I've been asked how I do housecalls with EMR. I did a housecall on Wednesday.
I review the chart before going. I print the CPP (which has the patient's date of birth, health card number, address and phone number on top). I take that to the housecall; it helps to have the address, I don't have to copy it from the chart.
During the housecall, I may make a brief note on paper; when I get back to the office, I document the visit in the EMR. For simple prescriptions, I give the patient a written script (entered in the EMR later); for more complicated prescriptions, I ask for the pharmacy number; I print from the EMR to fax it in later. I have an ethernet cable in my laptop bag, in case there is internet access where I am going.
On Wednesday's housecall, I had to call an ambulance. It was good to be able to give the ambulance attendants a printed CPP with all the information on it. It would be better if the CPP was securely available on-line when needed, but this can't be done yet.
I found out from a colleague that I can stop the paper lab reports; this does not have to be done as a group. It was was surprisingly easy to do--just two emails and a faxed letter.
I continue to be amazed at the satisfaction that I am getting from the paper Bgone process, and others are telling me the same thing. My consultation room is uncluttered, and my exam rooms are much neater. When drug reps come in, I no longer accept pads of patient handouts; I will take a single page if it looks interesting, and will scan it in later if it is really useful. The reps now manage the sample cupboard, they put the drugs in the cupboard (and never on the counter). A rep came in on Tuesday carrying two cases of enormously over-packaged samples; this was promptly rejected. My practice team is much more conscious of office space usage, and I think I feel more Green.
I've put patient instructions on my saved favourite DI reqs, so that these are always printed along with the req. As well, our Total Joint Assessment Centre has specific requirements for knee and hip XRs; I've saved those as a favourite DI req, so I know that the appropriate XR will automatically be done in the future. I've emailed samples of electronically generated Diabetes Education Centre reqs and MRI reqs to both centres, and have asked if I can use those instead of the scanned standard reqs. If I generate those electronically, they are part of the chart, all the demographics are automatically entered, there is no bad handwriting, and the referral can be tracked. They will have a look and let me know; there is a good relationship between the hospital and family physicians, so things like this often happen.
Very good
Michelle
Friday, April 13, 2007
Wednesday, April 04, 2007
Drug recall
We had a drug recall this week, for Zelnorm , a drug used for constipation in irritable bowel syndrome. Zelnorm was linked to an increased risk of heart attacks and strokes.
When I received the fax from the manufacturer, I ran a search for all patients on this drug. I also know how to put in alerts, and generate a mail-out. This wasn't difficult to do, as I've done it several times for preventive services. I sent out a "how to" email to my FHN colleagues, and also posted it on my on-line discussion group.
Zelnorm is not a drug used for many patients in family practice. It was good that the first drug recall with the EMR was small and manageable. I can see that the process works; it will work for a large recall, such as Vioxx, but the number of letters will be considerable. We should be be figuring out the role of the big pharmaceutical companies, they really should bear the costs of this targeted notification if one of their products is at fault. It may be time for our political organizations to get involved, ahead of time; this is certainly not the last time there will be a drug recall.
I found out that my application is part of the hospital's network, since the server is inside the hospital. This is interesting; I tried accessing my office from one the PCs in the doctor's lounge, which works. I think this is potentially very useful for members of my group who do OB, in-patient care or palliative care; they can access the EMR from any computer in the hospital.
On another note, I had an interesting discussion with a colleague on what exactly is meant by the EMR "dashboard", which is really a question about how information is presented. I think as a dashboard as an overall view of the information (like a car's dash). There are different ways of presenting that (and not one size will fit all).
I figure that there is a trade-off between a simple dashboard, which will be easy to learn, and a complex dash, which is more useful later on, but is harder to learn. Good programming will present the dash in a way that will shorten the learning curve, while preserving some complexity. A car is an example of a fairly intuitive dash, with some complexity; the fact that it is so prevalent in our society has made good engineering ubiquitous. You have a very short learning curve when buying or renting a new car, because of the similarities in dashboard construction. When you need more complexity, example, commercial airplane, the amount of training increases. Once you have used the dashboard for a while, the amount of unconscious processing increases dramatically; I can take in a lot when I look at the front page in my EMR, but this didn't happen at the beginning.
The Dashboard for individual patients, rather than practice level, would follow similar guidelines (simplicity vs learning curve; choosing the most important info to present, not too much, not too little; navigation issues). It is an interesting interface between the computer and human psychology; a Steve Jobs should get involved in EMRs--his elegance and flair for design would help.
Michelle
When I received the fax from the manufacturer, I ran a search for all patients on this drug. I also know how to put in alerts, and generate a mail-out. This wasn't difficult to do, as I've done it several times for preventive services. I sent out a "how to" email to my FHN colleagues, and also posted it on my on-line discussion group.
Zelnorm is not a drug used for many patients in family practice. It was good that the first drug recall with the EMR was small and manageable. I can see that the process works; it will work for a large recall, such as Vioxx, but the number of letters will be considerable. We should be be figuring out the role of the big pharmaceutical companies, they really should bear the costs of this targeted notification if one of their products is at fault. It may be time for our political organizations to get involved, ahead of time; this is certainly not the last time there will be a drug recall.
I found out that my application is part of the hospital's network, since the server is inside the hospital. This is interesting; I tried accessing my office from one the PCs in the doctor's lounge, which works. I think this is potentially very useful for members of my group who do OB, in-patient care or palliative care; they can access the EMR from any computer in the hospital.
On another note, I had an interesting discussion with a colleague on what exactly is meant by the EMR "dashboard", which is really a question about how information is presented. I think as a dashboard as an overall view of the information (like a car's dash). There are different ways of presenting that (and not one size will fit all).
I figure that there is a trade-off between a simple dashboard, which will be easy to learn, and a complex dash, which is more useful later on, but is harder to learn. Good programming will present the dash in a way that will shorten the learning curve, while preserving some complexity. A car is an example of a fairly intuitive dash, with some complexity; the fact that it is so prevalent in our society has made good engineering ubiquitous. You have a very short learning curve when buying or renting a new car, because of the similarities in dashboard construction. When you need more complexity, example, commercial airplane, the amount of training increases. Once you have used the dashboard for a while, the amount of unconscious processing increases dramatically; I can take in a lot when I look at the front page in my EMR, but this didn't happen at the beginning.
The Dashboard for individual patients, rather than practice level, would follow similar guidelines (simplicity vs learning curve; choosing the most important info to present, not too much, not too little; navigation issues). It is an interesting interface between the computer and human psychology; a Steve Jobs should get involved in EMRs--his elegance and flair for design would help.
Michelle
Saturday, March 31, 2007
One year into implementation: different levels of EMR adoption
April 3rd will mark a year since EMR start-up. I can no longer even imagine practicing with paper-based records.
My FHN group met last week; we took stock of how we are doing. Two of the nine of us are now using the EMR full-time. Two are not using it at all, and really never started, other than for billing/scheduling. The reasons for that include front staff not agreeing to use EMR; not being able to type; not really being ready to change and so not putting in the needed time and effort. We are not making our colleagues feel guilty about this; they will decide to change (or not) at their own pace.
Eight of the nine of us are now receiving lab reports electronically; one never notified the labs and therefore never started. We are still receiving duplicated paper copies of the labs; this is just shredded at my office, I don't even look at it anymore. We have to notify the labs as a group when we are ready to stop the paper reports, and so it looks like this won't happen for a while.
Of the seven EMR users, all are entering CPPs--most of those are now done. Five of us are documenting at least some encounters in the EMR, and four are prescribing electronically. I am the only one who has scanned and shredded all my paper charts; one of my colleagues is scanning a couple of relevant reports in, and then taking the paper chart off-site.
What we decided at the meeting was to have the two consistent users available as a resource to our five colleagues who are still transitioning. We offered to help either at our offices, or at their office, for individual booster sessions. One of my FHN colleagues already came to my office for a couple of hours. I think this will help, but the offer may not continue to be taken up unless I push for it; we just tend to get too busy with day to day practice.
It is interesting that we are comfortable with different stages and speeds of adoption. This is fairly easy in my group, since we practice in different locations; failure to adopt EMR in one office has a minimal effect on the other offices. Even one complete non-adoption in a two physician office (as with my own practice partner) does not have to stop EMR implementation. This must be different when several physicians practice in a single location; there will be more push to implement, and more peer-to-peer support, so perhaps more successes at a year, but also more problems if some physicians are not ready to implement.
Someone in my group said that EMRs are like onions, they have layers. We need to explore these layers at our own pace, with help for the inevitable tears. We're slowly getting there.
Michelle
My FHN group met last week; we took stock of how we are doing. Two of the nine of us are now using the EMR full-time. Two are not using it at all, and really never started, other than for billing/scheduling. The reasons for that include front staff not agreeing to use EMR; not being able to type; not really being ready to change and so not putting in the needed time and effort. We are not making our colleagues feel guilty about this; they will decide to change (or not) at their own pace.
Eight of the nine of us are now receiving lab reports electronically; one never notified the labs and therefore never started. We are still receiving duplicated paper copies of the labs; this is just shredded at my office, I don't even look at it anymore. We have to notify the labs as a group when we are ready to stop the paper reports, and so it looks like this won't happen for a while.
Of the seven EMR users, all are entering CPPs--most of those are now done. Five of us are documenting at least some encounters in the EMR, and four are prescribing electronically. I am the only one who has scanned and shredded all my paper charts; one of my colleagues is scanning a couple of relevant reports in, and then taking the paper chart off-site.
What we decided at the meeting was to have the two consistent users available as a resource to our five colleagues who are still transitioning. We offered to help either at our offices, or at their office, for individual booster sessions. One of my FHN colleagues already came to my office for a couple of hours. I think this will help, but the offer may not continue to be taken up unless I push for it; we just tend to get too busy with day to day practice.
It is interesting that we are comfortable with different stages and speeds of adoption. This is fairly easy in my group, since we practice in different locations; failure to adopt EMR in one office has a minimal effect on the other offices. Even one complete non-adoption in a two physician office (as with my own practice partner) does not have to stop EMR implementation. This must be different when several physicians practice in a single location; there will be more push to implement, and more peer-to-peer support, so perhaps more successes at a year, but also more problems if some physicians are not ready to implement.
Someone in my group said that EMRs are like onions, they have layers. We need to explore these layers at our own pace, with help for the inevitable tears. We're slowly getting there.
Michelle
Saturday, March 24, 2007
Doing a preventive health exam with EMR
Doing an "annual check-up" has changed with the EMR. I have programmed a template, using the preventive health tables, to make the whole thing easier. The template includes a check-box stating that I have reviewed and updated the CPP, the age/gender appropriate Preventive Table, a review of systems, and a physical examination. This makes recording the exam fast and thorough.
When a patient comes in for their complete check up, my secretary measures their height, weight, blood pressure (using the automated BP machine) and waist circumference. She records this in the EMR, and the patient is then shown to one of the exam rooms, and undresses. My secretary puts the room number in the EMR scheduler, which flags the chart and tells me that they are ready to be seen.
Before going in, I load the chart Summary (which shows me if there are any alerts or preventive services due), and then I come in the room. This gives me a chance to remind them of overdue services first. I then load the CPP, and put the Tablet on the exam table beside the patient; the screen is turned so that they can see it. I point things out as we review them together, and make any needed changes. When this is finished, I print the CPP for the patient. The majority of my patients now have a copy of their CPP, and I expect all patients to eventually have this.
Once we are finished with the CPP, I load the encounter. The BMI is automatically calculated, along with a note stating its range (underweight, ideal, overweight, obese); I show this to the patient. Since we started using the automated BP machine last summer, my patients know what their BP is, because my staff tell them. I then load the preventive health template, and put the Tablet aside to do the exam. I will sometimes glance at the template to make sure that I have done everything.
Once this is finished, I print medications, and then give my patient a verbal summary about their health. To emphasize preventive measures, I print a handout with common recommendations; I modified the handout from the Practice-based Small group's module on prevention. I circle things that I would like them to concentrate on, and then give the handout to the patient. A copy of this handout is reproduced below; I keep it in the handout section of the EMR, it is personalized with the patient's information on top, and the patient's record keeps track of the fact that it was printed. I have already remotely put a copy in the EMR of one of my FHN colleagues.
Then, I come out of the room to let my patient get dressed, and load the lab (usually one of my pre-programmed lab reqs, with additional tests as needed), and I send the req to the front printer. The patient comes to the front, and my lab technologist takes them for bloodwork, ECG, etc. If necessary, I also send a pop-up message to my secretary to book a follow up appointment.
This is very efficient and complete. There was a recent research paper which stated that family physicians would have to spend about 7 hours each working day just to get through all the recommended preventive interventions for their patients. With EMR, this is not true. My preventive health exams are booked for a half hour, and it is rare for them to take longer. The preventive health exam is very structured, and exams are very similar; the EMR can be used to guide the visit. It is worthwhile to think about the process of a visit, and to ensure that EMR tools are used to make the visit as effective and efficient for the patient as possible. Having the patient see their own information and share in building their chart, using a templated checklist at the point of care, giving written, relevant feedback, having your staff help you, and having point of care reminders are all easier to do with EMR than on paper. I have described the process in some detail to outline the changes that have happened in my practice, and to show the improvement in care that can result from the use of EMR tools.
Here is the patient Handout:
When a patient comes in for their complete check up, my secretary measures their height, weight, blood pressure (using the automated BP machine) and waist circumference. She records this in the EMR, and the patient is then shown to one of the exam rooms, and undresses. My secretary puts the room number in the EMR scheduler, which flags the chart and tells me that they are ready to be seen.
Before going in, I load the chart Summary (which shows me if there are any alerts or preventive services due), and then I come in the room. This gives me a chance to remind them of overdue services first. I then load the CPP, and put the Tablet on the exam table beside the patient; the screen is turned so that they can see it. I point things out as we review them together, and make any needed changes. When this is finished, I print the CPP for the patient. The majority of my patients now have a copy of their CPP, and I expect all patients to eventually have this.
Once we are finished with the CPP, I load the encounter. The BMI is automatically calculated, along with a note stating its range (underweight, ideal, overweight, obese); I show this to the patient. Since we started using the automated BP machine last summer, my patients know what their BP is, because my staff tell them. I then load the preventive health template, and put the Tablet aside to do the exam. I will sometimes glance at the template to make sure that I have done everything.
Once this is finished, I print medications, and then give my patient a verbal summary about their health. To emphasize preventive measures, I print a handout with common recommendations; I modified the handout from the Practice-based Small group's module on prevention. I circle things that I would like them to concentrate on, and then give the handout to the patient. A copy of this handout is reproduced below; I keep it in the handout section of the EMR, it is personalized with the patient's information on top, and the patient's record keeps track of the fact that it was printed. I have already remotely put a copy in the EMR of one of my FHN colleagues.
Then, I come out of the room to let my patient get dressed, and load the lab (usually one of my pre-programmed lab reqs, with additional tests as needed), and I send the req to the front printer. The patient comes to the front, and my lab technologist takes them for bloodwork, ECG, etc. If necessary, I also send a pop-up message to my secretary to book a follow up appointment.
This is very efficient and complete. There was a recent research paper which stated that family physicians would have to spend about 7 hours each working day just to get through all the recommended preventive interventions for their patients. With EMR, this is not true. My preventive health exams are booked for a half hour, and it is rare for them to take longer. The preventive health exam is very structured, and exams are very similar; the EMR can be used to guide the visit. It is worthwhile to think about the process of a visit, and to ensure that EMR tools are used to make the visit as effective and efficient for the patient as possible. Having the patient see their own information and share in building their chart, using a templated checklist at the point of care, giving written, relevant feedback, having your staff help you, and having point of care reminders are all easier to do with EMR than on paper. I have described the process in some detail to outline the changes that have happened in my practice, and to show the improvement in care that can result from the use of EMR tools.
Here is the patient Handout:
Thank you for coming in for your Preventive Health Exam; your health is important. Here are some things that you can do to stay well:
General Safety
• Wear a seat belt when you ride in a car or other motor vehicle
• Wear a helmet when you ride on a bicycle, motorcycle, or all-terrain-vehicle (ATV)
• Have a smoke detector on each floor of your home
• Regularly test each smoke detector
• Do not use alcohol or drugs when you are involved in activities such as driving, boating, cycling, or swimming
Please protect your hearing against excessive noise
If you are over 64 years old:
• Make sure that you do not have hazards (such as loose carpets, exposed extension cords, and stairs with no handrails) in your home that could cause you or someone else to fall or be injured
Dental Hygiene
• Brush your teeth with a fluoride toothpaste daily
• Floss your teeth daily
• See a dentist at least every year
Physical Activity & Exercise
Your daily physical activity should add up to at least 30 to 60 minutes (Include each 5- to
10-minute interval of activity or exercise.)
Pre-Conception Care
If you are planning to be, or could get pregnant, take a folic acid supplement
Potential Risk Behaviours
If you are a smoker:
• Would you like to quit?
• Have you ever tried to quit before?
• Are you interested in medication to help you quit?
• Are you interested in a smoking cessation program to help you quit?
• Do you have a “quit date” in mind?
I am always ready to help you quit; please use the tools (booklet, helpline, medication) available from my office
If you are sexually active, please:
• Take precautions to prevent an unplanned pregnancy
• Always use a condom to protect yourself from sexually transmitted infections (STIs)
• Avoid high-risk sexual behaviour
Diet
Please eat the right number of calories (enough to maintain a healthy body weight) every day?
Limit your intake of fat and cholesterol
Emphasize grains (such as cereals,whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet
Take enough calcium and vitamin D for a healthy body and bones
Saturday, March 17, 2007
Vacation
I was away on vacation this week. This is now the third time that I've been away on holidays since starting the EMR. It was also the first time that the week before vacation was manageable; I think the efficiency is really starting to kick in.
I've noticed that the majority of lab results come in by Saturday; I had 12 labs to look at on Saturday, and only a few results came in afterwards. It is good to keep that in mind if planning to log in while away: the bulk of the work is in the first few days. As for previous vacations, I let everyone know if I will be accessing the EMR. What seems to work best is intermittent access: I don't want to be forced to look at results daily while on vacation, but I don't mind having a look every few days. That means that my partner has a quick look at the incoming data, and only takes care of urgent problems (like abnormal INRs).
Here is what I ask my partner to do while I'm away:
I am still receiving lab results on paper as well as electronically. Once my group decides we're ready to stop the paper, we have to notify the labs; this must be done as a group. For the past several months, I have not been looking at my paper labs, and they go straight into shredding. I'm not sure what I'll do during vacation once the paper labs stop, since my partner won't have those to look at.
I wonder if this would work for some maternity leaves. I know it has sometimes been difficult to get locums for maternity. It may be possible for one locum to look after several practices via remote access; the physician can decide to come in half a day a week after a couple of months, while doing much of the work remotely during baby's nap (if they nap).
My schedule for Monday does not look horrible; I think the week before and after vacation is much easier to manage this way.
Michelle
I've noticed that the majority of lab results come in by Saturday; I had 12 labs to look at on Saturday, and only a few results came in afterwards. It is good to keep that in mind if planning to log in while away: the bulk of the work is in the first few days. As for previous vacations, I let everyone know if I will be accessing the EMR. What seems to work best is intermittent access: I don't want to be forced to look at results daily while on vacation, but I don't mind having a look every few days. That means that my partner has a quick look at the incoming data, and only takes care of urgent problems (like abnormal INRs).
Here is what I ask my partner to do while I'm away:
- Cc me on lab reqs so they go in EMR
- For incoming lab results:
- If they are normal, put them in the “to shred” box
- If they are slightly abnormal, put them in the “to shred” box
- If they need action, please write on them and then ask staff to put them on my desk after the action is taken
- For incoming letters/faxes, pls put them in the “to scan” box once you’ve seen them
- CPPs will be printed for you as needed
- If you need to see scanned old chart, there is a link on your desktop, double click on the file
- If you need to see a report on the EMR, go to Patient module, reports, then DI/lab etc.
I am still receiving lab results on paper as well as electronically. Once my group decides we're ready to stop the paper, we have to notify the labs; this must be done as a group. For the past several months, I have not been looking at my paper labs, and they go straight into shredding. I'm not sure what I'll do during vacation once the paper labs stop, since my partner won't have those to look at.
I wonder if this would work for some maternity leaves. I know it has sometimes been difficult to get locums for maternity. It may be possible for one locum to look after several practices via remote access; the physician can decide to come in half a day a week after a couple of months, while doing much of the work remotely during baby's nap (if they nap).
My schedule for Monday does not look horrible; I think the week before and after vacation is much easier to manage this way.
Michelle
Friday, March 09, 2007
Looking at my data
It has now been almost a full year since I started using the EMR. I am starting to get some good cumulative data for individual patients. I am also learning to search for conditions in my whole practice, by using clinical reports.
This ability to search is essentially not available in paper records, and is a major benefit of EMR. Here is what I can search for:
-diagnostic conditions
-immunizations
-family history
-medications
I can also search by gender, and by age ranges. These searches can be combined by using boolean terms (and, or, not). The Report feature is fairly user-friendly, once you've worked with it a couple of times. The search query terms can be saved and reused, and I've used my saved searches to see how I am doing over time.
The Report feature is still limited, since I cannot search for lab results (example, give me all patients with cardiovascular disease AND LDL >2.0), or vital signs (all diabetics with BP>130/80). As well, I get a list of patients, but not the number of patients; I got around that by importing the file into excel and manipulating the data.
This brings up an interesting problem: we can save data to local machines (as I just did). The Hospital for Sick Children was recently severely criticised for losing some personal health data: a researcher took a laptop with patient data home, and the laptop was stolen from his car. Security for the EMR is very tight, especially for remotely hosted applications; however, this does not apply to data downloaded to my Tablet. I put passwords on Excel files, but I don't know if that is enough; I'm not sure what we should do for what is going to be an increasingly common issue. There will need to be a balance between data encryption to protect privacy, and the need to access files. Perhaps we should look at a large purchase of data encryption software for all physicians, rather than leave individuals to fund and buy this individually. I'm pretty sure Sickkids does not make each research buy the software themselves.
In a recent editorial in the New England Journal of Medicine (Performance Measurement in Search of a Path, Dr Hayward, March 1 2007), the author noted that "Perhaps our greatest barrier to developing a worthwhile performance-measurement system is our unwillingness to invest in it." He notes that the Department of Veteran's Affairs, a world leader in quality, does detailed reviews of electronic medical records. I think it is now possible to do this with current EMRs; we need to invest in data reporting, and target priority conditions. What you don't measure, you can't improve.
These are recent reports I've run:
Michelle
This ability to search is essentially not available in paper records, and is a major benefit of EMR. Here is what I can search for:
-diagnostic conditions
-immunizations
-family history
-medications
I can also search by gender, and by age ranges. These searches can be combined by using boolean terms (and, or, not). The Report feature is fairly user-friendly, once you've worked with it a couple of times. The search query terms can be saved and reused, and I've used my saved searches to see how I am doing over time.
The Report feature is still limited, since I cannot search for lab results (example, give me all patients with cardiovascular disease AND LDL >2.0), or vital signs (all diabetics with BP>130/80). As well, I get a list of patients, but not the number of patients; I got around that by importing the file into excel and manipulating the data.
This brings up an interesting problem: we can save data to local machines (as I just did). The Hospital for Sick Children was recently severely criticised for losing some personal health data: a researcher took a laptop with patient data home, and the laptop was stolen from his car. Security for the EMR is very tight, especially for remotely hosted applications; however, this does not apply to data downloaded to my Tablet. I put passwords on Excel files, but I don't know if that is enough; I'm not sure what we should do for what is going to be an increasingly common issue. There will need to be a balance between data encryption to protect privacy, and the need to access files. Perhaps we should look at a large purchase of data encryption software for all physicians, rather than leave individuals to fund and buy this individually. I'm pretty sure Sickkids does not make each research buy the software themselves.
In a recent editorial in the New England Journal of Medicine (Performance Measurement in Search of a Path, Dr Hayward, March 1 2007), the author noted that "Perhaps our greatest barrier to developing a worthwhile performance-measurement system is our unwillingness to invest in it." He notes that the Department of Veteran's Affairs, a world leader in quality, does detailed reviews of electronic medical records. I think it is now possible to do this with current EMRs; we need to invest in data reporting, and target priority conditions. What you don't measure, you can't improve.
These are recent reports I've run:
Michelle
Friday, March 02, 2007
The Enterprise module: functioning as a group
I am now beginning to explore the enterprise module. This is the area for group functions, and is one of the most powerful features of the EMR.
I think of "enterprise" functions as things that we should be managing as a group, rather than individually, such as
I have started to use this. A couple of my colleagues wanted a copy of my diabetes flow sheets, and I just installed those on their office application. I helped another colleague remotely with the process of doing consultation letters. I figured out how to access the different schedulers. We have started talking about how to do shared prenatal care across the whole group, and about what would be best practices.
The team pharmacist has started logging on remotely to learn about the application; there were a couple of things that I needed to change in her permissions (the pharmacist profile), and that has been done. These permissions are set for the group so they don't need to be replicated.
My filing cabinets are gone; it is amazing how much space I have at my office. If my partner ever decides to go EMR, we will not need a single filing cabinet for charts. I am now trying to decide if the space should go to a third associate, or whether I should use it for some of the new allied health professionals we will be hiring for our Family Health Team. I am leaning towards the latter; there is still so very little inter-professional health care in Canada that there will be much to learn and invent in small family practices. If, for example, a social worker works out of my office some of the time, his or her schedule is always immediately available to the whole group through the single log-in. Any of our group's support staff can book the appointment and see the location without having to call. I think it will also be interesting for me to have lunch-time conversations whith whoever we hire.
This, in my mind, is what lies beyond the EMR transition: EMR ver2 can let us do as a group what we cannot achieve individually.
Michelle
I think of "enterprise" functions as things that we should be managing as a group, rather than individually, such as
- quality improvement projects (example, meeting targets in diabetes; protocols that the whole group agrees on)
- Shared care, such as prenatal care or palliative care
- Services that one physician is willing to provide for the group (example, IUD insertion)
- Allied health professionals attached to the whole group rather than to individual physicians
I have started to use this. A couple of my colleagues wanted a copy of my diabetes flow sheets, and I just installed those on their office application. I helped another colleague remotely with the process of doing consultation letters. I figured out how to access the different schedulers. We have started talking about how to do shared prenatal care across the whole group, and about what would be best practices.
The team pharmacist has started logging on remotely to learn about the application; there were a couple of things that I needed to change in her permissions (the pharmacist profile), and that has been done. These permissions are set for the group so they don't need to be replicated.
My filing cabinets are gone; it is amazing how much space I have at my office. If my partner ever decides to go EMR, we will not need a single filing cabinet for charts. I am now trying to decide if the space should go to a third associate, or whether I should use it for some of the new allied health professionals we will be hiring for our Family Health Team. I am leaning towards the latter; there is still so very little inter-professional health care in Canada that there will be much to learn and invent in small family practices. If, for example, a social worker works out of my office some of the time, his or her schedule is always immediately available to the whole group through the single log-in. Any of our group's support staff can book the appointment and see the location without having to call. I think it will also be interesting for me to have lunch-time conversations whith whoever we hire.
This, in my mind, is what lies beyond the EMR transition: EMR ver2 can let us do as a group what we cannot achieve individually.
Michelle
Friday, February 23, 2007
Paperless!
On Monday, we scanned and shredded the very last paper file in my practice. My secretary made one last DVD back-up, and that's it. We filled 20 gigabytes of hard drive; I now see external hard drives with 500 gigs, so storage is not an issue for any practice. Next week, I am taking my staff out to celebrate.
I found a buyer for all my filing cabinets, and they are gone as of next Monday.
It is interesting for me to look back at this diary; a year ago at this time, we were just about to switch over to the new system for billing and scheduling.
My husband went to see a specialist a few days ago. He came home and told me that there was a wall of paper files behind the secretary; the specialist wrote everything by hand, and also gave him a prescription scribbled on a little piece of paper. When he went back to the front to make an appointment, the secretary was on the phone with a patient, and was flipping back and forth in a paper book to try to find where the appointment was (which took a while).
While this is the current "normal" in health care, and is not too far removed from my practice of only a year ago, it does not have to be thus. We now have the tools to do better.
I had a couple of computer experts from a company called DM Link in the office today. This is something new that SSHA (the Ontario Government agency charged with connecting the health care system) has set up. I think one of the issues in small practices is that we are not IT experts, and can't configure or maintain these systems by ourselves. The EMR companies are mainly concerned with software, not hardware. The computer guys went around and made sure that all my computers had anti-virus working properly and that Windows updates were up to date (they said that this was a problem in a lot of offices). They also did an inventory and put labels on my routers so that I would know what things are. They wrote down my system configuration, and will send me a hard copy so I know what I have and how it works. They had a look at my routers, and made sure that the UPS device was properly set up so that power would not be interrupted in the event of an outage. I had a couple of questions, and they answered those as well; they even set up my printers to work faster.
This type of housecall is very helpful. Having some professional help and review from people who know what they are doing, and have a checklist to make sure everything works will likely save a lot of grief down the road. The whole thing took about two hours. SSHA has come in for a lot of (deserved) criticism in the recent past; however, this undertaking looks like the right approach.
Michelle
I found a buyer for all my filing cabinets, and they are gone as of next Monday.
It is interesting for me to look back at this diary; a year ago at this time, we were just about to switch over to the new system for billing and scheduling.
My husband went to see a specialist a few days ago. He came home and told me that there was a wall of paper files behind the secretary; the specialist wrote everything by hand, and also gave him a prescription scribbled on a little piece of paper. When he went back to the front to make an appointment, the secretary was on the phone with a patient, and was flipping back and forth in a paper book to try to find where the appointment was (which took a while).
While this is the current "normal" in health care, and is not too far removed from my practice of only a year ago, it does not have to be thus. We now have the tools to do better.
I had a couple of computer experts from a company called DM Link in the office today. This is something new that SSHA (the Ontario Government agency charged with connecting the health care system) has set up. I think one of the issues in small practices is that we are not IT experts, and can't configure or maintain these systems by ourselves. The EMR companies are mainly concerned with software, not hardware. The computer guys went around and made sure that all my computers had anti-virus working properly and that Windows updates were up to date (they said that this was a problem in a lot of offices). They also did an inventory and put labels on my routers so that I would know what things are. They wrote down my system configuration, and will send me a hard copy so I know what I have and how it works. They had a look at my routers, and made sure that the UPS device was properly set up so that power would not be interrupted in the event of an outage. I had a couple of questions, and they answered those as well; they even set up my printers to work faster.
This type of housecall is very helpful. Having some professional help and review from people who know what they are doing, and have a checklist to make sure everything works will likely save a lot of grief down the road. The whole thing took about two hours. SSHA has come in for a lot of (deserved) criticism in the recent past; however, this undertaking looks like the right approach.
Michelle
Friday, February 16, 2007
Working with your EMR company
After 10 months, I have a fairly good idea of how to work with the EMR company. My most common contact with the helpdesk is by email; if I can't get a good answer, I contact the helpdesk manager. Phone calls to helpdesk are rare, because I find this inefficient; it is more useful for things that are urgent or that are not getting resolved by email.
Some things are more of a "wish list", and I know that I may or may not get them. They get sent to the development team. As an example, I use "profiles", with the assessment ICD, medication and follow up preprogrammed (cystitis-595, Septra DS bid x 3 days, push fluids); I would like to have a bill pre-programmed as well. I think if there are lots of physicians asking for the same thing, it is more likely to happen. The on-line group that I belong to is monitored (we sometimes have a reply from someone at the company), so ideas from there likely percolate to development. We are getting an upgrade at the end of the month, so I'll find out then about the extra things.
My husband works in the coatings industry; they use a very large company for their corporate database, SAP. He tells me that despite millions spent on implementation, there are still problems, and upgrades are very expensive. His company also bought a colour computer to help with color matches; it took a year to get that working properly, and several sister companies never did get theirs working.
It is still not clear to me what the critical elements are for a successful transition. In the Compete study in Hamilton, 25% of physicians abandoned the EMR at the end of 3 years, and there were still 22 chart pulls per day after 18 months. I think there are also transition problems in South Western Ontario, at the DELPHI project. These projects provided a lot of support and help. It is unrealistic to expect 100% adoption (or to have everything working within half an hour); it looks like the major issue is the management of all the changes, and surviving the turbulence. There are other physicians like me who have managed the change, I wonder if we could help our colleagues. Some of the information will be company-specific, but some can be translated across all EMRs.
The EMR provided an unexpected finding for me this week. When managing depression, I have an alert in the chart for my staff to print a PHQ-9 questionnaire before I see the patient. Often, patients don't return for follow-up. A couple of days ago, I saw a lady for a sore shoulder, and she handed me a PHQ. She was seen for depression 6 months ago, but did not return for follow-up visits and did not get treated. Her alert remained in the chart, and so a questionnaire was printed for her when she came in. Her PHQ is now completely normal--she got a better job and fired the bad boyfriend. Now I wonder what the natural history of depression in primary care is; perhaps I'll get to find out a bit about what it is in my practice.
I am finding some creative uses for the EMR. I have put information on the home BP machine that I recommend in my list of prescription favourites, so now it prints as a prescription. Maybe I should do an exercise prescription next.
I guess with EMR,
You can't always get what you want,
But if you try sometimes you just might find
You get what you need
Michelle
Some things are more of a "wish list", and I know that I may or may not get them. They get sent to the development team. As an example, I use "profiles", with the assessment ICD, medication and follow up preprogrammed (cystitis-595, Septra DS bid x 3 days, push fluids); I would like to have a bill pre-programmed as well. I think if there are lots of physicians asking for the same thing, it is more likely to happen. The on-line group that I belong to is monitored (we sometimes have a reply from someone at the company), so ideas from there likely percolate to development. We are getting an upgrade at the end of the month, so I'll find out then about the extra things.
My husband works in the coatings industry; they use a very large company for their corporate database, SAP. He tells me that despite millions spent on implementation, there are still problems, and upgrades are very expensive. His company also bought a colour computer to help with color matches; it took a year to get that working properly, and several sister companies never did get theirs working.
It is still not clear to me what the critical elements are for a successful transition. In the Compete study in Hamilton, 25% of physicians abandoned the EMR at the end of 3 years, and there were still 22 chart pulls per day after 18 months. I think there are also transition problems in South Western Ontario, at the DELPHI project. These projects provided a lot of support and help. It is unrealistic to expect 100% adoption (or to have everything working within half an hour); it looks like the major issue is the management of all the changes, and surviving the turbulence. There are other physicians like me who have managed the change, I wonder if we could help our colleagues. Some of the information will be company-specific, but some can be translated across all EMRs.
The EMR provided an unexpected finding for me this week. When managing depression, I have an alert in the chart for my staff to print a PHQ-9 questionnaire before I see the patient. Often, patients don't return for follow-up. A couple of days ago, I saw a lady for a sore shoulder, and she handed me a PHQ. She was seen for depression 6 months ago, but did not return for follow-up visits and did not get treated. Her alert remained in the chart, and so a questionnaire was printed for her when she came in. Her PHQ is now completely normal--she got a better job and fired the bad boyfriend. Now I wonder what the natural history of depression in primary care is; perhaps I'll get to find out a bit about what it is in my practice.
I am finding some creative uses for the EMR. I have put information on the home BP machine that I recommend in my list of prescription favourites, so now it prints as a prescription. Maybe I should do an exercise prescription next.
I guess with EMR,
You can't always get what you want,
But if you try sometimes you just might find
You get what you need
Michelle
Friday, February 09, 2007
The non-EMR physician in a wired office
My practice partner seems to be happier. There was a lot of disruption during the EMR implementation, almost none of which benefited him personally. I think he tolerated this because he knew it was important to me. I was pretty careful with the financial aspect; I showed him everything, we agreed on the extra amount that I would put in for common computer expenses (such as networking), and if I had a bill that was clearly EMR related, I paid for it myself. The disruption is now over, and the office is running smoothly again (although with a split personality).
He still does not want to go EMR. He does not type fast, and is not all that comfortable with computing. Even with an office that is now fully configured for EMR, he just can't see making that step; I think the change is just too big. It is sometimes difficult for him to see my patients when I'm away, because he can't easily navigate an electronic chart. My staff helps, by printing CPPs for him. He knows where CPPs are, and knows how to look at encounters. I try to help by managing my lab and reports remotely when possible.
The resident in my practice spends half her time with him, and half with me, so that some of her patients are on paper, and some on EMR. We put alerts in the demographics so that the secretary knows whether to pull a paper chart for her. It is creaky, but it works for now.
I wonder what will happen as more parts of the system and more physicians go electronic. There may be a time when labs no longer issue paper reports, perhaps as a cost saving measure. At a family medicine meeting yesterday, almost half of the physicians put up their hands when asked if they were looking to computerize soon. My hospital will be going to Computerized Physician Order Entry this year. Their PACS Diagnostic Imaging system is working well--it is probably not a very big step to integrate the report with the EMR. Plans to link our community-based EMR with the hospital system are proceeding apace. I think we're just about to move past the early adopter phase.
It really is a different way of working. Here I am, writing this from home, with my email and my practice both loaded up on my computer. A specialist just called me a few minutes ago to discuss a difficult case; I had all the data in front of me--and I'm getting used to practicing this way.
And, of course, those of us who have successfully transitioned become IT enthusiasts. I wonder if my partner is becoming tired of hearing about EMR this and EMR that; living with a true believer is not a peaceful thing.
Michelle
He still does not want to go EMR. He does not type fast, and is not all that comfortable with computing. Even with an office that is now fully configured for EMR, he just can't see making that step; I think the change is just too big. It is sometimes difficult for him to see my patients when I'm away, because he can't easily navigate an electronic chart. My staff helps, by printing CPPs for him. He knows where CPPs are, and knows how to look at encounters. I try to help by managing my lab and reports remotely when possible.
The resident in my practice spends half her time with him, and half with me, so that some of her patients are on paper, and some on EMR. We put alerts in the demographics so that the secretary knows whether to pull a paper chart for her. It is creaky, but it works for now.
I wonder what will happen as more parts of the system and more physicians go electronic. There may be a time when labs no longer issue paper reports, perhaps as a cost saving measure. At a family medicine meeting yesterday, almost half of the physicians put up their hands when asked if they were looking to computerize soon. My hospital will be going to Computerized Physician Order Entry this year. Their PACS Diagnostic Imaging system is working well--it is probably not a very big step to integrate the report with the EMR. Plans to link our community-based EMR with the hospital system are proceeding apace. I think we're just about to move past the early adopter phase.
It really is a different way of working. Here I am, writing this from home, with my email and my practice both loaded up on my computer. A specialist just called me a few minutes ago to discuss a difficult case; I had all the data in front of me--and I'm getting used to practicing this way.
And, of course, those of us who have successfully transitioned become IT enthusiasts. I wonder if my partner is becoming tired of hearing about EMR this and EMR that; living with a true believer is not a peaceful thing.
Michelle
Sunday, February 04, 2007
Life after the transition
I sometimes look at one of my scanned non-electronic old charts, and I have trouble believing that I practiced that way for 20 years. Even though I tried to be organized, the record is still scattered (all the diagnostic imaging, consult letters, and lab reports are mixed together). I used flow sheets for diabetes and INR management, but nothing else. Trying to follow on-going vitals like BP or weight meant laboriously looking through the clinical record. I had to calculate every BMI myself with a PDA. I sometimes forgot to record medications, especially skin creams. Doing audits for quality of care was possible, but time-consuming.
I have been told that my transition was faster than that of most of my colleagues. Many things went right in my practice. My staff helped me; they often came up with suggestions, and were willing to try new things and to help me fix things that didn’t go right at fist. I was very committed to doing this, and was willing to put in time and money. I knew I would have initial problems (although I did not know what they would be), and was determined to solve as many things as I could, as quickly as I could. I knew just enough about IT, and could learn enough as I went along to be able to fix most things fairly quickly. The fact that my partner did not go along was disconcerting at first, but may have helped me: I did not have to spend much time helping him, and could concentrate on my own practice. Perhaps a definite “no” at the beginning is better than a half-hearted “yes”, although this may not always be possible with government funding (they fund entire groups, which must all agree to go EMR with the same software, rather than individual physicians).
One of the most helpful things was scanning and shredding the old charts. This accelerated the transition, as going back was no longer possible (there were no charts), and it made the use of EMR the default in practice. This is not for the faint of heart; we began scanning 3 months after EMR start-up. It does immediately reduce chart pulls, and demonstrates the efficiency of IT on a daily basis. The cost was minimal; hiring a summer student to do this is worth it.
I keep being asked if I am happy with my software, because many of my colleagues are now looking to computerize. This is a loaded question: the current market is crowded and competitive; what I answer may influence some people. It is impossible for me to judge other EMR applications because I don’t use them, and thus I can’t compare them to what I have. What I will say is that I use the software I have daily, for almost everything I do in practice, and that I like it. I will not say that it is better or worse than other applications.
One of the things that I like is that it does coding for diagnoses well. This was not a selling point for any EMR; I don’t remember it even being mentioned at the beginning. When I read Dr Nicola Shaw’s book, Computerization in Canadian Primary Care, one of her key points (repeated several times) was “learn to code”; I can’t say I paid any attention at the time.
When I enter a diagnosis at the end of an encounter, putting in the code directly in the code field (example, 401) is faster than entering most words, like “hypertension”. Sometimes I don’t remember the code, and I have to use the drop-down list to help me choose one. For example, for cancers I start to type “neop”, and all the cancer names drop down, with their ICD number in front: I pick the relevant one. ICD organizes the cancers by body systems, so all the digestive cancers are numbered consecutively from mouth to anus. After a while, you know where things are.
Sometimes I can’t find what I’m looking for, then I have to go look at the paper list of ICD codes I have from the Ontario Medical Association. I have a copy on my desk, and a scanned copy in my computer. This is the slowest method. After a while, I learned some of the common things, like 307 for a tension headache, or that ADHD is called “Hyperkinetic disorder” in the ICD drop-down.
A benefit of coding is that the ICD number flows directly into my bill (code once, use many times) and I can look for things in my EMR; every previous MI is coded as 410. As the government moves towards more pay-for-performance, we’ll need to identify and keep registers of patients with certain conditions. Using free text for diagnoses will make that difficult; free text for on-going medical conditions in the CPP is especially bad.
In the near future, we’ll start using primary care EMR data for health care system planning (because the data will be there, in usable, electronic form). We need to know how many people with diabetes there are, how many people with congestive heart failure etc, and what is happening with them. The free text diagnoses will not be good for that; it is much easier to look for all 401 than for all HT, HTN, hypertension, high BP, incr BP etc etc. Free text diagnoses are a relic of paper records; all EMRs should make diagnostic coding the default, and make it as easy to do as possible. If you are thinking of buying a system, ask your vendor to demonstrate this; it will not happen unless we ask for it.
Friday, January 26, 2007
Communicating electronically
In my practice, we now frequently talk electronically. One advantage is that messages are archived in the patient's chart. For example:
This is very efficient. Patients are now routinely informed of important follow-up results that are normal, which didn't happen in the past. Several patients have said that they really appreciated the information.
I recently installed a small pop-up program for instant messaging inside the office, Realpopup http://www.download .com/RealPopup/ 3000-2085_ 4-10367875. html. This was suggested by a colleague in my on-line users group, Dr Paul Hasson; the program is small and free. I used to give patients a note to present at the front if they needed follow-up, example "DM, 3 months". Now I just send a pop-up to the front, and the note never gets lost or forgotten. Yesterday, my secretary sent me a pop-up that there was a pharmacy on the phone, line 1, so I just went and got it. This is good for small, instant messages that don't need to be archived to the EMR.
Email with patients is becoming a bit more frequent; this month, there were 8 messages. I recently wrote an article about emailing patients; in the EMR, recording the email involves cutting and pasting it into an encounter (easier and more complete than recording a phone call).
While email is not secure, this does not seem to be a problem for most patients. One of my patients lives in the Far East, and needed his chart (he has complex medical problems). The chart had been scanned into pdf. I told him that I could mail it, or email it to him if he preferred, provided he was aware of the low security and gave me permission. We had communicated previously by email, and identification was not an issue here. He asked me to email it, and we sent a 200 page file electronically that day.
Another patient needed a back to work form emailed; I had to print the note for my signature (I don't have an uploaded signature), we scanned and emailed.
I have secure email via SSHA's ONEmail system; however, it periodically needs a new password, I don't look at it very often, and it won't forward a message to let me know that there is mail for me. I don't know anyone who uses it, because it is not very useful right now. It will probably be good for secure messaging between health care providers, but not for patients since the information goes outside of the system.
I probably should think about setting up an "office" email address for general enquiries; perhaps this should be through SSHA.
I connected the second PC at the front to the fax line (I used a line splitter). Now we can fax from both PCs. If there is a simple fax (a single pdf file, or a lab result from the EMR), my staff can fax straight from the computer, by using the "print, fax" command. No paper is printed.
I found out that I can copy and paste all the decision tools from MedCalc on the EMR. MedCalc is free on the OntarioMD site. I used the PDA version very often, but with this one, you do the calculation on-line, and the result is transferred to text or xml format, to copy into the EMR clinical record. Here is an example of what an atrial fib risk calculation looks like on the clinical notes:
"Decision Tool: Atrial Fibrillation Five Year Risk of Stroke or Death
Age: 60 (4 points)
Systolic Blood Pressure: 120-139 (1 point)
0 points for: Diabetes: No
0 points for: Smoker: No
6 points for: Prior MI or CHF: Yes
0 points for: Significant murmur: No
0 points for: LVH on EKG: No
Total Score = 11 points
Result Interpretation: 11 points : 20 %
References:
Wang TJ, Massaro JM, Levy D, et. al., A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study, JAMA, 2003 Aug 27;290(8):1049-56, PubMed ID number: 12941677"
It looks like it is possible to integrate a great variety of clinical prediction rules fairly quickly into EMR at the point of care. I think I'll try that in practice.
Michelle
| Oct 18, 2006 | to: staff | Greiver, Michelle | Call pt re results | A1C above goal (8.5%, should be 7% or less). blood sugar not controlled. pls make appointment Completion Notes:'pt informed will call for app' |
This is very efficient. Patients are now routinely informed of important follow-up results that are normal, which didn't happen in the past. Several patients have said that they really appreciated the information.
I recently installed a small pop-up program for instant messaging inside the office, Realpopup http://www.download .com/RealPopup/ 3000-2085_ 4-10367875. html. This was suggested by a colleague in my on-line users group, Dr Paul Hasson; the program is small and free. I used to give patients a note to present at the front if they needed follow-up, example "DM, 3 months". Now I just send a pop-up to the front, and the note never gets lost or forgotten. Yesterday, my secretary sent me a pop-up that there was a pharmacy on the phone, line 1, so I just went and got it. This is good for small, instant messages that don't need to be archived to the EMR.
Email with patients is becoming a bit more frequent; this month, there were 8 messages. I recently wrote an article about emailing patients; in the EMR, recording the email involves cutting and pasting it into an encounter (easier and more complete than recording a phone call).
While email is not secure, this does not seem to be a problem for most patients. One of my patients lives in the Far East, and needed his chart (he has complex medical problems). The chart had been scanned into pdf. I told him that I could mail it, or email it to him if he preferred, provided he was aware of the low security and gave me permission. We had communicated previously by email, and identification was not an issue here. He asked me to email it, and we sent a 200 page file electronically that day.
Another patient needed a back to work form emailed; I had to print the note for my signature (I don't have an uploaded signature), we scanned and emailed.
I have secure email via SSHA's ONEmail system; however, it periodically needs a new password, I don't look at it very often, and it won't forward a message to let me know that there is mail for me. I don't know anyone who uses it, because it is not very useful right now. It will probably be good for secure messaging between health care providers, but not for patients since the information goes outside of the system.
I probably should think about setting up an "office" email address for general enquiries; perhaps this should be through SSHA.
I connected the second PC at the front to the fax line (I used a line splitter). Now we can fax from both PCs. If there is a simple fax (a single pdf file, or a lab result from the EMR), my staff can fax straight from the computer, by using the "print, fax" command. No paper is printed.
I found out that I can copy and paste all the decision tools from MedCalc on the EMR. MedCalc is free on the OntarioMD site. I used the PDA version very often, but with this one, you do the calculation on-line, and the result is transferred to text or xml format, to copy into the EMR clinical record. Here is an example of what an atrial fib risk calculation looks like on the clinical notes:
"Decision Tool: Atrial Fibrillation Five Year Risk of Stroke or Death
Age: 60 (4 points)
Systolic Blood Pressure: 120-139 (1 point)
0 points for: Diabetes: No
0 points for: Smoker: No
6 points for: Prior MI or CHF: Yes
0 points for: Significant murmur: No
0 points for: LVH on EKG: No
Total Score = 11 points
Result Interpretation: 11 points : 20 %
References:
Wang TJ, Massaro JM, Levy D, et. al., A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study, JAMA, 2003 Aug 27;290(8):1049-56, PubMed ID number: 12941677"
It looks like it is possible to integrate a great variety of clinical prediction rules fairly quickly into EMR at the point of care. I think I'll try that in practice.
Michelle
Friday, January 19, 2007
Having fun with the EMR
Now that the transition is essentially over, the EMR is not just efficient, it is also fun. Everything is always done; everything is tracked; there is little to no loose paper flying around
My secretary was commenting on how efficient we have become. There was a call from a specialist's office, as they needed copies of some Diagnostic Imaging reports for one of my patients, from October. It took her under 30 seconds to load the chart, locate the reports, and fax them over, all without leaving her desk. Because of the enormous gains in efficiency, they have time to do more call backs to patients about test results. As a result, my staff are becoming much more knowlegeable about tests; I no longer put in normal ranges for fasting sugar when I send an e-note to call a patient, because they know this. They are becoming more like clinical assistants.
I am starting to use a lot of flowsheets; I have found that this is the best way to correlate several things (BP and medication changes; Asthma exacerbations; CHF: weight, eGFR, medications). This is a list of my current flowsheets:
I have figured out how to make results from several different labs mesh together, so that they go into one common flowsheet.
I have also made a couple of "history builders"; these are a type of template where you click on a link, and a series of phrases comes up, which you then save to the record. This is the builder called "normal neurological exam":
"Pupils are equal and reactive to light and accomodation. Fundi are grossly normal, with no papilledema. Cranial nerves II-XII are intact. Neck is supple. Motor examination reveals normal gait and normal strength bilaterally. Reflexes are equal bilaterally and within normal limits. Sensory examination is normal with respect to touch."
If there is something abnormal, you can always change it before saving. It saves a lot of typing. I have a two part Builder for BCP counseling; the first link is if I did STI counseling, and the second is for discussion of BCP benefits and side effects.
I probably should do one to document discussion of Steroid side effects. This is good for anything where there is standard counseling.
I had a look at my activity log; I've reproduced a bit of it below, without patient identification. This gives me a pretty good idea of what I am doing during my day.
I have my email loaded, which can be distracting at times. However, it does make sending links like the BP Action Plan from the Heart and Stroke Foundation, or the excellent self-care depression booklet very easy to do. I have the links inside the EMR, load them up, ask for permission from my patient, and then copy/paste the URL into an email to my patients. This is a really great way to extend the education done at the office; the EMR tracks the fact that a link was sent.
Some abnormal blood results came in for one of my resident's patient. I sent her an email to please log on to the EMR and have a look at the results. She had a look, and emailed me a very appropriate management plan. I am still responsible for the patient's care, and will manage any urgent reports, but this gives my resident the ability to look after her own patients even if she is only here one half day a week. Continuity of care in residency is now a reality. My group is talking about adding a nurse practitioner, since we are becoming a Family Health Team. Team based care can involve the same processes me and my resident are now using.
I know that the transition to EMR is challenging, having been there. However, now that I am paperless, I have found that the EMR is making my practice more fun, more efficient, and definitely more interesting. And I still expect more.
Michelle
My secretary was commenting on how efficient we have become. There was a call from a specialist's office, as they needed copies of some Diagnostic Imaging reports for one of my patients, from October. It took her under 30 seconds to load the chart, locate the reports, and fax them over, all without leaving her desk. Because of the enormous gains in efficiency, they have time to do more call backs to patients about test results. As a result, my staff are becoming much more knowlegeable about tests; I no longer put in normal ranges for fasting sugar when I send an e-note to call a patient, because they know this. They are becoming more like clinical assistants.
I am starting to use a lot of flowsheets; I have found that this is the best way to correlate several things (BP and medication changes; Asthma exacerbations; CHF: weight, eGFR, medications). This is a list of my current flowsheets:
| Active Flowsheets: |
| Flowsheet Name | Description | |
| Asthma flowsheet | Flow sheet for management of asthma | |
| BP | ||
| CHF flowsheet | ||
| COPD | ||
| Depression flowsheet | ||
| diabetic flow | ||
| INR | Flowsheet for INR | |
| Osteoporosis | ||
| TSH | ||
| Weight loss, BP |
I have also made a couple of "history builders"; these are a type of template where you click on a link, and a series of phrases comes up, which you then save to the record. This is the builder called "normal neurological exam":
"Pupils are equal and reactive to light and accomodation. Fundi are grossly normal, with no papilledema. Cranial nerves II-XII are intact. Neck is supple. Motor examination reveals normal gait and normal strength bilaterally. Reflexes are equal bilaterally and within normal limits. Sensory examination is normal with respect to touch."
If there is something abnormal, you can always change it before saving. It saves a lot of typing. I have a two part Builder for BCP counseling; the first link is if I did STI counseling, and the second is for discussion of BCP benefits and side effects.
I probably should do one to document discussion of Steroid side effects. This is good for anything where there is standard counseling.
I had a look at my activity log; I've reproduced a bit of it below, without patient identification. This gives me a pretty good idea of what I am doing during my day.
| 9:47 AM | Greiver, Michelle | Edit Encounter | |||
| 9:51 AM | Greiver, Michelle | Add Medications | |||
| 9:52 AM | Greiver, Michelle | Add Lab Requisition | |||
| 9:54 AM | Greiver, Michelle | Add Clinical Notes Subjective/Objective | |||
| 9:54 AM | Greiver, Michelle | Add Assessment | |||
| 9:54 AM | Greiver, Michelle | Edit Plan Notes | |||
| 9:54 AM | Greiver, Michelle | Sign off Encounter |
I have my email loaded, which can be distracting at times. However, it does make sending links like the BP Action Plan from the Heart and Stroke Foundation, or the excellent self-care depression booklet very easy to do. I have the links inside the EMR, load them up, ask for permission from my patient, and then copy/paste the URL into an email to my patients. This is a really great way to extend the education done at the office; the EMR tracks the fact that a link was sent.
Some abnormal blood results came in for one of my resident's patient. I sent her an email to please log on to the EMR and have a look at the results. She had a look, and emailed me a very appropriate management plan. I am still responsible for the patient's care, and will manage any urgent reports, but this gives my resident the ability to look after her own patients even if she is only here one half day a week. Continuity of care in residency is now a reality. My group is talking about adding a nurse practitioner, since we are becoming a Family Health Team. Team based care can involve the same processes me and my resident are now using.
I know that the transition to EMR is challenging, having been there. However, now that I am paperless, I have found that the EMR is making my practice more fun, more efficient, and definitely more interesting. And I still expect more.
Michelle
Friday, January 12, 2007
Managing my hardware
I am starting to own a lot of hardware and software.
EMR is so important to my local residency program that preceptors are offered a subsidy if they buy a laptop for the use of medical students/residents. I just bought an extra Tablet. I am very happy with my Tablet, and I think it is a good idea for my resident to have access to one; it will likely be a very common form of medical data entry.
The new Tablet arrived recently. I then realised that I didn't know how to access my wireless network--it is not a simple home network, there are a lot of security features. That meant an email to the EMR company. I also had to put my printers on the Tablet (they are accessed wirelessly via IP ports), and I had to configure access to the server. This is a lot of work, so I ended up sending the Tablet to the helpdesk. They did tell me how to access my wireless, and I will keep this information.
One of my FHN colleagues has a folder with all the passwords, and a list of all the printers and computers in her office. This is a good idea, I think I will do the same. I think it is still better to have someone else do the work of setting up a new computer, but it is wise to keep all that information safe someplace. I probably know a bit too much about networking for my own good (that is, just enough to get into trouble); I know how to fix an IP port for a printer, because I've had printers change their IP address.
I think many offices will end up with at least one person very familiar with common IT problems, mostly through experience, so many things will be fixed quickly on site once the transition is over. I have an office manual, which is updated periodically; I have started to put EMR information in there, and I will add information on common problems. I think that, as we move towards a Family Health Team, or group practice, it would be good to assign one staff person to be a resource for the entire group; maybe we should give him or her a blackberry.
I have started taking digital photos to put in the EMR; I had an extra camera at home, which I brought to the office. The Tablet has a SD card slot, so I can just remove the memory chip from the camera and put it straight into the computer. I then attach the picture to the patient file.
Because I carry the Tablet with me all the time, it is becoming highly customized for my needs. I have found that I access some extra information within the EMR (example: templates), some on the internet (example: CDC travel advice), and some locally on my Tablet (example: "cheat notes" for common conditions). I have stopped using my PDA at the office, since I can access everything on the Internet; I use the on-line version of ePocrates. The PDA is backed up to the Tablet, so I have access to my phonebook and calendar on my desktop. I needed a Gestational calculator, so I downloaded one from Medical Algorithms and made a couple of changes, such as a field for "today's date", and changing from a standard Excel file to a template, so it can be reused. The Gestational template is at http://ca.briefcase.yahoo.com/mgreiver@rogers.com, click on Shared, and you will see the file to download. I have it in a folder on my desktop, and just save data for each pregnant patient as an Excel file in the folder; because of the "Today" field, the gestational age is automatically calculated when the patient is seen. I print the excel if referring a patient for prenatal care.
Finally, I have been told that some of my templates will now be shared with my colleagues. Once they are shared, I can no longer modify them. The templates include the age-based preventive health tables; this was the tables on paper records, and this is what they look like on EMR (click on preventive health in the shared folder; it is a big file because of all the screenshots, and will take about 20 secs to download). The last screenshot shows what the template looks like when saved to the patient record.
I bought a temperature logger for my fridge. My filing cabinets are now advertised on Craigslist.
Michelle
EMR is so important to my local residency program that preceptors are offered a subsidy if they buy a laptop for the use of medical students/residents. I just bought an extra Tablet. I am very happy with my Tablet, and I think it is a good idea for my resident to have access to one; it will likely be a very common form of medical data entry.
The new Tablet arrived recently. I then realised that I didn't know how to access my wireless network--it is not a simple home network, there are a lot of security features. That meant an email to the EMR company. I also had to put my printers on the Tablet (they are accessed wirelessly via IP ports), and I had to configure access to the server. This is a lot of work, so I ended up sending the Tablet to the helpdesk. They did tell me how to access my wireless, and I will keep this information.
One of my FHN colleagues has a folder with all the passwords, and a list of all the printers and computers in her office. This is a good idea, I think I will do the same. I think it is still better to have someone else do the work of setting up a new computer, but it is wise to keep all that information safe someplace. I probably know a bit too much about networking for my own good (that is, just enough to get into trouble); I know how to fix an IP port for a printer, because I've had printers change their IP address.
I think many offices will end up with at least one person very familiar with common IT problems, mostly through experience, so many things will be fixed quickly on site once the transition is over. I have an office manual, which is updated periodically; I have started to put EMR information in there, and I will add information on common problems. I think that, as we move towards a Family Health Team, or group practice, it would be good to assign one staff person to be a resource for the entire group; maybe we should give him or her a blackberry.
I have started taking digital photos to put in the EMR; I had an extra camera at home, which I brought to the office. The Tablet has a SD card slot, so I can just remove the memory chip from the camera and put it straight into the computer. I then attach the picture to the patient file.
Because I carry the Tablet with me all the time, it is becoming highly customized for my needs. I have found that I access some extra information within the EMR (example: templates), some on the internet (example: CDC travel advice), and some locally on my Tablet (example: "cheat notes" for common conditions). I have stopped using my PDA at the office, since I can access everything on the Internet; I use the on-line version of ePocrates. The PDA is backed up to the Tablet, so I have access to my phonebook and calendar on my desktop. I needed a Gestational calculator, so I downloaded one from Medical Algorithms and made a couple of changes, such as a field for "today's date", and changing from a standard Excel file to a template, so it can be reused. The Gestational template is at http://ca.briefcase.yahoo.com/mgreiver@rogers.com, click on Shared, and you will see the file to download. I have it in a folder on my desktop, and just save data for each pregnant patient as an Excel file in the folder; because of the "Today" field, the gestational age is automatically calculated when the patient is seen. I print the excel if referring a patient for prenatal care.
Finally, I have been told that some of my templates will now be shared with my colleagues. Once they are shared, I can no longer modify them. The templates include the age-based preventive health tables; this was the tables on paper records, and this is what they look like on EMR (click on preventive health in the shared folder; it is a big file because of all the screenshots, and will take about 20 secs to download). The last screenshot shows what the template looks like when saved to the patient record.
I bought a temperature logger for my fridge. My filing cabinets are now advertised on Craigslist.
Michelle
Saturday, January 06, 2007
The cost of EMR
My cost to start the EMR was approximately $30,000, half for software and half for hardware. This is comparable to buying a new car (not a SUV), but does not depreciate as quickly. There are additional costs to the EMR, such as my upgraded VPN router (which cost $1,000 for parts and labour); as well, I have a backup internet line, at $500 per year. I have not had significant additional hardware costs beyond the router; however, I do expect to put in additional things, such as an automatic temperature logger for my fridge vaccine (about $100 for sensor and kit). The cost for scanning and shredding my charts was $300 for hardware (DVD reader, external hard drive), and about $1200 in labour costs for a student. My staff continued to scan and shred after the summer, during quieter office times, and I have a student coming in the evening to do this. Total labour costs to completely get rid of old paper charts are in the $1500 to $2000 range.
Once our 3 year EMR contract runs out, I expect yearly support and maintenance costs to be in the order of $3,000 per year.
It is difficult for me to say whether this makes business sense without government subsidies. There is a cost to continuing to carry paper records: The approximately $4500 in yearly rental costs taken up by filing cabinets and papers; the cost of the cabinets themselves (my 6 drawer end-file cabinets cost $1,054 each, new); the time for staff to manage the paper; the cost of inefficiency (lost files etc).
As well, there is the cost of managing preventive services on paper. The maximum incentive payment for reaching targets for five preventive services in Ontario is $11,000 per year. Doing this on paper is very difficult; either the physician or their staff has to do the audits, or it has to be contracted out to a private company for a fee. I understand that there is a company that does this; I have heard that the cost per physician is anywhere from $800 to $3,000 per year. Now that I have finished doing my CPPs, the EMR keeps track of preventive services for me. It generates a list of patients overdue, to print letters; I expect to look at the list about once a month--I may now assign this task to one of my staff. The letters are personalized and are very easy to print; a copy is automatically kept in the patient's record. I expect to see more pay-for-performance incentives in the future.
Private bills are much easier to manage with EMR. I print things like notes for massage therapy or sick notes at the front printer, where the patient collects and pays for the note at the same time. We have a PinPad at the front, so people can pay by credit or debit card. As well, the notes are all templated, and are much easier to generate than with paper records. A copy of the note is always and automatically generated in the electronic record; there is no longer any need to photocopy for the file.
Many of my colleagues are now contracting out block billing and private bills to outside companies. I contracted out block billing in the past, at an annual cost of approximately $2500. I have to figure out how to do the block billing, but the private bills are certainly done more easily and efficiently in the EMR.
Having said all that, I strongly believe that government subsidies are needed to kickstart the EMR process. In Ontario, there was a recent lottery, where physicians in FHGs (Family Health Groups, receiving fee-for-service payment) could apply to receive the $28,600 subsidy. They allocated $15 million to this initiative; 2100 physicians out of the 4,000 FHG physicians applied. If a physician gets funded and already has an EMR (provided it is from one of the approved companies), the funding is still given, provided the EMR continues.
There is now lots of physician interest. The initial cost continues to be a barrier, and governments can certainly do a lot to address this. However, I think a reasonable business case can now be made for EMR, if the ongoing cost of paper is taken into account. Additionally, it appears that if there is funding down the line, this funding will be retroactive.
Michelle
Once our 3 year EMR contract runs out, I expect yearly support and maintenance costs to be in the order of $3,000 per year.
It is difficult for me to say whether this makes business sense without government subsidies. There is a cost to continuing to carry paper records: The approximately $4500 in yearly rental costs taken up by filing cabinets and papers; the cost of the cabinets themselves (my 6 drawer end-file cabinets cost $1,054 each, new); the time for staff to manage the paper; the cost of inefficiency (lost files etc).
As well, there is the cost of managing preventive services on paper. The maximum incentive payment for reaching targets for five preventive services in Ontario is $11,000 per year. Doing this on paper is very difficult; either the physician or their staff has to do the audits, or it has to be contracted out to a private company for a fee. I understand that there is a company that does this; I have heard that the cost per physician is anywhere from $800 to $3,000 per year. Now that I have finished doing my CPPs, the EMR keeps track of preventive services for me. It generates a list of patients overdue, to print letters; I expect to look at the list about once a month--I may now assign this task to one of my staff. The letters are personalized and are very easy to print; a copy is automatically kept in the patient's record. I expect to see more pay-for-performance incentives in the future.
Private bills are much easier to manage with EMR. I print things like notes for massage therapy or sick notes at the front printer, where the patient collects and pays for the note at the same time. We have a PinPad at the front, so people can pay by credit or debit card. As well, the notes are all templated, and are much easier to generate than with paper records. A copy of the note is always and automatically generated in the electronic record; there is no longer any need to photocopy for the file.
Many of my colleagues are now contracting out block billing and private bills to outside companies. I contracted out block billing in the past, at an annual cost of approximately $2500. I have to figure out how to do the block billing, but the private bills are certainly done more easily and efficiently in the EMR.
Having said all that, I strongly believe that government subsidies are needed to kickstart the EMR process. In Ontario, there was a recent lottery, where physicians in FHGs (Family Health Groups, receiving fee-for-service payment) could apply to receive the $28,600 subsidy. They allocated $15 million to this initiative; 2100 physicians out of the 4,000 FHG physicians applied. If a physician gets funded and already has an EMR (provided it is from one of the approved companies), the funding is still given, provided the EMR continues.
There is now lots of physician interest. The initial cost continues to be a barrier, and governments can certainly do a lot to address this. However, I think a reasonable business case can now be made for EMR, if the ongoing cost of paper is taken into account. Additionally, it appears that if there is funding down the line, this funding will be retroactive.
Michelle
Saturday, December 30, 2006
At the nine month mark: a new year, a new beginning
I have just finished the last CPP. It took me nine month to enter almost 1,500 CPPs into the EMR; sometimes I got bogged down, when things were very busy, and didn't do any for a while. That's about 166 CPPs per month, on average. Done!!!!
During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.
Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.
My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.
One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.
In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.
There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.
It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.
There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.
I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.
Michelle
During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.
Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.
My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.
One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.
In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.
There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.
It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.
There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.
I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.
Michelle
Friday, December 15, 2006
Insurance companies
I dislike insurance companies. At times, it seems like their purpose is to make family physicians' lives miserable by inundating us with time consuming, difficult to fill, paper forms (multi-axial diagnoses; precise time of return to work; lenthy functional enquiries; detailed descriptions of amount of weight that a patient is able to lift; repeated requests for the same data, etc). I have noticed that, for the past several years, they are refusing to pay for the forms they request. Often, the request is urgent, detracting from patient care.
I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.
I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.
What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.
The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.
Fat chance.
Michelle
I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.
I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.
What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.
The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.
Fat chance.
Michelle
Friday, December 08, 2006
Working as part of a team
The EMR is allowing me to think about working as a part of a team.
My resident did a chart audit of my diabetic patients using remote access to the EMR. It did not take her that long for 70 patients, because the data was in the flowsheets, but I would like to have automated audits in the future. The results are not bad; (2003 audit results are in brackets):
% meeting targets (July 2003 results)
BP <140/90=83% (65%)
BP <130/80=66%
LDL <2.6=63% (50%)
LDL <2.0=40%
HbA1c <8.4=81% (74%)
HbA1c <7.0=48%
There is a new clinical pharmacist in our family medicine teaching unit at my hospital. She can do consultations for our patients who need extra help with their meds. What I was thinking of doing is identifying patients from the audit who need intensification of their meds (sugar, bp, lipids) and referring them to her.
Because I am paperless, I will not do this as a paper based referral. I will give the clinical pharmacist access to my EMR as a team member, just like my resident has. Because I don't know exactly what the scope of practice for a pharmacist is, I will configure the EMR permissions together with her. The EMR has detailed permissions (permission to view, permission to sign off, permission to prescribe etc, for each part of the EMR); we will need to discuss this on set up so that she has appropriate permissions, not more and not less than needed. I figure that, as the family physician, I am the custodian of the primary care record (I don't want to call it a chart, it is becoming increasingly different from a paper chart); therefore I need to think about who can and should have access and input for this record. The "pharmacist" profile, once set, is then available to my whole group. I have an extra RSA security fob for the pharmacist, and this will log and identify her for every chart access just like every member of the team.
Once this is set up, we will mail letters to the identified patients to let them know that the pharmacist may be contacting them. She can access their chart remotely from anywhere with internet access, and call to set up an appointment anywhere convenient; it does not have to be at my office. When she sees the pt, she will be accessing their EMR chart live, and she can enter information directly in their clinical record, live. That is, it is a fully shared chart, with remote access. If we continue, she can also access the chart later for monitoring and callback. The EMR has detailed audit capabilities, so I am able to find out what each team member is doing, and who accesses the chart. If the patient needs to see me for follow-up, the pharmacist has access to my schedule, and can book the appointment.
She is coming to my office Thursday; we'll give it a try.
Michelle
My resident did a chart audit of my diabetic patients using remote access to the EMR. It did not take her that long for 70 patients, because the data was in the flowsheets, but I would like to have automated audits in the future. The results are not bad; (2003 audit results are in brackets):
% meeting targets (July 2003 results)
BP <140/90=83% (65%)
BP <130/80=66%
LDL <2.6=63% (50%)
LDL <2.0=40%
HbA1c <8.4=81% (74%)
HbA1c <7.0=48%
There is a new clinical pharmacist in our family medicine teaching unit at my hospital. She can do consultations for our patients who need extra help with their meds. What I was thinking of doing is identifying patients from the audit who need intensification of their meds (sugar, bp, lipids) and referring them to her.
Because I am paperless, I will not do this as a paper based referral. I will give the clinical pharmacist access to my EMR as a team member, just like my resident has. Because I don't know exactly what the scope of practice for a pharmacist is, I will configure the EMR permissions together with her. The EMR has detailed permissions (permission to view, permission to sign off, permission to prescribe etc, for each part of the EMR); we will need to discuss this on set up so that she has appropriate permissions, not more and not less than needed. I figure that, as the family physician, I am the custodian of the primary care record (I don't want to call it a chart, it is becoming increasingly different from a paper chart); therefore I need to think about who can and should have access and input for this record. The "pharmacist" profile, once set, is then available to my whole group. I have an extra RSA security fob for the pharmacist, and this will log and identify her for every chart access just like every member of the team.
Once this is set up, we will mail letters to the identified patients to let them know that the pharmacist may be contacting them. She can access their chart remotely from anywhere with internet access, and call to set up an appointment anywhere convenient; it does not have to be at my office. When she sees the pt, she will be accessing their EMR chart live, and she can enter information directly in their clinical record, live. That is, it is a fully shared chart, with remote access. If we continue, she can also access the chart later for monitoring and callback. The EMR has detailed audit capabilities, so I am able to find out what each team member is doing, and who accesses the chart. If the patient needs to see me for follow-up, the pharmacist has access to my schedule, and can book the appointment.
She is coming to my office Thursday; we'll give it a try.
Michelle
Sunday, December 03, 2006
Efficient and effective processes
I had a flu clinic last Monday, and will be having another one on December 11. Here is the process for the clinic: I set up a separate schedule, called "flu shot clinic", with appointments at 5 minute intervals. When patients came in, my secretary swiped their card, and entered them in the flu clinic schedule. She then sent them to the back area, where I was standing next to the vaccine fridge, and I gave them their shot. When she had time, she opened their electronic chart, clicked the button that enters the flu shot in my preventive list, and then entered the full flu shot (the lot number and dosage are pre-set in the EMR, there was no need for her to reenter the same information every time). When the clinic was finished, I changed my pre-set billing code to G591 (the Ontario code for influenza vaccination), clicked the button to auto-bill the entire schedule, clicked send, and it was done. We were finished within 5 minutes of the clinic closing. There were no charts pulled or put back. My preventive services list was automatically updated.
The EMR allows for very efficient processes, with a high degree of automation for things that are repetitive. However, this doesn't happen by itself; you have to figure out how to make the EMR work for you.
As another example, I bought an Automated BP machine (the BP Tru) in the summer. My staff is trained on it and they know how to use it. If I get a patient that requires additional BP readings (perhaps because their last BP was above 140/90), I will often ask them to come on a Friday. I am not in the office Friday. My secretary takes their BP using the BP Tru, and enters the average reading (which the machine produces out of several BP readings) in the EMR. I see it remotely, and will send back a message if needed. The current guidelines say that if office BP is between 140/90 and 160/100, you need 4 to 5 visits to diagnose HT. I can get several visits done pretty easily this way. I also use home BP (Lifesource monitor) extensively. I also use the Friday BP visits for diabetic BP slightly above 130/80, for verification. The EMR generates lists and graphs of Blood pressures, so it is easy to follow them. Having my staff help me, and using automated electronic equipment and EMR has improved my quality of care.
My secretary tells me that I won't have a single paper chart belonging to me in the office by 2007. We are currently scanning the Inactive Patient charts, and that is the last of it. I will put 4 filing cabinets for sale on Craigslist over the holidays. I was trying to figure out how much we pay for the space for these: each filing cabinet is 1.5 ft x 3 ft. I have an exam room that is not usable because of filing cabinets, that is 9 ft x 9 ft. I also have to figure out some space to walk around the cabinets. In addition, I no longer store handouts or chart aids (they are scanned into the computer, or accessed from the Internet). This must be about 150 sq feet for my office; at $30 rent per sq foot in my area, that is $4,500 per year for paper storage. I wonder what an office designed with no paper from the start would look like.
Interestingly, I seem to be going through more paper since starting the EMR. However, I look at it as "good paper". For example, when a patient is in for their annual physical, they are usually sitting on the exam table. I have the Tablet sitting beside them, with the screen turned so they can see it. I load the CPP, and point to it as I talk, to verify the information. When that is finished, the last step is for me to say: "I will print a copy for you to have on hand, in case you need to use it". That is now routine. As well, I'll often print a copy of the flowsheet for diabetic patients, so they can see how their results compare with recommended results. I am certainly printing lots of handouts, such as calcium/vitamin D recommendations during full checkups. The storage cost for Good Paper is essentially nil, because they are just blank sheets ordered from the office supply store as needed.
Michelle
The EMR allows for very efficient processes, with a high degree of automation for things that are repetitive. However, this doesn't happen by itself; you have to figure out how to make the EMR work for you.
As another example, I bought an Automated BP machine (the BP Tru) in the summer. My staff is trained on it and they know how to use it. If I get a patient that requires additional BP readings (perhaps because their last BP was above 140/90), I will often ask them to come on a Friday. I am not in the office Friday. My secretary takes their BP using the BP Tru, and enters the average reading (which the machine produces out of several BP readings) in the EMR. I see it remotely, and will send back a message if needed. The current guidelines say that if office BP is between 140/90 and 160/100, you need 4 to 5 visits to diagnose HT. I can get several visits done pretty easily this way. I also use home BP (Lifesource monitor) extensively. I also use the Friday BP visits for diabetic BP slightly above 130/80, for verification. The EMR generates lists and graphs of Blood pressures, so it is easy to follow them. Having my staff help me, and using automated electronic equipment and EMR has improved my quality of care.
My secretary tells me that I won't have a single paper chart belonging to me in the office by 2007. We are currently scanning the Inactive Patient charts, and that is the last of it. I will put 4 filing cabinets for sale on Craigslist over the holidays. I was trying to figure out how much we pay for the space for these: each filing cabinet is 1.5 ft x 3 ft. I have an exam room that is not usable because of filing cabinets, that is 9 ft x 9 ft. I also have to figure out some space to walk around the cabinets. In addition, I no longer store handouts or chart aids (they are scanned into the computer, or accessed from the Internet). This must be about 150 sq feet for my office; at $30 rent per sq foot in my area, that is $4,500 per year for paper storage. I wonder what an office designed with no paper from the start would look like.
Interestingly, I seem to be going through more paper since starting the EMR. However, I look at it as "good paper". For example, when a patient is in for their annual physical, they are usually sitting on the exam table. I have the Tablet sitting beside them, with the screen turned so they can see it. I load the CPP, and point to it as I talk, to verify the information. When that is finished, the last step is for me to say: "I will print a copy for you to have on hand, in case you need to use it". That is now routine. As well, I'll often print a copy of the flowsheet for diabetic patients, so they can see how their results compare with recommended results. I am certainly printing lots of handouts, such as calcium/vitamin D recommendations during full checkups. The storage cost for Good Paper is essentially nil, because they are just blank sheets ordered from the office supply store as needed.
Michelle
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