Thursday, April 30, 2009


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.


Sunday, April 12, 2009

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, 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 . 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.