Sunday, September 27, 2009

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.


Tuesday, September 08, 2009

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.