Saturday, January 30, 2010

Signing off

The time has come for me to sign off.  As you can see in the title, "I will be implementing an Electronic Medical Record in my practice, starting in March 2006. This blog is a diary of what happened". 

The EMR has now been implemented; my practice has been redesigned to meet goals for patient access (wait times for appointments are now routinely same day or next available clinic day; time sitting in the waiting room is <1/2 hour, we use email with patients), quality (routine measurement and monitoring, regular team meetings), and efficiency.  We work as an interdisciplinary team now; these are not just "buzz words", we actually are doing it.

All of us in this primary care team have traveled far along the road to better care for our patients in the past four years, and the EMR has been a key part of this redesign.  We will not stop, but I do feel that a large part of the work has now been done.  The key issue remaining is that those of us using EMRs continue to function as electronic islands in a sea of paper and systemic inefficiency.  We cannot change this from our practices; such a change will take leadership and vision from the people managing our health care system.

As for me, I am finishing my Masters of Science; my thesis "Effect of EMR implementation on preventive services" will be completed this year, and I intend to publish it.  I will continue to work three days a week at my office and two days a week on research projects; I think EMRs and quality of care are an important subject, and that is what my research will focus on.

Thank you  for bearing with me as I navigated the twists and turns of an EMR implementation in this small community based family practice.  It has certainly been challenging at times, but the outcome is more than worth it.


Monday, January 04, 2010

Not yet good enough

Here we are, at the start of a new year.  This seems to be a good time to take stock of things.  It has now been almost four years that my group started using an EMR.  My office is much further along for some things than I thought we would be by now, but also much behind for other things.

We have done well in terms of getting rid of paper inside the office.  We have no paper charts at all, and no filing cabinets for patient data.  All patient data is stored directly into the EMR, whether entered directly by someone in the office, or scanned in.  All members of this practice (physicians, Allied Health Professionals, staff) use the EMR.  Almost all tasks and patient-related communication are entered in the system.

We are efficient.  As of next Monday, I am on Open Access; my patients have all received a brochure outlining what this means (this was mailed in October).  We have eliminated delays and waiting times to see me are now essentially 0 or 1 day. 

We are also effective.  We measure our quality monthly; 89% of diabetics in this practice have had an eye exam in the past two years, and 91% have had a foot exam in the past year.  We have consistent alerts and reminders for  overdue services, and are always looking for ways to improve quality.

Through QIIP, we were provided with a spreadsheet outlining how many visits were expected for a patient in each age group, for a family physician on capitation or fee for service.  I had 3709 encounters for a year; expected for my practice is 4301, a difference of 592 encounters (13.8% less than expected).

While this does not tell me what exactly is contributing to the difference, some of the effect may be due to:
  • "max-packing" visits (doing everything that needs to be done in a single visit)
  • increasing time between repeat visits if appropriate
  • phone management
  • use of email with patients
  • Allied Health Professionals and team-based care; task distribution
  • working to top of scope for all team members 
The monthly number of visits appears to have decreased since September, from about 290 per month to 220 per month.  The number of "no shows" has decreased from 20 to 10 per month, and was down to 3 in December.  It may be fair to expect the difference between expected visits and booked visits to be larger by next year.

And yet, it does not seem to be good enough; we continue to suffer from systemic inefficiencies.  The number of proprietary referral forms has not diminished; there is no electronic prescribing in my neck of the woods; email communication between doctors and patients continue to be poorly supported by our health and privacy organizations; and worst of all, the onslaught of non-electronic incoming patient data has not abated one bit since we started.  Not one of the paper based reports that we started scanning four years ago have been switched over to electronic format (hospital, Diagnostic Imaging, specialist reports, non electronic laboratories); all these continue to be reported on paper.

The new funding for EMRs will make a big difference in adoption; I think the majority of family physicians are now considering switching to EMR.  The funding is also available to specialists, and I think they will switch as well.  Perhaps this will provide enough "push" for the system to integrate at last; labs that do not transmit reports electronically may well see a significant hit to their business, as physicians actively drive patients away from those facilities. 

We are pushing ahead with practice redesign.  On the agenda for this year is Group Medical Visits, where several patients with a similar condition (for example, diabetes) are seen together; our clinical pharmacist is in charge of arranging this.  My secretaries are now routinely collecting email addresses from all patients.  I have configured Outlook Express on every computer in the practice with my office email (, outgoing only.  If the secretary has trouble reaching a patient by phone, she sends an email asking them to call back, or sends the date of the appointment and asks for a phone call to confirm.  One day we'll have online booking for patients.  Incoming email to the office address gets redirected to our office manager, and she then takes action or forwards to the physician if appropriate.  I have been told by eHealth Ontario that they are looking at the possibility of giving patients access to the secure OneMail; as well, they are considering adding pharmacies to OneMail--that would be good, perhaps the pharmacist could email me if they have a question, instead of faxing or calling.  Perhaps I could even send prescriptions via secure email instead of fax. 

I think we have made progress in re-engineering how we look after patients in this office, but I'm ambitious.  I don't think it is good enough yet.