end of the very first clinic.

One early challenge for us was not setting up and managing the clinic, it was communicating with Public Health. They had a great deal of difficulty letting us know if we would receive vaccines so that we could run our clinics and take some pressure off their own, overwhelmed vaccination program—and a few days later we heard that a private clinic downtown had been sent vaccines for their “executive physicals”. I understand that this will be investigated.

The vaccine supply chain at Public Health runs well for our regular supplies; it appears to have been initially overwhelmed by this large scale H1N1 program. I cannot tell where the internal problem was; I hope that processes similar to our daily debrief and rapid improvement cycles have been implemented. The problem at the present time, as I understand it, is vaccine shortages due to manufacturing problems.

We do have ongoing issues with our local Public health unit; as an example, we do not have an efficient method of reporting issues to them (usually this is by fax or by phone). For those of us on EMR, the issue is even worse, as they insist on paper-based proprietary lab reqs and will not accept anything generated out of an EMR; I cannot track HIV tests in my practice to ensure that I have received the result. I think the Public health unit does an excellent job in many areas, such as their “safe dining” restaurant program; however, they do less well when communicating and collaborating with family physicians.

The EMR company has programmed software to extract the data that public health needs in an excel format; we should be able to extract information such as age, gender, vaccine lot number, adverse reactions so we can report for our large clinic. This is a much better way to report than duplicating the information on a piece of paper for each patient. Perhaps we’ll eventually have a secure electronic method for forwarding these data; wouldn’t it be nice to be able to automatically send data on child vaccination to public health.

I am pretty proud of this Family Health Team for doing such a great job of organizing and managing this project. I think there are a couple of early conclusions that I am coming to:

1. This couldn’t have been done without a good organizational structure. Primary care has traditionally been composed of individual offices, often working in isolation; we are now moving towards more organized groups (Family Health Groups, Organizations and Networks, Family Health Teams)
2. EMRs are part of this new organizational structure. Newly forming groups should consider having one common database for all offices if they want to run projects in common in the future. This can be done with many of the EMR applications being sold
3. Local Public health units need to consider primary care as an integral partner. The experience with SARS shows that these new diseases often show up in our offices first. Talk to us, work with us, we can help you.
4. The IT infrastructure at Public Health may need to be revisited. They receive large amounts of data, and they need robust systems to analyze and manage the information. During SARS, information was tracked via yellow sticky notes on the wall; I hope it is different now. Upgrade Public Health lab to electronic reporting standards. Work on having EMR data from family practices reported electronically to the local Unit.

I think this H1N1 vaccination clinic is a beautiful example of a large, geographically dispersed primary care team banding together to provide needed services, quickly and efficiently. The EMR in this case is an important facilitator, but the key aspect was leadership and group cohesiveness. Family Health Teams are a fairly recent initiative from our provincial Ministry of Health, and our experience shows the value and benefit of this approach. I hope the FHT program will be expanded and offered to more of my colleagues in family practice.

Michelle

H1N1 influenza

There are increasing numbers of people with H1N1 influenza reported in the past two weeks. This feels a bit like SARS did in 2003 (my hospital was at the epicentre of the second Toronto outbreak). However, we are better prepared now, and I have electronic tools, both EMR and web based.

Public Health is running H1N1 vaccination clinics for the public. Their initial mail out about vaccine requests to family physicians almost sounded like they did not want us to order the vaccine: only order in lots in multiples of 500 doses, reconstitute vaccines with adjuvant and use the ten reconstituted doses within 24 hours. Send a report on the number of vaccines, number of males, numbers of females, ages, high risk conditions to Public Health every Monday by noon (their faxes are going to be very busy on Mondays, we may not even get through). There were also additional conditions for ordering this vaccine. I was told by a colleague who is a Medical Officer of Health that he was advising family physicians not to order the vaccine, due to the complexity of managing it.

I can understand that the requirements for this vaccine are different from the usual flu shot, and some of the problems are due to vaccine packaging, but the result is extremely long line ups for the Public Health clinics in Toronto, which are currently overwhelmed.

My Family Health Team quickly organized a common vaccination clinic for the 53 physicians and 60,000 patients registered in our practices. Our FHT executire director is pulling nurses out of offices, and most of our physicians have volunteered to man the clinic. This was all arranged by our executive team over email. All patients are being directed to the FHT clinic for H1N1 vaccinations, and we will not be running clinics in individual offices. I have added information on our clinics to our website.

We are getting more patient phone calls at the office about what to do; I post announcements on our practice website, http://drgreiver.com , and my front staff is re-directing inquiries there. This is helping us to keep the phone lines reasonably free, so that patients who do need to get through on the phone can get through. I am also getting a much larger volume of emails from patients than usual, and I am able to redirect these to our website as well, so this is currently manageable. Volume of visits to the website has more than doubled, but volume of visits to the office is holding steady so far.

The EMR company has added new vaccination profiles for the H1N1 (both adjuvanted and unadjuvanted) so that we can quickly enter the data. My colleagues in Nova Scotia have reported that their Public Health authority can obtain weekly reports containing all the data needed (without patient names), directly exported from the EMR, under the authority of the NS Provincial Chief Medical Officer of Health (through the Nova Scotia Public Health Act). What a fine example of collaboration between Ministry of Health, Public Health, EMR company and physicians! I wish we had this in Ontario; it really represents a good example of the reporting power of the EMR, especially under strained conditions, but it needs to have a health care system that is less fragmented than what we currently have in Ontario. One physician said that we should be using a similar system to report routine vaccinations to Public Health, something which is currently fully paper based.

Because of the size of our FHT, we have administrative support to enter data directly in the EMR when patients come to one of our H1N1 clinics, and we will be able to generate data similar to Nova Scotia's. Hopefully Public Health will accept our reports as long as the needed data is present, without requiring it be entered in their proprietary excel format (or worse, on paper).

Just prior to the outbreak, I volunteered to program the Public Health guideline on the diagnosis and management of H1N1 influenza as an EMR template. We had enough time for several colleagues to test the template and offer feedback; it was modified to make it as useful in practice as possible, and I then added it to all three EMR enterprises for our FHT. We now have a common management tool, with clear information on when to prescribe Tamiflu available to physicians electronically, and it is currently being used. Perhaps in the future we will be able to export this to Public Health in an anonymized fashion as well.


OntarioMD announced this week that about $280 million will be made available to subsidize EMRs for the majority of Ontario physicians. The subsidy is $29,800 for those using an ASP model, and $27,100 for those using a server located in their own offices. These amounts are very similar to what physicians in my group received, and will cover about 70% of the cost of EMR. I think we will now see large scale computerization in Ontario; this step is done in conjunction with eHealth Ontario, and this is the right approach for them to take. The auditor general said that there was no traffic on the super-highway that eHO built; having data generated in the majority of physician offices will put traffic there. Once we are computerized, we quickly learn to dislike non electronic data generated on the outside. However, there have been too few of us on EMR to generate the kind of pressure needed to get other organizations to connect to us for incoming data and stop using paper-based processes for outgoing data; I think this is about to change. I expect to see a lot of changes in the next few years; I think a lot of early adopters will also be kept very busy helping our colleagues implement and use their new EMRs effectively.

I was asked by a perceptive journalist if I still expected to be writing this blog over three years after EMR implementation started in my practice. I have to admit that I did not; I thought things would be settled and going smoothly by about 18 months--how wrong I was. It now looks like I am going to continue this journal; thank you for bearing with me through these interesting times.

Michelle

Open Access

We are continuing to implement new things in my office. Here you see an initiative to decrease the number of days that patients have to wait until they get an appointment. We count the "Third Next Available" appointment every Tuesday, and average it for each month. By Third Next Available, I mean that we look at my schedule, and see when the third next open slot is. This is the best way of measuring access to the physician. We went from 23 days to 11 days to 5 days, and last week, we had our first zero: you called that day, you got an appointment that day.

My practice Team is part of QIIP, the Quality Improvement and Innovation Partnership. We are using multiple Plan-Do-Study-Act cycles to change the way we work. It has been hard; after all, routine is comfortable and change is not. However, we are making progress on many fronts.

Part of what you are seeing up there is the result of multiple changes to improve efficiency; we are now trying to do everything when the patient comes in. If you are in for a cold, and the EMR shows that you are overdue for a foot exam for your diabetes, there is an alert in the chart and you get offered a foot exam. If you come in for a rash, and you are due for a Blood pressure check, you also get a blood pressure check. We use the phone a lot; my RN checks in by phone to follow up with patients who are depressed--we use the EMR for messaging about this. We distribute tasks: our Team Clinical Pharmacist now sees several of my diabetics for their routine follow-ups, and monitors all their parameters. I am always on site and available when she is seeing them, but it gives me the time to deal with more complicated problems. My Team is testing a much more complex EMR-based flowsheet (the Chronic Disease Management flowsheet) that incorporates templates that are linked to the CDM flowsheet, along with automatic time-based alerts--and other people in our Family Health Team are interested in doing this as well. In my practice, we have agreed on common ways for all of us to enter data so that it can be extracted to monitor our quality.

I don't just want to cut waiting times for our patients, I also want to maintain or even improve our quality. However, if there is no access there is no quality, so you have to work on both at the same time. I often hear about the effect of EMR on efficiency, and I think what people mean when they talk about this is how fast charting for encounters is, or how fast you can access information when seeing a patient, or how long a consultation takes. I think there is another dimension to efficiency, and that is how well the EMR helps you manage your practice as a whole, and how well it helps you function as a team. If these things improve, then you can see your patients sooner--efficiency gains translated as improved patient access.

Interestingly, the move to the new office has not translated (so far) into a significant decrease in the number of patients I look after. My current roster is 1296, down from 1306. What I have to decide now is whether to open my practice up to new patients again; if I do that without planning, then I think access will worsen and waiting times to see me will increase. My staff are tracking Demand; this is how many appointments are generated each day, whether because I ask the patient to book a follow up (internal demand), or because the patient calls to make an appointment (external demand). We also recently measured how many appointments I have available, by counting how many days I am in the office and how many patients I see each day; this is Supply. Having all this data will help my Team to decide what to do in terms of opening up the practice to new patients. Clearly, if we become more efficient, then we increase Supply; the EMR is an important factor there.

My Team has decided to go to Open Access in January. Several other Teams participating in QIIP have already make the leap, and we have used materials developed in Dr Peterkin's practice (Mapleton Family Health Team) to begin to let our patients know about the change. Open Access means reducing wait times: you call and you get an appointment same day or next clinic day. I have posted initial information about Open Access in this practice here, and Dr Peterkin's poster is now on the Community bulletin board in my waiting room with a note that we will be starting a similar initiative on January 11th 2010.

Michelle

Internet speed and quality of care

I have a fast connection to the Internet in my new office. The reason for this is that we have several practices on our floor, with a lot of physicians, staff and Allied Health Providers. eHealth Ontario has provided us with a bigger connection, because we are now a medium sized business rather than a single small office.

At my previous office, I had a “regular” internet connection, similar to what most of us have at home. There was some security overlay on this connection, through eHO’s central circuits, which reduced speed. Security is important (these are medical records we are talking about), but there is an effect on speed. As well, the security overlay failed at times, which affected multiple practices across Ontario. My access speed at home, via VPN, was always much greater than at the office. The single office internet access line was shared between all of us at my office, and the net speed per PC varied, depending on how many people were using our computers: number of physicians present, front staff, residents, medical students, “special projects” (such as our preventive services audits). As well, we found fluctuations during the day: it was slower when everyone logged on together at 9 am, or when there was heavy system internet use, such as 4 pm (probably kids coming home from school and logging in).

Our server at the hospital also had an older access line, and an older firewall. This limited speed of access at times, even if Internet speed was good. The lines coming into the hospital were unstable at times, and we had several outages.

eHealth Ontario has been working collaboratively with our IT manager to solve these issues. It does not seem like a simple problem to me; there is a cost/benefit ratio to providing faster lines, and I know that funding is not unlimited. There are many factors influencing speed. However, slow or unstable lines do have an impact on patient care.

The three months before my move were more difficult than usual, with more frequent slowdowns and outages; when the system slows, we call our IT manager, and he tells us whether to switch to our backup internet line, which we buy privately. Our IT manager is allowed to handle this for our group, as it works better than having each office call eHO individually. Switching to backup means that all office computers access the EMR via VPN (Virtual Private Network); we only have a limited number of VPN passwords, so the number of computers in use is restricted. Some networked printers don’t work. VPN at the office is unstable, and logs us off periodically. Using the backup internet line does not work well for more than a few hours, but does allow us to continue using the system. Once our IT manager tells us that the eHO lines are working again, then we switch back; we have to log off, stop the VPN, wait for 10 minutes for the eHO Internet connection to come back, change some computer settings, and then reboot all the computers. Because of all the work, it is impractical to do this while seeing patients; we stay on backup and switch at lunch or after last patient is seen in the afternoon.

During the slowdowns, I often could not look at my flowsheets, and I did not print information for my patients to the same extent that I normally do—no labs, no CPPs, fewer handouts. Printing just took too long and was too frustrating. I limited the amount of information entered in the chart to essentials, and less information was coded, because that took too long. I finished charts at home. If it was really too slow, I wrote prescriptions on a paper prescription pad. Sometimes patients would ask me about results, and I just couldn’t look them up; one of my patients commented that I had problems for two of her last three visits. In addition to being unable to look at and input information, I was very distracted and upset, which made it more difficult to give my patients the care they deserve.

eHO has now upgraded our hospital line, as well as the firewall at the hospital server. Access from home is noticeably faster. However, the biggest difference is access from the office, via the new lines— we are no longer on “normal slow”: my secretaries are not frustrated with information coming in at eyedropper speed, and I can look at records without thinking about what I can or can’t do. This just feels right.

A colleague in Markham on another EMR system told me that they had two sites: one with a local server, and a second with remote access to a hospital-based server. The second site eventually switched to local because of the same issues we had (access line speed and stability). His comment: “an absolute requirement is fast, stable access to servers”. We just don’t tolerate slow access speeds while using EMR.

Despite the difficulties, I still believe that ASP (one large server for multiple small practices, remotely managed) is ultimately the way to go. We could not have done our preventive services project, our diabetes reminders and common flowsheets, or the data quality improvement summer projects if we had individual, isolated servers in each office. I believe that Quality Improvement initiatives should start and be tested within individual practices, then be spread to the group if successful. Spreading QI is much easier if you have a common server—you can have similar data entry for several practices from a single location once you all agree on what to do. However, a prerequisite for this is IT stability and speed.

We have been talking with eHO, and I think there is a good understanding and appreciation of the importance of this issue with respect to the quality of care we provide to patients. I am now seeing sure signs of progress at the front line. eHO is upgrading the Small Office Firewall Appliance (SOFA) in our offices to a more modern firewall and router system in a month, as part of a provincial initiative. The move to my new office involved a complex IT installation; however, we were up and running from day 1, due to collaborative efforts between our IT manager, our FHT’s IT manager, and eHO’s staff. My husband’s large business moved last year, and he commented that one of the most difficult aspects of the move was making sure that the IT transfer was seamless. eHO has been criticized heavily in the press for their consultants’ billing practices; it is harder to talk about what goes well, and I can say that the job was done right in this instance.

In my practice, we are now posting monthly graphs for quality in our staff room’s bulletin board (for example, percentage of diabetics reaching targets for blood pressure, cholesterol, blood sugar control); you can’t improve what you don’t measure. Perhaps we should think about having reports of system access uptimes and access speeds for practices using EMRs posted online. I think that this may give a more genuine indication of progress at eHO.

Michelle

New office

I love my new office! We spent the weekend moving in, unpacking, hanging things on walls, and installing and testing all the IT we have. Our IT guy spent several days at the office making sure that everything works. I now have a new and very fast internet line from eHO: our IT guy, the Family Health Team's IT guy and the IT guys from eHO worked together to make sure it was ready for this week--it takes a whole village to raise an EMR. The telco company was there installing our phone and fax systems; the alarm configured their system as well. We met the lab technician next door. I went downstairs to say hello to the pharmacist in our building. Our office manager seemed to be five places at once, as she masterfully directed this symphony.

We reopen tomorrow.

This office was planned from the outset as a paperless practice. I now own a large number of redundant power bars--our old office had too few power outlets. We have a lot of grommets (the little holes in desks and countertops you put cables through); the grommet guy came by today to put more in where we wanted them.

The office really has very little paper; my partner was very good about getting rid of his at the end, and we shredded everything before leaving. We found some paper prescription pads; those were shredded, except for two pads in case of EMR outage. We are not ordering Rx pads with the new address.

Here is the basic plan for patient flow:

1. EMR schedule reviewed by MD (and RN if she is there) in the morning--the "huddle". Additional instructions for staff pre-work added if needed (example, take bp).
2. patient checks in; secretary verifies demographics. If there are alerts (example, print depression questionnaire and give to pt; give pt bottle for urine sample), she completes the requested action. Scheduler shows pt is In.
3. Pt is shown into clinical area; the initial area is the central nursing station, where the BP-tru, height, weight and waist circumference are done by a member of the front staff. There is a computer there, all vitals are entered directly into the computer
4. Pt gets put into exam room; scheduler shows which room (1 to 8)
5. MD/RN sees that pt is in room on Scheduler; loads chart, reviews notifications (example, due for FOBT), sees alerts and reviews CPP/lab/Diagnostic Imaging, loads chronic disease flowsheet as needed, then enters room and greets patient
6. After exam, pt goes back to central Nursing station, gets lab req/urine sample bottle if needed, talks to receptionist on duty in that area and books follow up appointment if needed. MD/RN can send pop-up message if a specific type of follow up is needed (example, diabetes--wt and BP--in 3 months). No little line up to talk to a busy front receptionist.
7. Pt goes back out through waiting room. Scheduler shows patient is Out.

We have a large staff room for back office work. We have two scanners, one in reception and one in the staff room. There are two fax machines; faxes come straight into a PC, but in case the PC fails, the fax machine will print the document. Outgoing faxes can be done from either machine. The secretary at the front reception will be there mainly to greet patients and manage flow; the second secretary at the side reception will be responsible for scanning/uploading, and for managing outgoing patients at the central nursing station (which is right beside the reception). There are two PCs at reception (front and side); 1 PC at Nursing station; 2 PCs in the staff room; a phone beside each PC.

There is a common consult room for the 3 physicians, and the RN has space there as well; there is some room for residents and medical students to sit and discuss cases, and they have space in the staff room to type their charts. Two of the physicians have desktop PCs in the consult room; all physicians have tablets or laptops to take into the exam rooms. The consult room has 3 additional portable computers ready to go, for the RN or other Allied Health Provider to use, or in case one of the MD's computers crashes or fails. The common room has 1 outbox for faxes/papers with action needed, and 1 outbox for scans; front staff periodically check this during the day. Each MD has an inbox on their desk. There is a shredder in the room, so that paper documents can be disposed of immediately if needed. There is a shredder in the reception area and in the staff room as well.

If a provider needs to have a private conversation, he or she can go into any exam room; rooms have phone jacks, so one of the phones can be plugged in. We have increased our phone lines to three incoming lines, 1 private line, and 1 fax line--hopefully this will reduce the number of missed calls and messages left because all lines were busy.

I'm sure this won't work out perfectly as planned, and we'll have to work out kinks over time. We've been talking about flow a lot over the past few months, and I have looked at a fair amount of literature on this. I think the basic plan is sound; I'll start to find out tomorrow.

Michelle

Of concrete blocks and EMRs

I am moving to my new office on August 22nd, next Saturday (or at least that was the plan). A 20 foot block of concrete fell from the third floor on the back entrance of the building where my new office is located last Friday.

We thought the building would be closed for several weeks; the city evacuated it that day. Two Family Health Team practices had already moved in, and the FHT head office is in the building.

Over the weekend, physicians made contingency plans. The practices that had already moved in are all using EMR through remote access. A call was put out to host fellow family physicians; all that was needed for them to access their records was internet access. These physicians had switched their phone system to VOIP, so were able to port the phones to other offices if needed.

Several physicians had hired a private company to scan all their old paper records; the company generously offered to make the copies available to the physicians if needed (paper charts were trapped inside the building). Secretaries were able to access the scheduler remotely to phone patients with appointments. Labs continued to come in electronically. The main issues was with the fax machines, as these were located inside the building, and incoming information could not be accessed or uploaded to the EMR.

It was very stressful, but also very interesting to realize how portable the information now is; this was good demonstration of disaster recovery. Had my colleagues still been using paper, their patient records would have been completely inaccessible. We also continue to need to work to decrease the amount of data coming in by fax.

I updated our practice website with the information; it was not clear over the weekend what would happen.

Finally, we received word on Monday morning that the building was re-opened; access was through the underground parking, which had been reinforced. Everyone was to stay away from windows until notified otherwise. We could move next weekend, although with some restrictions.

We had developed a communication plan for my practice should the move be cancelled. Our summer students were going to call all patients booked after August 21st. We were going to update our voicemail system and website. I thought about sending out an "allpatient" email relating the issue; although we have started collecting emails, this is still at an early stage, and we cannot do mass emails for now. It may be good to try at some point in time, we may need the ability to send something quickly out to all registered patients in the event of an outbreak. I don't know if there are any rules yet around mass emails from physicians; this is likely coming, we probably should start thinking about what is appropriate and what is not.

Email communication with patients itself is becoming more difficult to manage. Although I have communicated by email with patients for over 10 years, I am not sure that I should continue to allow this type of communication. We have been discussing email at QIIP, and here is what they said:

"A clinic email address for general inquiries would be adequate and admin staff could manage the inbox. However, for services like prescription renewals, medical advice (non urgent of course) or any other service that involves a healthcare professionals, a more secure line of communication is necessary. "

Our medico-legal insurer, the CMPA, has also recommended stricter rules for email; I have added a link to their disclaimer on my email signature. Email security and encryption is impossible for me to manage; a proposed solution is to only allow patient email through a portal, such as mydoctor.ca. It costs $240 per year, and each patient must pay $20 per year. I am not sure at the present time. I like the fact that this is secure, but I'm not sure about the payment. As well, my email has now been widely disseminated; I don't know how I would manage a switch to a portal instead of "plain" email. I also frequently email patients links directly from an encounter (for example, the DASH diet for patients with hypertension), and I'm not sure if I can continue to do this through a portal. I'll have to think about that one.

Michelle

Summertime data entry

I am now back from vacation. Our summer students did a lot of work while I was away.

In the previous post, I mentioned that we have missing data on smokers; we also found inconsistencies in terms of how the data was entered if the patient was a non-smoker. In this EMR program, a non-smoker is indicated through a check-box; most patients had this data entered correctly, but some had "non-smoker" entered as free text. Our summer student was able to identify all the free text "non-smokers", by looking for terms such as "ex-smoker", "x-smoker", "quit smoking", "non-smoker", "non smoker", and entered the correct information in the check box. We now have a more accurate list of non-smokers for my group.

As well, the summer student put in an alert in all the charts of all active patients age 15 and over who did not have any information about smoking in their Cumulative Patient Profile; while my partner was away this week, I saw one of his patients with an alert, and just added the information. We'll see if this approach works.

Our summer students verified our lists of preventive services, and double checked all patients. They also checked the lists of rostered patients sent by the Ministry of Health for my group, and updated the information in the EMR.

Our FHN administrator oversaw the work while I was away. I have a lot less supervision to do now. The main problem I have is that the students did the work so fast that it was completed ahead of schedule!


The move to the new office is now less than two weeks away. I am very happy that we are not moving our paper files, this considerably decreases the amount of stuff that needs to be moved. I have discarded some old textbooks that hid in my office; I no longer look at them as they are obsolete. We have gotten rid of the vast majority of paper handouts, and now print as needed. My partner continues to have paper in his office and exam rooms; he is currently away, and will need to sort what needs to come and what can be discarded when he returns. We have a common consult room, and there is very little storage space for paper--all opportunities to retain and use paper have been deliberately minimized in the new office. The first two group practices have already moved in on the 7th floor as of last week; I went to visit them, and they are happy so far. Our new offices are much brighter and better laid out, and are taking advantage of the fact that we are paperless.

I had a look at the FHT office, which is being built next door to mine; it will be interesting to work so closely with a large group of Allied Health Professionals. The fact that we are co-located will no doubt lead to multi-disciplinary medical education sessions; we need to start thinking about how to do this.

Speed of access at my current office continues to be an intermittent problem; I have been told that this will be fixed in the new office. We have had several service interruptions in the last two weeks as well, where I had to switch over to my backup internet line. I am not sure what the issue is, but it is always aggravating when things slow to a crawl, and this has been happening all too often recently. We lost service completely a few weeks ago; eHealth Ontario arranged to have a technician come over, and we found out that somebody had pulled out our internet line in the basement! The technician felt that this wasn't vandalism, but rather an error by somebody who didn't realize what this line was; he added a label on the line warning that it should not be removed. We need a stable, fast line; this is key to a well functioning EMR that runs remotely. This function is the core business of eHealth Ontario.


I continue to move towards more prepared, pro-active care. In the past several months, my practice team has decided to help patients prepare for their annual physicals. What that means is that we mail a letter to them asking them to do their blood tests before they come in. The first few letters were sent too late and patients did not have time to do the blood tests; we then decided to send a letter at least a month prior to the appointment. As things evolved, I added a reminder for my new location, added several lab locations, and then also added a space for the secretary to put in the date of the upcoming appointment. They usually phone the patient to remind them of the upcoming appointment, but we decided not to do this anymore, since a reminder letter is being sent. I then added a comment about self management (I got the idea from an article in Family Practice Management) , and then I added the preventive care questionnaire from a Practice Based Small Group module.

Now, once a week, I look at all the upcoming physicals 6 weeks from now, and then print the lab reqs for what I want. My secretary then prints the reminder letter, and mails it to all patients. The majority of patients have all their blood tests done by the time they come in; I ask what they think of this approach, and they feel that it is much better. We have a look at their lab together when they come in, and I print it for them. If there is a problem, my nurse calls, and asks them to do the follow up lab before they come in. I think this works very well, and illustrates the multiple cycles of Plan-Do-Study-Act we are using in my office to try to improve things.

Here is the letter

Dear

**We are moving to our new location, 240 Duncan Mill Road, suite 705, Toronto, M3B 3S6 on August 22nd 2009**

We are sending this letter to remind you about your upcoming physical; Please bring all your medications with you (including all over the counter medications and vitamins); please think about your self management goals and what you would like to accomplish at the visit.

APPOINTMENT DATE AND TIME:____________________________

Please have your lab tests done at least a week before you come for your complete physical; all the results will then be available for you at your appointment and can be reviewed with you.

Please make sure you fast for 12 hours before doing the tests. You can have water, and you can take your regular pills (except for medications that lower blood sugar).

You can also have this done at any CML or LifeLab locations. Please make sure you take the attached requisition when you go.

CML locations:
http://www.cmlhealthcare.com/

Address: 4430 Bathurst St. -
Cross St: Sheppard Ave. W. Phone: 416 - 636-2040
Hours: Monday to Thursday: 9:00am to 6:00pm Friday: 9:00am to 2:00pm

Address: 5927 Bathurst St.
Cross St: Drury; Phone: 416 225-1629
Hours: Mon to Thurs: 8:00am to 8:00pm Friday: 8:00am to 6:00pm Saturday: 8:00am to 1:30pm

Lifelabs locations:
http://www.lifelabs.com/Lifelabs_ON/locations/default.aspx

149-1333 Sheppard Avenue
Toronto M2J 1V1 Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m. - 5:00 p.m.
Fri. 8:00 a.m. - 4:00 p.m.
Sat. 8:00 a.m. - 12:00 p.m. Toll Free :1-877-849-3637

4800 Leslie Street, Toronto M2J 2K9; Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m.-5:00 p.m,
Fri. 8:00 a.m- 4:00 p.m.

217-4949 Bathurst Street, Toronto M2R 1Y1
Phone : 416-675-3637
Hours of Operation : Mon. Tue. Thu. 8:00 a.m. - 4:00 p.m.
Wed. Fri. 8:00 a.m. - 2:00 p.m.
Sat. 8:00 a.m. - 12.00 p.m. Toll Free :1-877-849-3637


Preventive Health Questionnaire for Adolescents & Adults

Please complete this questionnaire before you come for your check up.
We will be pleased to help, if you have any problems or questions.

Please circle the most appropriate answer for each question: Y = Yes; N = No; X = Not applicable or Don’t know

General Safety
Do you always:
• Wear a seat belt when you ride in a car or other motor vehicle? Y N X
• Wear a helmet when you ride on a bicycle,motorcycle, or all-terrain-vehicle (ATV)? Y N X
Do you:
• Have a smoke detector on each floor of your home? Y N X
• Regularly test each smoke detector? Y N X
Do you regularly protect your hearing against excessive noise? Y N X

If you are over 64 years old:
• Do you have hazards (such as loose carpets, exposed extension cords, and
stairs with no handrails) in your home that could cause you or someone else to fall or be injured? Y N X

Dental Hygiene
Do you (every day):
• Brush your teeth with a fluoride toothpaste? Y N X
• Floss your teeth? Y N X
• Have you seen a dentist in the past year? Y N X

Stress Management
During the past month:
• Have you often felt “down,” “blue,” depressed, or hopeless? Y N X
• Have you often had little interest or pleasure in doing things? Y N X

Physical Activity & Exercise
Does your daily physical activity add up to at least 30 to 60 minutes? (Include each 5- to 10-minute interval of activity or exercise.) Y N X

Pre-Conception Care
If you are planning to be, or could get pregnant, are you taking a folic acid
supplement? Y N X

Potential Risk Behaviours
Do you smoke? Y N X
If you are a smoker:
• Would you like to quit? Y N X
• Have you ever tried to quit before? Y N X
• Are you interested in medication to help you quit? Y N X
• Are you interested in a smoking cessation program to help you quit? Y N X
• Do you have a “quit date” in mind? Y N X

Do you ever:
• Try to cut down on drinking or drug use? Y N X
• Feel annoyed if someone mentions your drinking or drug use? Y N X
• Feel guilty about drinking or using drugs? Y N X
• Drink or use drugs as soon as you get up in the morning? Y N X
• Use alcohol or drugs when you are involved in activities such as driving,
boating, cycling, or swimming? Y N X

If you are sexually active, do you:
• Take precautions to prevent an unplanned pregnancy? Y N X
• Always use a condom to protect yourself from sexually transmitted infections (STIs)? Y N X
• Avoid high-risk sexual behaviour? Y N X

Diet
Are you eating the right number of calories (enough to maintain a healthy body weight) every day? Y N X
Do you limit your intake of fat and cholesterol? Y N X
Do you emphasize grains (such as cereals, whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet? Y N X
Do you take in enough calcium and vitamin D for a healthy body and bones?
Y N X


Thank you for taking care of yourself and helping to prepare for your visit.

Phase change

My moving date to the new office is August 22^nd 2009. We are getting very busy with the many details that go into the move.

Informing everyone is very challenging. As soon as the date was set, we sent a letter to all the patients in the three practices in this office. I also periodically update my website (http://drgreiver.com), and we have the date and new address on our answering machine’s message.

We have been informed by eHealth Ontario that the new Internet connection will be ready on time; there will be several family practices, as well as the Family Health Team’s main clinical location (home office for Allied Health Professionals, program managers) all operating from the 7^th floor at 240 Duncan Mill. About half of the physicians in the FHT are moving to the new office; all of us will be using the same EMR software, and all accessing the software remotely; there will be no server on the premises. My husband tells me that these days, many larger companies (including his) are distributed all over the place and no longer have a server with their corporate database on site; his is actually located in Cleveland. If you include all physicians moving in, Allied Health Professionals, support staff, medical students and Residents, we’ll have between 75 and 100 people accessing data remotely at the site. I hope we have a big enough connection for our size.

Our Family Health Team is actually fairly complex; it is composed of six smaller groups of family physicians (Family Health Networks or Family Health Organizations). Some of the groups had already chosen their EMR system before the formation of the FHT, which is why we ended up with two different systems. As well, some groups chose to transfer their software to the new provincial eHealth Ontario ASP server; my group had thought about it, but for reasons detailed earlier, decided to stay on our server at the hospital. Within our server, there are two groups, mine (with 14 physicians) and our sister Family Health Organization with 9 physicians. Even though we use the same server and the same database, we cannot share EMR data across our two groups.

17 colleagues in two different Family Health Organizations decided to go to the eHO ASP model, but as a single data base with shared data; they use the same EMR software as I do.

14 of my colleagues use another EMR software. Four are in one office as part of a FHO, with their server in the office. Ten physicians in a different FHO are dispersed and access a server located in one of the offices.

That makes 6 physician groups, two EMRs, 3 databases using one software application and two databases using a different software application. No wonder our Executive director is getting grey hairs! Even though we are now a mid-sized company as a FHT, our IT infrastructure does not make running programs in common very easy. In retrospect, I guess it may have been better to form Family Health Teams first, and then choose a common EMR and common database for all of us. However, primary care renewal initiatives happened at the same time as the EMR transformation, so things like this were bound to happen. We’re not the only FHT with this issue; a large FHT in Hamilton has 6 different EMRs. Maybe what will happen over time (perhaps a long period of time) is that we’ll eventually join our information in a single database (or maybe two databases, one for each EMR) so that we can actually run and track programs based on our actual data. I can’t imagine any mid-sized corporation not knowing how they are doing, and not having data for forecasting and planning purposes—and yet that is how we operate at the present time.

In any case, we are slowly starting to develop some Data Management skills in my group of 14; part of this is through participation in studies like CPCSSN, where we have a Data Manager to help us, part is through Quality Improvement collaboratives like QIIP. My practice has a Facilitator through QIIP, and she is helping us think about how to organize our data so it makes sense. There is no FHT Data Manager, which is a bit strange considering how much data we have.

For example, having some idea of what percentage of smokers are in our practices is useful if you want to think about planning a program for this. We have 9515 patients with data on smoking; of those, 1964 have been tagged as smokers (20%). I’m sure there are issues with inconsistent data entry, data errors, etc, but at least it is a start. We need to figure out how to identify patients who have no entry on smoking in their chart, and perhaps decide as a group to put a reminder or alert in the chart, so that the next clinician who sees that patient can ask them if they smoke or not.

As you can see, change in ongoing for me, for my practice Team, for my partners, and for our Allied Health Professionals. When I look at this ongoing diary, I guess one way to think about this is as a very slow motion train wreck. However, it does not feel like that to me at all; I prefer to think about it as a slow thaw towards a much more interesting state—ice to water. Phase change.

Reviewing and changing my scanning process

I have changed my scanning process. My EMR company had provided software called "ADM" (or Advanced Document Management) in the past, but I didn't use it. The reason for that was that the quality of the images (they were in jpeg) was poor.

There are two ways to scan data in my EMR:

1. Through the ADM program, which is separate from the EMR, and automates much of the process
   
2. Directly to the EMR, through an upload and attach process in the application

I used the second method; we scan documents as pdf files, save them to a folder on the PC's desktop, and then upload and attach to each patient's file. This is a very laborious process, but the images are very clear. I prefer to have a longer process at the front of the office and to end up with better quality images.

However, I heard from several colleagues that the new ADM program was significantly better; I went to see it, and it was better. Another physician in my group came to my office to have a look at our scanning process (she was using ADM). We had a look at her scans during lunch, and figured out that some of the quality problems were due to the fact that she was not using the right software to open the files. Her scanned files were saved in tiff format; we switched to MS document imaging--it looked better and we could use OCR (Optical Character Recognition) very easily. I had found out how to associate file extensions with different programs because of a home computer problem, so I was able to do the switch for her.

The ADM software does not work out of the box. My IT guy had to install it and to tweak some other files to get it to work properly. However, once that was done, it worked. He showed us how to use it; we started and had to make a couple of changes, but now it works well.

My scanning tech can now scan papers in batches: she puts a whole stack of papers in the scanner, and scans everything into a single file. The program automatically saves it to the right area without the need for naming the file. Once it is in, the ADM software shows her what has been scanned, and she uses it to attach different pages to different patients and different areas of the chart. The software then uploads the file to the right area of the EMR.

I then see it as a tiff file attached to a patient chart in my EMR inbox (separated into lab, DI, correspondence). I can click on the file's link to open it up. Once I see it, I run the OCR process (using the little "eye" icon in MS doc imaging), which is very fast, and then I can highlight what I want and copy and paste it into the "comments" section.

OCR in tiff seems to work better than in pdf--it is easier to highlight the section you want to copy. I find that I am copying more of the letter to the EMR.

This is still problematic. OCR is not perfect, and there are always errors. You have to proofread and correct the text, which takes time. I have a saved copy of the original, so what I do is look for bad errors (numbers being wrong etc), and leave minor problems alone--example: MRI OP BRAIN.

Anything which is OCR'd and copy/pasted is now saved as part of the EMR record (not a scan), and is searchable. If you are parsimonious with what you put in, you end up with a nice summary which is easy to look at (CT chest: granuloma RUL. Echo: Normal). If you put in lots of stuff, it becomes harder to wade through the information or you have to do a text search. If you put everything in via OCR, you don't have to individually load each scanned document when printing a referral or a transfer, but you can end up with a lot of misspelled garbage, and there is no formatting--it is hard to look at.

I'm kind of in between the two. I'll copy the relevant paragraph to the EMR (diagnosis, management suggestions), and leave the rest as a scanned document. When we transfer a chart because a patient is moving to a new family physician, my secretary copies the EMR chart to a CD, but not the scanned documents. I figure the EMR really contains the relevant summaries of everything that is needed. I don't know if I should start including only the EMR summaries instead of the scanned documents when sending referrals; I guess it depends on what the referral is for.

You can see what it took for me to change my process:

• Better software from the EMR company
  
• Seeing for myself that the quality of the images had improved
• Figuring out the file attachment problem (over lunch with a colleague)
• Having a good IT person who could both do the installation for me, and troubleshoot it afterwards
• Training on the new processes and revising how the secretary scans at the front and how the doctor looks at the scan
  

Of course, there were problems in the first couple of days: my scanning tech found the pictures on the screen too difficult to look at (until we figured out where the magnifying glass button was); there were errors in attaching scans (wrong area, wrong patient). My partner has MS Office 2007, and MS document imaging doesn't automatically install itself in that version--I had to go online to figure out how to make it load on his computer. You have to have patience with these new things. Our IT guy also figured out how to make faxes and scans automatically go into the same folder, so now the upload process is fully integrated. It doesn't matter whether the incoming is via fax or via scanner, it all looks the same.

I don't mean to imply that I like scans now; I still think that it is a waste of everyone's time to have to re-digitize documents that were originally produced in digital form. However, the hardware and software is getting better at handling this necessary evil.

Michelle

User group meeting

I went to the annual user group meeting last weekend. I believe that bringing together users is extremely valuable; we shared many tips and tricks on how to use the EMR more efficiently and effectively. We complained a lot, and laughed a lot too. I met several colleagues who were at various stages of implementation; more experienced users were extremely generous in terms of sharing what works for them.

The EMR company's executive team were there; at the end of the meeting, we discussed our "wish list". Some of the requests were:

• Templates that can be exported and shared with others (the #1 request)
• Increased scheduling flexibility for larger groups
• Improved data mining and reporting capabilities
• Better ways of entering and reporting chronic disease management data
• Ongoing training
  

The head programmer demonstrated the new data mining software they are working on; this looks like it fishes data straight out of the database, and should give "power users" a lot of control over what is reported. I can't see having everyone learn database management skills, but several of us are getting more and more interested in seeing what we can do with all the data we are accumulating. Perhaps what will develop in some groups is data expertise (this does not have to be a physician), so that quality improvement projects can be started for entire groups. It will be much easier to do this for groups of physicians rather than for solo physicians. I think the formation of groups in Ontario (Family Health Groups/Networks/Organizations/Teams) is likely to bring benefits in terms of data management capabilities.

The company talked about their plans for "reportable fields". There was a lot of interest around this. As far as I understand it, this is new fields that can be inserted into templates, and that automatically go into into flowsheets, and that can be searched for later.

Altogether, I think this was a valuable meeting to attend, and I plan to attend next year. The EMR is now so central to our practices that it is worth investing time and effort to build and maintain proficiency in it.

Our last two filing cabinets were sold and picked up, and I did a happy dance over the floor space where they used to be; there is now a lot of space at the front. Our moving date to the new office looks like it will be in August (likely August 22nd), and I am trying to get rid of as much paper as possible. We still have some paper handouts, and these are getting tossed out. I'll have a look around and make sure that we are as paper-lite as possible.

The move to the new office is much more complex due to the EMR. eHealth Ontario is overseeing the internet connection in the new office, and we have to make sure that there is overlap (we need to have two SOFAs--Small Office Firewall Appliances) during the transition so that we can continue to function. We are investigating VOIP phones as a group. I have to make sure all the wiring is planned properly and that there is redundancy for the future. I have a small IT closet in the office for all the routers. I started an Excel spreadsheet of all the things we have to do, and this is growing faster than public health swine flu notices.


I took part in the CPCSSN national meeting later in the week. CPCSSN is composed of 9 different sites in Canada, and all sites are reporting anonymous EMR data on five different chronic illnesses: diabetes, hypertension, depression, Chronic Obstructive Lung Disease and osteoarthritis. I am part of the Toronto group, Nortren. There are eight different EMRs involved, so this is a very complex project. It looks like this is feasible, and primary care can be used safely and effectively for chronic disease surveilance. This likely represents an important part of the future of Public Health.

Finally, it upsets me a great deal to read about the problems currently besetting eHealth Ontario. I agree with Dr Brookstone's post, this will be a major distractor for the organization. My group has had multiple difficulties with eHO and its predecessor (SSHA), mainly centered around service provision and communication; however, I completely agree with Allan that this is a large and complex undertaking. The current chair, Dr Hudson, and the previous CEO, Sarah Kramer, have extensive knowledge and experience in this sector; I hope the executive branch of eHO will be able to maintain focus on their priorities. This news release came from our Minister of Health, David Kaplan, today:

"The board reported to me that the current uncertainty surrounding eHealth Ontario threatens to delay initiatives that are crucial to our government's plan to modernize and improve our health care system.

I am acting immediately upon its request to revoke Sarah Kramer's appointment as eHealth Ontario President and Chief Executive Officer. Ron Sapsford, Deputy Minister of Health and Long Term Care, will serve as acting President and Chief Executive Officer of eHealth Ontario until an interim President and CEO can quickly be appointed.

This decision is an important step to restore public confidence in the agency and its mandate of modernizing our health care system."

Michelle

Quality improvement, year 3

Our quality of care for preventive services continues to improve. We have 9,985 eligible services. We provided 87.75% of these services, compared to 73.53% last year, an increase of over 14%. It was interesting, because quality of care went up for every service, for every physician. We also went from 9 physicians to 12. Part of the improvement was better, more consistent data entry by everyone, and part is an actual increase in services; I can't know which is which, but I have no doubt that there is an actual increase in services.

Pap smears went from 74% to 89%; mammograms from 74% to 88%, and influenza vaccinations for the elderly from 71% to 85%.

Our Fecal Occult Blood (FOB) screening program has now started. We were able to extract a list of patients with Colorectal cancer or Inflammatory Bowel Disease for every physician (through ICD codes); these lists were then faxed to each physician for verification. Our data entry person has now entered a code in all Cumulative Patient Profiles to exclude those patients from screening. Every practice knows about the code, so patients newly diagnosed can be excluded in the future.

My colleagues have been good about entering colonoscopies consistently and in the right area of the CPP; we generated lists of all patients with colonoscopies <5>

We will then cross check the remaining patients with the paper lists of FOBT (from lab billing data) that the Ministry of Health recently sent us; we mailed FOBT letters last year as a trial, and this worked, so once all the data entry is done and cross-checked, we'll go ahead with mailing patients overdue for this screen. Our FHN administrator will notify everyone ahead of time, so all practices have time to prepare (order extra FOB kits, make sure that everyone knows to put in a lab req when patients come in to pick up the kit etc); we also email a copy of the letter template to every physician for approval prior to mailing. This will enable us to monitor FOBT from now on and to add FOBT to our regular 3 monthly mailings. I expect this to be completed by July or August, with the first mailing going out then.

Here is the letter to patients:

Dear

Our records show that you are due for a Fecal Occult Blood (FOB) screening test. FOB screening has been found to decrease the risk of dying of cancer of the lower bowel, and should be done every two years.

Please come to the office to pick up your FOB kit. You do not need to make an appointment for this.
If you have had a colonoscopy in the previous 5 years, then you do not require this test. Please inform the office if a colonoscopy has been done.

FOB screening is an important part of keeping you healthy; more information on early detection of lower bowel cancer can be found at http://www.coloncancercheck.ca

As your Family Physician, I appreciate the opportunity to work with you to prevent illnesses and enhance your health.



We are now at 14 physicians in my FHN; we'll add our two new colleagues to the preventive program this summer, which will bring us to just over 15,000 rostered patients. We will also get data auditors to cross check the paper lists to make sure that patients who are rostered on the EMR are shown as rostered on the Ministry lists. We'll do a cross check for patients who already have two letters mailed, to make sure that they have not had an overlooked service. You have to maintain your database, and double check things. As well, during the summer, all patients with two reminder letters and still no response get an extra phone call, as we hire summer staff for this.

We are also getting data entry for our diabetes registry; this adds reminders to look at the flowsheets every 3 months. Several physicians in my group have been looking at overdue reminders, and have called to remind these patients to come in. I thought this was a good idea, so we had a look and found 6 diabetics who had not come in for over 6 months. My secretary called all of them, and four have booked appointments.

As a test, I had data entry done for all my diabetics for last date of retinopathy check (for eyes) and neuropathy (foot exams). I was able to generate a list of overdue retinopaties (>2 yrs)--17 patients--and these are now all getting a reminder letter; as well as overdue foot exams--14 patients--and these now all have an alert in the chart. My nurse saw a diabetic in for another reason, noticed the alert, did a foot exam and marked it as completed. The system now shows me the list with that exam completed, and the date it was done.

I think that our system is slowly maturing, and I have evidence that we are using EMR capabilities to improve quality. I think this is what you should be able to achieve by the third year of EMR.


The last two filing cabinets have now been emptied; all paper charts are gone from the front. I put the filing cabinets on Craigslist yesterday, and sold them today. Paper charts have no place in this clinical setting.

Michelle

Outbreak

We are now in a Category 5 outbreak, with several cases of Swine Flu (H1N1) reported in Ontario.

I went through SARS in 2003; my hospital was at the epicenter of the second wave of the outbreak; I had been on the floor where the first cases were detected. I was quarantined; my practice partner volunteered for the SARS unit of the hospital and he took care of our colleagues and co-workers who were ill. I remember this.

At that time we had no way of rapidly communicating information. Most of us were receiving everything by fax; Public Health and other government agencies had no email lists of physicians. Our hospital department could not reach us (they didn’t have our email addresses either); the physician’s lounge was closed, and we could not pick up reports or information. Our department chiefs went to work and rapidly built up email lists; giving your email is now a routine part of reappointment for hospitals and medical organizations, and the lists have been maintained.

Since I started using the EMR, I have left my email on at all times at the office. I am now receiving updates on the outbreak from Public Health several times a day. My hospital also sends out routine updates and reminders, as does my Family Health Team; so do medical organizations, such as the Ontario College of Family Physicians and the Ontario Medical Association. It is a bit overwhelming at times, as I get the same information from several different sources, but I am updated. Many of my colleagues use a Blackberry. I think the information “push” is now very good, and certainly light years of where we were in 2003.

However, it is still difficult for me to send back information to Public Health. They want us to report the information on cases of suspected swine flu by phone. This is going to be a problem if the numbers surge: they are going to be quickly overwhelmed, just like the last time. I think it would be better to upload via secure web, email, or fax as an alternative. Ideally, I’d like to send the information electronically straight from the EMR, but I know this is not possible because systems for this were never put in place.

I also think we should be able to automatically send some anonymized EMR data straight to public health; I would certainly volunteer to be a sentinel practice for this. Here is what I mean: I would like to automatically upload to Public Health temperature readings from my office (they are in a field in my database) with their associated EMR date and time stamps, linked to the patient’s postal code (only the first half, or Forward Sorting Area, FSA). It would not be difficult to aggregate temperatures and FSAs from several practices; Google does this kind of thing very well. Sort through it and pick out temperatures >38 degrees. You can quickly see the clusters of fever by geographic area. This would require special protection for privacy, but would potentially allow real time tracking of an outbreak in an emergency situation.

I’ve been thinking of the most efficient way to remember what I have to do and to record the data in the EMR; this is through an encounter template. What I did is program a template for my entire FHN (since we are on a common database), which contains all the information sent by Public Health—so we know what to do. As the information changes, I’ll just update the template. I put the phone and fax number of our local public health unit in our common FHN phone book; when I have a suspected case, I’ll load up the template, fill it, and save it to the record. I’ll then start a consult note to Public Health (which automatically contains all the required patient demographic information straight from the record, as well as my name, address, phone number and email), attach the encounter note to the letter, and electronically fax this to Public Health. Then I have a record of what I did, as well as of the fact that it was reported.

Perhaps Public Health could set up a secure email address for reporting, through eHealth Ontario’s ONEMail system. I have access to ONEMail (see previous post), and this would actually be a very good use of that system. Reports emailed within the ONEMail system are completely secure.

Here is the structure of the template; it is very simple. If you have an EMR, you are welcome to reproduce or modify this as you see fit.

• Swine flu (ILI, Influenza Like Illness) template

• Report all cases of Influenza-Like Illness (ILI) with a travel history to Mexico or contact with a case of swine flu in the last 7 days to the public health unit, phone xxx fax yyy
• 
  
• Travel to Mexico in past 7 days? (Y/N)
• 
  
• Contact of swine flu case in past 7 days? (Y/N)
• 
  
• Date of symptom onset:
• 
  
• Outpatient (Y/N)
• 
  
• Upper Respiratory Tract infection? (Y/N) OR
• 
  
• Lower respiratory tract infection? (Y/N)
• 
  
• 
  
• Other Major symptoms such as gastroenteritis?
• 
  
• Temperature:
  
• 
  
• For patients presenting with ILI (Acute onset of fever and new/worse cough or shortness of breath; additional symptoms may include sore throat, arthralgia, myalgia, headache or prostration. In children under 5, gastrointestinal symptoms may also be present.) and a history of travel to Mexico or contact with a confirmed case within 7 days of onset of symptoms, a nasopharyngeal swab can be sent to the Toronto or regional public health laboratory.

Michelle

The three year old EMR

I now have a three year old EMR. I am way past that terribly disruptive newborn period, have dealt with the Terrible Twos, and am starting to reap some nice benefits from a maturing system. The EMR is definitely more responsive and pleasant these days, although it can still throw the occasional tantrum.

I now have three years' worth of data in my system, and am increasingly interested in using this data to improve my quality of care. My practice team went to the Quality Improvement and Innovation Partnership (QIIP) a few weeks ago; there were 50 Family Health Teams represented. My team was able to generate some statistics from our system, but few others could do this. Almost all FHTs are using an EMR, but many are newly computerized; the ability to routinely generate practice-level information (how many diabetics do I have? How many of those are at goal for their cholesterol?) is still very rare—even for those with older systems. It was a little worrisome to see that all this information cannot be put to good use because it cannot be routinely aggregated within practices.

I think that there are a couple of reasons for this

1. EMR systems were initially designed for individual patient care, replicating our paper charts. They are not designed for practice-level audits (which are critical to improving quality)
2. We do not enter data consistently; in other words, we do not have good Data Discipline. If you enter “diabetes” as T2D, NIDDM, DM2 etc, you can’t consistently look for diabetes afterwards. You have to code your diagnoses.

We have to report on a whole series of measures for QIIP, for diabetes, colorectal cancer, and office efficiencies, and I can see that this will present a whole lot of problems for all of us. Perhaps it will make us demand more and better auditing capabilities from our EMR vendors. Perhaps it will make us think more about how we enter data in our EMRs.


I will be moving to a new FHT office designed specifically for the EMR. We have just signed the lease, which is very exciting; construction will start now and I expect to move this summer. We have printed announcements on cards which we are handing out to patients, and we are asking them to regularly check my website, http://drgreiver.com for updates.

We finished scanning my partner’s paper charts into the hard drive at the front, and they have been backed up to two sets of DVDs. He won’t allow my staff to shred the paper; I think many of us still need the old charts for security. I have not allotted any space in the new office for filing cabinets, so the charts will have to go to his basement or to storage when we move; then we’ll finally be paperless. I am selling the last two remaining filing cabinets on Craigslist soon.

The Allied Health Professionals (AHPs) in my office are now using the EMR routinely and consistently for all care. We decided to use eMessages in the EMR instead of faxing referrals; they check the EMR remotely on a very regular basis, and this avoids generating paper. We talked about where to enter data, and our Team’s Social Worker, Dietitian, and Clinical Pharmacist all decided to enter their reports in the Clinical Notes. They sign off when done, and send me a short eMessage linked to the patient’s chart. Both my practice partners agreed to try this system, and are much happier with it; I hear this approach is spreading to other practices in our FHT. If I have a question about a patient, I just send a message; this has greatly enhanced Team communication. For example, I routinely fire off a quick query to our Clinical Pharmacist when I have a question about the best approach for a patient’s medications; she links to and reviews the chart, and sends me back a note along with a link to appropriate on-line resources if needed.

The schedule for the AHPs was being managed centrally at the FHT’s office, using non EMR software. We all decided that it would be better if the schedule was within the EMR and in our office. I made a schedule called “Allied Health Professionals”, and when I need to refer somebody to our Dietitian, they just go to the front and book the appointment with my secretary. The Dietitian can see her own schedule both remotely and when she comes in the office, and she brings up the patient’s eChart directly from Scheduler.

AHPs in other FHT offices must be hearing about this, because I am now regularly being asked to set up them up in the EMR; everybody wants to use the EMR. I don’t mind doing this, because I can do it fast, and I think it is important to do it correctly. Our FHT’s AHPs get their initial training at the EMR company, and then some come by at lunch for a quick orientation and help with initial log in. I think the integration of all Team members will accelerate even more once we are co-located at the FHT office, and can do EMR “lunch and learn”.

My FHN colleagues are doing some very innovative things with their system. Quality Improvement initiatives and good data entry practices seem to be routinely on the agenda at our FHN meetings. For example, one of my colleagues systematically looks for patients who are overdue for their diabetic visits (using the EMR reminder system we set up last summer), and sends them a recall letter. Another physician decided to have her FHT RN recall the overdue patients and manage their visit. I think we are starting to mature as a group, along with our EMR. I updated our FHN diabetes registry (we now have 805 diabetics out of 15,000 patients), and the coding was much better than last year.

My office administrator recently received a letter from a specialist in MS Word, emailed to our office address drgreiveroffice@rogers.com . We talked about what to do with it, and decided to copy and paste the note into “comments” in the incoming correspondence part of the EMR; no printing, no scanning, no OCR, and no OCR-related errors. It is not quite as good as a direct electronic import into the chart like labs, but is so much better than fax; I would really like to use secure email, but the SSHA email system is very impractical so nobody uses it—you have to change your password every six weeks, you can’t have a general office email for people to send things to, it won’t forward a notification that there is something waiting for you. I don’t use it. It looks like it was designed by security experts, with no emphasis on the practical aspects of a communication system. The results are a continuing lack of electronic communication; you get the system you plan for.

Overall, I think things are coming along nicely. There certainly has been a noticeable decrease in EMR-related stress in the past few months; I think our system is now well domesticated, and we can start planning more and better things.

Michelle