Paper chase

We have started to scan and destroy old charts. My secretary said that she just can't believe how much paper we have accumulated over the years, all stored in different locations in the office (current charts, charts of patients not seen for over 2 years, deceased, transferred, part 2 of a large chart, seen offsite at the senior's clinic, piled up for pending consult request, or just plain sitting on the doctor's desk). The time and space taken to manage this is huge.

On Tuesday, we scanned the first paper charts to pdf, had a look at several scanned files to make sure they were good, and tested the back-up. We've also been shredding, but I may send some of that to a commercial shredder. We're putting out five large bags daily; my small office has enough shredded paper to confetti at least one medium size parade. It was very strange to see a filing shelf without the usual collection of crammed, dog-eared files.

I saw a new patient yesterday, and he gave me a copy of his old chart (on paper). Eventually, we'll be able to transfer a chart electronically , but I can't imagine this will come anytime soon. I will review his chart, enter the relevant information in my electronic CPP, and the paper will be scanned to pdf just like the rest of the old charts.

The pop up alerts in the EMR came in handy yesterday. I had seen a patient for a check-up; a recent guideline recommends an ultrasound for men between 65 and 75 who have ever smoked, to rule out an abdominal aortic aneurysm. I saw that on my preventive checklist, when signing off the electronic record (but he was already gone), and put in an alert. The patient returned yesterday, the alert popped up when I opened the chart, and he was sent for his ultrasound. I also saw a patient with Hepatitis C; vaccination against hep A and B is recommended, and public health supplies the vaccine for free. When entering her CPP, I had noticed that she had not been tested for A or B antibodies, and put in an alert for myself to do so. She came in yesterday for another reason, and was tested. I should probably run an audit for Hep C when I'm finished with all the CPPs.

I will be away on vacation at the end of August. I will need to figure out how to let my practice partner (who is paper based) look after my patients. We can print the CPPs for him, scan his clinical notes to the chart, and have him review faxes/mail on paper before scanning. I will show him how to find things in the chart as well, and my staff can help. I do not know how he will handle incoming electronic lab results (I will ask), and I don't think he can print consultation requests from the EMR; we'll have to scan those in. Coverage in hybrid practices is more difficult. On the other hand, any of my colleagues in my FHN can have access to the full chart; perhaps, in the future, coverage will be via "virtual" groups like mine, where the physicians may not be all located in the same office, but can all access the information if needed.

Michelle

Organizing the CPP

I don't think we called the helpdesk at all this week. Things are definitely going more smoothly.

I am reviewing previously entered CPPs when I see patients, and correcting earlier mistakes. I am now systematically entering CPPs from my alphabetical list of rostered patients; I am about 30% done. I see about 10% of my patients without any paper charts being pulled at all; we are still often pulling charts that have been marked as "EMR".

There are different ways to organize a CPP. The way I've organized mine is:

1. current, ongoing health conditions (diabetes, asthma, hypertension etc). These are all coded in 3 digit ICD 9, for easy searchability
2. allergies (drug, non drug); coded from the drug reference software
   
3. social history (smoking, alcohol, marital status etc)
4. family history; all coded in 3 digit ICD 9
5. past medical history. This is free text, and thus not easily searchable, but easy to enter. It contains previous operations; previous limited medical problems (eg, gastritis); previous antibody results (rubella Ab, varicella status, hep A/B Ab); date of last previous screening tests (pap, mammo, DXA, FOB); date of last full check up
6. procedures (structured), with date and result: gastroscopies, colonoscopies, hysterectomies, previous breast cancer. The last 3 are to help me with preventive audits, the gastroscopy is because I can never find it in the paper chart
7. immunizations
8. alerts
9. labs (entered directly via a button in the electronic lab result, eg: pap, FOB, Hep B Ab, others). The free text Past Medical History area is only for old paps and FOBs. All new ones go in the CPP lab area.
   
10. flowsheets
11. Framingham cardiac risk score
12. referrals (entered directly from the EMR referral)
    

I have been told that my templates can be put on the general server; I will ask Nightingale to transfer the preventive health templates, the sore throat score, the small smoking cessation template, and the Ottawa ankle and knee rules.

On Tuesday, we start scanning all the old charts. Happy Canada day, everyone!

Michelle

At the three month mark

It was an interesting week. It started very badly, and ended well.

On Monday morning, I came to the office to find out that there was no internet access at all. SSHA had upgraded their system over the week-end, and it all crashed on Monday. Luckily, I have a back-up internet line. However, I found out that it does not work with the SSHA router (the SOFA, Small Office Firewall Appliance). No dice. I will need to get a separate router, and will have to access the server via the SSHA VPN (virtual Private Network). I seem to be learning to talk computer. We don't have the SSHA VPN yet, and were told that there are still technical problems holding it up at the hospital server; they are working on it.

It is worthwhile making sure the back-up systems work; that is good to say in theory, but in practice I have been so busy managing the EMR start-up that there just wasn't time for that. I think I'll do it now, though.

We went back to paper for the morning, just like the previous time. Patients were very understanding (we couldn't book appointments, test results were not available etc). I think pretty much everyone has experienced computer problems at some point in time. We were back on-line in early afternoon.

An SSHA analyst had a look at my line again, and contacted me. He said that it will be much better by today, as he will make sure it becomes faster. I phoned my secretary a couple of hours ago, and she said there was a noticeable difference.

I am just about at the three month mark. A couple of patients who have recurring appointments every three months came in this week, giving me a chance to look back at their chart to see what I did at the very beginning. I had to fix a couple of things, especially with medications (I put expiry dates on continuing meds, some of the dosages were odd etc). One of my diabetic patients told me that I had forgotten to do her annual foot exam and monofilament testing, so I did it now and put it in the EMR diabetic flow sheet. My quality of care went down at the beginning, because I was figuring out all these new things; I also think you can expect to have less than perfect records as you learn.

I am now having more good days than bad (except for Monday). Practice flow seems to have stabilized, and efficiency is back to normal, but not yet better. It seems to me that the first three months are the hardest, as everything has to change at once. I probably should have booked more lightly for a bit longer. This is not something to do in the middle of flu shot season!

I am now entering CPPs much more quickly; I am pulling charts in alphabetical order at lunch, and after the office. I'm about 25% done. I figured that I could do my pap, children's vaccination, and mammogram audits at the same time, since I'm looking at all the charts anyways. I found a button on the EMR chart summary that reminds me to do a pap or mammogram. When I hit the button, I can enter the date of the last pap or mammo; then the alert does not pop up again for two years. At the same time, I also started using the area that generates reminder letters for patients who are overdue, and have sent out several letters (pretty easy to do, 1 click for the letter, then 1 click to print). Once I record the date of the pap/mammo on the summary button, the patient's name disappears from my overdue list, and I don't generate a letter.

As we continue to use the system, sometimes we would like to have things added. For example, when my secretary makes an appointments with a specialist, she now enters the date in the application, so we can keep track of this. However, there is no area to record the time of the appointment. I emailed Nightingale, and received a reply that they will put this on their list of enhancement requests. That's how programming changes happen: if there is something you need or would like, you send a request to the company, and if enough people ask for it, it gets programmed for the next upgrade. I think the process must be fairly similar for other vendors.

A family came in, and mom asked me to look at her son (who did not have an appointment). It was very easy to just pull up the file on my Tablet (and quickly make sure he was up to date on his vaccinations). That's a definite improvement over paper.

In summary, the first three months are probably the most disruptive, because of all the changes. Try to plan for change where you can, and take the time to solve problems as they happen. If possible, book lightly, and do it during a quieter time at the office. Expect delays with various things, like lab, VPN etc. Talk with your staff a lot, it is just as challenging for them as it is for you. Doing it as a group is a good idea, because you can talk to your colleagues when problems happen (or just for moral support), you can split various tasks, and you can share ideas. Use the helpdesk often, that's what they're there for; encourage your staff to use them as well. There will be extra stress, so take a bit of a vacation in the middle if possible. Above all, don't let the inevitable problems and difficulties discourage you; the ladders do outweigh the snakes.

I think I'm now at the end of the beginning for this project. On to the second half of the transition period.

Michelle

Handling scanned documents

Last week was very good. Everything worked, and I even entered all the CPPs ahead of time for two days. I was completely paperless those days, which gave me a taste of what my office will be like in three to four months. I like it.

I got a call from someone who works in technical services at SSHA. He said that the inconsistent speed was because the wiring in my area is very old; we have copper wires. They are working with Bell to try to improve this, and may be able to give me some work-arounds.

A colleague was asking me about how scanned documents are handled in the EMR, so I will give a brief overview here. There are two types of scanned documents:

1. the old chart
2. new incoming documents (Diagnostic imaging reports, consult letters etc)

1. It is not useful to have the old chart scanned as part of the EMR. You would have to classify each piece of it (is this report filed as DI? Is this a consult letter? etc) which is very time consuming. What we will be doing over the summer is scanning each old chart as a single pdf document (the scanner does 25 pages per minute, or 50 pages if you scan both front and back). Each scanned chart will get a file name (last name, first name). Those charts will be then be saved to an external hard drive, which will be attached to one of my computers and shared across the network. If security is a concern, you can assign a password to the files. I will also back up the whole thing to a DVD, which will be kept offsite.

You can load the pdf file from the network if you need to look at the old chart; also, pdf files are searchable.

For files of deceased/transferred patients, there is no need to keep them on the network, because I will not need to look at them. They will be put on a DVD (locked away at the office), with a copy on a second DVD, kept offsite. DVDs cost about $1 each.

I have hired a student to do my scanning this summer. The reason to scan the old charts is that then the paper is gone forever from your office, and the cost of ongoing storage is zero; also, with a back-up to DVD, you can never lose your charts to an office fire.

2. All new incoming paper/fax documents are scanned to the EMR. They can be classified in the chart as DI, consult notes, lab, ER notes etc. My filing clerk does this when she scans and uploads documents. She also adds extra information, such as the name of the specialist, or the type of DI. When I look at the file, I may put in a comment, for example "XR normal". Then I have a good overall summary of all DIs for this patient in a single area of the chart.

Loading the scanned document so you can look at it takes time; I try to put the useful information in my comments area so I don't need to bring up the whole document. This is usually very brief (example, for a derm consult: Dx acne rosacea, Rx metrogel). If I need to copy a bigger piece of the report for the comments, then I use OCR (optical character recognition). There are various ways to do OCR; what I do is send the scanned report to Microsoft Document Imaging (file, print, MS Document Imaging), then I hit the OCR button, then copy and paste to comments.

I also had to decide what to do with various pieces of paper that can't be efficiently scanned to the EMR, for example, ongoing allergy shot records, or 2 step TB tests (4 visits) for hospital volunteers. The allergy records are now kept in the box with the allergy serum, and not with the chart. I will scan that in when the allergy series for that year is completed. For the 2 step TB, I give the form back to the patient; it is their responsibility to bring it back each time they come in. We scan the report when it is completely filled in.

Michelle

Plugging away

I spoke with the pharmacist across the road from my office. He gets inspected periodically; if the inspector sees a script signed electronically, that can lead to trouble for him. At the College of Physicians and Surgeons, they told me that this policy comes from the College of Pharmacists. This is not something I can change for now, nor do I want to cause problems for pharmacists. I am now printing and signing my prescriptions in blue pen.

My lab and my EMR company have been talking with each other; the pap requisitions will be reprogrammed soon so that they conform to the Ontario Laboratory Accreditation program. It looks like that problem is about to be solved through cooperation, which is good to see.

I have found access speed to be inconsistent. Sometimes it is OK, and at times, it feels like data is coming through an eyedropper. The government told us they can upgrade our internet lines, so I applied for an upgrade. I received a new line, and a new modem, which the people from SSHA installed. However, I had to connect this to my network myself, and I had no idea how to do this. Trying to connect wires by myself did not work. It took the better part of an hour last Thursday morning, on the phone with the SSHA helpdesk, to figure out what to do (something to do with IP config). Then all my printers went off line; this did not get fixed until late afternoon. The new line is not faster, but I understand that they are working on this.

These are complex systems, and problems will happen; I sometimes miss the simplicity of paper. I still think EMR is the way to go, but I was not happy that day.

I found out that if I print a handout from an internet site accessed within the EMR, this is tracked in the patient encounter. I like that; I print a lot of handouts (from my own website, from the College of family physicians of Canada, from the AAFP website). Now I can see in the record that I gave the patient a handout. I can also see if I generated a cytology req; pretty soon, I'll have the rest of the reqs as well. I've also started printing some XR requisitions. I am beginning to see how this can capture and track a large part of my process of care. I don't know if it will make those processes better, but at least I'll have a chance to look at what I am doing.

I have been talking with a colleague about joining us; she is thinking about starting a new practice. If this works out, she will start paperless from day 1. I have a student coming in two weeks to start scanning all my old charts, which we will then shred. This will free up space, allowing us to take on an extra physician (but only a paperless one).

Michelle

Interacting with others in the health care system

The lab called me to ask why I was sending these non-standard pap requisitions. I am continuing to send the computer-generated reqs, with the data circled in red, and a note asking them to please accept this paper. They said that the size of the paper is different, and it is also a different thickness, so this will present filing and tracking problems for them; also, the technologists are not used to seeing the data presented in this way.

We had a nice conversation. I explained that having the pap reqs printed from my computer avoids mislabeling with the wrong patient info (it is done right from the patient encounter, no sending to the front for a label). The pap is tracked from my system, so I can make sure I receive it. As well, I use the tracking for my preventive bonuses (I get a bonus if 80% of women age 35 to 69 in my practice have had a pap in the last two years - pay for quality).

I think the lab will start to see a lot more computer-generated requisitions; it might be good to start planning for it now, while it is just a trickle. They seemed receptive to that argument, so we'll see what happens.

I received an email from a patient, commenting on the fact that the pharmacist told her he'd have to call my office regarding the prescription I signed on the Tablet. We had talked about it at the office, and she thought it was silly as well. Maybe I'll email my College representative to see if he can help; if introducing EMRs is deemed to be important for patient care (as Canada Health Infoway says), then our regulatory agencies can do their part to help.

I have been thinking about coding my diagnoses. If I want to do audits in my practice, I have to enter diagnoses consistently. I can't call a UTI a bladder infection one day, and cystitis the next. Right now, I am entering diagnoses as 3 digit ICD 9 codes. We send bills to the government using the ICD9 codes for diagnosis, so at least I know some of the numbers. I know that Health Infoway is thinking about having everyone use SNOMED, so that different computers (hospitals, home care, physicians) can share data, but there is no way I can learn and use this in practice. It's just too busy. Maybe there is some way they can translate ICD9 into SNOMED.

I am using a flow sheet to track depression. It was surprisingly easy to program. I enter the PHQ9 score, the Quality of Life score from the bottom of the PHQ9, the meds, and comments. I have an alert on the EMR asking my staff to print and give the questionnaire to my patient to fill in the waiting room, so I get the result right away. I referred a patient who had been on several antidepressants (with no change in the score) to the psych intake program at my hospital, along with a printout of the flowsheet. I think this will give the consultant an organized summary of what happened.

I will be taking on a family medicine resident for the first time, starting this July. She will be working with me and my practice partner, and so will see both an electronic and a paper-chart practice. She'll also see the transition to EMR; I think it will be interesting for her.

Michelle

Less chart pulls

Once I have put the Cumulative Patient Profile into the EMR, I mark the front of the chart with a red line. This week, we decided to stop pulling red-lined charts.

We had to figure out how to mark the fact that a patient is in the exam room, since there is no chart on the door. On my scheduler, there is a drop down list beside the patient's name, where you can note that the patient has checked in, is a no show, etc. We added two more items to the list: "room 1", and "room 2". When the patient checks in, the scheduler automatically says "in" once their card has been swiped. When the patient is put in one of my exam rooms, my staff puts "room 1" or "room 2" on the scheduler, and I can see it in my EMR. For now, I put a sticky note with "1" or "2" on the door, but I'm going to buy more professional looking numbers.

I've made templates for the Ottawa knee rule and the Ottawa ankle rule. I don't see why these evidence-based rules can't be incorporated directly into the record; having templates makes it easy. I'm going to make a template for the Wells DVT rule. I've also made a template for the "5 A's" approach to quit smoking (ask, advise, assess, assist, arrange), with a drop down list for the stage of change the patient is at. This is the approach recommended by our Clinical Tobacco Intervention program, and there is a new fee code for doing this. I try to do it anyways, but now I can document it easily as well; I put a note on the template to remind me to bill the new smoking cessation code.

Three pap smears with electronic requisitions came back today from my lab because the requisition was non standard. I sent an email to the lab's IT manager asking him to please send a memo saying that electronically printed reqs are OK. The data on the reqs is the same. I like doing electronic reqs better, because it shows that a pap was done right in the patient record, and I can also track the pap to make sure it comes back. I don't want to go back to paper reqs.

Michelle

At the two month mark

It has now been two months since I started using the EMR.

I am prescribing all drugs on the computer, and recording all encounters electronically. I now have electronic labs coming in regularly. I am writing all my consultation requests on the EMR. I am becoming increasingly comfortable and confident navigating the electronic chart.

The initial hardware hassles have been solved. My networked printers are working well, and my wireless network seems robust. I use the Tablet all the time, and turning the screen around as needed seems very natural. I put the Tablet in the docking station regularly at lunch to allow it to recharge; it has enough power to last a half day without problems, but not a whole day. I bought a laptop lock to attach the docking station to my desk, and can leave the Tablet securely docked if I go out for lunch.

I am using templates and flow sheets regularly, and have programmed several on my own. I am starting to use computerized forms for pap smears, and will try lab forms when they become available next month.

We are using clinical messaging regularly, and my staff is now very proficient at this. They are calling people regularly to inform them about some of the abnormal lab results. They are also becoming proficient at finding out where things are in the EMR. New office processes, such as scanning, are becoming smoother and more routine.

I have become more efficient at letting the helpdesk know when there is a problem. I have a "dummy patient" file to practice on. When there is a problem I can take a screen shot, using the "print screen" button; I copy this to a word file, and email helpdesk the picture. They can see what the issue is, and can often fix it without a phone call.

On the negative side, writing Cumulative Patient Profiles is not going as quickly as I would like. I find it tedious, and am probably avoiding doing it (especially when tired). I am now running a hybrid system, so I don't always know where things are (is that lab result in the EMR or the paper chart?). We leave the paper chart on a plastic sleeve on the exam room door when a patient is in, and I now sometimes forget to take it. I will have to figure out a way to indicate that a patient is in the room without the "chart on the door sign" once we are completely paperless.

Prescriptions continue to be an issue, as I am still getting random faxes from pharmacies letting me know that my Tablet signature is not acceptable. I have a stamp with my signature, and my staff stamps the script and faxes it back. This just seems silly.

My practice is diverging from my partner's; we will have to figure out what to do for holiday coverage. I think he is annoyed at times with all the disruption. We will be getting a family medicine resident in our practice for the first time, starting in July; it will be interesting for her to see both a paper and an EMR-based practice.

I am still going home later than usual. Since most patients do not have all their meds in the EMR yet, I am not yet reaping the benefits of rapid refills. Remote access through SSHA has not been established yet, although they are working on it. It will help once we have that.

Michelle

Electronic and paper charts

My electronic charts look different from my paper charts. I think of the paper chart as a book, and the electronic chart as an internet document: paper is linear, while EMR is hyperlinked and searchable. For example, I am always looking at what a patient weighed at their previous check-up, to see if there are any changes. Finding this fairly simple bit of data in a paper chart means flipping through several pages; finding it in the electronic chart means clicking on a link. Paper just does not work very well, because you are trying to track too many disparate bits of data; every chart is a daVinci Code.

I can see how my charts are beginning to get organized. Incoming data from the outside is separated into different areas: scanned labs (EKGs, Pulmonary Function Tests), Diagnostic Imaging reports, consult letters, other correspondence. This is the equivalent of having paper charts with tabbed separators for each section; we never did it for my charts, but it is possible to do this. Electronic lab results are hyperlinked and searchable, and automatically go into the flow sheets I made up; you can't do that in paper charts.

Electronic labs bring up an interesting problem. If my practice partner (who is not using EMR) sees one of my patients while I am away, and orders a lab test under his name, I will not get electronic results. We'll have to manually scan the results into the chart and those will not be linked. I think what I will do is ask him to cc me on the requisition; then he will get a paper copy and I will get an electronic one.

I am going to have similar problems for patients co-managed with specialists, and will likely have to scan results that are not copied to me on the req, or that are not done at one of the 3 electronic lab companies. This will be a problem for diabetes care, because my flow sheets are lab-specific (I guess the lab companies must use each use their own software). As well, my vitals (weight, BMI, BP) are hyperlinked to the flow sheets, and these measures cannot come in electronically from a visit to a specialist. I do not co-manage many diabetics with specialists, because it just introduces more complexity into an already complex problem; this is about to get worse.

This lack of ability to share the chart electronically with specialists will not matter for one-off consultations, such as a referral for gall-bladder surgery. It will matter for longer term shared care. I will have to think about when shared care makes a difference: likely this is for problems I do not see very often, with very complex management issues (MS, rheumathoid arthritis), and not for common problems with clear guidelines (Type II DM, asthma, COPD). My hospital's Diabetes Education Centre is very interested in sharing a piece of the electronic chart; maybe what is going to happen is that part of the primary care chart will be shared with chronic disease programs (diabetes, congestive heart failure, asthma), rather than with an individual specialist.

I did my first electronic chart search last week. The government recently introduced new fees for maintaining a flow sheet for diabetics. I ran a search for all diabetics in my practice; it took less tan 10 minutes to do. I printed the list and gave it to my secretary so she could bill the new code for all those patients. I can see that maintaining a register of patients with chronic conditions is not going to be that difficult with EMR; however, I have to make sure that I enter the condition in the chart consistently. I wonder if there will be more pay-for-quality incentives; EMRs will definitely be useful there.

Michelle

Flow sheets and lab requisitions

We had a "booster" session at the company last Friday, where we could go over things and ask questions. I wasn't sure how to start my flow sheets, and found out how. It's always a problem setting up new things, but once it is done it becomes routine.

I now have a flow sheet for my INRs; the lab test automatically goes into the sheet, and I have a blank area to enter dosage changes and timing to repeat the blood test. This is accessible both from the clinical area and from the demographic area so my staff can see it. I was keeping paper INR flow sheets on the back of the charts, and some of my colleagues use binders where they keep all INR flow sheets for easy reference. This electronic version replaces both; once we have VPN established, I'll be able to do it remotely.

I have been sending electronic messages about labs to my staff; for example, if a blood sugar comes back slightly abnormal (between 6 and 7--a pretty common occurrence), I'll notify my staff. There is a button on the lab report that I use, and they may get a message such as "fasting sugar 6.3, pls let pt know. N is <6,>7. Repeat FBS; req left at front". The electronic INR flow sheet now makes it possible for me to do the same for coumadin dosage. I have 15 patients on coumadin. All of them now have an electronic flow sheet, with the last coumadin dosage entered in. Thyroid dosage is managed electronically as well; if the TSH is our of range, I send a note from the lab result, and I print a synthroid prescription at the front to fax to pharmacy or mail to the patient (along with a lab req for repeat TSH).

I also made up a diabetes flow sheet, with all the required lab tests, vitals (weight, BMI, waist circumference, Blood pressure), and areas to fill in for eye tests, flu vaccines and foot tests. Most of the information (lab, vitals) gets entered automatically from the chart, so I don't have to do duplicate entries anymore.

I did my first electronic pap smear requisition today. Maybe I should send that to the front printer as well, since it is handled at the front.

I sign prescriptions and lab requisitions on the Tablet screen. That allows me to send them to any office printer. Today we had our first "signature" complaint from a pharmacy: they told us that they would not accept an electronic signature. This was not for a narcotic (it was for synthroid and blood pressure meds). We asked them to fax it over, I signed it in pen below my electronic signature and faxed it back; the two signatures are not distinguishable. This must stem for a College policy, and really does not make sense to me. It is probably time for a policy update.

Michelle

Power failure

This Monday morning, there was a power outage at the regional hospital where our server is located. The hospital's computers all shut down, and so did ours. We have a UPS (a back-up battery that the computer is connected to), but I guess it doesn't power the server for that long. We had no EMR for 2.5 hours.

My secretary could not book appointments; I had no electronic charts. I still have the CPP on paper, and will continue to have this (although not updated) once the charts are scanned into pdf. What I did was write notes on paper for later scanning or transcription into the EMR. Long notes were scanned; brief notes were transcribed. I had to write 7 prescriptions for one patient by hand, which was beyond tedious; it is amazing how fast you get used to EMR prescribing. I think if this happens again, we'll do the same thing; I will probably not write multiple repeat scripts, but will tell the patient we'll print and mail to them/fax to their pharmacy once the power is back on. I will not have access to lab reports/DI reports/CPPs; it will feel like walk-in work, where there is no access to patient information.

Physicians in my group were very upset with this, and we had emails flying back and forth. It can be challenging for the IT lead to maintain enthusiasm for EMRs in the face of the inevitable problems and delays. Starting an EMR is a bit like being pregnant: you get nausea and swollen ankles first, and the good part doesn't come until much later. EMR transition is easier for some than others: I told one of my colleagues that I was having a normal vaginal delivery, while he was having a difficult C/section.

I wrote a template for the sore throat score. Notes in the EMR look very complete due to templates: you can dump a lot of information into the record very quickly. On paper, the default clinical record is that nothing was done; on an EMR template, the default can be that everything was done. For example, my preventive services template shows that all services were provided; if I am not careful, and do not uncheck what I did not do, the record shows I did everything. Peer reviews of charts for the provincial colleges may look very different on EMR.

I had a look at my list of favourite drugs. It has now been just over a month that I have been prescribing electronically, and the prescription counter just went over 400 (multiple drugs prescribed at the same time count as a single prescription). The medication Favourites likely represent a pretty good overview of my internal formulary. I have no clear idea of why I favour some particular drug in a class; I wonder if I should review this. I wonder if it will be more difficult for drug reps to influence doctors using EMR, since prescribing a drug on the current "favourites" is easier than entering a new drug (all the information is pre-written and fills by itself after a few keystrokes).

I entered a link to Canada411, my College's physician look-up, and Canada Postal code finder on the new quick link icon provided in the EMR. That will help my staff find the information from within the program.

Michelle

Reducing paper

I've found an area in the EMR where you can monitor your patients' preventive health automatically. It tracks things like pap smears or mammograms, and gives you a list of patients who are overdue. You can then write a letter to all patients who should have the service. I am still not sure how that works, but I'll have to find out.

I've now done about 100 Cumulative Patient Profiles; I've started to pull files from my cabinets alphabetically. I want to be completely switched over to the EMR by September, before I get busy with flu shot season. I've made plans to scan and transfer all my paper files to pdf format over the summer; I'll put those on a shared drive on my office network, so I can access them when I need to look up a record pre-dating the EMR. I'll get a reputable shredding company to take the paper files.

Nightingale is installing the upgraded software on our server Tuesday night. This includes the ability to do flow sheets integrated into the CPP. This will be very useful for things like INRs: the lab result will be placed right into the flow sheet, as will the dates and comments on dosage. I'll also program a flow sheet for diabetes management, with things like A1C, cholesterol profiles, weight, automatically updated on the flow sheet. We will also getting the ability to print lab requisitions from the EMR in about a month (since the government changed the lab reqs recently), which will help track missing results. Interestingly, the company also said that we will be able to generate bar codes, so perhaps that is coming for lab samples.

I still have to deal with paper forms. Some institutions are very wedded to their paper requisitions; I have to send a specific paper to order hemochromatosis genetic testing, or Tay-Sach's screening, or cardiac rehab. Government is very picky about forms as well (a form to order an eye exam, a form for coverage of certain drugs etc). These can't be printed from the EMR. What I've done is stamped the form with my name and address, and scanned them into a shared drive on my network. Now I no longer have to search for these forms, as they are alphabetically ordered, and accessible from my computer's desktop.

I've started faxing some simple referral letters (for example, dermatology) from the EMR. If the specialist accepts a fax and allows the patient to call directly, I "print to fax", and the fax gets sent straight from EMR. I'm hoping to be able to communicate electronically with specialist colleagues in the future. The referral process itself is needlessly complicated (each specialist sets their own rules on referral, there is limited to no information on waiting time per specialist, sometimes they do not see certain problems and we don't know that); perhaps, with better communication, this can be improved. There is no reason why a program can't keep track of each specialist's waiting time, and why a referral can't be made to a program instead of to a particular physician for most problems. There will be exceptions, but this would be much better than the current disjointed, fragmented, paper-based process. The program coordinator would make the appointment, and inform the patient of the address, time and date (perhaps electronically), with a copy sent to us (also electronically, straight to the EMR). Of course, this is a pipe dream.

Michelle

Templates and handouts

We got rid of the old computer; we no longer need our previous billing/scheduling program, and the PC was just taking up space. I took the hard drive out, and smashed it with a hammer.

I found out that most of the templates that I have been using were programmed by my colleague, Dr. Scot Mountain. Likely all EMR software companies have repositories of useful templates; I wonder if there is a way to share them across platforms--likely not, which is too bad. I used pieces of Dr. Mountain's template to complete a template for the initial full physical: I programmed the preventive health tables that I use (based on the US and Canadian Task Force's A and B recommendation for prevention), and added the physical exam that was already programmed. You end up with a very full assessment that loads with just a few clicks. I'll use that for a while and then share with my colleagues in my Family Health Network if I see it works well. I'll do templates for follow up preventive health exams.

I also programmed a handout based on the PHQ-9 for depression. This is a questionnaire based on the DSM IV depression symptoms; the patient fills it out, and the score is very useful for tracking remission. One of the problems I have with it is that the patient often fills it out at the end of the visit, but I need the score to see how they are doing at the beginning of the visit. What I did is I put the PHQ9 as a handout in the EMR. When I finished seeing one of my patients, I put an alert on her electronic chart to print and give her the questionnaire to fill out in the waiting room next time she comes in. We'll see if that works.

We had a meeting for the physicians in my FHN yesterday. Not everyone has switched to EMR yet; most people are quite a bit more tentative than I am. Several of us are now prescribing electronically, and some have started completing CPPs. We were told that the VPN for remote access should come in sometimes this month. We talked about the glitches that we had been experiencing (especially scanning), and about how to share templates. What I think we may do is go back for a booster educational session in a few months.

Nightingale sent us a note about enhancements. We will be getting the ability to link to educational sites directly from the application. I think that's very useful; I often look up formulary drugs at the Ministry of Health's website, and I use the OntarioMD site as well. I use their eCPS drug look-up (much faster than using the large blue book to look up drugs), and some of their resources, such as the Stat-ref textbooks. I had a patient with febrile neutropenia on Monday, and having Stat-ref there helped me to know what to do. I wonder if I am allowed to copy some of the content and paste in the CPP of patients with rare conditions so I know what to do when I load the chart.

I worry a bit about linking from the EMR to commercial sites, because I know some of those collect information about me via cookies and other things (it says so right there on their privacy policy). Getting information about physician's prescribing habits is a valuable thing for pharmaceutical companies, and I don't know what the potential for web-based programs to access what I am prescribing at the point of care is. I am going to be very selective about the sites I link to.

Michelle

Looking back at the first month

It is now four weeks since I switched over to EMR. For the past week, I have felt very comfortable using the Tablet routinely for everything; the EMR is now becoming an integrated part of my practice. What works for me is carrying the computer around in Tablet mode, and opening it as a laptop in the exam room. I like typing better than writing, and I don't see why I should store my bad handwriting in the computer. I type during part of the patient encounter as I am listening to my patients. Some of my clinical notes are starting to get completed during or right after the encounter, and I plan to get more of them done that way.

One of my colleagues said that his notes became much better once he switched to EMR: the usual scribbled information looked very scanty when typed, so notes became much more complete. Templates can also put a lot of information in the record very quickly.

What happens during the encounter is that I start typing in the clinical notes section. If there is a problem that needs a template (for example, a cold), then I load and fill the template. Other issues continue being written in the clinical notes section. It splits up the subjective/objective part into several sections, but seems to work.

I've made a template for my abdominal examination (Abdomen soft, bowel sounds normal, no hepato/splenomegaly, no masses, no tenderness). If there is something abnormal, I just uncheck the check box and write comments. Templates are really good for automating things that you do over and over again, and for documenting groups of normal findings.

The ability to look at sequential results for electronic labs is interesting. I had a patient with a mild anemia, who had another blood count done two weeks later. I clicked on the check box beside her hemoglobin, then clicked on the tab for "tabular results", and showed her that her hemoglobin was 107 two weeks ago, and 112 two days ago. This is much better than leafing through paper lab results. The software also does graphs; you click on the "graph" button. This is very useful for on-going conditions, such as A1C's for diabetics, or INRs.

I had a look at the scanner that I bought. It can scan documents into Adobe Acrobat pdf format. It also can do "duplex" scanning, which means that it takes a picture of the front and the back of a page at the same time. You can put 50 pages in the automatic document feeder, and it scans 25 pages a minute (or 50 pages if you do front and back at the same time). I tried that for some of my clinical notes, and the pictures are really clear and sharp. This is very interesting, because it means that archiving charts of my transferred or deceased patients is not going to be all that difficult or take all that long. I will get the clinical notes scanned in duplex, and the lab forms/consult letters in simplex (one side of the paper only). We'll call the files something like Doe, Jane clinical notes, and Doe, Jane labs; I'll hire a student in the summer to do this. I'll put the files on CD ROM disks, and keep two copies, one locked at the office, and one locked offsite. You can search for things easily within pdf documents, so this is useful for data retrieval. If this works well, then I'll scan and archive paper charts of active patients, once I've fully transferred to EMR. Maybe I can then sell my filing cabinets on eBay. I wonder what I'll do with all that freed office space.

Michelle

Scanning and working with electronic faxes

We are still having difficulties with electronic faxes. The faxes come into a fax folder on the computer; they get transferred to the scanning software on the desktop. The filing clerk then has a look at them on the scanning console, files them electronically (both under the patient's name, and as a category--diagnostic imaging, consultation note etc), and uploads the report to the EMR.

At least that is what is supposed to happen. We're not quite sure where the faxes actually go; sometimes faxes stay in the fax folder, and sometimes they appear both in the fax folder and in the scanning console software. I found reports for several patients attached to a single patient this morning, so this was uploaded incorrectly. Clearly, the software is problematic and we're having trouble with this process.

Our IT lead has talked to the company, and they told us that a software fix is on the way. As well, I have to minimize the risk of misfiles from scans or faxes. If something is electronically misfiled, it is going to be very hard to trace.

What we decided to do is to print all faxes for now. I will look at them without chart pulls, to make sure that I've personally seen them, and will initial them. We have a "to scan" box, where I will then put the printed faxes. Once scanned, the print will be put into a "pending shred" box. I'll have a look at that box every few days, and if I'm satisfied that I've seen the report electronically and that it is OK, then I'll transfer to the "ready to shred" box. Then and only then will they be shredded.

We found that it is too difficult for my secretary to scan and upload while answering the phones and doing several other things; that is likely to lead to misfiling. What we decided is to leave scanning for the filing clerk, who will do nothing but take care of scans and electronic faxes when she first comes in in the afternoon. I can see that it will be difficult for the clerk to decide what is "DI", what is "cytopathology", etc, so she can allocate the scans properly. I will spend some time reviewing that with her, and explaining it. If that is done properly, it will be easier for me to find things in the electronic chart's sections, but this will not happen by itself. For scans, like for faxes, I told her to put everything that she has scanned into the "pending shred" box; it will only be shredded once I've reviewed it and transferred it to the shred box.

Sometimes patients have documents that need to be copied to the chart, with the original returned to the patient right away. I thought that this could be scanned, but the problem is the scan has to be filed, which is hard to do if my secretary is very busy. What she will do is just photocopy the document, and put the copy in the "to scan" box for later scanning. If, however, it is quiet(er), then my secretary will scan and file it on the spot.

This whole decision process happened this morning, during Monday morning madness (phones ringing incessantly, patients checking in and out). Sometimes you really do have to solve problems on the spot.

I expect the whole fax/scan issue to settle down eventually; however, I want back-up systems until I'm sure we've got the whole thing right. You have to figure out how to minimize the possibility of errors while all your office processes are changing--not that easy to do on a Monday morning.

Michelle

Electronic lab results

My lab results came in electronically today. When I looked at my practice summary page this afternoon, there was a message saying that 147 labs were waiting for my review. The lab system sends the reports directly to the patient's chart. They also automatically flag abnormal results.

When I clicked the link to the lab results, all the results were there in two lists: abnormal (alphabetically by patient last name), and normal (same). The lab sent me all my results since March 23rd, which is why there were so many. To access each lab report, I clicked on the patient's name in the list, and the report came up, with abnormal tests highlighted. There is a section where you can make comments (I just put a "N" if the abnormality was irrelevant). You can print the whole report, or a subsection to give to the patient. You can also forward a note to your staff (for example, call the patient to let her know that the results were normal). When done, one click files the lab into the electronic chart.

Reviewing all these results and filing them electronically took me about 20 minutes (I'd already seen them before). My secretary would not have been happy if she had to pull 147 charts, put the results on the front, and then file the charts away again. I told my staff not to pull charts for lab results anymore, starting tomorrow. They will just give me the paper lab results unfiled; I want to make sure that there are no problems with the electronic results. If the two match, then the paper reports will be shredded. In a little while, I'll ask the lab not to send me paper reports anymore. The system checks for results every two hours; I'll have faster updates than through the current courier system.

I now have several patients who do not have any paper charts. Some are new patients; all new patients have electronic charts only. One new patient transferred from another practice with a bulky old paper chart; we scanned a couple of recent results and relevant consultations into the EMR. The rest went to the back room as a chart #2. Newborn babies do not have paper charts either: we scan the bit of paper we have, and the rest is electronic. The EMR generates percentiles for height, weight and head circumference automatically when I enter the numbers in, and the growth charts are also done automatically.

I'm getting more comfortable with doing some typing in the exam room. I'm a fairly good touch typist, so I can type while looking at and listening to patients.

I bought a docking station for the Tablet. I have a full keyboard and a mouse attached to the station; it also recharges the Tablet while it is docked. I leave it docked at lunch, and when I am finished seeing patients; I find that billing is much faster with the numeric keypad on a full keyboard.

My group is meeting on May 2nd. One of the things we will be discussing is remote access via VPN (see glossary); we don't have this yet, but it is supposed to happen sometimes in May.

Michelle

Having a bad day

Last Wednesday was a bad day. I could not look at my scanned documents (a phone call to helpdesk), then I had trouble accessing the server and finally could not access it at all (another call to helpdesk). The Passover Seder was that night and I had to leave on time; I was also short of patience and very irritated. My lab is still not coming in, and I will be sending off another email to the lab company to remind them to start sending electronic reports. Some scanned images are printing as landscape instead of portrait, with nicely elongated letters. My Tablet crashed.

I also got a phone call from a patient asking why her glyburide was changed to bid. Her pharmacist noticed and called her. It is very easy to choose "bid" from the drop down list instead of "od". This was for one of the first prescriptions I wrote, on March 23rd. I apologized, and explained why this happened. It is challenging for me to transfer every single prescription to the EMR, and I am now very paranoid and very careful about re-reading what I print. As I was talking to her, I updated the glyburide order on the chart; at least I know that I cannot make that mistake when I refill her medications.

I have to remind myself to expect problems, especially at start-up. Every time I install a new program on my home PC I have glitches, and EMRs are so much more complex. This is where having support really helps; if you don't have this, days like last Wednesday can turn from bad heartburn to major disaster. Most of the time, when I call the helpdesk, they can help me; sometimes they take my computer over remotely and fix the problem. I also get screenshots emailed to me, so I know what to do the next time. Sometimes the person at the helpdesk can't help me right away, and then I get a "ticket", which is a number that they use to track my query. I get an email or a phone call sometime later. The "ticket" seems to be for annoying but not critical problems.

Problem solving is also much easier if you are part of a group. Our IT lead is not shy about making her views known (you go girl), and I've just received an emailed copy of her communication about the landscape printing problem; it is the same at her office. We all have similar hardware and software, so you can see pretty quickly what is a local problem in one office and what is a software glitch that needs to be fixed for the whole group.

I survived; Thursday was a better day, and then I was off for the long week-end.

Michelle

Unbound medicine

I've been wireless for two days now, and using the EMR with patients. I had a look at what my colleague, Dr. Brookstone, said about using the EMR in the examination room, and adopted the recommendations. The pamphlet that Dr. Brookstone's site links to is worth looking at.

I start the patient file in the EMR before I go in the room; that way I can say hello to my patient instead of fiddling with the computer. I keep the computer in Tablet mode , so that it looks like a clipboard, and it gets carried in that way together with the paper chart. Before EMR, I did not take very many notes during the encounter (other than numbers, such as blood pressure, because I was likely to forget those). After EMR, this has not changed. I figured out how to enter numbers quickly in the vital signs area using the tablet pen; this replicates writing the number in the chart. I've shown several patients their data on the EMR by picking the tablet up and holding it like a clipboard. My patient sits on the examining table, and we look at it together. This works. One of my patients had come in for an asthma exacerbation last week, and I entered her new peak flow yesterday, and showed the two readings to her as a graph; I think it helped her to see that. She's buying a peak flow meter.

I asked several patients what they thought of this, and had rather positive comments. When I did not ask, no patient commented on the computer being present. When I am not using the tablet in the exam room, it lies on my desk just like a chart would.

I sometimes convert it to laptop mode, when I need the keyboard. This is typically to enter medications; typing is faster than entering with the pen. I tell my patients that it will take a bit longer than usual for me to write the script, as I am learning to use the new system. I expect that doing refills will be faster with pen entry, since you just need to click on the drug's checkbox and hit the "refill" button. I also use the laptop mode to quickly look up handouts and print them.

We used the scanner for the first time yesterday, and got stuck. We had forgotten one of the steps. Another call to the helpdesk; nothing ever works perfectly the first time, and you have to expect glitches. Today, it was no problem. We talked about when to scan, and decided that my filing clerk would take care of this. It is hard for a medical secretary to scan and upload in the middle of phone calls and greeting patients. We made an inbox where all the documents to be scanned and shredded are placed, to be done when the clerk comes in. The faxes are all coming in electronically as well; my clerk will also manage this: some will be printed (for my partner), some deleted (junk faxes), and some uploaded to the patient file.

When my IT trainer was in on Friday, I gave him my home laptop to configure for my office system. I was worried about dropping and breaking the Tablet, and being stuck without a computer. I bought a laptop lock, and am leaving the laptop turned on, beside the vaccine fridge. Now my staff have an extra data entry area, and I can unhook the laptop and use it in case I drop the Tablet. I also have medical students in from time to time, and that is going to be their computer.

I started using the EMR without patients for a week and a half, because my wireless was not set up. By the time I took it in the exam room, I was familiar with basic navigation, and had less problems with finding my way around while trying to listen to patients. This was due to serendipity, but it is not a bad way to do it. You have to be comfortable with excusing yourself from the room to load the encounter and write prescriptions, for a week or two.


Michelle

Looking back at the first week

I've finished my first week after switching to EMR. Since coming back from March break vacation 3 weeks ago, I've logged more hours than usual at the office, probably 1 to 2 additional hours every evening. One reason for this was the post-vacation backlog, but the EMR implementation has been a major factor. I am trying to customize the software to work best for my practice, I have been charting in the EMR, and I am trying to enter at least 2 or 3 Cumulative Patient Profiles every day. There is always the temptation to play with the software, which I've given into way too often.

This Thursday, much to my surprise, I finished at my usual time. My charts were all written up, all my phone calls and letters were done, and I got away 1 hour after seeing my last patient. I can't imagine that this is going to continue, but it was good to see that it was possible.

I'm starting to learn little tricks like using the tab key to switch between fields, instead of the mouse (tabbing is much quicker if you are using a keyboard). I've started to make a template for the preventive health exam.

There is an area in the software that keeps track of pending consultation requests. When I write a consultation request, the software asks me to put in a date to check for the report. I put in "one day" for one of the requests (this was just for a derm consult for acne, but I wanted to see what it looked like). If it is overdue, it is highlighted in red, and is very obvious. Once the report comes in, you can click on the "received" button, and it goes off your list. Most of my requests are for 3 months from the date sent, but I wonder if I should make this longer; I don't usually know what the specialist's waiting list is like. This "pending report" list may be a problem for me to manage; sometimes patients don't go, and I'll have to be very rigorous about taking pending requests off when the report comes in. I already have 19 requests on the list.

I heard from my regular lab. It looks like my lab reports will start to come in electronically next week. I also received a note from the Ministry of Health: it looks like they're finally giving up on the old style lab requisitions, which have carbon copies (bad for privacy protection), and have to be tractor-fed into a dot-matrix printer. The new lab requisitions are printed sheets; EMR software applications should be able to print them straight from a patient's chart, so that the physician's information and the patient's demographic data is automatically entered into the requisition. That will avoid having to print labels for requisitions. As well, I'll be able to track which lab tests are overdue, since the software will be able to match incoming lab with ordered lab. I may have some trouble with that; patients often don't go for tests, and I have large volumes of results. Wading through pending lab data may not be possible.

Today, we had two people from Nightingale in the office, to do the last parts of hardware and training. They installed and configured the scanner, and did some additional training on how to use it. It scans much faster than my photocopier copies. The scanned copy is kept on the computer, and can be filed electronically at any time; if a patient needs their paper back, my secretary will be able to scan quickly, let the patient leave, and upload to the chart later. I can see that, in the future, printing copies of the chart for transfers, legal reports or insurance reports will be much less of a hassle. I think I will still be somewhat selective about scanning old charts, because the scan is just a picture: it is not searchable. This is good for storage only, which is not very useful if you want to find something in a very large file. We do EKGs and PFTs in my office, and those will be scanned into the file; there is a comment field in the EMR, and I will enter comments electronically rather that writing them on the report, so that I do not have to load the whole picture to look at what I wrote.

Electronic faxing was also configured. All faxes will now come into a computer, so we can upload them directly into a patient's chart without having to scan. We can delete junk faxes without having to print them; we can send outgoing faxes either from the computer or from my fax machine.

I now have 3 patient charts that are electronic only. These are relatively new patients to my practice; we scanned the 2 or 3 papers that I have for them, and I entered the Cumulative Patient Profile directly into the EMR. I put an alert into the patient demographic area saying that the record is EMR only, so that my secretaries don't waste their time looking for a paper chart.

The wireless router is now installed and ready to go. On Monday, I start taking my Tablet into the exam room.

Michelle

eDay

Today was the day that I officially switch to EMR. I am definitely getting faster at entering clinical encounters, to the point that I may have tipped over to being faster on the computer. My staff is now entering all heights and weights in the EMR; I have figured out how to have the "vitals" template (which includes height, weight, BP, Heart rate, Peak Flow) pre-loaded into each clinical encounter, so accessing it from that area is a single click. Phone calls are recorded in the computer. I have been notified by one of the labs that they will now be sending me results electronically; however, that is not the lab that I use the most often, so electronic lab reporting is not happening yet.

We are all trying to figure out how to decrease paper as much as possible. The chart for the second patient I saw today could not be located; that is one thing that won't be happening any more.

I have more letter templates, such as a transfer of information request. I have the referral letter process down pat. I have now written over 100 prescriptions, and my "favourite drugs" list is getting to be very useful. It is interesting that the EMR software numbers my prescriptions sequentially, so I know how many scripts I write each week. I can see that I'll be able to search easily for drugs. I get a prescription profile each January from IMS, which is a company that buys information on physicians' prescriptions from pharmacies and resells this to pharmaceutical companies and others. Those IMS summaries never looked very accurate to me, but now, I'll know.

My staff has "read only" access to clinical data in the chart; a patient had lost a prescription and my secretary was able to access that for the pharmacist from the electronic chart. We are getting used to finding out where things are in the EMR.

I can see that I will need to start building templates for XR facilities that I use most often, so I can print XR requests from the computer. I am sure that most places will not mind if I don't use their forms--it is probably more important that the information is clear, complete and legible. My information and the patient's information will automatically be generated on the diagnostic imaging requisition, along with the CPP if needed. I'll get rid of all those paper pads.

I've been trying to figure out how to get information from my tablet as efficiently as from my Palm. The EMR does not have good clinical calculators or decision support (the only one I found is Framingham for heart disease prediction). I'll still need to use outside software for that. The PDA is really good for quick decision help (for example, Medrules) and quick calculations (like MedMath). I found something that I think will work for me at the CMA website, InfoRetriever. It is at www.cma.ca, click on the "clinical resources" tab, then "InfoPoems clinical tools" on the tab on the left, then "InfoRetriever". It is very good for decision help (for example, the sore throat score), but not very useful for calculations, like creatinine clearance, because chemistries are in mg/dl (US values) not umol/l, which is what we use in Canada. I can use the decision help program to look up things, but will have to enter the result manually into the EMR. I wonder if that kind of thing can be integrated in the EMR, so I can load the rule straight into the patient record.

All in all, not a bad start.

Michelle

How good will my data be?

I spent the past two days at a conference organized by my University's department of Family Medicine. There was certainly a lot of interest in EMRs; it will now be possible to contribute data for large studies. If (God forbid) we ever do get an influenza pandemic, it will be incredibly useful to be able to track things like patient temperatures directly from the charts in family medicine. I remember how helpless and out of touch I felt during the SARS crisis, and I hope better communication will help if there is a next time; SARS killed a family doctor.

The researchers will have to be very careful with protecting patient and physician confidentiality. I have done a bit of research in family medicine, and probably should think about how to use the EMR for that.

The EMRs are customizable, which is good because this lets you put in the data in a way that fits you best. On the other hand, everyone will enter data in somewhat different ways, so the charts will all look different. As well, there is some "free text", which is where you can enter things in any way you like. The free text is the easiest way to enter information, but will probably make it more difficult to search for things in the future. There will need to be some balance between "hard-set" entries, where you have to put in data in a certain way (so that you can do audits for things that interest you and to improve your practice), and ease of entry. A tricky proposition.

Maybe we should think at some point about making records more similar across many practices, so that we can share data more easily (for example, transferring a chart to another family physician, sending data to a specialist, to Diabetes education or to a hospital). I know that Canada Health Infoway is working on common standards (HL-7). It would be good if there was a common standard: if an EMR company goes under, the patient data is too valuable to allow it to be lost. A common standard may help to transfer the information into a different platform.

Perhaps, in the meantime, groups of physicians using the same software application can decide to record things in similar ways. I don't know how easy this would be (probably very hard), or how exactly it would be done. Maybe physicians who are interested could get some help with that.

Michelle

Getting faster

We had our second (and final) training session this morning. We learned how to generate different kinds of letters, and to build our own templates.

I've already been doing letters in the EMR; I've done several referral letters, and now I'm comfortable doing this. I've set up templates for administrative forms that I commonly have to do, such as notes for massage therapy or orthotics. The form is printed at the front, where my patient picks it up and pays for it. This works very well.

My prescriptions are getting much faster; my "favourite drugs" list is getting built up, so prescribing is becoming easier. I have not used my prescription pad since Monday afternoon. I've only gotten one phone call from a very puzzled pharmacist, asking me what "30 doses" of Tylenol #3 were. I have to excuse myself for now, and go out of the room to write prescriptions, so I'm looking forward to having the computer in the exam room with me.

My wireless network is still not up and running, and I have been told that it will be installed next Friday. I don't want to write any more notes in the paper chart; I am jotting a couple of things on paper while in the room, and then write the encounter on the computer afterwards. Putting the clinical encounter in the EMR is now taking me about the same amount of time as writing it on paper, and the notes are much more complete and legible; I am using templates for repetitive things like Upper Respiratory Infections. Today, all my clinical notes were written in the EMR.

I have been putting 2 or 3 Cumulative Patient Profiles per day in the EMR. This is still a time-consuming process, because it has to be very thourough and accurate. Maybe I'll pick one day to do a bunch to speed things up. Once I've transferred a CPP, I write "EMR" on the paper copy, so I know it is done.

My staff will be entering height and weight in the electronic chart; BMIs are automatically generated once you do that, and I will be able to make graphs in the future. I was thinking of buying one of those electronic ear thermometers, so that my staff can check and enter temperatures before I see the patient. Maybe I should buy an electronic blood pressure cuff, so that can be done and entered ahead of time as well; or perhaps I shouldn't--it might be good to leave some work for me!

I should probably do a template for chart forms that I use very often, such as the Preventive Health tables. I can see that I fill out most of the tables at the initial full check-up, and then only go over parts of it at the following preventive exams. I seem to be asking about dental care (flossing), mood, diet and exercise (amongst other things) every year, but I don't need to ask about seat-belts repeatedly. I'll make one big template for the first check up, and then a smaller one for on-going preventive maintenance.

My scanner hasn't been installed yet. Once that is done, we'll start scanning (and shredding, if I see that it works well). I've notified the labs, so I should start getting electronic lab results in about two weeks.

It's a start.

Michelle

First EMR steps

We had our first EMR class on Tuesday. I have to admit that it looked overwhelming at first; there seems to be so much to learn. We learned about the basic set up of the electronic patient chart, how to generate electronic lab and XR requests (and make sure that they are tracked), and how to document a basic patient encounter. I'm sure I forgot 3/4 of it; it's a good thing we have notes and handouts to take home.

After I got back to the office, I thought that I might as well start trying a couple of things. My Tablet is still sitting in my consultation room, wired to the network. I excused myself during a patient encounter, went to my consultation room, and generated a prescription from the EMR. It took about 5 minutes, and it was probably good that my patient did not seem me fumbling around. I had to read it carefully after I printed it; a local pharmacist told me that he had been seeing several odd-looking prescription instructions from physicians who have recently switched to EMRs. It looked reasonable, so I signed it and gave it to my patient. The good thing was that the drugs on the prescription were now stored in my list of "favourite drugs", so prescribing will be faster next time. As well, I did not copy the medications in the paper chart, as this would be duplicate entry. The meds were automatically entered in the Patient's electronic cumulative patient profile. The pharmacist won't have to call me about an illegible prescription anymore.

By Thursday night, I'd written 39 electronic prescriptions; I'm getting better at it. However, I've turned off the automatic drug interaction software. I couldn't figure out how to accept and print a prescription if there are interactions that don't matter; since we have the EMR2 seminar next Wednesday, I will ask then. I can see how some potentially useful (but irritating at the beginning) parts of the EMR can be bypassed; workarounds must be very common. I should probably take a refresher course in a few months.

I've also started documenting patient encounters in the EMR. I often write charts at the end of the day, so I thought I'd try a couple then. I type faster than I write. That actually wasn't too bad. I found a couple of useful templates (pre-made forms), and used those for patients presenting with a cold, for a couple of well-baby visits, and for complete check-ups. On Thursday evening, I wrote about 1/4 of the charts electronically. By the time I start using the EMR in the exam room with patients, on April 3rd, I'll still be slow, but not a total neophyte.

I tried entering my first Cumulative Patient Profile (CPP), which took me about 20 minutes of my lunch hour. I should have started with a simpler CPP, not a patient with complex medical conditions. I am very picky about my CPPs, want a lot of detail in them, want to do it right, and I'd like to make sure I can search them in the future. I'm going to start slowly with CPPs, and maybe do one to three daily. Some data, such as medications, will be entered directly from the clinical encounter.

The software offers a lot of customization for the CPP: you can set up categories and sub-categories for many things. For example, for "smoking", I set up a "never" category, a "social smoker" category in addition to the pre-set category of number of cigarettes/day and age quit. It is more time for me now, but will pay off in the future once this is all set. It reminds me of my electronic financial program, Quicken; I also had to find out how to do everything at first, and now I can't imagine doing my home or office bookkeeping without it. I bought my first copy of Quicken in 1993.

I typed my first consultation letter in the EMR. I signed it on the Tablet's screen, which was kind of interesting.

My front staff is calling the helpdesk less often. I've called a couple of times; once, the nice man at helpdesk took over my computer remotely; it was very strange to see the mouse moving about via an unseen hand.

My wireless router was delivered this week. I expect it will be installed sometimes next week; maybe I'll try unhooking the Tablet and bringing it into the exam room once that is done.

Michelle

Staff turn-over

I came back from March Break holidays to find out that one of my staff is leaving, as of next week. This is not due to EMR implementation (although this can be an issue); she has found another job, for which she is eminently qualified, and is very upset about having to leave now. As well, one of my other secretaries will be away most of April for family and personal reasons. I was planning to switch to entering patient data on the EMR as of April 3rd.

I have 3 part-time medical secretaries and 1 student in the evening, for two family physicians. This will leave us very short-staffed in April. We had an office meeting today to decide what to do. The staff member who will be staying in April offered to work full time for that month; as well, I have an extra person familiar with the office who can fill in on a casual basis in the afternoons. What we will do is have the casual worker come in daily in the afternoon to do filing/faxing and office work, leaving my secretary time to do the phones and booking.

In May, we'll all look at scheduling, and decide if we need to hire an extra person, or see if the rearranged schedule with a filing clerk in the afternoons works.

I now have to decide if I still want to start EMR on April 3rd. After thinking about it, I see no reason not to; I can certainly start to enter patient data in the EMR instead of the paper chart. We had already blocked off some appointments in April so as to give me time to enter data; slower scheduling then will be better for my secretary as well. I will likely wait a month before introducing EMR functions that require changes at the front, such as scanning documents into the chart. I am going to the EMR training sessions tomorrow morning and next Wednesday, and may as well start to apply what I will learn.

I have emailed Nightingale to find out about training if we hire an extra person. I would like new hires to get training, but this will have to be modified, as the new person will not have to learn about all the customization features; the program will already be customized to fit our practice. I am not sure if we should do this in-house; the answer will likely become more clear to me as we start using the EMR.

I don't think having an EMR will limit the opportunity to hire staff. The ability to deal with several requests at once, people skills, a solid dose of common sense, and some computer ability will continue to be key requirements. The rest can be dealt with through training.

Let's see how things go. I'm looking forward to tomorrow's training session.

Michelle

Week 1

Here we are, one week after switching to the new system for billing and scheduling. We've been calling the helpdesk often, whenever we're not sure of something. The scheduling part is working well. We're starting to figure out the ins and outs of the phonebook in the software application; my staff is switching from rolodex to computer. I've started putting in patient recalls, like abnormal pap smears.

I took my Tablet home over the weekend, to try it out. It works well as an electronic book because it is comfortable to hold and read while lying on a couch. I was at a meeting, took it out, and found a cluster of people around me; the tablet definitely has a high coolness factor. I showed it to a couple of patients, and told them that I would be using it in the exam room next month. I am starting to think that a wireless network and PC Tablet is definitely the way to go for EMR. I've bought a wireless mouse, and will probably buy a numeric keypad (I find entering numbers for billing much slower without the keypad).

On Friday, I received remote access to the hospital's database from home or office. I can now see XR reports, lab data, medications and consultation notes for inpatients and patients in Emergency. I'm not sure how I will put that into the EMR, perhaps cut and paste. There needs to be integration between the two systems, perhaps as an "import data" function.

Since Monday, I've looked a the CDC website twice to see if one of my patients needed malaria prophylaxis; I've printed two asthma management plans for patients from the FPME website; and I've printed contact information on the Alzheimer's society for a patient from the Toronto 211 site. I'm starting to develop a list of favourite websites at the office. The Tablet still sits in my consultation room, wired to my network and printer, so I go there to look up and print things. I can see that once I'm wireless and unbound, I'll be doing a lot more of this; that will come after I start using the EMR, April 3rd.

All in all, no major start-up glitches, and we're still sane. I'll be taking a week off for March break, and come back for the EMR training sessions afterwards.

Michelle

Going live

We've fully switched. The 2 label printers and the card swipe are now installed. We're printing little labels to put on test tubes, and big labels for lab requisitions. We're all getting used to billing and scheduling in the new system. Checking people in today was slower than usual, so it was good to book lightly.

We tried clinical messaging (sending short emails back and forth between different people in the practice), which was kind of fun. I think that this is something that I will use more often in the future, as I stop using the paper charts. My secretary told me that I could probably start retiring simple paper charts fairly early on: once I enter the CPP, we can scan a couple of lab reports (eg, last pap), and then retire the chart by putting it in the back closet. We'll have to mark the chart as retired by putting a stripe on it; I'll put a note in the electronic chart that the paper chart is retired, and does not need to be pulled.

I used the tablet today, but only as a laptop. We don't have the wireless router installed yet, so I'm leaving the tablet on my desk, and accessing the internet through the wired network. I don't like the little red button mouse that sits in the middle of the keyboard, so I'm going to buy a wireless mouse for the tablet. Maybe I'll leave a wireless mouse in each exam room.

I've synced my PDA's calendar and address book to the internet so that I can access them from the tablet PC. I'm not sure how much I'll continue to use the Palm once I start carrying the tablet around; probably a lot less.

I noticed that there is a bar code on the vaccine boxes. Perhaps I could get one of those bar code readers like they have in the grocery stores, so that the vaccine lot number and expiry date can be entered automatically in the patient's chart. I run a flu shot clinic in the fall; last October, I vaccinated about 100 people in a couple of hours. Being able to scan the vaccine in would save a lot of repetitive data entry.

Michelle

Switching to the new system for billing and scheduling

We are switching tomorrow. Actually, we've already switched. The computers got installed and configured yesterday, which took most of the day. The installer worked while patients were being greeted, checked in, and seen--somehow it was OK. Once this was done, we started re-entering patient appointments in the new scheduler software.

It is interesting being connected to the Internet. I actually did send an email link to the DASH diet while my patient was getting dressed; I was able to look up malaria prophylaxis on the CDC website for a patient going to the Philippines pretty quickly. I also got an email query from a patient, and I cut and pasted that into the "phone record" area in the EMR; that seems somewhat better than laboriously recording a phone conversation in my usual chicken scratch.

The tablet PC came today; I'll start using it everyday so I can get a good feel for it. It is about 3 lbs, which isn't too bad, since I'll be carrying it around all day.

My dedicated staff members stayed very late yesterday and today to make sure the schedule was completely transferred. We also started billing from the new system today; the government may get some odd bills. A card swipe arrived today, along with a label printer. Our project manager came by to make sure everything was OK. We get a trainer at the office for the morning, but I think we are comfortable with the basics.

We'll spend this month getting to know the administrative functions of the software. After March break, I go back for two sessions of EMR training.

Michelle

Birth pains and other glitches

My office switches over to the new system for billing/scheduling on Thursday. My colleagues in the FHN have been switching one practice at a time, since last Wednesday. We've encountered some problems.

There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.

I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.

The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.

I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.

I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.

I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.

Michelle

Skinny labels

We had two more training sessions last week. The first one dealt with billing, both to the provincial government and for private bills. The second session dealt with scanning documents and managing security. There is a high level of security with the RSA security fobs (see Glossary) , and we have different passwords for everything (logging in at the office, logging in from home via VPN, logging in to manage security fobs, logging in to server to submit claims to the government). These passwords are proliferating like yeast spores.

Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.

We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.

Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.

We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.

Michelle

Communicating on-line

I've started to communicate with everyone at my office via email. I've also changed my email software to web-based mail, so I can access mail from both home and office.

My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.

The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.

We have now put up signs letting patients know about the change, and asking for their patience.

My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.

Michelle

Evidence-based programming

I've been playing around with the training software at home; I think this will work.

I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).

It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.

I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.

As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.

I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.

I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.

Michelle

Starting to train

We had our first training session today, for four hours. They train 8 people at a time; we all had a computer in front of us, the trainer shows us things via a projector and then we practice. We had a mix of physicians and staff members. There was a very wide range of comfort with computers, from one "super-user" who had already been using the software in another office, to someone who had never used a mouse or email (and was not too thrilled about all this nonsense).

We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.

The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.

We go back in one week for more training. The computers should come in in the next 10 days.

Michelle

Doing things differently

The EMR will allow me to do things differently. How differently will depend on what me and my staff decide to change; it won't happen by itself.

One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:

"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:

I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/

Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."


I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.

One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:

"I use a Hoboware temperature recording device in my vaccine
fridge. It is connected by a USB port to a nearby computer.
It records  temperatures every 30 minutes continually, and
these readings can be downloaded to the computer when desired.
I use one of those cheap temperature displays for looking at,
but nobody needs to write down temperatures.

You can't continually display the temperature over USB because
it sucks the battery too quickly, so we left the cheap
thermometer attached, but nobody needs to write down temperatures
anymore.

I have been doing this for 18 months and it works well. Public
Health here is quite pleased.

You don't need to download the temperatures every day. Once
weekly seems adequate. Glancing at the external temperature when
opening the fridge is good enough for every day."

You can get the Hoboware here. You need the logger, software and cable. Although there is a cost, it will make your staff's life easier because they no longer have to record fridge temperatures twice a day. This is something I will definitely do.

Michelle