Dr. Greiver's EMR

Signing off

2010-01-30T12:03:00.000-05:00

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.

Michelle

Not yet good enough

2010-01-04T22:14:00.000-05:00

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 (drgreiveroffice@rogers.com), 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.

Michelle

Upgrading the office hardware

2009-12-05T20:36:00.000-05:00

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

2009-11-10T09:07:00.002-05:00

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

2009-10-30T20:30:00.003-04:00

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

2009-09-27T16:22:00.007-04:00

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

2009-09-08T21:25:00.000-04:00

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

2009-08-24T21:40:00.002-04:00

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

2009-08-17T22:16:00.002-04:00

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

2009-08-09T15:37:00.003-04:00

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

2009-07-07T22:00:00.003-04:00

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

2009-06-17T22:31:00.003-04:00

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:

Through the ADM program, which is separate from the EMR, and automates much of the process
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

2009-06-06T22:14:00.004-04:00

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

2009-05-06T21:58:00.002-04:00

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

2009-04-30T22:00:00.003-04:00

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

2009-04-12T16:54:00.004-04:00

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

The importance of communication

2009-03-15T17:25:00.003-04:00

I had a difficult day last week. A patient came in with two reports: one (from a downtown hospital) showing a decreased bone density, and a second (from a different downtown hospital) showing some compressed and fractured vertebrae. This patient needs medication for osteoporosis. The issue for me was that neither of these reports were sent to me, and there was no treatment. The patient was seen at hospital #2 for a different reason; a physician gave her the report and told her "if I was your family physician, I would treat you". The patient handed me both reports. The report from hospital #1 had my name on it, but was never sent to me. The patient's comment was that the system seemed to be failing her. I agree.

Our current College of Physicians and Surgeons magazine talks about the importance of communication; the article discusses two plane crashes that happened because of poor communication between flight crew, cabin crew and flight control. When this happens to planes, there is an investigation, and they figure out what happens and how to prevent it in the future. The CPSO's comment is that "the more complex the system, the more sophisticated the communications"; health care is at least as complex as aviation, if not more.

A problem in health care is that we often don't learn from our mistakes, so we just repeat them. The example above will go unreported, unsolved, and unimproved. We have the technology and the ability to send reports electronically today (my labs come in this way), but I continue to receive most of my reports by fax or mail (or via patients). The reasons why this is happening are multiple:
-other priorities
-lack of money
-lack of time
-the tragedy of the commons (this is an issue that affects everyone, but is no-one's responsibility in particular)

The error above occurred due to multiple systemic factors; however, there is no agency responsible for investigating this or for recommending a better system of communication (send it to me electronically). Each individual hospital has their own individually maintained address book (with all the attendant problems that these duplicate entries entail), and there is no obligation to send reports back to the family physician if he or she didn't order the test. The ordering physician cannot reasonably forward all tests to the family physician. The list of rostered patients (which patients are registered with which family physician) exists at the Ministry of Health, but is in no way tied to any of the hospital's physician address books. The CPSO mandates that we give it an updated list of addresses and contact numbers, but this database is separate as well. We need to make sure that all this information is securely tied together (with all privacy safeguards).

Everyone in my practice team (physicians, nurse, front staff, administrator, social worker, dietitian, clinical pharmacist, residents) is now using the EMR; there is no paper record. We communicate via the record. If there is a problem, I get an electronic message, and it is tracked--and I want to hear about it. I recently had a difficult mental health issue, and my social worker sent me a message remotely, which prompted me to call the patient--the chronological story was recorded in the record.

A physician in my group was not receiving her pap results; I believe that a database error at the lab caused them to be sent to the wrong location, and the other office simply bounced them back to the lab. They were never forwarded. It takes 3 months for us to get our paps back, making it difficult to remember who had the test. Because this physician had decided to generate her pap reqs within the EMR, she was able to generate a list of all pending paps so these could be tracked. We know that the system sometimes fail us and fails our patients; being able to track things in the EMR has a lot of value; you would think that everyone recognizes this, but that is not the case--and sometimes the problem is one of communication.

One of my electronic reqs for Diagnostic Imaging was rejected, because it did not look like the standard paper req. My problem was that I became so upset by this that I was going to make the issue worse by not communicating; I decided to phone instead (after calming down a bit), and they were more than helpful in helping me to resolve this. The problem turned out to be that the person receiving the reqs at the front had not been notified, and found the fonts too small. I can understand this; I'm also a bit past high noon, and can't suture without drugstore glasses anymore. Communication is a two way street; it will take a lot of it to change this system.

This enormous process of change that we are undergoing is a social one. In this system, we function as independant units far too often, and we need to start talking to each other more. The EMR is of incredible value in enabling this type of communication; there is no one in my practice team who would go back to the old way. However, EMRs are still isolated within the whole system, and we continue to have far too few electronic links. Perhaps once we can talk more, we will talk more and better; as the CPSO puts it, "among health-care teams (and in any field), the best communications feature a clarity of roles, a unity of purpose, the ability to not just carry out orders but share ideas, and respect for each other's professionalism and views. That's what will allow any team to take flight."

Ministries and regulatory agencies need to recognize this need for communication, and to enable it. This can't be the responsability of individual teams alone.

Michelle

The spread of EMRs

2009-02-22T17:42:00.003-05:00

We had our monthly departmental meeting recently; about 50 to 60 local family physicians regularly attend. These colleagues tend to be more involved in the department (teaching, committees etc) than those who don't attend. My hospital is community-based, but has a strong teaching mandate, especially in family medicine; several of us are involved in research activities.

Our Chief asked people who are or were about to start using an EMR to raise their hands. About 85% of those present did so. Granted, this does not represent all of the family physicians in this area, but it was impressive to see this. Perhaps we have a technology cluster in this area. Certainly, EMR is a frequently mentioned at our meetings. We recently had a brainstorming session for priorities for our department at our executive; members then voted on their top two priorities. The #1 priority was linking the hospital and the community EMR electronically: we all want to reduce scanning. This has not happened yet, but now there is vocal demand for it.

I belong to a Practice Based Small Group (PBSG); we meet monthly for ongoing medical education, since 1995. A year ago, I was the only one using an EMR. This year, out of 11 physicians, three are currently using EMR, three have purchased and are about to start, and two are in the process of buying an EMR. Only three of us do not have immediate plans to start. We use four different EMR systems, which is going to make sharing information and EMR processes a little challenging!

I think that, at least in some geographic areas, we are now past the early adopter stage, that is, an Early Majority of physicians are now purchasing these systems. Purchasing does not mean implementing; I think we will continue to see implementation failures, and the focus of support may need to change towards supporting those who have purchased, rather than encouraging purchases.

I write the occasional PBSG educational module; we have just finished work on the module on Depression. It incorporates some information relevant to physicians using EMRs. I think EMR-specific information will become increasingly added to other types of medical communication and educational materials, as more physicians adopt these systems.

I will be attending the Quality Improvement and Innovation Partnership (QIIP) introductory meeting this week. This is for members of Family Health Teams interested in systematically improving quality in their practices. Although having an EMR is not a requirement, I don't think that many QIIP Teams are still paper based; it is simply too difficult to audit practices without electronic means. Our FHN administrator, our RN, our FHT Clincal Pharmacist and Dietitian are on the Team. It is a good mix. The FHT Executive Director and Medical Director will also be coming. We have two EMRs in our FHT, so a team using the other EMR application will also be participating--and I think this is a very good thing. Unfortunately, some of us have become very proprietary about our EMR application (my EMR is better than yours), and we sometimes forget that we are all on the same Team. Having us participate as a Team in the same project will help us figure out what is similar about our EMRs, and how we can run programs in common across applications (at least to some degree). Or, perhaps we'll have some competition as to who can provide better quality--and that's not a bad thing to be competing about.

Michelle

Structure, process, outcome

2009-02-16T15:08:00.003-05:00

An academic group I belong to has been having a pretty lively discussion on the initial difficulties with starting an EMR. There is consensus in this group (in which everyone is using different EMR systems) that, for the first little while, there is a lot of loss of efficiency. You are quite a bit slower on the computer than on paper. The gains don't come until later, and many people still find that recording a consultation in the EMR (while the patient is in the room) is slower than on paper.

Why is that? Paper is simple. You write things down. It doesn't matter how you write things down. Paper doesn't crash.

The benefit of the EMR is that you can have point of care reminders and you can mine your data for useful information at the practice level. This doesn't happen until (and unless) you enter information consistently, and in the right areas--in other words, you have a well-tempered chart. It is harder to do that than to just jot something down on a piece of paper, and the EMR can make it difficult to enter things in the right area. I went to a conference where the keynote speaker, a GP from England, showed a short clip of how he struggles to write a prescription--after more than a decade of using EMR.

The initial difficulties are magnified by the start-up problems inherent in this technology. Let me explain what I mean by that.

The EMR involves both software and hardware. The hardware means lots of different machines that all have to work properly together. The number of hardware permutations and combinations (servers, routers, firewalls, connectivity, networks, printers, scanners, labelers and all their assorted drivers and software applications) is very large. Failures due to issues involving hardware are very common since there are so many possible points of failure, and can be very difficult to diagnose. There is no dedicated funding for hardware maintenance, nor local expertise in most small medical offices. The EMR companies know more about their own software than about our hardware; they cannot possibly be aware of all the different hardware pieces present in many different offices (unlike corporate branch offices, each medical office is an independant operation, with an individual IT setup). Sometimes the EMR company can't help with hardware problems; we have machines from different vendors, and it can be very difficult to know who to call for help. We also lack the knowledge to plan for hardware failure and redundancy.

"Structure" failing means your printers won't print, your computer doesn't work, you can't connect to your server, your speed is slow. If you don't have a sound Structure, you can't even get to your Processes, and you certainly can't change your Outcomes. Structure is where many EMR projects fail to launch, and the root causes of this are systemic (see above). Paper has a very simple basic Structure (filing cabinets, file folders, pieces of paper), and can't fail at this stage. EMR can, and does.

"Process" is the way in which we do things. If you can't access your records because of a Structure failure, this is moot. If you have solved the Structure problems, then you have to tackle Process; not always easy or intuitive--takes time and thinking. Those that have not bought into the EMR, but are just there along for the ride because their group got one, are much less likely to invest in this. They may benefit from herd immunity, because the group is now functioning better, and the front staff is more efficient--but will be slower with their own patients and in most aspects of their practice.

"Outcomes" is where the big payback happens. This means that the quality of care actually changes: more of your diabetics now have their BP at goal. This requires the ability to not only enter data properly (good Structure and Processes), but also the ability to audit your data and then decide what processes to change, and then re-audit. This is present in potential form in the EMR, but cannot and will not happen unless and until we solve the earlier steps--and if this doesn't happen, you will continue to see studies showing that the EMR is not making much of a difference.

We had a FHN meeting recently; we regularly have EMR booster education sessions at our FHN meetings now. I demonstrated changes since the recent upgrade, such as improvements in our drug module and consultation letters; I also handed out notes. I think it is important to have on-going EMR education. Interestingly, the mood was quite a bit different than in some of our previous meetings: we had less complaining (but not zero), and more interest in what the EMR can do for us and our patients. One of my FHN colleagues talked about how he uses his diabetic reminders to recall people who haven't shown for their regular 3 month visit: he can see the list of overdue visits. This represents a change in Process that is likely to produce a change in Outcomes. It took us three years to get to this point.

Structure - Process - Outcome is a very common way to assess the quality of health care. I think it is equally applicable to EMR implemention.

Michelle

EMR transition for the second wave of physicians

2009-01-30T17:26:00.004-05:00

My practice partner is continuing on his journey through the transition. It has now been nine months for him. He is definitely not a "techie", but has now adopted the EMR, and has adapted fairly well.

There is no longer any data going into his paper charts; they are now "volume 1" of the record. All his encounters are in the EMR. He started electronic prescribing about two months ago, and is now generating almost all of his scripts through the EMR. Complicated medications continue to be a challenge for him, but he has learned to deal with the commonest issues.

He was still writing referral notes on paper at the beginning, and those were then scanned in the EMR. As well, most of his faxed repeat medications requests were authorized on the paper from the pharmacy, then faxed in and scanned. My secretaries noticed a significant increase in the volume of scanning. He is now doing his referrals via the EMR; if the drugs have been entered in the CPP, he'll just click them on the EMR, and the pharmacy rx paper no longer gets scanned in. If the meds are not in the EMR yet, it is faster for him to write "Ok" on the paper, generating a scan.

He uses flow sheets, especially diabetes and INRs. He has had no difficulties using the eMessaging or To Do notes. He really likes the remote access, and logs on both from home and from the hospital when he is working on the ward.

He is using our preventive services point of care reminders; his rate of flu shots (88%) is better than mine (86%)! He is now part of our FHN's regular preventive mailing program for the past several cycles. Our FHN administrator will be mailing the next letters in early February.

His CPPs are not finished. His practice is older, and has more complex patients with big CPPs than mine. Putting in this data certainly is a massive job, and I think it will be better for him once this is done; it is one tough slog.

He knows how to access and manage his electronic lab data and scanned data. He is now regularly using electronically generated electronic lab reqs, and is using some of our bundled reqs as well. He is less comfortable with DI reqs, but uses them.

We sometimes go over tidbits of EMR information in the evening if neither of us is too tired. That is useful, because it involves things that he has questions about and is very practical and short. He periodically asks me to show him things during the office. My office administrator is very helpful, and will show him things when he is ready as well.

We are now scanning and shredding his paper charts; we have hired a temp to do this. All of the "inactive" charts are gone, and we are now starting on the Deceased. The charts in our back closet are gone. My partner's office currently looks like a bit of a disaster zone, as there are charts piled everywhere, but I expect this to start getting better now. We are planning to move to the new office this summer, and should be completely paper-free by then.

I think that the transition is more manageable for the second wave of physicians, that is, those transitioning once office EMR processes are already in place and working well. There is more in-house knowledge and support. There is still additional stress and time during the transition for the physician, as you have to learn the EMR and put in all the data, but it is less than for the first wave (and that is a good thing). Patience, willingness to learn and to help, as well as a sense of humour all help.

It is possible to have completed most of the transition, even for non "techy" physicians, by nine months. It does require some extra support. It would have been nice to have this for the first wave.

My EMR company has now started web-based training on a regular basis. I think this is very helpful. I attended the first session; what happens is that you have a trainer and several physicians phoning in via teleconferencing. Everyone logs in to the same website, and the trainer demonstrates various aspects of the EMR. This is a good way of doing training for IT, because you can see what is happening right in front of you. The session was 1 hour, which is a good length, I think. We will be having our first user conference in May, and I've been asked to do a seminar. I'm not sure what I am going to do yet, maybe "the efficient office visit".

We will be having an EMR booster session for my FHN in mid-February. I am now familiar with the features in the new version, so that I can demonstrate the most important elements. I think we are starting to do better with our ongoing training.

Michelle

What to do when your connectivity fails

2009-01-23T14:15:00.004-05:00

We had a long, hard look at whether to change to the new ASP model run by eHealth Ontario--eHO--(previously called Smart Systems for Health Ontario, or SSHA), or to continue with our server, based at the hospital.

We decided to continue with our server for now.

There are several reasons for that decision. While I strongly believe that ASP is the way to go over the long term, I am reluctant to switch today. We now have good IT support for the server, through our own IT manager, and have bought additional hardware insurance. The server generally functions well and is closely monitored.

I cannot say the same for our connectivity, which is managed by eHO. We have had several outages in the past six weeks, and two outages this week. On Tuesday, we were off for the whole morning, as the eHO lines were down. Regular Internet was fine, so I was running on my backup line.

Trying to run a backup Internet line using the rules imposed by eHO is a daunting task. We have to use a SOFA (Small Office Firewall Appliance), through which the internet line connects to the office. I have a second, private, internet line coming to my office in case of failure. I had a private company install a failover router, so that the second line picks up when the first one fails. That itself failed the fist time SSHA's internet line went down. When SSHA was back up, the private modem interfered with the SSHA modem, so we could not re-connect properly.

What I had to then figure was how to force the two system to cooperate (a bit like what is happening between all the different players in the EMR field).

Basically, when we fail to connect to our server, we check Google. If that fails, then we know that it is the eHO lines (again). We go to the back closet, turn off the eHO modem and turn on the private internet modem. The private modem bypasses the SOFA, and is connected straight to the main router for my office.

What that means is that we have to connect via VPN (which is our bypass software). I have the VPN software installed on every computer at the office. We load the VPN, and then log on. VPN is not meant to be used in this way, so we sometimes get kicked off the EMR, but at least it works somewhat.

I have a list of instructions posted on the wall besides my router, just in case this happens when I am not there. I have shown my practice partners and my office administrator, so they know what to do. There is no help or manual to figure this out, and the way I have done it is by learning from my mistakes with each subsequent failure; I do not think that this is a good way of planning for problems.

When the eHO lines go back up, we reverse the process. We have to then wait for 5 minutes for the eHO internet lines to connect, so I either wait for a call from our IT guy letting us know that we are good to go, or we try at lunch. We can't do this in the middle of the office, as physicians are seeing patients, and staff are fielding calls and incoming patients at the front.

Today, three HydroOne transformers blew near my hospital, so all internet connections coming into the hospital are affected. We have no service at all, even through backup. We are now starting to wonder if we should have a backup line going to the server--if eHO allows this.

These issues have affected our decision on ASP. The ASP server is hosted at eHO's facility. Their service and communication (we still don't know what happened Tuesday) have been consistently less than stellar--and we are still off-line at the time I am writing this. It would be fair to say that we do not trust that organization with hosting a server managing our data; I think they will have to demonstrate improvements in reliability and communication before we reconsider.

We have to deal with eHO for the lines coming to our new office. I have just received forms for the Order Agreement, which I do not fully understand. I will need help filling those out; I am now frankly worried about whether that organization can supply the connectivity for the 80 to 100 people who will be accessing the EMR remotely in the new location. I guess we'll have to see what happens.

Michelle

Adding more machines

2009-01-13T20:44:00.004-05:00

My partner's tablet just spent a month in the shop getting fixed, as there were several things wrong with it (bit of a lemon). It came back after major transplants, and is now working well.

However, we were short 1 machine for a while. He took the Resident's tablet while his was away.

I had bought a very small computer for travel recently (the Acer Aspire). This machine costs $400, and runs Windows XP. During the past month, my RN and the residents used it (they don't need reading glasses). The nurse told me she likes the little machine better than the Toshiba laptop that was also available, as the Acer is much more portable. I found it somewhat surprising that something so small (and inexpensive) was actually useful; the EMR actually runs well on it.

I did not add MS Office to the Acer, as I don't need it; I downloaded OpenOffice, which is free and runs my word processing well.

We only use a fraction of the computing power on most of our machines, and most of what we use is repetitive. Much of the slowness in computers is due to adding new software (especially software that loads at start up and takes up a lot of memory), and not maintaining the hard drive. Hard drives need to be defragmented from time to time.

I don't like Vista all that much; I'm used to XP, and my network runs well with it. I'm not enough of a "techy" to be able to figure out the Vista-XP network problems (and I'm not that interested in doing it). The problem is that new computers have Vista on them. I'm going to need some additional computers for my new office, and I've been thinking of buying some good off-lease Dells, which are sold by several reputable companies. They're about $350 to $450 each. I'll put OpenOffice on the new machines.

The Family Health Team's Allied Health Professionals working in my practice all use the EMR now. The clinical pharmacist has been using it the longest and is very proficient. The dietitian uses it routinely. Our new Social Worker just started entering electronic notes; I sent her a message in the EMR, and was pleasantly surprised to receive a note back within two hours--she was logging in remotely.

What we had decided to do was to have everyone record things in the clinical notes instead of in separate areas of the chart. You can view a summary of the clinical notes which indicates which provider signed off, so it is easy to find the dietitian's notes if I need to review them. However, if a note is scanned in I'll see it because I have to review and sign it off. If something is written and signed off in clinical notes, I can't tell that there is a new entry and may not see it. What we decided to do is have our Allied Health Professionals send me a message in the EMR that there is a clinical note to review. So far, this seems to work well.

I now send a message within the EMR to our pharmacist that there is a patient to see her. As well, she now has her own schedule in my practice, along with "pharmacist appointment" that with a special colour. My staff is starting to book patients directly into her schedule. I think an e-message or direct booking are far superior to faxing a referral. I'd like to try this with the other members of our team.

I need to make sure that there are enough machines for everyone when they come in. On Fridays, the social worker and dietitian are in. My partner is in, as well as her resident; they need the Toshiba laptop and the Resident Tablet. I have an older Dell laptop in the office, as well as that new little ACER. However, if one of the machines goes down, we're now short. I just bought an off-lease Tablet for $700 (same machine as what I am using). We now have far more people in my office than when I started the EMR almost three years ago, and most machines are in use most of the time. It shows you that you really have to think about expansion when you start an EMR, and the investment in hardware does not stop; you can't see patients unless you have access to the record, and you can't have access to the record unless you have a computer.

Our fax machine bit the dust. My secretary bought a new one, a Brother MFC 7220. It came with some interesting sofware that makes faxing from the computer much easier: print the document, choose PC Fax and you have a single pop up to enter your fax number (or you can load your address book and choose a recipient from there). I can also fax from any computer on my network--the PC Fax software thinks it is a printer, and can be installed as a network printer. My staff were impressed, and I think they are going to start faxing straight from their PC very routinely. This even works over the wireless, so maybe I'll install it on the Tablets and laptops. New peripherals seem to be getting much better.

I think that eventually I'll have to replace all of my computers all at once. I'll plan for a new network then, and who knows what the technology will look like. In the meantime, what I have seems to be working.

Our residents have completed diabetic audits for six of my FHN colleagues, so now seven of us have results. 77% of the patients had data on BP, A1C and LDL within the past year available. Of those, 54% were at target for BP (<130/80), 38% had LDL <2, and 57% had A1C <7%. It is not bad, but we should figure out what happened to the 23% of patients with missing data; LDL is problematic, and we need to figure out how to improve those results.

Michelle

Workflow is king: how to maximize a Peer to Peer visit

2009-01-05T20:41:00.001-05:00

I did a Peer to Peer visit to some colleagues working in two large group practices, in another city. The visit really highlighted the value of reviewing and updating current workflows. The physicians and staff at this site did a very substantial amount of preparation, which greatly enhanced the value of the visit.

I can certainly give quick tips to my colleagues on how to use the EMR more productively. Much of this comes under the guise of “task analysis”, which relates to the speed and efficiency of data entry. For example, keeping hands on the keyboard (instead of switching back and forth to the mouse) and reducing the number of clicks and travel between clicks needed to achieve a task (especially a repetitive one) can make a large difference. For example, double clicking on the “Invoice” tab to bring up a bill is much faster than clicking “Invoice”, then “New Invoice” in a different part of the screen. I use the Tab button to go to the next cell, instead of the mouse, and I use the spacebar to fill in a checkbox, not the mouse. However, there is much more to workflow than individual data entry.

My colleagues had structured the visit over two days. The first part was a large group session, with the EMR being projected on a screen (using dummy data). They had prepared questions ahead of time, and asked me to demonstrate different areas of the chart. The benefit of having a clinician do this (instead of an EMR company representative) is that I have had the chance to think through all the various issues in actual practice and with patients, because I am familiar with both practice and EMR. As well, I am not financially tied to the company, so I have the freedom to show where the bugs are, and how to get around them.

There was a lot of interaction and many questions during that initial 1.5 hour session; I spent most of the session demonstrating the “quick tips” above. Once that was done, we went to see the scanning area, and the front area, and I spoke with a nurse and an administrator. This group had clearly decided that EMR implementation was done as a team, and wanted to make sure that I saw how different areas of the clinic functioned; this is the right approach to take. We went through what happens when a patient checks in at the waiting room, then gets their initial work up (done by a Practical Nurse), and then gets put in a room. What was really interesting was that the lead physician identified bottlenecks in flow as we were going through the clinic; the first step in solving a problem is to actually see what the problem is. At lunch, we went over the bottlenecks as a group, and brainstormed several possible changes.

For example, I saw the front secretary taking calls, checking patients in, and being handed a couple of papers by another staff member. There was a small queue of patients waiting to give her their health cards, and the phone was constantly ringing. The problems here are that incoming calls can’t always be answered and patients can’t get through on the phone; this leads to call backs and telephone tag (extra work, less patient satisfaction); as well, multitasking can make it challenging to do work well. One of the things we came up with was the concept of the “front and back”: the front secretary could direct traffic (greet patients and check them in), but not answer phones, and the back secretary could answer the incoming calls and do outgoing calls as needed. Any papers or tasks that do not have a direct impact on the front need to be given to the back secretary. We also talked about management of notes that are paid for privately; in my office, these are printed at the front (not in the physician’s office), and payment is received at the front. Payment, in other words, is directly linked to work produced (the form). What that will mean at that site is networking the front printer to all of the clinic’s PCs, and having agreement on a common workflow for the notes and payment from all clinic members. The front secretary can handle payments, unless the clinic prefers to direct patients to the back secretary for this.

For the second day, I went to the other site, and again observed different areas of the clinic. We then had several small group sessions with a projector, to go over particular problems that had been identified. For example, one of the administrators was having difficulty with large group scheduling. We sat around the table with her; there was a lot of discussion and input, ideas were flying back and forth, and we kept trying different scenarios on the projector. Within a half hour, the issue that had caused her a large amount of stress was substantially resolved. She still has the work of implementing the suggestions, but we could all see that the problem was solvable.

We then had an additional large group session. Several physicians had already tried some of the “quick tips”, and were happy with them. We discussed further improvements in charting, such as using coded entries for chronic conditions. I showed how to rapidly enter data in the CPP, as this had been a common query. This session gave everyone a chance to solidify the gains that they had made in the previous day, and to think about additional changes.

The last part of the day was a “debriefing” session with the key physicians, staff and the unit administrator. The administrator ably helped the group to decide which changes in process they were going to implement first and how, and which changes were going part of the next phase.

We have planned a return visit to my office in several months; I think a very worthwhile thing to do is for one or two of their key admin staff to spend time with our FHN administrator. We did this following another P2P meeting, and it worked well; you can’t change processes if you don’t involve all staff, and I wish the program allowed non-physician members as P2P consultants--in other words, a Team consultation.

What was done at this visit shows how to maximize the value of a consultation; the more you put in, the more you get out; have good processes in place for the consultation itself. The value to this group was largely due to the fact that they were well prepared, had clear questions and goals, and were ready to consider how to implement changes at the end. It also helps to have a cohesive group, were there is mutual respect and good communication between team members. I was very impressed with this group.

I am starting to wonder if one of the outcomes of this Peer to Peer program may well be the formation of a group of physicians familiar with both EMR and workflow analysis in primary care practices. This was not the intent of the program, but EMR implementation is so intimately tied with workflow re-design that an effective P2P physician must address both. There are already practice management consultants (through organizations such as MD Management), there are physician leadership training programs (PMI), and there are “EMR experts”; what I don’t know is whether there are “cross-overs” familiar with primary care practices—and those are the ones who may be the most useful as we transfer from paper to EMR. Perhaps Infoway should discuss this with the Practice Management people.

Michelle

After the upgrade

2008-12-21T16:58:00.002-05:00

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

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

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

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

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

By Monday, the system was working again.

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

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

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

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

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

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

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

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

Michelle

Upgrading our EMR software

2008-12-07T11:59:00.003-05:00

Our EMR software needs to be upgraded. The version we are currently on does not conform to the new OntarioMD requirements (Clinical Management Systems Version 2.0). We are getting the upgrade next Tuesday.

I view upgrades with both anticipation and trepidation. The anticipation is about the new features (improved medication management, vastly enhanced ability to search the record). The trepidation is about the unknown problems that we will face: will our printers and labelers still work? Are there bugs that we are not aware of?

These programs are now so complex that it is impossible to predict what changing things will do. As well, each province sets its own requirements for EMRs, and the software applications are programmed to meet these requirements. The requirements are usually tied to funding, and are thus more important than user requests; you get the system you plan for.

I understand that it is quite expensive for each EMR company to meet the requirements, on the order of $200,000 to $300,000 per province. This will make some of the smaller companies drop out of the market (not necessarily a bad thing in the long run). However, there does not seem to be a rigorous process for testing the new software, which means that physicians and other front line users are exposed to what is essentially an untried product. Even Microsoft can have missteps with new releases (see Vista).

Another issue is the interoperability factor. Some large physician groups have managed to negotiate a connection between their system and their hospital's system. However, these are currently one-off solutions, meaning that they cannot be replicated. The difficulty here is that the software upgrade needs to be tested in the environment it is currently in to guarantee continued interoperability. Two things can happen:

1. Testing does not happen, and interoperability (or parts of it) fails with the upgrade, or
2. Testing does happen, but only after a long delay; that group is now several versions behind their colleagues

I hear that these issues are common in the business world as well. Even large, enterprise-level databases (such as Oracle or SAP) cannot be completely tested; the results of new implementations can be dropped customer orders, difficulties connecting electronically to large external customers, materials being shipped in twice the quantity ordered due to software bugs, and difficulty with planning production due to missing/incorrect information. Testing can take so long that implementations are rushed in due to deadlines, with unknown consequences.
It takes time, money and work to fix the universal initial software problems, and these may be less available in small medical offices than in large corporations.

We received a 47 page document a few days ago on what is available in the new version of our EMR, as well as a 10 page document on medication enhancements. I am going through the documentation in preparation for the upgrade. However, I am concerned about my FHN colleagues; most of us are unprepared, and have had no training with the new version (and may not have the time to go over the documentation). I think what will happen is we'll get the upgrade, I'll give it a few weeks to see what the issues are, and then we'll schedule a booster learning session for my FHN. I think some formalized training may be useful: it is not necessary to train the whole group; having a web session for the "super-users" may be what's needed, as we can then spread the knowledge to our colleagues.

Michelle

Forms, forms, forms

2008-11-30T21:49:00.002-05:00

We certainly had quite a bit of audience participation at the talk Dr Stephen MacLaren and I gave at the recent Family Medicine Forum conference (EMR: the first year of computerization).

Of all the family physicians in the room, about a third had implemented an EMR; none were paperless. There was a lot of interest on managing incoming and outgoing paper-based communication.

We manage incoming slightly differently: Stephen has the scanning tech use OCR (Optical Character Recognition) on the majority of the letters. The benefit is that the notes are converted to a text based document (rather than a pdf picture); this is then searchable. The drawback is that the tech has to proofread every document for accuracy prior to shredding, as the OCR process is not 100% perfect. You have to have a well trained tech, and it can be labour intensive.

I prefer to have my scans as pdf, which is essentially an image, but which preserves the original format and does not require proofreading. However, I then have to either summarize the report in "comments", or run OCR from my machine and copy/paste the text into comments.

I find that some simple reports can be summarized; for example: "Dr Smith: pt stable, monitor", or "CXR normal". Some are longer; most of the useful information in specialist reports can be found in the last paragraph, so this is what I copy and paste into the comments.

Regardless of the method used, this is unsatisfactory. Most of these reports are generated using a computer; they are then printed and mailed or faxed; then when they get to my office, they are scanned and imported into the computer.

This process is akin to writing an email, printing and mailing it, and having the recipient then either type a summary or scanning and importing the information into their in-box. Clearly no-one in business would put up with such an inefficient process for information transfer, yet this continues to be our daily reality in health care.

The process for outgoing forms is no better. Most programs continue to be wedded to forms. Both Stephen and I have attempted to replicate the look of the forms in our EMRs, so that they are ok at the other end. The information is there, but unless the format is "acceptable", the letter gets rejected. We both described the process of negotiation that is required to get the "electronic" version of the form accepted (not really electronic, but really a paper output of what our EMR generates, modified to conform to paper-based norms); Stephen has successfully negotiated with his hospital's senior management, while I have had some success with the front-line clerks. For both of us, persistence has been the key.

The friendliest department has been Diagnostic Imaging; they seem happy as long as the appropriate information is there, and it is signed. In fact, one of the XR techs at my hospital told me they like my EMR referrals because they are so clear and legible. No community or hospital-based DI facility has yet rejected an EMR generated form.

Programs (diabetes education, mental health etc) are a mixed bag. Some are progressive, some are not; it really depends on who works there. The toughest have been labs. I won't even try to send something that does not look like a provincial lab form, as I am sure that rejection rate will be 100%; I do not think that this is within the purview of the labs themselves, but rather stems from Ministry directives. The public health lab is similar. I now generate both an EMR and a paper-based form for my paps, as I consider tracking of this test to be vitally important. I think this may be the first lab component to accept electronic forms, as the paper form is proprietary (each lab has their own); the argument for improved quality of care for electronic data generation (tracking) is fairly strong.

Our colleagues continue to fear our regulatory colleges. I spoke about how I disposed of my old paper charts (scanned, backed up x 2 and verified, then the paper was shredded); I was asked what the College policy was on doing this. Here it is:

"When a physician scans his or her paper records to convert them to electronic form, the original paper records may be destroyed in accordance with the principles set out in this policy."

I think that what may be helpful to the profession are some explicit examples of what can and can't be done; otherwise we will continue to be confused. The College's intent is to protect and serve the public, and it is now always easy to balance all the different (and sometimes competing) interests. However, more clarity would help, as well some charity towards members embarking on the EMR journey; after all, these systems have been found to be beneficial to patients and to the health care system.

Michelle

The first year of computerization

2008-11-15T20:35:00.005-05:00

I will be presenting a workshop on the first year of computerization at our national family medicine conference, in two weeks. I am doing this with a colleague, Dr Stephen McLaren.

I wanted to do this with someone who is practicing in a different setting, and is using a different EMR system. Whenever I do a workshop or presentation, I find that I learn a lot just through preparation; it was the same here.

My colleague has been using his system for almost ten years. He practices in a large group; I was in a small office of two physicians, and my partner did not wish to implement an EMR at the beginning.

When we started talking about the presentation, I think we assumed that there would be large differences in our implementation. In fact, there were far more similarities than differences. Our goals were the same, and the difficulties we encountered (especially with regards to the problems of external, non electronic data) were similar. The solutions and work arounds we came up with have differences, which fit our individual settings and styles. We even found that the challenges of dealing with our EMR companies were similar.

There are no secrets to a successful implementation; it is the same as any other large scale change: "Plan-Do-Study-Act". The first year is very hard; the rewards (increased efficiency, ability to improve quality) do not come until later, once all the data is in, and the EMR system is used consistently. I believe that there is now enough practical knowledge about what works and what doesn't to make the transition a bit easier, and that's what the workshop is all about.

Our practice team is slowly learning how to use the chart in common. This works best for those of us in the same office: my front staff and my practice RN enter everything in the EMR. We hired a new secretary in September, as well as a high school student for evening relief, and there were no training issues; they used the EMR from the start. Our Family Health Team pharmacist, who usually manages patients off site, came to my office to see a challenging patient with me, and while she was there we discussed flowsheets. I showed her how they worked, and told her that she was welcome to enter data there if she felt that it was relevant to team care; our RN, for example, routinely enters data in the diabetes and depression flowsheets. A few days later, I noticed that the pharmacist had entered information remotely into a chronic pain management flowsheet.

We have had a lot of staff changes with our dietitians and social workers, which has made implementation of a team approach more challenging; these practice team members never had a chance to start the EMR before they left. I received the first clinical message from our new dietitian, as she had a question about a patient she was to see the next day; she is enthusiastic about the technology, which is helpful. While our Family Health Team has not yet discussed where our Allied Health Workers should chart things, I think they should write in the same clinical notes as I do. I don't know if it is necessary for me to review all their notes (likely not); our clinical pharmacist sends me a message to look at her notes when she is done. We should think about whether it is better to do it this way, or better to have the physician sign off, which is what I do with my RN, or have the physician co-sign; this should all be negotiated.

I am currently attending a research conference, NAPCRG. I consider this work, so I told my practice partners that I will be checking in daily for my results. It was very busy before I left, so I did not complete some charts; I needed to go home and pack. I finished my charting from my conference. Remote access makes going to a conference a lot easier to do, and I don't feel like I am burdening my partners too much. Most of the coverage while a physician is away does not involve seeing extra patients, it involves reviewing and managing lab results and other incoming tests and consultations--these can all be done remotely.

My older partner is now six months into EMR implementation, and although he is charting pretty much everything electronically, he is not prescribing. He types the prescription into the clinical notes, and gives patients a hand written script. I asked him if he could prescribe faxed-in refill requests electronically for me while I am away; as of now, he writes "ok" on the faxed request, the secretary calls it in and the paper is then scanned. That is not useful for me, as it does not update my electronic meds. I showed him the process for managing this electronically: the secretary leaves the paper form for him, he loads the patient's chart, checks off the meds, hits the "print" button, then cancels printing. This generates the refill. He then sends an electronic message asking the secretary to call it in, with the phone number.

This process is more tedious for the doctor than writing "ok" on the paper form, but it does preserve the integrity of the data (which is lost with the paper form). I have been strongly discouraging the use of faxed/phoned refills; we have a message on our machine that we do not accept them, and we charge $25 for this service--with exceptions in some circumstances. I do not feel that phone/faxed refills, with no patient contact, represent good care; my patients are always given enough medications to last until the next appointment. There is no quick and easy way to manage phoned refills in the EMR, and there is no clinical necessity for the majority of those--they are often done for convenience.

Michelle

Space planning for my next office

2008-11-02T21:18:00.003-05:00

Planning a new office is a good time to re-examine what I do and how I do it. This will be my third office (and my first paperless office). I have learned something new with each planning exercise, and worked on the current drawings with a space planner. There is a very useful podcast on the subject at Canadian EMR.

This office is being built for three family physicians, and is about 2,000 square feet. We teach, and have two residents in the practice. All of us are members of a Family Health Team; we have a nurse, a social worker and a dietitian seeing patients at various times.

One of the biggest differences between this office and my current office is that there is no space for filing cabinets. Instead of paper storage, I have exam rooms; there are eight of those. I work best with two available rooms; while I am seeing one patient, the next patient is put in the exam room, and a third patient is in the lab area getting their vitals done. Each physician will have two dedicated exam rooms; all three physicians are rarely in the office at the same time, so I expect to have four extra rooms available most of the time for the use of our Allied Health Professionals and students. The residents are encouraged to take extra time at the beginning for their patient encounters; the additional exam rooms ensure that this does not impede patient flow for the attending physician.

The exam rooms are mostly 8 x 10 feet. This is enough for an exam bed, a sink, a bit of counter space, and a small desk to put the Tablet on. I will also be putting a printer in each room, and have low stands for those, with space underneath to store extra printer paper and magazines for patients to read while they are waiting. I use transparent file sleeves attached to the wall for the very few paper forms that are still needed, and for my clipboards (I use clipboards to sign forms and to go over handouts with patients).

We decided to have a common consultation room; this is a major departure from my current office, where each physician has their own consult room. The shared room is far more space efficient, but does entail some loss of privacy. There is also minimal space for paper storage; paper tends to spread and fill all areas allocated to it. I designed the room for 5 people: 3 physicians with allocated desk and storage space, and two shared areas for residents, Allied Health Professionals, and the RN (with the ability to use the allocated areas when a physician is not present). In my current office, I share space in my consultation room with our RN when she is in, and with our resident (I added an extra desk for them); I find that this leads to much improved communication. I expect an increase in “corridor consultations” if all health professionals sit in the same room, and I consider this to be an important aspect of Team building.

If one of us does need privacy, for example, for a personal phone call, we can use one of the exam rooms and a cell phone. One of the things we will look into is having small wireless phones as part of our system for physicians to carry around while in the office, or having telephone jacks in exam rooms.

There is also a staff room. I find that we have an increasing amount of “back room” office work (billing, managing our preventive services, following up on OHIP numbers etc). This is often better handled away from the front desk, so that the staff person at the front can attend to patient flow in the office: checking patients in, getting vitals done(the vitals area—scale, stadiometer for height, BP machine—is right beside the front desk), putting patients in rooms. The staff room is also a good area for lunch away from the front desk or consult room, and can also be used for staff meetings.

I have not allocated space to drug samples in the lab "nurse" area. Sample storage is very space consuming, as the packaging can be wasteful. As well, we have to manage the samples: periodically, a staff member has to review expiry dates, and discard expired samples in our contaminated waste (which is very expensive). We have been asking drug reps to check and refill our cupboards, as this is not something that my staff should be doing; however, samples still expire. I also find that samples tend to spread to the space in adjacent cupboards where we still store some paper handouts. In my new lab area, there is no space for paper handouts (the best ones are all scanned in); the cupboards are for storage of clinical materials (urine dipsticks, pregnancy tests, gauze etc). We will have shelves for overflow clinical materials in the Staff room, so that only the most useful things are stored in the lab, where they are most accessible. I’m not quite sure where samples should go, but probably not in prime space.

In terms of the IT, I have a small closet for the routers, firewall, and other boxes that I want kept out of the way. My telephone system will also go in there. My wireless access point will be installed centrally in the ceiling, and tested before I use it. I plan to have network drops (RJ45 plugs) in every exam room, at the front, in the staff area, in the lab area and at each workstation in the shared consult room. These are easy and inexpensive to install when building a new office, and I prefer to have redundancy. The printers in each exam room will be plugged into the network access points. If there is only one RJ45 plug, and two devices need to be plugged in, I can use an Ethernet switch (costs $25).

You can see how I have tried to plan this office with workflow, team work, communication, and appropriate storage in mind. I have tried to think of who does what, and what the best place and flow for each member of our practice team is. I have also deliberately minimized the amount of paper-based storage; I find that if there is no place to store paper, you just naturally decrease the amount that you keep around. The basic principles for designing an EMR-based office are the same as those for a paper-chart office; the major difference is in the opportunity to decrease the wasted space allocated to paper.

Michelle

The Well-Tempered chart

2008-10-25T14:26:00.002-04:00

This image above shows an example of automated data capture with the EMR; I am now tracking data on my visits for several different diagnoses. I can see that my annual check ups are stable, visits for common colds have seasonal patterns, and that I have changed my practice towards more chronic disease management and away from the treatment of acute, minor conditions.

The chart above is for the number of visits billed for hypertension; these are clearly declining. This is interesting to me, because it reflects the outcome of a number of changes I have made in my management of hypertension.

I use an automated BP machine in my practice; my staff do the BP readings, not me. I think the quality of BP readings in my office has improved as a result. Patients come in every 6 months if their BP is stable, consistent with current evidence. If BP reading is above goal, they are asked to drop by on a Friday (I am not in the office that day) to obtain an additional BP reading from the machine. These visits are not billed. I see the result remotely, and can send a message to obtain one more reading if needed, or to ask my secretary to book an appointment for medication optimization.

I also use home BP machines much more often. I have two loaner machines in my office.

The end result is good BP control, but fewer visits with the physician (see graph above). I don't think that routine BP measurement is a good use of my time, but I have switched from Fee for Service to a capitated payment system; this rewards efficiency instead of service intensity--there are pros and cons to that.

I can look at my data and plan further improvements because I now have "Well-Tempered charts". What I mean by that is that I have tried to enter good data, and to enter it consistently so that I can search it later. It was a learning process for me; I knew that my data would not be very good in the first year, and would then improve. I now enter "250" (diabetes) only when the patient is diabetic, and not when Impaired fasting glucose (or "pre-diabetes") is present. If I think the patient has angina, but I'm not sure, I will code the diagnosis as 785 (chest pain not yet diagnosed), comment "possible angina"; I code for angina, 413, only once I have the diagnosis. When I search my records, I now know that my diagnoses are highly specific (finding a code for diabetes means that the patient is truly diabetic). The searches may be less sensitive (may miss some diabetics), because some of my patients with pre-diabetes actually have the disease but have not been diagnosed yet.

This coding schema in my brain applies to important chronic conditions, because I really do want to identify patients with on-going problems that I want to manage better. I am less careful with minor conditions, such as colds; I may identify a cold as laryngitis or acute bronchitis (when they get an antibiotic).

Even though the EMR system allows me to use free text for conditions, I have limited this. I think trying to search for "DM II", "diabetes", "T2D" etc has far less value that coding the problem properly--even if you never misspell the condition.

Every prescription is entered in the EMR database; I avoid "free text" prescriptions whenever possible. Once I built my list of drug favourites, prescribing through the Multum database became much faster. All phone repeats are entered as prescriptions. I can now search through my prescriptions with a great deal of reliability.

Entering data is a pain; getting data out is the real gain. We need to think about the minimal requirements for the Well-Tempered chart, and I have outlined what I did above. I think coding correctly for about 10 common chronic conditions (DM, HT, depression, Asthma, COPD to start with) is a good start. Using the EMR to prescribe is helpful. Switching to labs that provide electronic results is a very good idea. None of this is terribly difficult, but it does take some effort to learn how to do it, and some discipline to enter data consistently.

JS Bach showed us that well thought out, orderly musical compositions are pleasing to the ear. I think we can learn from the Master, and apply his principles to the content of our records.

Michelle

Age of the Machine: managing hardware

2008-10-18T21:25:00.011-04:00

Using an EMR means having a lot of machines around.

I recently took stock of what we have. In an office of three family physicians, all part time (4 days a week, 3 days a week, and 2.5 days a week), we now own:

3 Tablet PCs

1 laptop

5 desktop PCs

Total: 9 computers in the office

As well, there are 8 laser printers, four label printers, and two scanners. There is a wireless transmitter, a Small Office firewall, two broadband internet routers (a main one and a backup), and a failover router. There is an external hard drive for storage, and an external DVD writer for larger scale back-ups.

Some of the printer are attached to desktops, others are network printers. The scanners act as photocopying machines and faxes; we also have a "regular" fax machine. We have several UPS devices in case of power failures.

On any given day, any of this can fail. My wireless has gone down, the internet access has failed, various computers have crashed, printers have disconnected, and labelers have printed little necklaces of labels with nonsense on them. I have learned to try for the best, and plan for the worst. Sometimes it feels like being in Samuel Shem's "House of God": the first thing I do in a crisis is take my own pulse--then I call my IT Guy.

Here is how I manage my PCs. All computers have anti-virus software, set to run scans on a weekly basis. I periodically defragment the computers, and check that Windows updates have been installed. Everyone has been taught to use "Winkey-L" to lock their workstations when they leave.

We run a small peer to peer network; I set this up to have shared documents on the front computer and external hard drive. My old charts have been scanned to the external drive, and then shredded. Those paper forms that the outside agencies simply won't give up have been scanned to the shared folder on the front computer; I made a copy on the external hard drive. Every PC can access all the printers that are likely to be useful at that station.

Much of my hardware was installed at the beginning; I added extra parts as needed-- some after a problem occurred. Whenever I added something new, there was always work to make sure it functioned properly; no hardware or sofware component ever works perfectly out of the box.

Looking at this, it does seem like a lot of work. However, much of what needs to be done (once installed) is simple maintenance, like a preventive health exam or taking the car in for a tune-up. This is still so new to small practices that we don't have good preventive routines yet; many physicians may not be all that computer literate, so machine failures get magnified because they can't be fixed quickly. I don't know how many of us have access to a good IT guy (instead of the neighbour's teenaged son); I know we didn't when my group started.

When things malfunction, the process of diagnosing computer problems is a bit like what we do for our patients. You try to figure out the likely cause of the problem by taking a history and formulating differential diagnoses, you run some tests, and then you try various things to fix the issue. The problem here is that this happens on top of patient care during a busy office, and the physician may be functioning at the level of a medical student in term of IT knowledge (especially at the beginning). I think it really helped us to function as a group so we could help each other out.

Interestingly, most of this hardware actually works pretty well, most of the time. Here are the things that can help:
1. do some preventive maintenance (antivirus etc)
2. have a good IT guy that you can call
3. buy good machines (not the cheapest ones)
4. keep all your CDs (drivers, software) in one place in case you need to find them
5. try to form a collaborative group with colleagues so you have someone you can call if you can't figure out what to do

And, if all fails, go and have a cappuccino--after all, these are just machines.

Michelle

Helpdesk Tango

2008-10-10T17:04:00.003-04:00

Working with your EMR company's Helpdesk is a bit like dancing the Tango. If done well, it can be quite good, but if your partner drops you during a dip, it can be a disaster.

We have had our ups and downs with the Helpdesk. They were very helpful at the beginning (we got to know several people by name); then there was a period when the phones were not being answered. Now we live in an uneasy truce with them.

There seems to be a fair amount of turnover in that department. I think it must be a very stressful job: when a physician or staff member calls, there is something wrong and they're not happy. New releases always seem to cause problems and everyone calls at once, so the helpdesk is overwhelmed and messages get re-routed to call answer; people are even less happy.

Having a super-user around decreases the number of calls to Helpdesk. We can often help our colleagues faster than they can, as we are familiar with our local setting. I now seem to be in charge of managing our VPN access. As well, I send periodic updates on how to use the software. A colleague in a very well managed large group practice told me that his group made a decision as to who calls their Helpdesk, so that they don't get the same calls repeatedly; his EMR company rewards groups with less than the average number of calls financially--not a bad idea. I wish Helpdesk kept a list of key contacts for each group and managed those calls a bit better.

We had an issue with our label printers not working properly after one of the upgrades. Our FHN administrator figured out what the issue was; she sent out an email, and was able to help several offices fix the problem.

If the EMR went down, we often didn't know who to call. The failure could be because the SSHA Internet connection was down (call SSHA), because the application was causing a problem (example, running a report that was too large), or because the server needed to be re-booted. Over time, between our two FHNs, we worked out processes to deal with this. Each FHN has one person responsible for calling (and a back-up in case the physician is away or not available). If there is no service, we log in to Google (check the Internet). If that works, then it is the server or the application. It is not always possible for us to know; our IT guy told us to phone him first, as he can check the server remotely. If the server is ok, then we notify the EMR company.

We sometimes have problems with our labs coming in. To get lab results, the server uses what I have been told is a very old, phone-based application (Winblast). This application can get easily turned off, and sometimes seems to go off on its own. If it is off, then no labs come in. Helpdesk then get calls and emails, and they have to go in to turn the program back on; due to security issues, we don't have direct access to this program. This has happened repeatedly. Our IT guy finally put together a small program that automatically checks and turns the phone application back on; problem solved.

We are trying to manage as many issues as we can; we don't like calling Helpdesk. Calling takes time that could be spent on patient care, and they can't always help. However, when we do call, we don't want to be dropped on our back. It took quite a long time for us to figure out the processes we now use; perhaps EMR companies should develop a list of common issues, and help physician groups develop workflows to make things work more smoothly when problems do occur (an ounce of prevention). Some problems are likely very common; I am sure Helpdesks keep call statistics (or they should). Sending out information about common problems and solutions may help; helping the local super-user help their colleagues, and investing in the development of local skills certainly will help.

As users, we have had to learn to manage our Helpdesk. I think this department must be expensive for the EMR company, and they are certainly a cost centre (every call costs them money). There are things they can do to manage those costs without antagonizing physicians through deficient service, but this requires planning. Perhaps one of the factors for survival in the current EMR wars will be service: how to keep users satisfied without having Helpdesk costs go through the roof. Only the smartest companies will survive.

Michelle

Small fish in a big health care system: living with uncertainty

2008-09-26T09:10:00.004-04:00

Ontario's subsidies for EMR systems have now ended, as of August 31st. By that, I mean that no new physician groups can apply for EMR funding. The groups that have applied and been approved receive funding support for three years.

About 2700 physicians have been approved, representing the majority of those of us eligible for funding. There are about 2,000 physicians in Family Health networks and similar "primary care reform" sites (mainly paid by capitation). There was an EMR lottery for those in Family Health Groups (mainly paid by Fee for Service, with a smaller amount through capitation); about 2400 physicians applied, and 800 were funded.

It is clear to me that subsidies lead to physicians buying an EMR; not all who buy will go on to adopt. In the two FHNs on my server, by 18 months, 12 physicians were using the EMR full time (all encounters), and 6 were not using it--they never started (2/3 adoption).

This was an interesting experiment. The outcome of the Ontario subsidy program was the emergence of a market leader, with about a 45% share of funded physicians, or 1101 funded users. There are 6 "second tier" EMRs, with anywhere from 139 to 221 funded physicians (5.7 to 9.1% market share); the EMR I use is one of those. 5 EMR systems have a very small share, likely too small to survive in Ontario, for a total of 147 physicians.

There is now considerable uncertainty as to what the future holds. I cannot see any indication that funding will continue for those of us who have EMRs (unlike Alberta). Funding for my group ends in early 2009. The ongoing costs of EMR are about $600 to $800 per month; this does not include things like calling the IT guy because something is not working in the office, or having to replace computers and printers etc. There are a lot of unexpected costs in an EMR practice, because we have a lot of IT equipment (which breaks randomly and doesn't last forever).

I also have not heard anything on EMR funding for additional physicians; perhaps the government had decided that it is now the responsibility of individual practices to pay for and support EMR systems. We have a federal election going on, and there is not very much talk about health care this time around. We also have a new provincial contract offer, negotiated between the Ontario Medical Association and the Ministry of Health: I cannot see any funding or support for office-based EMRs there (perhaps it was simply not part of the negotiations). There is some funding for a new diabetes registry, but I think this this may simply mean having us put patient names on a secure website--no integration with EMR, no point of care data in our e-chart. Just a data push to the registry.

The business case for EMRs at the individual practice level remains equivocal--the EMRs mainly benefit patients and the health care system. Integration would make a huge difference; by that, I mean having data from hospitals and other outside agencies flow directly into our EMRs instead of being laboriously scanned in. This is not happening, and I do not see any initiatives that are likely to make this happen in the near future.

What does this mean for me, my partners, my staff and my patients? Well, continued uncertainty. I have things working well in my own office. We now have good things happening via the EMR for my FHN (preventive services, diabetes quality initiative). This is for 14 physicians, so EMR implementation can be done within a practice or physician cluster.

For my FHT, 40 physicians, we still have two EMR systems; little to no chance of integration in the near term. 25 physicians co-locating to one big office in 2009, including me and my practice partners.

For my local area, hospital, LHIN, I still cannot see movement towards system integration.

For my province, no further funding for EMRs (for now at least). I think it is likely that the small EMR companies will now start dropping off; possibly some of the second tier companies will fail too. Physicians will have to transfer from one EMR system to another. While in Alberta, there is planning to help physicians do this, I do not see evidence of such planning or help in Ontario.

I do not know if small to medium size EMR companies can continue longer term; we still have several in Ontario. If a large financial institution in the US can fail, then the risk to small IT companies has to be substantial. I would assume that smaller companies are dependant on venture capital, and it looks like turbulence there in the next little while. If there is no capital available, or it is too expensive due to risk, then there will be problems. Physician users may not get much warning before a failure occurs.

This is not where I wanted to be after 2 1/2 years of EMR implementation. I was hoping for the availability of patient access to their own chart, for seamless flow of data to and from hospital and home care to my system and for more data portability from one EMR to another, perhaps through common standards. While there continues to be much talk, there is very little "on the ground". I was also hoping for some support for early adopters, in case of EMR failure, and ongoing funding (both for new systems and for ongoing EMRs). I am essentially done in my office; however, if my EMR system is one of the non-survivors in the next little while, I have no way of planning for a transition to another EMR system.

"May you live in interesting times" has certainly been the case in my practice; it looks like the Interesting Times are about to continue.

Michelle

Our future: deciding on ASP vs local

2008-09-15T21:55:00.002-04:00

We are coming to the end of the three year initial period; our EMR contract runs out early in 2009. My group now has to decide whether to stay on our local server (located at the hospital), or to move to the provincial ASP server.

We are not the only group deciding on this. There are now three approved EMRs on the ASP server; many of my colleagues, especially the ones in larger, distributed groups, have started considering this issue.

For those getting lost in this jargon, "local" means a server that you own and manage. The machine does not have to be in your office; it can be located elsewhere, for example, at the hospital (all physicians access remotely), or in a physician's office, with colleagues in other offices accessing remotely.

ASP, or "Application Service Provider", means the server and all the software sits in a large server elsewhere, and you just rent space. You don't own the server or the software, only the data; everything that sits outside of your office is managed for you. No worries about upgrading the server, about operating systems becoming obsolete, etc.

Google, gmail, google docs could all be considered as ASP. Your copy of MS Word that sits on your computer is "local".

Seems like ASP is an obvious solution, since who wants to manage a server and all its hardware and software. However, like everything else in life, it is much more complicated than this.

First of all, the ASP server is hosted by SSHA; we have not had an ideal relationship with them. SSHA has had many growing pains, see the 2006 Operational report by Deloitte and Touche. They supply our internet connection with the server, and speed continues to be an issue. Moving to ASP means more of a relationship with SSHA, and we are worried about this. Rightly or wrongly, we do not have much confidence that the server will be well managed.

Second, the SSHA ASP model for the EMR we use is new; like most groups considering this, we don't want to be the first. We simply do not know what issues will arise through the data transfer.

Our local server will soon be three years old. We now have additional physicians on it, new Allied Health Professionals, family medicine residents and medical students, locum physicians, and more administrative staff, all adding data. For example, we now have 70 registered users just for my FHN of 14 physicians. The other FHN on our server likely has a similar number of users, and our Family Health Team is still actively recruiting Allied Health Professionals.

Our IT guy manages the server, but I wonder if this is enough for an enterprise of this size. While we continue to think of ourselves as small businesses, I think we are now at least a middle-sized company (but we do not function as one). I worry about whether we can continue to manage a server without a formal IT department. We now have an IT committee, consisting of two physicians from each FHN (I am on that committee), but I am not sure we have the needed expertise. One of the physicians has been putting in an extraordinary amount of time troubleshooting issues that come up.

Our government funding will be coming to an end in early 2009; to my knowledge, there is no more funding forthcoming, unlike our colleagues in Alberta (they get ongoing funding). There may well be considerable costs for managing our server and the rest of our IT, and I am definitely worried about what will happen when we start to talk about costs with my FHN colleagues who are still sitting on the fence with regards to EMR.

I still favour ASP (cautiously), but there is a lot of uncertainty in our IT committee. The uncertainty is certainly justified; we simply don't feel that we have the information we need to make a decision as of yet.

I am also looking at moving to the new FHT office in 2009; our main lease was finally signed, and we can start the renovations in the next few months. We will have 5 practices, with 3 to 6 physians in each practice, all moving to the same floor of a building, but maintaining their own practices. We will have the main office of the FHT, with our Allied Health Professionals located there. This comes to about 21,000 sq feet, and includes a lab. I have the layout of my new office (I am moving with my current two partners). I now have to think about what to do with my IT (wired access points, where to put the wireless etc). The plan is to have the entire FHT office on EMR.

Despite all this uncertainly, things are generally good at my office. The programs we have implemented for preventive services are working well. My staff told me that several patients came in to the office to pick up FOB kits after the reminder mailing, and all of our FHN secretaries knew to include a requisition when the kits were being picked up. We are now on our 5th or 6th cycle of mailings for paps and mammos, and everyone knows to expect phone calls with questions or to book a pap after mailings.

I have now moved to three days a week, since the beginning of September, with very little disruption; my schedule looks reasonable, and I can see several open spots for next week. I can see that I do not need to reduce the size of my practice for now, as I can manage 1300 patients with the EMR and the additional Allied Health from the FHT. We even have a new resident on block time (more or less full time with us) this month, and are functioning well. My desk continues to be clear of paper.

My staff are now scanning everything that comes in for both of my partners; the volume of scans is increasingly problematic. We still do not have any electronic transmission from the hospitals, from Diagnostic Imaging facilities, or from specialist. Nothing.

I think I am managing well within the walls of my office. The rest of the system continues to present problems; solving those is out of the hands of family physicians like myself, and we continue to wait (and hope) for leadership in the IT front at the local and provincial level.

Michelle

Diabetic audits: measuring quality with EMRs

2008-09-05T17:48:00.013-04:00

My most recent diabetic audit has just been completed. The results are:

2004: BP<=140/90: 65%;

LDL less than 2.6: 50%

A1C <= 8.4%: 74%

2006: BP<=140/90: 82%; <=130/80: 66%;

LDL less than 2.6: 63%, <=2: 40%

A1C <=8.4%: 81%; <=7%: 48%

Missing: BP 19 patients, LDL 26 patients, A1C 20 patients

2008: BP<=140/90: 90%; <=130/80: 83%

LDL less than 2.6: 79%; <=2: 52%

A1C<=8.4%: 81%; <=7%: 42%

Missing: BP 0 patients, LDL 5 patients, A1C 3 patients

The averages for my practice are:

2006:

BP 125.8 / 76.8;

LDL 2.32;

A1C 7.37

2008:

BP 121.7 / 71.4;

LDL 2.17;

A1C 7.42

I am happy with those results. I can see that I have steadily improved my results for BP and cholesterol control; however, my A1C results for 2008 are slightly worse than for 2006.

Before I discuss this, I would like to talk about how I track these diabetic results. The EMR auditing process is not as good as I would like, but it is significantly better than what I was doing on paper.

The 2004 audit was done prior to the EMR. I had a co-op student from the local high school, and she did the audit. I used billing data from my old billing/scheduling program to get a list of my diabetic patients. At that time, I put in an initial quality improvement step: the student put a yellow sticky note with a reminder (example: LDL) in the progress notes of all patients not at goal while she was doing my audit. I wrote a short article about this process for Canadian Family Physician.

The 2006 audit was done by my resident (all residents have to do a quality improvement project), and entered in Excel. She did this in August 2006; this was four months into the EMR, so not all of the diabetic data was in electronic form yet. That is why there are so many missing results. I had already started using diabetic flowsheets; the time required for audits was significantly shorter than on paper. At that time, I put in reminders for myself to check the flowsheet every 3 months, and started sending Actions to my front staff more aggressively when parameters were not at goal (example: cholesterol high, call patient and ask her to double up on lipitor). I also started using pop-up alerts.

The 2008 data is much more complete. All patients now have flowsheets. My secretary did the audits for me, and I have asked our new resident to do the initial audit for my practice partner.

The EMR audit process is not perfect; I would like, for example, to have a program that automatically extracts all of the last BP results for every diabetic (as well as all LDLs, and all A1Cs). This is not available, so I generate a list of diabetics from the EMR, and the data is manually extracted from the flowsheets and entered in Excel. It is still much faster than using paper charts: all the data is in the flowsheets, so once the chart is loaded, you access everything in a single area. The data is clear, legible, and easy to find.

I would like to have this data available for all of my colleagues in my FHN; I have asked residents to do the audits for others in my group (with permission from each physician), so we will get additional practices done. If I had automated audits, like I do for our preventive services, I could get this done more often and for all of us. I think that it is important to track your results, so you can set goals and see if your Quality Improvement program works. You can see what I am currently doing to try to improve diabetes care here.

I should start talking to my Family Health Team about spreading this to all FHT physicians. It would certainly be possible to do audits for all 40 physicians; we likely will need a bit of funding dedicated to such a project.

I now have an interesting quandary. I don’t know if I can improve on BP or LDL anymore; I can see that I need to maintain my current efforts. However, my A1C average is getting a bit worse. The recent ACCORD study randomized diabetics to tight (aim for A1C <6.0%). The group in the tight control had an average A1C of 6.4%, while the standard group's was 7.5%. The results: "As compared with standard therapy, the use of intensivetherapy to target normal glycated hemoglobin levels for 3.5years increased mortality and did not significantly reduce majorcardiovascular events."

My average A1C is 7.42%, which is very similar to the standard group's results in ACCORD; based on this study, I am not convinced that I should change my management. Perhaps guideline developers should consider changing the A1C target to between 7 and 7.9%.

Michelle

Vacation: on being redundant

2008-08-22T14:22:00.002-04:00

I took a fair amount of time off this summer, some at the cottage (no internet access) and some travelling with my husband. I think it is good for everyone to re-charge their batteries, and there is no better time than summer to do this.

Of course, a drawback in our connected world is the flood of emails awaiting you when you return.

Patient care still needs to be managed while a physician is away: we have agreed to cover for each other in my practice, and both my partners are now on EMR. Incoming labs and scanned documents are reviewed electronically by a physician, daily. The covering physician who reviews the document will put "R" (for reviewed), their initials, and a note if needed in Comments. The labs and documents are left in the electronic in-box, and the physician on vacation does a final review and files them away when they return. My partners also saw a few patients in my absence.

I logged in once a week while away; this seemed reasonable. I also spent several hours on the EMR at home on the day prior to my return to the office; this was to review and clear all messages and incoming materials. I returned to the office with a fairly clean slate; there were a few paper-based insurance forms to complete, but that was about it. The office was much busier before and after my vacation, but that is the same with and without EMR.

Being away does not mean that no work was being done for my group. The difference this year is that most of our work flows are already set-up, and are being supervised by our FHN administrator (making me mostly redundant). The data entry was done by summer students, just like last year. The new programs for FOB screening and Diabetes were set up earlier in the spring.

Here is the email I recently sent to my group:

"As the summer comes to a close (too soon), I would like to briefly review the work done this year on chronic diseases and preventive services in our FHN. This was expanded from last year's initial program.

The FOB review and mail out program is completed; the letters are ready to mail for all the overdue patients. Your staff may have patients dropping in to pick up FOB kits, please make sure that they put a lab requisition with "FOB" ticked off in each kit a patient picks up. [We audited the electronic charts of all patients between the age of 50 and 75; eligible patients who had not had a Fecal Occult Blood screening test for 2 years or more were mailed a letter asking them to pick up a kit at the office--my secretary tells me that we had 10 to 15 patients drop by this week, and a couple of patients showed me the letter while seeing me for another reason].

Patients who are overdue for FOB have a reminder button in their Summary page. Please bill $6.86 when FOB results come in for these patients. [in Ontario, we have a fee that applies when a patient is reminded about a preventive service, and subsequently receives the service].

The next preventive services reminder letter (paps, mammos, kids vaccines) will be sent before the end of August, for all overdue patients who have received 0 or 1 letters. All patients who have already received 2 letters have been called over the summer, and this is recorded in the EMR.

Our Diabetes program (flowsheets, four reminders to look at the flowsheets, and pre-programmed lab reqs) was completed earlier this summer. Please click the reminder button when you review a diabetic, and bill the applicable fee. We have a diabetic registry for the FHN, and the yearly management fee was billed for all diabetics earlier this summer. If you have new diabetics or diabetics no longer in your practice, please let me know so that the registry can be kept up to date and your billing sheet for the Diabetic Management Fee can be updated for next year.

The total cost for this year so far is $3,900 for our FHN, which includes wages for the students over the summer ($2,700), and cost of envelopes, stamps and supplies. This is much less than last year, as most of the cost was in starting the preventive program up."

In addition to all this, the students also entered the data for these program for three physicians who have joined our group and have now started EMR (my two practice partners and another physician). We are now looking after these services for 12 physicians.

I kind of liked being redundant this summer!

Michelle

Power outage

2008-07-16T20:45:00.000-04:00

We had another power outage last week, this time for over an hour. It is hard to keep working when the power is out; however, my back-up systems worked.

My routers are plugged into an Uninterruptible Power Supply (UPS) box; if the power goes out, the UPS battery takes over. The two front computers are also on UPS. The Tablets are battery powered. The UPS battery only gives you a half hour of power; we have to shut down the front computers after a short while. However, the routers use so little power that they can function for quite a while, so access to our remote server was not interrupted.

The fact that we still had computers working gave my secretary access to the scheduler; she was able to call several patients to let them know that the power was off, and some appointments were rescheduled. Our phone system was down (the phones are dependant on electricity), so we used cel phones.

We were still able to see patients, to some degree. Only two of the five exam rooms have windows, so me and my practice partner were down to one room each. Although all the Tablets worked, none of the printers did, so I could not print lab reqs, prescriptions or handouts. I have frequently emailed handouts to patients, so I just switched to email for this. I left some prescriptions in the chart (issued, but not printed), and asked the patients to call in their pharmacy numbers later; I sent this as a “to do” to my secretary. I had a pharmacy fax number on file, so I emailed that prescription via Internet fax; fax via the phone line didn’t work (our fax machine and fax box are electricity-dependant), but I could use my Internet fax, which did work. For the lab reqs, we used blank forms and my lab tech had to copy the patient information by hand.

It is not fun to work without power, but it can be done in an EMR office; as in a paper based office, you are limited to where there is available light, and many things (especially peripherals like printers and labelers) don’t work. You need to have the critical components (routers, your server if you are on a local system, at least 1 front computer) plugged into UPS devices; for offices using desktops only, it may be worthwhile considering having a laptop in the office to take over from desktops. You will also need 1 wireless router, and make sure that it is plugged into a UPS. I can see that offices in remote areas (or even not so remote, like my cottage, which has chronic power outages) also need to have a generator as back-up.

We had a group EMR learning session in the evening, later that day. My FHN lead had arranged for a room and projector at our hospital. Because the server is at the hospital, I can plug my Tablet into a network jack and have access to the EMR from anywhere within the institution.

Space and equipment to set up a Booster learning session may be a problem. Some groups have access to their own boardroom, with computers. Some, such as my group, don’t have access to this (we are a collective of small, independent offices). The Boardroom approach is best, I think, because everyone can log in to their EMR during the session and follow along. However, the simple setup with just a room and projector, worked well; I think most groups may be able to get that from the local hospital. You have to make sure that you can log-in to the EMR. Failing that, see if you can get a demo CD ROM of the application from your vendor; you can set the demo version up on the laptop attached to the projector.

I had done individual visits to each of my FHN colleagues in May, so I was familiar with the questions that they had. Several problems had been solved while I was on-site. A group training session is a bit less useful (all of us are at different stages of implementation), but is more efficient; individual visits are hard to arrange. I am very familiar with small group educational sessions, because I have been a facilitator for my own Practice Based Small Group for over 10 years; I think this is a fairly effective way to learn things. There is no question that we need on-going training, and that this is not well provided through the EMR companies, if done at all; the lack of on-going education is something I’ve heard from colleagues using several different EMR systems. We do get the initial training at start-up, but afterwards, education is very haphazard.

We spent about an hour and a half at our small group booster session, going over several things. If you would like to see the basic layout of the session, it is below; some of it is specific to the EMR we use, some is likely generalizable to most EMRs.

Booster session July 8, 2008

Prescribing

Basics: using quick fill in encounters: start typing the name of a favourite drug, and the rest auto-fills. If there are several dosages (example, amoxil), pick your dose from the drop down list (amox susp 125 tid x 10 d; amox 500 tid x 10 d)
Expiry date: that is what makes it stay on or go off your CPP

Short for short term drugs
Longer (eg, 1 yr or more) for long term drugs

Discontinuing or modifying drugs in the encounter: double click on the Medications tab, then pick Update or Discontinue.

How to check drug interactions before you prescribe: click on the checkbox for the drugs you want, and then click the “interactions” button on top.

Hx button: check on what happened to your drugs; you get a quick history of what you did (changed dose; stopped drug because of adverse rxn; drug no longer needed etc)

CPP, Archived to see previous drugs, or double click on Medications in Encounter

Lab bundles and diabetes

Using bundled labs: all the recommended annual lab tests are saved in the “diabetes” lab, which everyone now has. Double click on the requisitions tab, click on the checkbox for the “diabetes” lab, then Sign and Print. If you want to add more tests, click on the blue link for the lab test, Open, and then add extra tests. Save, Sign and Print
If you have a lab that you would like to re-use (example, annual check-up, female), click on the “save as favourite” checkbox.

Practice functions

Dashboard, My practice: click on the MyPractice tab to see how many of your patients are overdue for preventive services
Dashboard, My Settings: use that to change your overall preferences
Adding tracked diagnoses to Dashboard: Use MySettings, MyPractice to pick what you would like to track (example, how many diabetic visits you have per month, and per year); this is updated daily, overnight
Checking your overdue preventive services list: go from MyPractice, click on the blue link for your service and it will bring you directly to your list of overdue patients

Coding

Code long term conditions through Assessments in Encounters or in your CPP. **Do not use free text for Assessments in CPP, these cannot be used reliably for registers or for tracking**
Do not code if you are not sure (example, better to code 786—respiratory problem not yet diagnosed-- than 493 for asthma, if you are not sure the patient has asthma); when you go to Reports to pick out your conditions, you only want to see patients who actually have asthma.

Lost in Transition: why residents use EMR and the rest of us don't

2008-07-03T21:34:00.004-04:00

A large US survey of EMR adoption was published today in the New England Journal of Medicine. It found that "fully functional EMRs" exist in only 4% of practices.

Welcome to medicine in the 21st century: information starvation in the midst of data plenty.

It is still too hard to implement an EMR, and full implementation continues to be the exception instead of the norm. In the NEJM article, younger physicians were more likely to adopt (same as for the Canadian National Physician Survey); perhaps it will be the next generation of physicians who will practice in an electronic office, and not us.

We have two residents who started today in my practice: one starting with my new partner, and another one starting with me and my "old" partner, who is away this week. The new residents will be with us for two years; most of the time, they are in the practice for a half day a week.

Here is what it took to get the residents set-up: a computer for them, a registration in the EMR with permissions set at the Resident level, a log-on ID and a security FOB. I bought a Tablet for residents two years ago, as my department recognized that this was needed for teaching practices, and funded an extra computer for learners. I know how to set up all the basic log-in, so it did not take long, but it still needs to be done by someone (either a physician or a clinic manager). There is extra work for EMR set-up, which does not exist for paper-based practices.

My new resident came at lunch time, and my clinic manager oriented him to the practice; she gave him his security FOB. We logged him on to the resident Tablet, and he set up his PIN. I set his basic chart preferences to make sure that they were the same as mine; I don't know if I have the "ideal" preferences set-up, but it seems to work for me, and I'll be showing him how to use the software.

My resident followed me for the rest of the afternoon. I showed him how to load encounters and CPPs. He took his Tablet in, so that there were two computers in the exam room. He saw how I was using my Tablet, which helped give him a sense of how the EMR works and can be used in a patient encounter. He could also load screens on his Tablet during the encounter, since he had the same electronic chart open as me, but on his own machine.

He saw me touch type while talking to patients, write prescriptions, do a consultation letter while in the exam room, look data up in various areas of the chart (CPP, DI, labs, flowsheets), order labs and Diagnostic Imaging electronically, respond to pop-up alerts and other care reminders, and use e-messaging and Office Actions sent to staff. While he was there, an electronic message came in from our clinical pharmacist via remote access from another site; she had reviewed a problematic case for me and sent some suggestions in the patient's chart. She had also emailed me a relevant article via regular email.

My resident had never been in an office using EMR. He will only use EMR while working with me; there is no choice, since there are no paper charts. I spent at least as much time teaching him the EMR as discussing clinical matters. I don't think that's bad for the first day, since his care will depend on his familiarity with the chart.

On the other hand, he has access to all my saved favourite drugs, all my batched labs, all the CPPs are in the EMR, and drugs automatically go into the encounter. There is also a lot of knowledge in the office about what to do when computer problems happen.

I simply cannot imagine that he will be willing to revert to paper after two years here. Many of our residency teachers affiliated with my hospital have now switched, or are in the process of switching to EMR. We have 8 academic Family Health Teams in Toronto, and these are the teachers of family medicine. Although not all have implemented, three now have (including our FHT); all units have either bought or are considering buying EMRs. I don't know if EMRs are more common in practices that teach, but this is worth exploring. I think many teachers are modeling EMR use for our new physicians.

We get new residents every two years. While one resident will be exposed to the initial pain of transition, the next one will see the EMR at a later stage.

I think many residents will use EMR during their training, and will then start working in practices that have computerized. The rest of us will have far more difficulties.

My practice partner is away this week. He decided to spend the week at home, and use some of his time to catch up with his work. I sent him aan EMR message about whether he wanted me to look at his results during his week off, and he emailed me back (in the EMR, via remote) that he would take care of them. He is now used to looking at the EMR via remote access, and can see all his labs and scanned reports. A student started entering his CPPs as of yesterday. Remote may well be one of the most useful features of the EMR for him.

Michelle

Research and Quality Improvement

2008-06-22T15:26:00.003-04:00

I have been interested in research for several years, and have a couple of projects under my belt (Using a PDA for the diagnosis of angina; Cognitive Behavioural Therapy in primary care; effect of incentives on preventive services). I think EMRs have enormous value for research that is relevant to family medicine and useful for patient care; beyond that, the data in EMRs can certainly contribute information to run our health care system more effectively and efficiently.

The issue will be how to collect data from our practices; you want to fully protect the privacy of both patients and physicians, yet ensure that you still collect enough useful data for analysis.

I am a co-investigator in two studies that have recently received funding:

Canadian Primary Care Sentinel Surveillance Network (CPCSSN), and
Development of an Electronic Medical Record primary care research database, at ICES

These represent two different way of collecting EMR data for research. The CPCSSN sites will collect data on some chronic conditions locally from many different EMR systems in Canada; the data will not contain patient identification. All this data will then be amalgamated at the national site.

The benefit is that you can collect data from several different EMR systems (as we have a tower of Babel of EMR systems in family medicine). The drawback is that you depend on local investigators to try to collect data from their EMRs, and that you are pretty limited in terms of what you collect. You have to say what you collect at the beginning; if you forgot or just couldn't get something important, you don't have it in your database.

For the ICES study, we will explore anonymization software; this will allow, in the future, collection of the entire EMR database while protecting privacy. All names and identifiers are scrambled; after this is done, no one has access to the scrambled data, except for an ICES analyst. Researchers only have access to data after it is analyzed (once they obtain permission), and only for larger groups of patients, never for a single record. In other words, what you get is things like x% of patients in this geographic area have diabetes, y% were prescribed a cholesterol drug, and z% have a cholesterol level that is at goal.

The benefit is that you have a fairly complete description of care; if the database is mirrored (sent automatically to a second server), data collection is on-going and is pretty much live. The drawback is that the anonymizers will have to be programmed for each EMR software, since they all work differently. You will only get data from a select group of physicians, and there will have to be some extrapolation and assumptions if you say that the data represents an entire population.

Because the practices in my group are run remotely out of a single server, we can collect data without having to personally go to each office and access the server. In fact, the amount of bothering physicians, staff or patients is pretty much zero. Ideally, that is the way it should be--we're busy enough during the transition without imposing more work related to research. We will have posters informing patients, and giving them the option of opting out.

I do not know which way is best, and I think these two projects will test both approaches. We will start small, and go slowly and carefully; it may well be that we need a variety of approaches for data collection.

It is very interesting to me that some of the ground work that makes this possible started out of our group Quality improvement initiatives. We wanted to use our common EMR to improve our preventive services, and our diabetes care. Out of that came the realization that data could be collected remotely, and we also learned how to do it.

Research is difficult and time consuming. You also have to go through a Research Ethics Board, and there are lots of forms to fill out. I am not saying this is a bad thing, although sometimes it is very bureaucratic and it doesn't always make sense. Quality Improvement does not require all this overhead; in fact it works better when you have a goal, try small things, see if they work, then fix problems and keep going. This is called a Plan-Do-Study-Act cycle (PDSA); much of what I learned about collecting data in my group's EMR was through that process. For Research, you have to plan thoroughly, apply for your grant, hope it gets accepted, then implement and hope it works. This is not a great way to start something with as many unknowns as EMR data collection. We probably need to re-think the interface between Research and QI.

As for me, I think I probably have something to contribute to this nascent EMR research enterprise. I have now finished the coursework for my Masters, and am writing my thesis (on the Effect of EMRs on preventive services in a Pay-for-Performance environment). I have asked my University department for a second day of research, and will take Wednesdays for this, as of September. I'll practice three days a week, and devote two days (and some evenings and weekends) to research. I have asked for permission to join ICES; we'll see how things go.

Michelle

FHN staff meeting

2008-06-06T20:41:00.002-04:00

Our FHN administrator organized a meeting for staff at all of our FHN practices, earlier today. She asked me to attend, which I was happy to do.

Every practice was represented (7 offices), most with more than one staff member. It was very gratifying to see that both my colleagues and their staff considered this to be important enough for time off to attend.

The first problem we had is that my office is too small! We really need a boardroom, which we don't have. Much of the discussion involved the EMR, so everyone crowded around the three computers in the front office area.

Interestingly, one of the first questions was about what a FHN is. In Ontario, we have a regular alphabet soup of primary care reform (FHN, FHT, FHO, FHG, CCM). Don't ask. I explained that the main difference between independent Fee for Service practice and a Family Health Network is in the payment (largely capitated, or one set fee per patient per year) for FHN, and piecework for FFS. As well, in a FHN, patients roster, or identify a particular family physician as their physician.

We did not find much change in our practice when we became a FHN. I think capitation is supposed to decrease small visits for minor problems, and encourage visits for prevention and chronic disease management; I'm not really sure this works. One of the main reasons we joined was that the government said they would subsidize EMRs for physicians joining FHNs.

Our FHN administrator went over the rostering process, and why it is important to keep rosters up to date, using the monthly update list. The roster list in the EMR drives the preventive services; only rostered patients get recall letters (that is the way the government set it up). I think that it really helps if people know why they are doing things. Maintaining the list ensures that letters are sent to appropriate patients and not to those who don't need them (patient moved, switched physician etc). We went over the process for de-rostering patients, both with the paper form from the ministry, as well as tracking in the EMR.

We showed the list of preventive reminder letters, and showed everyone how to easily access it in the EMR. Our administrator showed how phone calls are tracked, and reminded everyone that patients are now getting called if they have already received two letters and have not answered yet.

Staff member were very enthusiastic about participating in the FHN preventive services program. We discussed the fact that reminders do make a difference in cancer prevention, and they know they are taking part in a good program.

We discussed efficient messaging in the office, as well as pop up messaging. We have a summer student that will go around and install the pop up software, as well as fix computer glitches as needed. Several offices were interested in having electronic faxing installed, so that they could import faxes straight to the EMR without having to print and scan.

Finally, our FHN administrator took everyone's email address. It is not sufficient to email physicians, some things need to go to their staff as well.

Overall, it was a very productive and interesting hour and a half (included lunch). I think there is a lot of value in involving practice staff, not just physicians.

My practice partner is progressing quickly. He now writes some prescriptions, and has done several consult requests in the EMR. He uses office messaging and "to do" notes consistently. He is starting to write electronic encounter notes more and more often. The Tablet goes in with him consistently. He is using INR and diabetic flowsheets. All incoming reports are getting scanned in, and no charts get pulled; his labs are electronic. My staff still pull his charts for him for patients coming to the office, and I expect this to continue for several months, until there is enough data in the EMR. His first preventive services mail-out went out last week.

It has been a month on EMR for him, so I think this is not bad. There is still a ton of extra work for him, mainly the CPPs. We occasionally go over things quickly after the office, and I'm there to troubleshoot minor problems. He does not have to call the Helpdesk, which is a big difference from when I started. It makes a big difference once the EMR is up and running; adding extra physicians is not quite as tough.

We are getting two new residents in the practice in July; it will be interesting to see how they pick up the EMR. I was lucky to have an exceptional resident for the past two years; she bore with us during the transition with good grace, and is pretty expert at the use of the EMR now.

Michelle

Generating new ideas

2008-05-27T16:39:00.007-04:00

I am sometimes asked about how I think of new things. The EMR is a powerful driver for new processes, because if you do things the old (paper-based) way, it does not work very well.

Very few things are completely new and world-changing like Google; my new ideas are small re-combinations of older things. This ability to figure out things is very human; machines certainly can't do this, and most animals probably don't either--at least my cat does not appear to.

Usually, I start with something that bothers me. For example, printing something and then re-digitizing it so it can be faxed seems silly; how do I fax directly from my Tablet? I don't have a fax server, and installing one does not seem practical. I can email; perhaps there is a way to combine email and fax.

The next step is to google "internet fax", and many sites pop up. Wikipedia gives me a quick run-down of how it works, and it seems reasonable. I give it a try, and it works.

I now have to figure out how to collate documents: many of my faxes consist of several documents (a consult letter, labs, scanned diagnostic images). I have to put all these into a single file, so I can email it to fax; if I don't do that, I have to save all the files to desktop, then attach a whole bunch of documents to the email-fax. That is too labour-intensive, and won't work.

When I write a consult letter, I sign it on the Tablet, then I print it. I have Adobe Pro; I can print it to Adobe and it saves it exacly, including my signature. I look at the Help in Adobe, and it tells me that I can create a document from multiple files; that seems pretty easy to do. I open three files, and try it, and it saves it as a single document. That works, and it is fast.

On top of the document, there is an email icon. I click that, my email program loads and I enter the fax. It works and is faster than printing and putting the letter at the front with a sticky.

Now I have a bunch of fax numbers saved in my address book. Sending a fax is now the same as sending an email. I still put long, complex faxes at the front, but most of the smaller notes go straight out from my Tablet.

That is how I do new things; it consists of figuring out what the issues are, trying things in small incremental steps, and solving problems along the way. Being curious and persistent helps.

If you like trying new things, the EMR is a gold mine for this, because it is early in its life-cycle. Bonus for innovators. If you prefer to let someone else start new things, but are open to trying them out for yourself, there are now enough innovations that you can help yourself from the menu. The on-line helpgroups for your EMR are a good place to look; provincial organizations like our EMR Advisor in Ontario also have good suggestions.

As another example, I am trying out new templates to help me with the clinical management of various conditions. At our recent Practice Based Small Group educational meeting, the module suggested a 3 question screener for suspected dementia. It seemed like a good idea, and you can see the resulting template at the top. I put a drawing area in the template, and the patient can draw the clock directly in the Tablet. It is saved as part of the record. I put this template in our Enterprise section, so it is available to everyone in my FHN.

The ability to try new things is a real EMR asset; the speed of communication also allows for a potentially very rapid spread of new ideas. I kind of like that.

Michelle

Preventive services results for our group

2008-05-21T12:36:00.000-04:00

We now have my FHN’s results for our preventive services:

Children’s vaccinations: 98%;
Pap smears: 74%
Mammograms: 75%
Influenza vaccinations: 71%

We mailed out 7,666 reminder letters in the past year. Our FHN admin is emailing individual and group results to each physician.

The results are OK. I think they are not as accurate as they could be, because it was hard for us to figure out how to keep our patient rosters up to date at the beginning, so some patients are on the list and shouldn’t be. We are now much better at it: most practices fax the monthly update to our FHN administrator, and she enters the changes in the EMR. As a result, our patient databases are becoming much cleaner. I received a note that the Ministry of Health will soon be sending us our patient Roster lists electronically, so that will help--if it does happen and if the EMR company programs an interface for it.

I expect that our preventive results will be better in the second year because we are better organized and we have worked out the initial problems. I think this was a good experience overall for my group; I am now getting requests from several colleagues to start a Fecal Occult Blood screening program.

We are about to do our next mailing; this is now routinely happening every three months. We are also organizing a system to phone patients who have already received two letters and have not responded yet.

The five new physicians joining our FHN will be part of this, once they implement the EMR; my two practice partners have started, and we will do their initial mail out this month. Having a project that you do as a group is a good idea: it will make you function as a group (groups don’t really happen unless you do things in common), and these projects can be used to help with EMR implementation, because they add value to the EMR.

The diabetes project is going faster than expected. Most of the flowsheets have now been put in; the work is all being done remotely, since we no longer have to go to each practice to get data from paper charts. We are now going to start putting in automated reminders for diabetes care.

I have now visited five practices in my FHT. There are different things happening at each practice, but I am starting to see a couple of things that are common. Several of my colleagues wanted the vitals and current medications to load automatically into the encounter. I showed them how this is set up in Preferences, and we changed it while I was there.

I installed several batched lab requisitions at some practices, as well as requisitions for Diagnostic Imaging. For other colleagues, I went over how to prescribe using the favourites list, and how to quickly enter ICD codes for assessments. I re-worked saved letters and handouts to make them a better fit, after asking what my colleague needed; several people will now be doing sick notes directly from the EMR.

At several of the practices, I also spoke to the front staff. I have a CD with my scanned requisitions and patient handouts, and I installed this on a networked folder on the front computer.

I can see that this type of individualized assistance is of value. I was able to fix some annoying problems fairly quickly, and I think everyone was happy with the experience. I spent 1.5 to 2 hours at each practice, and the visits were pre-booked: the physicians cancelled appointments to make sure that we could sit together. I don’t expect that everything we discussed will be done, but I know that some things will, because we changed the Preferences and practiced together; if two or three common things work better, I think that’s pretty good.

It was interesting that while I was at their office, several colleagues told me that the computer made them feel “stupid”. You really have to wonder why this is happening to intelligent, very competent physicians. I think we have a lot of experience and knowledge about caring for patients, and we don’t have the same for computers. I reminded my colleagues that the amount of education and training we receive in Information Technology is several orders of magnitude less than what we receive in medicine; we are physicians and not IT specialists, after all. I don’t expect my lawyer to solve my computer problems. The stupidity lies on the side of the machines: if they worked perfectly, we wouldn’t have to deal with their frequent mood swings and reboots. My patients are used to hearing me vent at my stupid Tablet.

I went to another group on Tuesday evening, as part of the “official” Peer to Peer program. The issues were somewhat similar; their administrator was there, and we discussed work flow issues for different conditions, such as diabetes; I have now posted several entries on workflow at EMR Advisor. I showed how to make new templates using pieces of old templates. This took about two hours, which I think is about the right amount of time; more than that and everyone gets a headache.

Little pieces of integration are starting to happen on their own. I am receiving the occasional email about patients; I received a note from a specialty clinic asking if we would prefer to receive consultation letters via email. Even if the “System” makes it difficult, electronic communication is starting; perhaps we can use “going green” as an excuse to avoid paper and fax.

Michelle

First week on EMR

2008-05-10T11:54:00.002-04:00

My practice partner has just completed his first week on EMR. The student pre-entered his CPPs for this week's patients.

My partner started doing some encounters. He is taking his Tablet into the examining room, and typing things in. He still has the paper charts with him, and I expect this will last for several months. He has prescribed a few medications, starting from the first day; this is more challenging for him, and he is still writing many scripts on paper. The medications that auto-load from the CPP into the encounter, as well as those that are in his list of favourites, are easier for him to do, so he has started with those. Prescribing using the drug database is much more challenging.

Interestingly, he noticed that the dosage of acetaminophen in Tylenol #3 was 300 mg, and he sent me an e-message about this. Dosage of regular tylenol is 325 mg of acetaminophen, and we both assumed this should be the same in T3. I had to look it up in the CPS (our drug bible), and in fact, it is 300 mg in the T3; a new pair of eyes is a powerful thing!

My partner is comfortable entering coded diagnoses in his encounters, and is now doing this fairly routinely. Family physicians generally know the ICD9 codes, because we use those in billing. Having the diagnostic codes will help once he goes on to the more complex aspects of the EMR, such as searching his whole practice for health conditions.

Our staff is scanning incoming documents for him. He still wants to have a look at the paper, so these are left in an area at the front for him. However, the secretaries are no longer pulling charts for scanned documents or electronic labs; this has immediately cut down on clutter at the front. If he wants to see a paper chart, he asks for it (verbally, or via e-message). Once he is done with the paper report, it is shredded.

Faxes come in to the front computer, and are uploaded to the EMR without printing; what we do is print the fax to pdf, save to the "Files to upload" folder, and then upload to the EMR. My partner has asked that the faxes be printed for him for now, so his faxes are both printed and uploaded at the same time.

He is spending more time at the office because of the EMR; we had discussed this, and he is prepared for the extra time investment. Our staff is trying to book him very lightly. He sometimes asks me for help if he is not sure what to do, and I am very happy to assist; our staff members are also very supportive.

We went over how to use a Tablet in the previous week. He is a bit tentative with the stylus, but is getting used to it. He has the same Tablet that I do (a convertible, with a keyboard), so I was able to show him how to use the Tablet effectively.

Overall, he says that the first week was OK. I think starting with basic things like putting in an encounter and assessment, and trying some prescriptions, works well. My partner is getting used to the way the CPP looks, and has entered some data in it.

What helps a lot in this case is the fact that the office is familiar with the EMR, so he is not starting from zero. There is a lot of on-site knowledge and support from both his practice partner and his staff; there is no need to call the helpdesk, which can take a lot of time. We are able to handle glitches and questions pretty quickly, so that if he has a problem, it gets solved. The questions he asks help him to figure out what the system does (and doesn't) do.

We have started to scan his old charts; I have ordered a second scanner, so we can do all the charts in the summer, and he is getting a student to do this job. He goes to a senior's clinic off-site, and he does not want to drag the paper charts with him any more. Those charts have been scanned in, and backed up to his Tablet. He will be logging in remotely while at the Senior's clinic.

I now have received the lists of diabetics back from my FHN colleagues, so we have a diabetes registry. There are 801 patients on this registry. I have a summer student now; he is currently entering the data for the preventive services for the new FHN physicians (rostering, checking off patients who have received the service). This is going much faster than last summer, because we are used to the system. Once he is done with that, he will be putting in electronic flowsheets and reminders for all diabetics on our common register. I have notified my FHN colleagues that this will start happening in the next few weeks.

I am currently trying out Internet faxing. Our system continues to be fax-dependent; even though secure email exists, no-one is using it. The way Internet fax works is that I upload the documents via email to a fax server, and it then transmits the information to fax at the other end. It is electronic (fast and easy to use) from my end, and paper-based fax (slow and non-secure) from their end. This may be one way to bypass the paper system. A problem is the cost: $14 per month includes 100 outgoing pages; I sent out 35 pages the first day. I then figured out how to avoid a cover page, which will reduce the number of pages I produce.

Something that happened once transmission was easier is that I am sending out more information. I had a lab result that I thought might possibly be useful to the geriatrician who co-manages a fragile patient with me; I emailed it to his fax. I would not have done this by plain outgoing fax, because you have to print it, put a sticky with the fax number on it and bring it to the front, then the secretary faxes it. I was off site at the Senior's clinic when I saw the result, and just emailed it. Make transmission of information easier to do, and it is more likely to happen; too much security can mean a loss of information, and there is little attention paid to the downside of security measures. Make a system too secure and too difficult to use, and the result is that nobody uses it; this is what has happened to our SSHA email system. Of course, fax is neither secure (everyone can see the pages that come out, sometimes you fax to the wrong number), nor fast or particularly easy to use--we're just used to it. It is time to consider abandoning our fax addiction.

Michelle

Taking care of our server

2008-04-27T11:57:00.003-04:00

Our server is getting full. This is both a good and a bad thing. We thought we bought plenty of capacity when we first started; however, we are running out of space, after a little over two years.

This reflects the fact that the EMR transition is going fairly well; pretty much everyone is scanning everything in. We are increasingly giving up on paper-based processes. All labs are coming in electronically.

As well, we are now adding five more physicians to our group. Information Technology changes at such a rapid pace that what was considered pretty good two and a half years ago, when we bought our server, is now barely adequate. We now have to add extra capacity, and are working with our EMR company to do so.

When I switched to EMR, I ditched my old computer, which dated from 1996. EMR applications are far more demanding, and you use them constantly. It is a good idea to maintain and update both hardware and software. Some peripherals, like printers will last longer; the computers' hardware and software will likely need upgrading sooner. You also have to think about replacing parts.

For example, a label maker broke recently and we had to replace it. I just ordered a second scanner; I will have to buy a PC to go with it. I bought a new battery for my Tablet, after a year and a half. We broke three shredders when we first started (buy shredders with a replacement warranty).

However, the server is at the heart of your practice. It will need to be upgraded, and eventually replaced. Plan for this, and budget for it; a server that does not meet your needs is dangerous: it will slow you down, and it will eventually fail.

The IT committee for my group is functioning well, and we are meeting regularly; we also talk frequently by email. We have met with OntarioMD and with SSHA, as well as with the head of our hospital's IT department. We are still weighing the risks and benefits of a move to ASP; in Ontario, there are now three large EMR companies on ASP (1 previously approved, and two approvals are pending). We see the finite lifespan of a server happening in front of us, and what server maintenance for a mid-sized group of 23 physicians entails. Going to ASP means renting space on a very large, continuously updated server (not that this is without problems either); doing this would mean completely outsourcing server maintenance and upgrading.

In Ontario, government subsidies for EMRs end after three years. We will be at that mark in 2009. I can see that there are on-going costs; in Alberta, the government has decided to continue to subsidize and support EMRs. Perhaps this is something that Ontario should consider as well.

I have joined the IT committee of the Ontario College of Family Physicians. We are reviewing the key issues impeding the transition to EMR; failure of the system to connect continues to be right at the top of the list. I am increasingly reluctant to forward any proprietary forms. We have a new tri-hospital initiative to expedite colonoscopy after a positive fecal occult blood test; however, the first thing that the program did is send us copies of their proprietary referral form. We discussed this at my hospital's recent family medicine business meeting; programs have to realize that this approach is no longer acceptable. I had a patient with a positive Fecal Occult Blood last week; my first referral was generated in the EMR, with a note requesting a waiver from the form (Je Refuse).

I am now generating public health requisitions within the EMR; the req contains the same information as the proprietary form. I have staplers in every room, and I staple a blank proprietary form behind the real form with four staples so it is strongly attached. There is a Six Sigma Method for improving quality; I call this method the Four Staples Method for patient safety.

Michelle

Summer students

2008-04-23T20:38:00.002-04:00

University students are now finishing their last exams. High school students will be out in two months.

Getting some help from students is very common during the transition to EMR; my partner hired two students for data entry. The students are entering the CPP, and my partner then reviews those for accuracy and completeness. Several other physicians in my group did this when we initially started the EMR.

It is not bad to start the EMR transition in the spring; the office is quieter then. As well, you have some idea of what the EMR looks like by the summer, as you hire your student help.

However, CPPs are not the only thing that bright students can help with. Data entry for the preventive services for my group, last summer, was done with student help. It worked, so we discussed a diabetes quality improvement project at our recent FHT meeting, with funds allocated for data entry. There was consensus that we should go ahead. This is the project:

1. Get a list of all diabetics for each practice
2. Verify the list
3. Put in an electronic flowsheet in each practice location
4. Put the flowsheet in every diabetic's e-chart
5. Put in reminders to look at the flowsheet, every 3 months

It looks simple, but it is actually fairly complicated. Not everyone is entering the ICD code for diabetes (250) in the CPP or in encounters. As well, this code is sometimes used for Impaired Fasting Glucose ("pre-diabetes"), or Gestational Diabetes (diabetes only during pregnancy). These patients don't have diabetes. What I will do is get the list of all patients with 250, together with "comments". We often enter a comment like "IFG" if the patient does not qualify for diabetes. If the Diabetes list is poorly populated (I expect about 10% of adults for each practice), I can extract the billing code specific for diabetes.

Once the list looks reasonable, it gets faxed to my colleague's office for review and approval. We proceed with putting in flowsheets only when the list has been approved.

The advantage of electronic flowsheets is that much of the data is automatically populated. Vitals and labs go in automatically; the vitals go in straight from the encounter, and the labs straight from the e-results. I don't have to re-enter this data twice.

However, like everything else, this is not perfect. The labs all use different databases, and patients don't always go to the same company's lab. What I did for my group was meld the databases: in our Enterprise module, there is a place where you can say "this test from lab A is the same as that test from lab B". For some reason, it works very well for two of the three electronic lab companies, and not all that well for the third. It doesn't work at all for paper-based lab results, like the hospital's. When it works, results from any lab just go into the flowsheet.

To get around this problem, I have a cell called "notes" in the flow sheet. I just type the non-electronic tests there. I also give patients a handout with their lab form, with locations and hours of the two preferred lab sites, along with the URLs for lab locations. We do most of my lab tests in my office. We really need to have a common nomenclature for lab tests, as well as a common way to store and transmit lab results electronically; I keep hearing this will happen (OLIS), but I see nothing happening yet at my end (maybe this year?).

There are blank areas in the flowsheet to record other things, such as foot exam and monofilament testing. I ordered some free monofilaments last month from LEAP, and distributed them at our recent FHN meeting.

The students will take the approved lists, and enter a flowsheet in each chart. They will also put in a reminder to look at the flowsheet and check diabetic parameters, every three months. Finally we have a code that we bill every year for managing diabetes and reviewing flowsheets. The students will do a billing list for every physician, and if this works, we will bill this yearly as a group.

I don't yet know what problems I will encounter with this summer student project; I learned a lot from last summer's project, and I think I'll be able to figure out ways to fix things as they happen. Because we all access a common database remotely, all this will be done from my office, with no disruption to any practice; there are some very significant advantages to remote access.

What I hope to achieve is:
-a registry of all diabetics for my whole FHN
-use of flowsheets for every diabetic

My resident is almost finished her two years in my practice, and will be graduating as a full-fledged family physician soon. We will miss her. We get a new resident in July; one of the things that residents have to do is a practice audit; my resident did one for me on my diabetics two years ago. Audits are now a lot faster with EMR; I think I will ask the new resident to audit my practice, and if it is really quick, we'll ask some of my FHN colleagues for permission to remotely audit their practice. We can probably get some very good baseline and on-going data that way. I think I may get to find out if this little diabetes quality improvement project works.

My FHN is growing, and we now have 14 physicians. All three hybrid practices (EMR/paper) in my group are now going to be EMR only, as all practice partners have joined the FHN. We will go from a 12,000 patient base to about 16,000 patients. I expect that we care for about 1200 to 1400 diabetics (there are 89 diabetics in my practice). I think we can use EMR tools to make a real difference in their care, and I plan to have our summer students put in some building blocks to enable this over the next few months.

Michelle

EMR housecall

2008-04-13T21:48:00.002-04:00

I have now done the first two “EMR housecalls”.

At the first office, I could see that the Tablet was running out of power very quickly. Rechargeable batteries do not last forever; after a year and a half or so, they no longer hold their charge. My colleague has a spare battery, and I asked her to put it in and charge it overnight. I think this must be a common problem for my FHN, as we all bought Tablets at the same time; we have an upcoming FHN meeting, and I will mention this.

My colleague was interested in starting to use the EMR-based lab requisitions. I asked her to tick off what she normally would do at a complete check-up and a check-up for diabetes, and installed those as “lab favourites” while she went to see a patient. When she was between patients, we tested this; I also showed her where the pending lab reqs are kept; sometimes a patient loses the req, and the secretary can print an extra one. This seemed to be a common problem at her office, and the secretary was especially happy to find out how to reprint. I also showed my colleague how the system indicates that lab tests were ordered, as part of the encounter. I showed her how to do her own favourite reqs, and we did one for Fecal Occult Blood testing (a common req due to our new provincial colon cancer program). I configured Diagnostic Imaging reqs for her, and she will now start ordering these electronically.

She wasn’t sure of how to add a patient’s health care number to consultation requests. This was causing difficulties, as her secretary had to enter those manually; I put it in her letter templates and printed an example for her. She was happy with that.

Her scanning system is the same as mine; our FHN admin had shown her secretary what our processes were. I showed her how to use MS Document Imaging to quickly copy a part of the scanned pdf document, then paste it into comments. She practiced this, and I wrote it down for her; it will save her a lot of time.

I installed a shared (networked) folder on the front computer, and made sure it was accessible from the Tablet and from the back computer. I have copied all my handouts and scanned requisitions on a CD, and will give those to her at our upcoming FHN meeting. Her secretary will copy it to the shared folder, so that they can both access it from anywhere.

At the second office, we went over things with three colleagues during lunch. They had thought carefully about what was bothering them. We went over “preferences”, which is where you set how you want the system to work for you. For example, I showed them how to default all the currently active medications in the encounter; this makes it very easy and fast to prescribe, requiring only checking the tick-box, then “Sign and Print”. I also showed them how the system handles “active” and “inactive” medications: there is an “expire by” area on the top of the prescription. My long term prescriptions all have “expire by 1 year”, so they don’t drop off the active list. For short term prescriptions, such as antibiotics or skin creams, the expire by is 1 week (these expiry dates are all saved in favourites, so that I don’t have to remember them). The short term drugs stay in the CPP and show up in new encounters for 1 week and then they’re off. I showed my colleagues additional places where expired medications are kept, as well as rapid methods to remove drugs from the active list. We also went over tricks in prescriptions, such as how to prescribe glucometer strips using three keystrokes.

My colleagues were not sure of how to do sick notes; I showed them how to do a template for letters, and we put a sick note template in. We practiced doing one together on a test patient, which is very simple once the template is in; there is a copy of the note kept in the system. They are now comfortable writing sick notes and letters for massage therapy very quickly. I also suggested that they print the notes at the front desk, so that payment could be managed by the secretary; we put a footer regarding payment at the bottom of the note template.

They use desktop computers, and there is very little desk space in the exam rooms because of the keyboard. I suggested buying some plastic sleeves that could be attached to the walls, some of the paper on the desk can be stored there; as well, a couple of clipboards can be placed in the top sleeve, and these can be used to hold papers to sign prescriptions, or to discuss handouts. There are no printers in the exam rooms, so they walk a lot. Installing a small printer in each room may work; there is space for that.

I think there was considerable enthusiasm by the end of lunch; they had lots of ideas and thoughts about how to improve EMR processes. I was impressed by their rapid grasp of new ideas and their willingness to implement new things.

One of the physicians emailed me with an idea: we could have meetings at the hospital to learn how to better use the EMR. We could use a projector tied to a laptop; one physician would act as a facilitator. Each physician would bring their own laptop and would log on to their own EMR application to try things out.

I think this may work; in fact, I was at a conference for my University Department on Friday. At lunch, a colleague who is using another EMR told me that her group of 22 physicians does exactly that: they hold monthly “EMR learning” meetings, and use exactly the same process. It has helped them a lot. EMR companies do not really offer much broad-based ongoing training, and we really need that.

At the departmental meeting, a physician who had come to visit my office with his whole office team a few months ago came by to say hello. He told me that things were running much more smoothly for him and that he was much happier. It was the processes we outlined that made the difference, although he was the one responsible for implementing them. He was now paperless, and ready to send all his paper charts to the basement.

I think that this type of individualized physician to physician dialogue on EMR is helpful. There is no one better able to say what works and what doesn’t than a physician in his or her own practice. Having a peer who has solved many of the same problems do an EMR housecall is valuable because it adds an extra pair of informed eyes and ears. I don’t expect that everything I suggest will be done; I think each practice is best placed to choose what they would like to implement, when and how. I was asked to do a follow-up housecall in a few months; the problem for me will be managing my time. I just don’t know if there are enough of us around to do this on a wide scale; however, I can see that even a couple of hours will help: each housecall took 1.5 hours.

My practice partner has now chosen May 5^th as his EMR start date. Two students are coming by next Thursday morning: they will start entering his CPPs for him. I will give them a bit of training and supervision for the first few entries. My office staff is now booking him very lightly for the month of May; it is important to do that, because he will be much slower at the beginning.

Michelle

Giving back

2008-04-04T14:34:00.003-04:00

I will be giving a seminar at our national family medicine convention (Family Medicine Forum) in Toronto, this November. I put a submission together with my colleague, Dr Stephen McLaren, on "Electronic Medical Records: the first year of computerization". We have invited a Practice Management Consultant from OntarioMD as an additional resource. It should be fun and interesting; we'll really concentrate on the practical aspects of implementation.

I have now just finished my last class of my MSc; I am writing my thesis, much of which is about the transition to EMR. The last course was Thursday mornings, from 9 am to 12 noon; what I have done is left that time slot open for a couple of months. I think I will use the time to put what I have learned --through day to day implementation as well as from my courses-- into practice and give something back to my community: I will go visit some of my colleagues at their office. We have this new Peer to Peer program from Health Infoway, it says that we can offer support on-site; perhaps some of this can fit the PtoP program. I'll see if I can fill my dance card.

My practice partner works at the hospital today. I configured access to the EMR in the doctor's room, on the floor where he works; he told my secretary yesterday that he will be looking at his lab results remotely. He no longer has to call her for results on Fridays. He is now comfortable using our e-messaging system, and is also assigning tasks electronically; he told me that all his INRs are now managed via electronic flow sheets. I printed and gave him my list of medication favourites; he ticked off drugs that he uses often. I entered those in for him, which will give him a head start on prescribing. We practiced entering medications in the CPP, and did a prescription together.

He is approaching the transition with an open mind, and trying things out. He knows that the EMR is not perfect (not even close), but he is also aware of the significant advantages it has over paper records. I think that this is a very sound and very realistic attitude to take. He does have more support than most of my colleagues who are adopting EMRs; I hope that over time, what I am describing will be the norm rather than the exception.

We continue to have issues with medications. For example, a new study showed that one of the cholesterol medications we use (Ezetrol, or ezetimibe) may not be effective: it lowers cholesterol, but may not prevent heart disease. The study may or may not apply to my patients: a search of my EMR today shows me that two patients are taking the drug. I have asked our FHT clinical pharmacist to review the information, and to log in and see if it applies to my patients. She will also prepare a summary for me. I will review that, and draft a letter. Her summary will also be forwarded to my FHN colleagues; thanks to our experience with preventive services, we are familiar with the process of mailing information to patients as a FHN, and not just individually. We will then decide whether such a mailing is needed. We can accomplish far more as a group than individually.

Michelle

Uncertainty principle

2008-03-30T21:53:00.002-04:00

We will be coming to the end of our EMR contract in early 2009. Most contracts in Ontario are signed for three years, because that is how long the subsidy lasts.

Now we have to decide what to do next. Our main options are to stay Local (server at the hospital), or to go ASP (server hosted at the big SSHA box). It is a difficult decision.

We were one of the first large local installations, with 18 physicians at multiple sites, all managed from a single server at the hospital; we own the server. This freed us from having to deal with lab downloads, backup issues, upgrade installation, and all the other server management problems. On the other hand, our server went down recently, and it was not clear who needed to reboot it (the hospital's IT department? The EMR company?) This led to a delay in rebooting the machine, and a loss of service; remote hosting is not without its problems. We are now growing, with additional physicians joining our FHN, as well as all the new Allied Health Professionals. While our server is still adequate to meet our needs, we don't know how long that will last.

Going to ASP (Application Service Provider) would mean moving our data to a fully managed server; the company owns the server, and we just rent space on it. There would be many more physicians also using the same server, so all upgrades happen at once to everyone, and problems are dealt with (or not dealt with) for many of us. We do not know if we can move our data safely to this new server. As well, it may be better for our FHT if all of us were in one large application, so we can share templates and information; I do not know if that is possible.

Because the problem is complicated, we have formed a committee to look into it. Committees are sometimes good: they spread the work (and the blame if needed) around. We'll be looking at the pros and cons of each alternative; just like when choosing EMR software, there are no perfect solutions.

After two years, I think my group has done pretty well. There are now 10 of us in my FHN (and my partner is about to start). We are now at 50% paperless, 40% partial (both paper and EMR), and 10% never started. It is very difficult to come by figures for the "average" implementation; it seems to me that partial implementation is the norm. The National Physician survey shows more family physicians on both paper and EMR (19.4%) than physicians who are paperless (12.3%). It seems to me that about 25% fail to implement, 50% have partial implementation, and 25% are paperless; that is the sense that I am getting from what I have read.

One thing that worries me is what happens when funding stops. For those who never implemented, this is not an issue, they will simply drop the EMR and only pay for billing/scheduling. The physicians who are paperless will not go back to paper. It is those in the middle, who are progressing more slowly, who are at risk; if there is no funding, I think some will abandon the EMR. It seems to me that this may still be a majority of physicians once funding stops.

More uncertainty for us; I thought we were finished with that once we bought the software, but it was just the beginning.

Michelle

First fruits of the FHT

2008-03-21T12:00:00.002-04:00

In my Family Health Team, we are starting to talk about quality of care, and using EMRs to effectively improve care. We have two EMR systems, and perhaps we should switch to one; there is no consensus on this subject as of yet. It is quite apparent now to several of us that the systems are not fundamentally different, and that it is how we use them that makes the difference.

Here are some axioms of EMR implementation that we have developed:

Axiom 1: EMR implementation is far more dependent on us (our Communities of Care) than on the EMR software.

Axiom 2: Improving our care depends on changing our processes to take advantage of the EMR.

Axiom 3: We can accomplish far more as a group than individually.

We have been talking about how to improve our chronic disease management as a group. We are looking at using more flowsheets, reminders, and audits within our practices. All these are certainly possible with EMR systems, but often they are not used; for example, in the Annals of Family Medicine, Closson found that "The use of an EMR in primary care practices is insufficientfor insuring high-quality diabetes care. Efforts to expand EMRuse should focus not only on improving technology but also ondeveloping methods for implementing and integrating this technologyinto practice reality."

I also think it would be good for us to decide on what kind of diabetic program we would like; for example, we can have a Nurse practitioner do electronic audits, and follow up with patients who have not shown for their appointments, or who are not at goal for their blood pressures or blood sugars. We can develop and use good processes; we can work as a group. I am seeing inklings of this in recent emails.

It is interesting for me to reflect on my group's experience with managing our preventive services. We decided that we were going to use the EMR in a common way for those services across practices (click on the "done" button to indicate that the service was provided). We have one of my staff members as a Project Manager; she is responsible for following up with rostering, and regular mailings to patients. We agreed on the initial processes for entering the information (hire students for data entry over the summer). It took discussion, collaboration, consensus, and on-going work for it to happen. The result is a well-organized program, with tracking and consistent reminders being sent to our patients; in other words, better quality of care. The EMR enabled this, but it was the "human factor" (us) that made it happen, see Axioms 1, 2 and 3. I have talked with colleagues using the same software application, as well as other software applications, and this has often not happened in other practices.

The EMR is a major change; in my Knowledge Translation course, a student put this quote up: "change does not necessarily lead to improvement, but improvement is impossible without change."

We have also started talking about how to code our encounters consistently, to enable future searching for conditions across practices. If we can develop a system that we can agree on, we may then be able to build up a very good picture of what our community's health is like. There is a lot of brain power in this FHT.

My Knowledge Translation course is almost finished; it has been interesting, because so many of the concepts reflect what has happened in my own practice and in my FHN. Much of what we learn and decide to do and change is dependent on what things are like in our own practice, and on discussions with our peers and others (context, facilitation). I would like to start visiting some of my local colleagues at their offices, and see if we can try to figure out together how to do things better with the EMR; a sort of "practical Knowledge Translation" put into action. I'll have to figure out a way to do that.

Michelle

Wag the dog: of forms and cookies

2008-03-07T19:18:00.002-05:00

I am not the only one who thinks these proprietary forms are simply bad care. Here is what a colleague in my on-line EMR support group said:

"I hate the multiple forms we have to use and I have dutifully filled out the exact forms they wanted to make the clerks' lives easier. I now take the stand that if I can increase the completeness of my record and as long as all the clinical info is there I will use the form of my choice and it is up them to convince me otherwise.

However when I talk to them I am very nice and it is amazing what a bribe of cookies can do :) "

I think that perhaps we should form an alliance, and collectively refuse to send or receive proprietary forms. After all, the EMR based forms are typed, are legible, and contain all the needed information. Bring on the cookies!

I am now generating my pap reqs from the EMR; we attach the paper based req on the front, with no information other than the label. The proprietary req says "see attached"; the real information is on the EMR req. I wonder what would happen if we forget the patient label. My public health reqs are now generated from the EMR, which stores the appropriate code; a paper req is clipped to the front, with "see attached".

My practice partner has now decided that he would like a Tablet, so we've ordered one for him. We've also ordered 3 network printers, one for his consult room and one for each of his exam rooms. The total hardware cost to equip a new physician is about $3,500, far less than what it costs to start.

He likes the electronic labs; this is one of the best parts of the EMR. Our community-based labs really have it right; the reports are unbelievably fast and efficient. I probably shouldn't complain so much about pap reqs; I think I'll send my lab a box of cookies, they deserve it. My partner started using the flow sheet for his INRs on the first day; our secretary showed me a message from him to call the patient about the result. He now knows how to use the e-messages and task lists. Paper-based INR sheets are gone as of now.

He seems intrigued by templates; I showed him how to use a Rourke well baby template, and how the EMR remembers the lot number and expiry dates for immunizations. I also showed him how an assessment in the encounter can be simultaneously placed in the CPP, the "write it once, have it go three places" principle of EMR. I will be away for March break next week, and I am hoping he will find some time to play with this. He does some in-patient care at the hospital; there is access to the EMR in the doctors' lounge, and I told him that it would be pretty easy to have it on the floor where he works. He can log on to see his office lab results, and won't have to call our secretary anymore.

I am starting to find more ways to look at my data. For example, there is a place in the EMR that tracks my referrals. In the past 30 days, I've made 8 referrals to social work, 5 referrals to dietitians and 2 to our clinical pharmacist. The total is 15 referrals within the Family Health Team. These represent new things for our health care system, as they would not have existed prior to the FHT. Remote access to our EMR for our FHT Allied Health Professionals has just been enabled, so those referrals will soon start to be generated and recorded within the common e-Chart.

As far as specialist referrals, the most common is Derm, with 6 referrals. Total number of referrals (specialists, programs and allied health): 60 in the past 30 days. 15 / 60, or 25% are within the FHT. This 25% represents the beginning of an integrated system.

Michelle

Helping my practice partner start the transition

2008-02-29T18:12:00.004-05:00

My partner has been away in the past week. I had a look at his computer, and made sure that he has access to all the scanned documents on the front computer. These now include all the requisitions for programs at our hospital, and all the documents that I had previously scanned.

As well, I configured things for him within the EMR software. He has access to all the handouts, to outside links for patient education, to pre-made DI requisitions, and to ready-made consult requests. Many of those things (such as our phone book) can be shared, but some cannot. It took me about an hour to organize this, and I consider it time well spent; this work will ease his transition. We sent an email to notify the labs this morning, and the first electronic results already came in this afternoon. Things move much more quickly now than they did when I started. As of today, my partner has hybrid charts; he will need to decide how quickly he moves to fully electronic--that is where the biggest gains are.

I think I will put in some medications favourites for him; I have a list of drugs that I commonly use, and I will ask him to pick some. Maybe I will sit with him periodically at lunch, and we'll have a look at things together.

I sent him an e-message while he was away, and made a dummy chart for him to practice on. The flow sheets are programmed and are ready for him to use; I have a pretty good selection of useful templates as well. I have profiles and billing short cuts that are ready to use.

Setting all this up made me think about how much I now know about EMR, and how much work I did. When you first start, most of this is just not in the application; it can't be, since practices differ, and different physicians use different diagnostic facilities, have different referral patterns etc. I had to put in things at the beginning without really knowing how the software works. In retrospect, it was actually easier for me to start by myself, and to have a hybrid practice for a while. The new physician who joined me helped me to work out the bugs of having several physicians in the office on EMR instead of just one. She now requires no assistance from me, and is using many of the advanced features of the EMR, after only three months. I think things actually worked out well.

My secretary has started scanning in the paper charts for my partner's deceased patients. These are going into the networked hard drive at the front, same as mine. We have made new folders for his patients. He had a look at several charts from his computer, and I think he was happy with the excellent quality of the scans. We showed him how to use the "pages" tab on the left side of the pdf file (this produces thumbnail pictures) to quickly find what he is looking for. We have started shredding the paper charts that have been scanned in.

He now has a lot of work to do; all his CPPs will need to be entered in. I think he is considering hiring a student to do part of this work, which is not a bad idea. I will talk to him about coding his ongoing medical conditions in the paper CPP; he can enter the ICD code besides each condition, and that will help the student with accuracy. He will need to review each CPP that was entered.

There is still some uncertainty about when we move to the big office; I think this will most likely be in late Fall. It will be tight for him to complete the transition before the move; I have not allocated any space for paper chart storage. Starting now is not too early.

Michelle

EMR for the non-believer

2008-02-17T19:19:00.002-05:00

My practice partner will be implementing the EMR. This is not because he strongly believes that it will make a difference. He is doing it because EMR comes as part of a package: we have decided to continue practicing together; he is joining my FHN; he will be joining the FHT; he wants to move with us to the big office. EMR comes as part and parcel of all of those, and the benefits to him of going in this direction outweigh the risks of staying put. This is called "relative advantage", and I think this calculation is increasingly tilting in favour of Electronic Records.

I do not think that doing this type of calculation makes you a "bad" physician, or an "IT laggard". I think it is a realistic assessment for many of my colleagues, given the initial difficulties with implementing EMR. I also think that it is up to our health care system to help us; EMR subsidies are important. Other possible rewards are giving incentives for quality of care (such as the preventive care incentives in Ontario) that are easier to track and measure through EMR. I would like to see more of this; these incentives will drive the programming of EMR systems towards making sure that we can measure and improve what we do. This programming is still in its infancy.

Another very important aspect is making sure that we are connected: reduce the amount of scanning due to non-EMR data, help to ensure that other parts of the system accept EMR generated forms. This is not something that can come from physicians, it must come from the top (leadership). If a private Diagnostic Imaging facility can send me reports directly into my EMR, I am more likely to refer there. I wonder at which point competition will come into play; I would prefer to remain within the public system, but will use private facilities if their care is better because they are connected.

What I am trying to say is that there is a very important role for government, and for policy-makers. There is a role for incentives that favour adoption at the same time as quality of care; we also need policies that promote effective and efficient information transfer, instead of the current status-quo of outdated forms and processes.

I just went to a conference on the management of mental health issues, which I attend annually. At the conference, several of my colleagues told me that they were about to adopt an EMR, or were in the early transition; this is a change from a year ago. A physician who started using an EMR two months ago told me that his staff are unhappy, and that it is hard for him because everything is taking so much longer. He had a realistic assessment of this, however, and told me that he knew the early slogging was tough, and that things would get better; he wasn't giving up. EMR even came up in one of the small group meetings (these are run by a psychiatrist and a GP psychotherapist); a family physician said that prescribing some of the complex psychiatric drugs was now better because of the automatic interaction and allergy checking. I do not think that the GP psychotherapists are adopting these systems; these physicians restrict their practice to talk therapy, and I cannot see EMRs as having a relative advantage for them. There will likely be corners of the medical system with late or non-adoption; however, these will run the risk of being disconnected from an increasingly inter-connected system.

Michelle

On-line Support group

2008-02-11T21:49:00.002-05:00

I have an on-line support group for my EMR. We have about 70 members; some are more active, some less. There is also an area where you can post useful files, such as an excel gestational calculator template, or examples of EMR processes. The support group is monitored by the company, and sometimes we have replies or comments from them. When someone posts an entry, I get a copy by email; there are anywhere between ten and 50 entries or so per month, so it is not overwhelming.

Occasionally, a new user posts a question, and the replies have been very helpful and generous. I have noticed recently that comments are switching towards data extraction: my colleagues are asking for more Reports (procedures, labs, social history); we are talking about how to enter data in the EMR so that we can get good quality information on our practices. It seems to me that we are now starting to head into "phase II", which is the interesting part of EMR implementation: there is enough data in that we are now thinking about getting data out.

In my own group, I have noticed more clinical queries (or Reports); we can share queries as a group, so you see who programs and runs queries. Some of my colleagues re-use my queries for their own patients (and I am happy to see this happening); there are also new queries being done. I think our coding is becoming better in the second year of implementation; we are now used to entering the ICD diagnostic code routinely for every encounter, and this is no longer an issue. The payback is being able to search for diagnoses consistently. What this means is better data quality in the charts.

My new partner was asking me how to do a referral for audiology; I set this up for her, and showed her how to generate the request as part of the encounter. She told me that most lab/DI/allied health requisitions at her previous office were still done on paper pads. This is rare here; we use EMR reqs whenever possible, or scanned reqs if we have to. I do not think physicians are wedded to paper forms; I see my new partner using EMR forms, because these have been set up in the system. The work for EMR is all upfront: do it once to set it up, re-use it forever. For paper forms, there is no set-up; the work is all back-loaded and on-going: store and find the forms, stamp them with your name, write the patient's name on the form, or send to the front to label. I prefer EMR.

My new partner is not familiar with our local specialists, so I asked her how she was referring. She uses our EMR phone book. We have two phone books: one local (just for my practice), and one shared with all my FHN colleagues at any of our seven locations; I don't use the local one. In our shared phone book, information on the specialist's referral preferences (fax then patient phones, etc) is entered in Notes, and is shared with everyone; there is also a field where you indicate specialty. My new partner told me that she just searches for the specialty, and sees who we refer to. This is a good way to use aggregate information collected by the group; it made me realize that we now have a fairly extensive phone book. The information is used in referral letters as well as on the electronic lab reqs (the address of the specialist we are cc-ing to automatically appears on the req). I have access to a provincial database of physicians in the EMR, but our local phone book is better, because it is more up to date and has extra information.

My current practice partner has now decided that he is going go EMR. I have started showing him some of the really cool things in the system, as he starts to prepare for his transition. He will need to decide whether he prefers desktop or wireless, so I have asked him to try using the resident's Tablet so he can get an idea of both set-ups. We will need to figure out how to make the transition as easy for him as possible; I have printed a list of my medication favourites, and have asked him to pick out some of his commonest prescriptions. I will enter those for him, so he can see how it is done, and can start prescribing. We'll get lab and DI favourites set up for him. I expect that it will be harder for him than it was for our younger colleague; I have a fair idea now of what the likely start-up issues are, and having EMR processes already in place will help.

As for me, my encounters now start with a look at my reminders, the vitals are pre-entered by my wonderful staff, and the on-going meds are already all pending in the encounter, just waiting for a click and signature. I have access to the vast resources of the Internet at a click. One of my patients needed a referral to an addiction centre near him; I googled DART. We were both looking at the site on my Tablet, and decided together which centre he would be referred to. I think that the EMR helps me to be a better physician, and I like that.

Michelle

Snow storm

2008-02-01T10:03:00.000-05:00

The weather is just awful today, so I am working at home. My labs all came in at 9:30 am. An INR is slightly abnormal, so I've just sent a note for my secretary to call the patient and adjust his coumadin dose. She can log in remotely from home if she cannot make it to the office.

My husband is working in our home office as well. He is accessing his office via VPN, as I am. His large database is in Cleveland, but the results for queries are near instantaneous. I guess many large companies are functioning via remote access (the common database is somewhere else), but they have made sure that the pipeline is big enough. We still have a long way to go with SSHA; I heard that there were outages last week in several locations on Ontario, making it impossible for practices to access medical records. I think this would be unacceptable in a business environment (my husband's multinational company could not function); I really don't see why this is acceptable in a medical environment, with people's health at stake. We have been promised good access at the new clinic; we'll have to see if SSHA does come through.

A blood sugar just came in as elevated for another patient, confirming a new diagnosis of diabetes. I've just called the patient to let her know. This lady has other serious health issues, as well as limited English and literacy; I had recently asked our FHT RN Case Manager to see her. The RN Case Manager does not have access to the EMR yet; the referrals are done by fax. I've just notified the Nurse of the lab results by email, without using the patient's name: "recently referred pt -initials- has new dx DM II". Once the RN has access, I will e-message her within the EMR, which is much better. I will probably need to send her an email to let her know that she has a message in the EMR.

It is taking a while to establish all the EMR connections within our team. Each FHN requires its own log-in, and there are two different EMRs to learn. All together, it is complex. I would like it done yesterday, as the benefits are so glaringly obvious, but I know I have to have some patience. We have a bit of IT support for the FHT, but it is limited at present; I am worried about what will happen when all of us move into the big office--will we have enough support to run all these machines and software? I can run my office as our FHN has its own IT person, but I don't know what will happen to the rest of the group. We probably should really start thinking about coordinated IT support.

My resident is now talking about joining me after graduation; I know of several young physicians who have joined EMR/FHN practices recently. I think the current primary care environment is much more attractive for new physicians.

My new partner is functioning well in the EMR environment. After a month and a half, we have worked out most of the initial bugs, and she now has remote access.

She is getting a fair number of old charts from her previous practice: we scan those to the networked external hard drive (I have made a folder for her) after she has seen them. Some of her old charts arrived on CD; we simply drag the file to the external hard drive; the patient can have the CD back immediately if they wish, as the process takes next to no time.

She is getting some lab/DI reports for patients who are not registered in her new practice at my office; we don't know if these patients will transfer here. Rather than starting a new chart, we scan those to a folder; if the patient does come in, we start an electronic record, and the files are then uploaded to the EMR.

She told me that scanning was very slow in her previous office; up to 3 months. It made it very difficult at times to know where results were (on loose paper waiting to scan? in a paper chart? attached to the electronic file?) leading to a lot of wasted time. The reason for the slowness was that scanning was only done in the evening, and the clerk did not have enough time to do everything. This does not work; in my office, scanning takes 1 day, or at the most two. It is really worthwhile investing in a good, fast scanner, and making sure that you have enough personnel to do it properly.

My practice partner is actually talking about converting to EMR! He can't type (using 2 fingers), which will present a problem. I think what would work for him is dictation:

Subjective/Objective
Favorite Notes:

The Subjective/Objective part can be dictated (dragon dictate, other). The Vitals are now often entered ahead of time by my staff. If not, these don't take long to put in.

The medications should be typed in. However, once his list of favourite meds is done, it will only take a few keystrokes to enter, as the rest is auto-filled:

Drug Name

amoxicillin 500 mg Refill: 0 Direction: Take 1 Tab(s) PO TID for 10 Day(s);

The Assessment requires typing the 3 ICD-9 digits (if you know them), or a couple of keystrokes to get the drop down list:

Assessments

ICD - Description

Status

Comments

CPP

-

401 - DISEASES OF THE CIRCULATORY SYSTEM/ESSENTIAL, BENIGN HYPERTENSION

The Plan notes can be dictated as well:

Plan Notes

Favorite Notes:

His CPPs are very organized and legible, we can hire someone to type these in for him. This combination of some typing and some dictating will likely work.

He may not be able to get to the office today. If my secretary can get in, he can call her for results, but otherwise it will be difficult for him to access anything. In Canada, we have snow storms; the EMR certainly makes it easier for us to cope with our weather.

Michelle

Planning my new office

2008-01-18T15:36:00.000-05:00

Thinking about my new office presents challenges. I may have to change some of my technology (phone, fax), and rethink some of my practice processes (again).

For example, should I consider VOIP (internet-based phone)? What about Internet faxing? A fax line costs $50 per month; Internet fax costs about $10 per month, there is no need for a fax machine, and it is always on (without the need to leave the computer attached to my fax on). Long distance is free. My secretaries are already faxing directly from the computer more and more often. We can use the scanner to fax things that are paper-based. On the other hand, I don't know if Internet fax is secure, and I have not seen how it works. I really don't know anything about VOIP.

We will have many physicians and allied health workers in the new office; there will be 5 practices, each with 3 to 6 physicians. Our Allied Health Professionals will have their central offices there. The FHT administrative offices will be there as well. All of us will be on the same EMR system, and the plan is that physicians will be able to access it remotely for booking. EMR training for our AHPs has just taken place. We will need significant Internet bandwidth to take care of all this, and probably someone on-site to manage the IT. It is exciting, but also more than a little scary to me; it feels just like before we embarked on the EMR project, with many more questions than answers.

My group is now starting to think about what to do when our EMR contract expires, in 2009. We can choose to remain on the hospital-based server, or go to ASP. Our provincial subsidy ends after three years, so we no longer have to comply with the provincial stipulations (use SSHA's internet lines, use a Certified EMR etc). Many of my colleagues in Ontario are going to be in the same boat.

The benefits of staying with our current server are that it is a known quantity. However, it will need to be upgraded (we are taking on new physicians, and the amount of data going in is increasing).

The benefits of going with the SSHA ASP is that provincial healthcare data is going there, so there is a better chance of linking with the rest of the system. Hospitals and Home Care are sending data there. However, much of this is still theory, not fact. The drawbacks are that we have to continue to deal with SSHA; this has not been a physician-friendly (or even customer-friendly) organization in the past.

The benefits of going with the company's ASP (which is not Certified, we could not do this under the terms of our current contract) is that we can access over regular internet (faster than SSHA). This is much simpler and easier.

I am leaning towards the SSHA ASP. I know the problems with SSHA; however, I do think this type of structure gives the best chance of having the data follow the patients. As well, we need to have our data professionally managed and backed up; I was speaking with someone who had been at at physician's office, and saw a sign asking people for patience, as they had lost two months of data. I worry about the small servers in solo or small family practices; not all of us are good at backing up our data. Data loss happens, not everyone is careful; while there are risks in large data centres, I think the cumulative risks in many small, unsupervised practices are likely greater.

I was looking at CanadianEMR, and saw that the results of the 2007 National Physician Survey are now available. It looks like 19% of family physicians are now using a combination of paper and EMR records; that may well represent people currently transitioning to EMR. 12% of us are using EMR only; that must be those who have completed the transition. The total for EMR (full or partial) is 31% of family physicians; for all physicians under age 35, it is 45%. These are much higher rates of adoption than previously reported, and the numbers may mean that we are now in the "early majority" phase of EMR adoption.

Michelle

the New Normal

2008-01-13T22:02:00.000-05:00

On Friday afternoon I had a meeting at the hospital. After the meeting, I went to the doctor’s lounge to get a coffee and to log on to my EMR from one of the Lounge computers.

I had several things to review. I had told one of my patients to stop her blood pressure medication a month ago (she had several BP readings in the 110-120 range). I asked her to drop by in a month to get a reading done by my secretary on the Automated BP machine. My secretary had started the Encounter, and entered her blood pressure, which was now above goal. The fact that the patient had come in was visible on the Dashboard as I logged in; I viewed her BP, and reviewed her Hypertension flow sheet to remind myself of what I had done. I re-started her medication and signed the prescription electronically, then sent a message to my secretary to call and let my patient know, and to fax the signed script to the pharmacy.

Lab tests had come in. One of my diabetics had an elevated A1C (blood sugar level). This patient had come in the previous week; my EMR has reminders to check diabetic parameters every 3 months, and he had not been in for 6 months; Summary immediately showed me that a diabetic visit had been missed. I explained why it was important to manage his diabetes, and that I wanted to work with him on preventing complications. His blood pressure was above goal (I increased his BP meds), and his weight had increased. He told me that from now on he will be making his next appointment prior to leaving the office (decreasing the risk of missed visits), and I sent a pop-up to the front for him to return and get wt/BP rechecked in a month. I also asked him to get fasting blood for cholesterol and sugar done in the next few days.

When I saw his A1C on Friday, I called him, and asked him to start on a new medication. I explained the side effects. Summary showed me that he did make an appointment in a month, and I told him that I would review the medication again with him at that time. I asked him to give me his pharmacy number, prescribed and signed the new medication on the Encounter (which also automatically placed it in the CPP), made a comment on the flow sheet, and sent a message to my secretary to phone the prescription in.

A holter monitor had also come in for another patient with palpitations. This showed Atrial Fibrillation (irregular heart beat). Fibrillation is a risk factor for stroke; we use coumadin (a blood thinner) for stroke prevention. I phoned my patient and asked her to make an appointment for Monday; a discussion of fibrillation and coumadin management is something that requires an office visit. When she comes in, I will use the MedCalc 3000 atrial fib stroke risk calculation, import this into the EMR, and give her a handout. The handout will be logged into the visit.

While this was going on, I was simply sitting at one of the Lounge workstations, a specialist colleague was dictating a routine hospital encounter beside me, and others were discussing their weekend plans. It was not until a few hours later that I thought about how extraordinary my New Normal really is.

This is how I practice now: remote access from anywhere; ability to manage problems over the phone or at the office, depending on what is most appropriate; immediate recording of phone encounters into the chart; alerts and flow sheets to enable improved chronic disease management; enhanced communication with my practice team; ability to delegate tasks; implementation of evidence-based tools into encounters; and more. What I see in my practice is not just more efficient care, but better, timelier care as well.

I think this should be Normal for everyone in the Health Care system. It cannot be individual physicians’ sole responsibility to pay for and implement EMRs, as is the case for too many of my colleagues; patients and our System benefit even more than physicians. It truly is time for our Governments to look at rational Health Care IT funding.

I have been thinking about what else I can do. We will be having our national Family Medicine conference in Toronto this Fall (FMF 2008). I spoke with a colleague I respect about doing a workshop together, on EMR implementation issues. He uses a different EMR, works in a larger group office, and has been very successful in resolving challenges with computerization. We also invited one of our experienced Practice Management Consultants at OntarioMD as an additional resource. I think having a mixture of experienced users from different settings, along with a consultant, is likely to result in an interesting and productive workshop. The submissions are peer-reviewed (and there is always lots of competition), so I do not know if this will be accepted. If it is, I will post the date when available.

I now write occasional blog entries for OntarioMD, in the EMR advisor section. They recently asked me if I would be interested in answering EMR questions from colleagues, a sort of “Dear Abby” approach; I thought I’d try, so they put a link to do this on top of my entries. I don’t promise I’ll answer everything, but I’ll do my best, and will ask experts when I don’t know.

Michelle

My Team: multidisciplinary care

2007-12-30T22:12:00.000-05:00

The New Year will mean more Team-based care for me. A part of it will be the move to the Big Office, but much of it will stem from the on-going development of our Family Health Team: we are now deciding what programs to launch, and how to go about this.

The reason for FHTs is to increase access (more patients rostered, improved access for current patients), to create Teams so that care can be better coordinated, and to increase activities directed at health promotion and disease prevention.

We now have nurses, a RN case coordinator (for tough problems that need system navigation), dietitians, social workers and a clinical pharmacist. We are planning on hiring a clinical psychologist as well. The Social Workers were an immediate hit, and are now so busy that there is a bit of waiting time to see them. We do not have Nurse Practitioners, because there are very few of them, and they’ve all been hired by the other FHTs.

We have a board of directors (mostly family physicians), and an executive director, as well as admin support staff. We have identified several areas that we would like to focus on. Our Allied Health Professionals are getting a full week of in-service training in early January, followed by EMR training the following week.

I’ve been asked to talk about Medical Directives during the in-service training; this is something that we can now start thinking about as a group. Medical Directives allow AHP’s to do delegated act, for patients who fit criteria. For example, I would like to have a directive that will allow my nurse to do a quick strep (or throat swab) for patients who have a positive sore throat score, without asking me for permission first (nurses are not allowed to order diagnostic tests independently). Things like that are easier to do if you use EMR templates; I’ve seen my nurse use the sore throat template correctly several times (it is visible on the EMR Encounter as soon as entered), before I go in to review the history with her; she knows when to do a quick strep, and she has no difficulty in interpreting it correctly. We’ll have to start thinking about what makes sense, and is likely to improve access and quality of care.

There has been some thinking about how to use the EMR; we may go to a centralized booking system for the Allied Health Professionals, accessible remotely. I don’t know how well that will work; I have a feeling several offices will prefer calling rather than logging on to book. We have two EMR systems in our FHT (I heard that in Hamilton they have six!), and some AHPs will work mainly in one system, while others will be assigned to the other. This will be easier for AHPs working inside family practices; I’m not sure how it will work for those assigned to programs.

I have not been actively involved with our FHT board or planning committee, but I am the beneficiary of their work. One physician in particular has been instrumental in bringing this project to fruition, after years of hard work (and lots and lots of meetings for him). It is always like that: there have to be people with vision and dedication to make projects like this happen, and sometimes they are not recognized or rewarded. This is true for some of our EMR pioneers. It is gratifying to see that our provincial government has decided to re-invest in primary care; I think this will pay large dividends.

There will be significant changes related to Team-based care in 2008 for me and my FHT colleagues. I expect that, by the end of the year, my practice will have dramatically changed from what it was as of my first entry in December 2005. Although the upcoming changes may not always be directly related to EMR, IT will be a large component of the final transformation. I am planning to post regular updates on this last part of the journey here.

Michelle

Year 2: looking back, looking forward

2007-12-24T10:46:00.000-05:00

A year ago, I had just finished entering the last of my CPPs into the EMR. It has now been a year since I have been fully electronic.

This is a log of a routine diabetic visit; I have erased the date and the patient's name:

	10:41 AM				View Summary
	10:43 AM				Add Encounter
	10:43 AM				Add Clinical Notes Templates
	10:44 AM				Edit Clinical Notes
	10:44 AM				Edit Clinical Notes Templates
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:46 AM				Add Lab Requisition
	10:47 AM				Add Immunization
	10:48 AM				Sign off Encounter

I view Summary as my entry screen, by default; this lets me see if there are any outstanding issues for a patient. In this case, she was overdue for her flu shot, which was the first thing I did (the two minutes between Summary and start Encounter). The active medications are auto-loaded into my Encounters, and they are batch printed (that's why they are all stamped on as being at the same time, this is the time they are printed). I sent the patient for an A1C (lab req), and recorded her flu shot. Log lets you get a quick snapshot of how your encounter goes; it doesn't include everything (I also looked at the diabetic flowsheet and the CPP), but it is pretty good.

I keep looking for ways to improve efficiency; the EMR software application is so large and complex that there is still lots to find and use. One of my colleagues was telling me that he feels he uses only about 5% of the functionality; I probably use more, but there is still lots to discover.

My new partner has been using EMR from day 1. I can see that there are some things that are still challenging, such as learning to prescribe more complex drugs (example, gardasil, at 0, 2 months, and 6 months, to be given in physician's office), or doing referral letters. The basic encounter was pretty easy for her to learn. Periodically, we sit down for a few minutes and I show her things. She did not go for EMR training, as it did not seem necessary; she is learning it as she uses it. I will buy a new Windows XP PC for her, because I just can't make Vista connect to my XP network properly. There were a couple of start-up problems: for example, we had to figure out how to make sure that encounters that are started for her by my front staff (they put the vitals in) are sent electronically to her and not to me. Her off-site access does not work; it seems to be a problem with her router blocking the VPN, and that needs to be solved.

She decided that she preferred desktops (wired) as opposed to wireless. Because I have network "drops" in every room, it was very easy to accomodate her. She has her own exam room (the room where paper charts used to be stored), and this now has the desktop with a local printer attached. The printer is the same brand as what I use in the rest of the office, so that we don't have to manage cartridges from different companies. We share an exam room, and she just leaves the laptop in there on the days that she is using it.

Overall, adding a new physician in my office was a lot of paperwork and some extra EMR work (configuring the machines, learning to work with two EMR physicians instead of one), but this is much less than initial EMR start-up, and is manageable. It has not been as difficult as I thought it would be, although there are still things that we need to fix. It helps a lot that my new partner is so easy to talk to, we can solve problems. I expect that, once she gets going, she will be teaching me things.

My son moved out of residence this year, and moved in with two other university students. They have a brief "house meeting" every two weeks, do discuss outstanding issues. He keeps minutes. This is working very well for them; it sounds like a good idea, and I think I will try that with my new partner.

I have been talking to several colleagues about joining me, as I will have a three physician office in the big FHT office; I do not yet have a third partner yet.

While there has been progress, there is still a lot that remains undone. What bothers me the most is the lack of action on the "electronic island"; we are still not connected to the hospital or to outside agencies beyond the labs, there has been no decrease in the incoming data that needs to be scanned, and there has been no progress on decreasing the number of proprietary (non-electronic) outgoing forms. There seems to be lots of talk, but there is no change in my practice.

As an example, we are now being forced to send out proprietary public health forms for Chlamydia urine PCR; up to a month ago, the Ontario lab req was accepted. If you make it more difficult for me to screen for chlamydia, I am less likely to screen (a decrease in quality of care).

There is nothing that a front line clinician like me can do to improve this. Because the health care system is still so fragmented, it is difficult to know who to talk to about these issues, and each problem has to be solved in isolation. We certainly have lots of organizations dedicated to decreasing fragmentation (the LHINs, Canada Health Infoway etc), but I cannot say that their work has percolated down to my practice. Maybe next year.

On the other hand, EMRs are spreading. I have now started the study that I will be writing up as part of my Master's thesis (effect of EMRs on preventive services). We are recruiting colleagues in family practice in my area, and have recently sent out letters of invitation. 26 physicians out of 130 have already replied; of those 15 have or are planning to implement an EMR, and 11 are not planning EMR.

In my own Family Health Team (composed of 6 Family Health Networks), all 40 physicians have or will have EMR by next year. Our Allied Health Professionals are getting EMR training the second week of January. I expect to have more EMR integration at the FHT level next year: by that, I mean that our social workers and dietitians will enter data directly into the EMR. My practice nurse and our clinical pharmacist already do this.

We are getting ready to start renovations on the big FHT office. My own office at the new location will be just over 2,000 sq feet; plans to move in later in 2008 are on track. There was a good article on office planning in a recent issue of Future Practice, by Dr Kendall Noel; just like him, I really like the fact that my patients can see the computer screen--it allows them to participate more in their own care. Almost all of my physicals are now done collaboratively with my patients: I point at what I am looking at on the screen (and I often ask patients age 50 and over if they need their reading glasses--because I'm starting to need those more routinely). It is important that you don't have your back turned to your patient while entering data. It is simpler to do this with wireless because the computer is portable, but the new flat screens make this a lot easier to do with desktops: they take up much less space, and it is easier to place them where they make the most sense.

For the next year, I look forward to planning the big move; this will make my practice fully electronic, as all physicians will be on EMR. I look forward to working as part of a Family Health Team. Now that I have lots of data in, I want to learn to use the capabilities of the EMR to systematically improve care: that will mean doing audits to figure out what patients need, deciding what to do, and using the Team to put our plan into action.

I would like to thank readers of this blog for your company through this journey, and wish everyone a good and peaceful 2008.

Michelle

Divorce, EMR style

2007-12-16T21:04:00.000-05:00

At a recent OntarioMD meeting, several of my colleagues who are early adopters talked about being on their second EMR system. I've also heard from colleagues who are not happy with their system, and my new partner is now on her third EMR system because of changing to new practices.

I think going electronic is a bit like a marriage; you use the darn EMR all the time, sometimes it works and sometimes it drives you crazy. If it drives you crazy enough, then you get a divorce, which is difficult and expensive, but is sometimes necessary. No guarantees on whether the next partner will be any better.

There is no way that the electronic data from my partner's previous practice can get transferred to the new EMR. Her previous office manager is printing the charts of patients who are following her; she has to then re-enter the CPP. We are scanning the old charts that are arriving into the office's external hard drive. This is the current state of affairs.

In Ontario, all approved EMR applications will now have to be portable; in other words, you will be able to transfer data to a new EMR vendor if you switch. This document has what must be portable on page 40 and on. It is a bit difficult for me to understand, but it looks as if most of the CPP, lab and clinical notes are in there. I can't imagine that is will be easy or seamless, since EMRs store things in all kinds of different ways, and in all kinds of different databases. I'd like to see this in action; I think the most important piece will be the CPP.

In my EMR, I now see a Data Export and Data Import piece, so they are getting ready for this.

Having some data that is similar across EMRs is a good idea; perhaps one of the unintended (or maybe intended?) consequences of this initiative is that there will be a common CPP that can be transferred back and forth to hospitals, home care, and specialists when needed.

It is interesting that I have not heard of instances where the divorce was back to paper; the difficulty is with the initial transition to EMR. There is no reversion back to paper, but there is failure to launch EMR.

My Family Health Team is getting ready for the big move; about half of the physicians in the Team will move their practice to the same premises as our Allied Health Professionals. This looks like it will definitely be happening in 2008; I will be moving, along with my new partner and a third physician. Our AHPs will be getting EMR training early in the new year. It will be interesting to see how things get integrated. I've been asked to talk to the FHT Allied Health about medical directives in the new year, so now I have to think about what I would like them to do.

Three of the practices that are moving are now on EMR, and two will be transitioning after the move. On the Master Plan, there is space allocated for high density filing for the non-EMR practices only; I cannot see much wasted chart areas in the EMR practices. I will not be moving any paper charts to the new office; others in my FHN who are moving are now disposing of their paper as well. One physician has moved files to her home, another to a storage company, RSRS (and she is quite happy with the service). I think we are starting to witness the beginning of the end of paper records.

Michelle

Being irritated

2007-12-07T21:39:00.000-05:00

We just got a new version of my EMR software. The colours are all different, the layout is somewhat different, my label machine didn't work and I get error messages with some of my bills. We got the new Ontario lab reqs, and I had to reprogram my saved lab favourites. I don't really like new software versions, it seems they never work quite right at the beginning and it takes a while before everything settles down again. Even giants like Microsoft can't quite get it right (Vista is very buggy).

I fixed the label machine; the billing error message is annoying but the bill goes through. I'm getting used to the new layout, and there have been some improvements, such as making the DI and lab areas of the charts easier to access without leaving the encounter. There have been some changes in the prescriptions that I haven't quite figured out yet; on the other hand, one of my FHN colleagues found that the EMR can now print a "non-prescription prescription" when drugs are stopped. That's useful, because I give this note to the patient so they know what has been stopped, and they can pass it on to their pharmacist.

I figure that if I'm irritated, I might as well be an oyster and see if I can make something out of it. I figured out a much faster way to get my lab and DI reqs into the record, which I hadn't seen before. I also followed up on my colleague's comment on the previous post, and now auto-load a pap requisition into the record, so that the pap can be tracked; while I was at it, I emailed the general manager of my lab company to ask him if it would be possible to send him my computer-generated req instead of the proprietary pap form. I sent him an example of a requisition, which is reproduced below. Maybe they'll agree this time.

Some of our lab processes are unnecessarily complicated; for example, a first prenatal exam involves generating a req for prenatal blood work, a second lab req with "IPS, part 1"(Integrated prenatal screening), along with a special Genetics form for the IPS; an Ultrasound req for Nuchal translucency; and a special public health lab form for HIV and other public health labs. That's five forms, plus the handout on IPS that I give patients.

I generated EMR form favourites for the two labs and the US, and they're now clicked into the encounter and batch printed. The special IPS form and the public health form (with my own information pre-entered, and all the public health blood tests pre-checked) are now together as a single file; Adobe Pro lets you put several pdf files together. I also include a letter of explanation that says: "book your ultrasound between 11 and 14 weeks; take the special IPS form, along with the lab requisition that says "IPS I" and the ultrasound requisition to the ultrasound place. The technologist will keep the ultrasound requisition, and write the results in the special IPS form. Take that form and the IPS I lab requisition to the lab on the same day; they will take your blood and keep both forms."

The single file with this letter, the IPS form and the Public Health lab form is then printed. That's one print for the EMR forms, and one print for the rest (instead of 6 load and prints--or having to look for a bunch of forms). Also, I'm much less likely to forget one of the forms, which I've done in the past.

This is my EMR pap req:

Cytopathology Requisition

Dr. Michelle Greiver

212, 5460 Yonge Street

North York, ON

M2N 6K7

Email:	mgreiver@rogers.com http://drgreiver.com
Phone:	(416) 222-3011
Fax:	(416) 221-3097

COPY TO:

Lab company

Phone:

Fax:

Patient: Dummy2, Patient

123 any street

Toronto, ON

M1M 2M2

Date of Birth:	Oct 1, 1947
Phone:	(416) 222-2222

Date Created:	Dec 7, 2007
Priority: Routine

Tests requested:
Date of LMP:	December 2 2007
	Endocervical

Comments:

PAP SMEAR, LIQUID BASED, using broom.
LMP 2 weeks ago. Cervix appears normal

Physician OHIP number:

Adding a new physician

2007-11-23T11:26:00.000-05:00

A colleague will be joining me in my practice on December 3rd. She has joined my Family Health Network (lots of paperwork), is coming on staff at my hospital (paperwork), will be using my EMR (paperwork) and will be receiving the OntarioMD subsidy (paperwork). I wonder if we could combine all this paper into one giant Sequoia. We also notified the labs so she can start receiving electronic labs from the outset.

I have been thinking about how to make it easier for her to start the EMR. It took a little while to register her properly on the system. I already set up her preferences for her, so that the system works from the beginning; these large systems are highly customizable, but the downside of that is that you have to set things up. When you first start, you don't know much about the options available, and it may not be intuitive. I have a good idea of how things run efficiently, so I put that in and she can always change it later. I've set up things in the EMR like lab favourites (1st prenatal etc) for quick lab ordering, quickfill for DI ordering, physiotherapy reqs, basic form letters, referrals etc. It takes a while to start a new physician, it is more complex than adding staff, a resident, or Allied Health; it is important to try to do it properly.

My secretaries know quite a bit about this, so they will help as well, and my nurse can assist.

She bought new machines, but the Vista system does not seem to see the Window XP machines on my network, so her computers can't access all my scanned documents. I will need to call my IT guy to have a look. In the meantime, I will lend her one of my machines so that things work from the beginning. There is a learning curve for the EMR, and it helps if everything is already set up and if you have some help and advice from the outset. I think one of the things that make the initial transition so hard is that you have to deal with everything at once: the hardware never works properly at first, and the software is terra incognita.

She has been using another software application in the practice she is leaving, and does not like it all that much. I'm not sure what the issues were, probably some combination of process problems and computer issues. I'd like to see if I can do a bit better, but I'm sure there will be glitches. I'm hoping to have everything running smoothly within 6 months, which I think is reasonable, and is certainly shorter than the 18 months that has been quoted for a transition from a full paper-based practice. It will be easier for the next generation of physicians.

I've just had a quick look at my overdue lab reqs: there are nine reports that were done but results were never received, from June to mid-November. We will have to call the lab and request copies. I cannot track paps that have not been received, because the lab will not accept electronically generated reqs (mine will only take their own proprietary form). I scanned the pap req in, and print it as needed, but that makes it non traceable. I have had a patient come back and ask for her pap result, which was missing. We called the lab and had them fax it; I can also look results up on line, but that doesn't help me if I don't know that the report is missing. Whether by fax or online, results do not flow into the EMR: we have to scan in.

I wonder why results go missing, and what can be done about it. We sometimes had paper lab reports delivered to us that belong to a different doctor, which explains missing labs on paper. It is more difficult for me to understand why electronic labs go missing; perhaps a technician miscodes the physician's name when the lab form is received. It is time for bar codes, which my system can do. There should be some way of having labs track missing results systematically, especially for the electronic labs.

Michelle

the structure of the chart

2007-11-12T12:38:00.000-05:00

I have now used electronic charts for more than a year and a half. The way I look at the chart has changed substantially, because the chart is now much better organized and it is much easier to find data.

However, I look at my "plain" clinical encounter notes less often. In the past, much of the data was located there; for example, I'd have to search to find previous blood pressures or weights. Now, I click a link or look at my flowsheets.

There has been debate about "the patient's story" in the chart; in the past, that mostly meant ongoing longitudinal data in the encounter notes (legible or not). Now, the story tends to be all over the chart; the data is more easily accessible, but it is also more scattered. Some of it is only accessible in electronic form.

Much of my chronic disease management is captured in my flowsheets; the encounter is a poor format for following chronic diseases. For lab follow-up, I am less likely to write "hemoglobin was 88, now it is 97", because that is clickable in the electronic lab. I do put in assessments in encounters, although this is more likely for in-person encounters (for billing) than for phone conversations. I put in reasoning for treatment or investigations, so I can see what I was thinking. However, I will often not put in "DXA ordered"; the DXA (bone density XR) order is a link within the encounter. If I print the chart, the link will show a DI was ordered, but you will need to access the electronic version to see what it was for. Similarly, my lab requests show up in the encounter as a link, and not as discrete blood tests.

The data is generally richer and more extensive (because much of it flows in automatically), but some of it is standardized because of templates, such as a low back examination or a visit for a cold. My annual check ups also are standardized. This probably reflects an attempt to provide good care for everyone, but it does make the record less individual. I am probably conscious of the fact that there will be patient access at some point in the future (and I fully support this), which may make me a bit more cautious about what I write.

I think we may need to start thinking about "the patient's story" in a less linear manner. I am not saying that the clinical encounter document is not important, but it does seem to me that it is assuming less importance; I look at it less. I'm not sure if that's a good or bad thing.

Michelle

Peer to peer

2007-11-03T16:29:00.000-04:00

I have often received requests to visit my practice; I think that there are still so few computerized offices in my area that people want some idea of how the EMR works in a real life setting. I also get requests from physicians who have recently started an EMR, so that they can see how things flow in my office and get ideas for their own practice. I have had visits from people in academia who are interested in the EMR transition.

I recently went to visit Alan Brookstone in BC, and got a chance to tour the recently opened PROOF office. This is a regular medical office, set up for EMR, so that physicians can test hardware and applications in a real setting that mirrors their own practices (waiting room, exam rooms etc). There is demand for this; having something organized and easily available will make it much more accessible.

I don't know if we can get something similar in my area; it will take someone to organize it. In the meantime, I have started passing requests to visit my practice on to OntarioMD. We have the new InfoWay Peer to Peer Network, and it says that one of the things we are supposed to do are "individual demonstrations of Electronic Health Records technology". To me, that means "come see my office". At OntarioMD, we have Practice Management Consultants (PMCs), who help with the process of choosing the EMR and receiving funding. I passed the last request on to my local PMC, and she arranged to meet with the physician's group to discuss things such as the subsidy and what their needs are. Once they are ready, she will then arrange for them to come to my office. I think that this is a much more efficient way to do things, and it also provides my colleagues with much more than a simple visit could.

I wish I could make an organized inventory of work flows that I use. I did not find such a thing, and had to invent many things as I went. I am sure many of my work flows are similar to other physicians'. I was watching my colleague, Dr Stephen McLaren, speak about this subject. The video will take a bit of time to download, but it is well worth the wait. This type of practical, day to day work flow advice is invaluable; maybe we should have some type of document on work flow (paper, or CD or internet based and searchable), with "how to" sections. There are enough power users now that we could have screen shots of different EMR systems so that the document is reasonably vendor neutral; I think it is important to have screen shots so that you can see how it is actually done.

All EMR systems have their strengths and weaknesses. I have been talking to users of other systems, and I am starting to see what those are. It is helpful for us to talk across platforms, because we will then go back to our own vendors and work with them to improve our products. In terms of choosing a system today, my advice is the same as Dr McLaren's: there are enough larger, established products now on the market; do not pick a small vendor--you will be a pioneer, there are no established peer networks for support, and your vendor is more likely to fail.

I am not saying that the cavalry is here to save your implementation; I am saying that there is much more available now than a year and a half ago, when I started. For those of my colleagues at the tipping point of deciding to computerize, your peers who have done it can tell you that the time is now.

Michelle

Reporting my data

2007-10-26T10:58:00.000-04:00

OntarioMD has now announced that two new companies have been approved for ASP funding. My EMR software is one of them. This is good news for my group; our contract finishes in a year and a half, and we will be looking at whether we should then transfer to the ASP product. Doing this will mean that our software will be hosted in the SSHA Data warehouse. Other services, such as home care and some public health data, will be hosted there as well. I am sure there will be lots of bugs and difficulties, but this represents the future of health care in this province; it represents the best chance of integrating health care.

I went to the North American Primary Care Research conference last weekend. There was palpable excitement about what is happening with computerization in primary care. There were many presentations dealing with this subject.

As I look at my data over the past year and a half, I can see how valuable it is. Everything possible is going into the EMR now. It bothers me that Diagnostic Imaging reports continue to be reported on paper (despite the fact that DI is highly computerized), and that hospitals are still not connecting. That is unsafe and bad for patient care.

We also continue to receive stacks of paper from the Ministry of Health for our roster lists (list of all patients signed up with a family physician), every three month. These are generated by a computer, is there no way to receive them electronically, and match them with the EMR roster list?

It is now time for us to think about how to give our data back safely, and with full privacy protection. This data can and should be used to improve our health care system. For example, there is much talk about Wait times, and a lot of money is being poured to improve this. I don't really know how good the data is. In my EMR, we routinely collect wait time data as part of everyday care. When I send a patient for Diagnostic Imaging, the requisition is generated in the EMR (with a time stamp). This is the same for a specialist referral. When the specialist's office notifies us of the date, my secretary calls the patient and enters the date into the EMR. When the letter or DI report comes back, it is matched with the req (so we know it has been received), and that date is stamped in as well. I think it is now possible to start reporting on wait times from primary care, which is what is most relevant to patients. I think the public has a right to know, physicians and other health care providers should know, and our government (which funds health care) would want to know. If you don't know there is a problem, it is very difficult to fix it.

I do not think most of my colleagues would have much of a problem with this, provided privacy is strictly safeguarded. I think there is large value for patients as well, with the same caveat. I know I have several colleagues who are thinking the same thing. It is time to get going on this.

One of my colleagues was mentioning the fact that proprietary requisitions seem to be proliferating. Every specialist and hospital program wants their own, usually based on a paper form. This is not the way to go. I generate generic requisitions for DI, and have started generating EMR based reqs for Diabetes education. I simply append their form on the top, with "see attached". That seems to work. Dr Brookstone in BC has managed to get programs in his area to post their reqs on a secure website, but it takes work to make sure this is regularly updated. It is better than what we have here, which is nothing. I think it should be the responsibility of programs to make sure they are accessible when needed. Give up on proprietary forms (health is not proprietary), and make all programs accessible from a common area. Toronto211 is a good example for community and social services, we need something like that for medical programs.

It is time to ensure that the necessary data is there, both for our patients and for our health care system. I can see this is starting to happen now.

Michelle

Back to paper

2007-10-14T20:26:00.000-04:00

Due to personal circumstances, my practice partner had to suddenly be away and unavailable from his practice for the past week.

What that meant was that I was looking after two practices, one EMR and one paper-based. This was a somewhat rough way to compare the two systems. The picture above shows what the front of the office looked like after four days, and there were more charts piled up on my partner's desk. He is very meticulous, and wants to look at everything, so nothing got filed away; we must have had well over 150 charts out.

The logistical problems for my staff were tremendous: trying to find a chart to attach a result to quickly became very challenging: labs often send a partial result first, then a final result; this leads to two separate chart searches. My secretaries stacked the charts in alphabetical order, so that there was some chance of finding the right file.

I had trouble finding data in the paper chart. Looking for previous results meant having to thumb through several papers instead of doing a simple search or clicking a checkbox to get a list of results. Labs, consultation notes and Diagnostic Imaging reports were all mixed together. The CPP was up to date, but drug prescriptions were often very hard to follow, as they were in the clinical notes. There was no easy way to refill prescriptions, those had to be written by hand. My partner keeps excellent notes, and has handwriting that is much more legible than mine, but the logistic challenges were still large.

I know that many of my colleagues who have gone to EMR have stated that they would never go back to paper. Having had to go back to paper for a week, I can unequivocally say that no, absolutely not, under no circumstances, and no way would I go back to paper. It doesn't work.

Having said that, EMR does present its own challenges. My resident is on block time (in my office most of the time) and was a great help in the past week. However, her Tablet went on the fritz on our busiest day (Thursday). It suddenly refused to load the EMR software properly. I have a backup laptop for those occasions, but had lent it to my Nurse who takes it to my colleague's office Thursday afternoons. My resident went back to paper (since she was seeing my partner's patients), and my secretary called the EMR company. They had to "remote" into the Tablet (that means they take control of it from a remote location). Apparently, the hosts had disappeared; I don't know what that means, it sounds like something from the hospitality industry. They reintroduced the hosts, and the Tablet was fixed and happy. This took about 45 minutes.

I have been asked what I do when my Tablet crashes. Computers crash, and they usually do so at the worst times. If mine crashes in the middle of a patient encounter, I either leave it to reboot in the room (if I'm doing something else such as examining the patient), or I put in my consult room to reboot and I go take the backup laptop. The backup laptop is left turned on and ready to go; I just log in. You really have to have some redundancy; however, as noted above, even the best laid plans sometimes do go astray.

I do not pretend that EMR systems are free of problems and aggravation (they are not); however, the past week has made it very obvious to me that EMR is far superior to paper. Just try asking your kids to function without the Internet--asking a computerized doc to go back to paper will lead to the same reaction.

Michelle

The Efficient EMR

2007-10-05T14:45:00.000-04:00

I am currently in the office three days a week (I am taking a course at the University of Toronto Mondays, and do research projects on Fridays). My roster size is at 1,320 patients and I have about 100 to 150 unrostered patients. That makes a practice of about 1,450 patients.

In my FHN, the average practice is about 1,200 patients. I have a slightly larger than average practice.

If a patient is not too particular about the time of the appointment, they can almost always be fitted in within a few days, and often the next day. The only appointments that are troublesome are full check-ups booked in the morning (so that a patient can get fasting blood work done at my office on the same day). If they can get their blood done prior to the visit, the appointment can be scheduled much sooner; we mail them the requisition along with a list of labs (only ones that do electronic results) and weblinks to lab locations. This is in the Handouts section of my EMR.

The university provides hotspots for students, so I log on to my practice on Mondays; I am usually logged on remotely Fridays as well. I can review results and reports, and assign needed actions to my staff or my practice nurse.

What that tells me is that there is less need for my patients to come in personally for minor problems. If they do need to come in, they can usually be see fairly quickly. Much of this increase in efficiency has been gained by using the capabilities of the EMR (remote access, e-communication), along with having the entire practice work as a team. It helps to have excellent staff. I am starting to see some improvements with my new nurse coming on board, and expect to see more as other Allied Health Professionals join us. My Family Health Team now includes dietitians (I've made several referrals already), and I met our new Social Workers yesterday. The RN and our Clinical Pharmacist already enter data directly into the electronic chart-in-common; the other AHP's will get training; for now, their notes are done on paper and are scanned in.

If I can look after a full roster on reduced hours, this tells me that I may be able to expand my practice if I go back to my regular hours. This is part of the payback for EMR and for adding extra people to primary care. I will have to decide whether I should do more research or see more patients.

I have now taken on a new physician as a partner; she will start in December, and will have an EMR practice from the beginning. We are already starting to keep a list of people wanting to join her practice. I think most of the pain happens during the transition; once an EMR is established (meaning that all the new processes work), it is much easier to add a new member to a practice. I have seen this with my resident. That bodes well for the next generation of physicians, provided that they do not start a paper-based practice.

My nurse will be giving my patients flu shots on a drop-in basis every Monday afternoon, once the shots are available. We will be doing a mail-out to my older patients to notify them of this. We are doing the mailing as a group, just as we did for the other preventive services: the letters are already in everyone's EMR; our FHN admin will print and mail them as soon as we have confirmation that the shots have been delivered to our offices. Several of my colleagues have also decided to have the RN run the flu shot clinic in their office.

It is increasingly difficult for me to remember what it was like to run a paper-based office; I am pretty sure that I would find the inefficiency and lack of communication difficult to tolerate. I no longer believe that paper-record based medical care has a future.

Michelle

Electronic communication in the office

2007-09-30T21:54:00.000-04:00

Communication in my office is becoming increasingly electronic. I get 5 to 10 messages from my staff per day (often a patient or a health care worker wanting to talk to me, sometimes a drug refill). Messages are linked to the patient's file (I can just click to access the entire file if needed), and no message gets lost or forgotten anymore. Most of the e-messages I send out are "Actions", or things to do, often stemming from lab results (example, please call patient and tell them that A1C is improved, now at 7.8%; or, INR is 3.8, reduce coumadin to 1 tab daily and repeat INR next wk); typically, there are 5 to 10 of those per day. The "Actions" can be assigned to a group, such as "front staff". This is very helpful if you have several people working at the front; any of my staff can do the requested action, and mark it completed, thus avoiding miscommunication.

I have been assigning complex Actions to my practice nurse, such as discussion of cholesterol results and possible courses of action, or informing a patient about a new diagnosis of impaired fasting glucose. She can often discuss things with my patients over the phone, and she records the phone conversation in the clinical notes; if needed, she will book a patient in to see her. She sends the clinical notes to me for final sign-off when she is done, so I always know what happened.

I use pop-up messaging often as well (Real Popup). This is a small application that pops up in the right lower corner of a PC whenever someone in my office sends an instant message. The message is not part of the EMR. I use this to send a quick note to the front regarding follow-up appointments (example: Mr Smith: DM 3 months). The secretary sees the popup, and gives that patient an appointment marked as "DM", so that the patient automatically gets a weight and BP done when they return, before they are shown to a room. Some of my patients have wondered how the secretary knows what they will be asking for before they even speak! My resident often sends me a popup for a quick question while she is seeing a patient; she also uses this if she wants me to come in and double check something before I see the next patient.

The office environment I have described seems complex, but it works and actually makes the office much less stressful. There is no need to duplicate messages on notes, nothing gets lost, and everything is done. This improved communication is one of the biggest benefits of EMRs.

I have now gone back to signing my prescriptions on my Tablet. So far, I have only had one phone call from a pharmacist inquiring about this, and he was satisfied when informed that it was acceptable practice according to the College of Pharmacists. I think we have progress.

Michelle