We had our second (and final) training session this morning. We learned how to generate different kinds of letters, and to build our own templates.
I've already been doing letters in the EMR; I've done several referral letters, and now I'm comfortable doing this. I've set up templates for administrative forms that I commonly have to do, such as notes for massage therapy or orthotics. The form is printed at the front, where my patient picks it up and pays for it. This works very well.
My prescriptions are getting much faster; my "favourite drugs" list is getting built up, so prescribing is becoming easier. I have not used my prescription pad since Monday afternoon. I've only gotten one phone call from a very puzzled pharmacist, asking me what "30 doses" of Tylenol #3 were. I have to excuse myself for now, and go out of the room to write prescriptions, so I'm looking forward to having the computer in the exam room with me.
My wireless network is still not up and running, and I have been told that it will be installed next Friday. I don't want to write any more notes in the paper chart; I am jotting a couple of things on paper while in the room, and then write the encounter on the computer afterwards. Putting the clinical encounter in the EMR is now taking me about the same amount of time as writing it on paper, and the notes are much more complete and legible; I am using templates for repetitive things like Upper Respiratory Infections. Today, all my clinical notes were written in the EMR.
I have been putting 2 or 3 Cumulative Patient Profiles per day in the EMR. This is still a time-consuming process, because it has to be very thourough and accurate. Maybe I'll pick one day to do a bunch to speed things up. Once I've transferred a CPP, I write "EMR" on the paper copy, so I know it is done.
My staff will be entering height and weight in the electronic chart; BMIs are automatically generated once you do that, and I will be able to make graphs in the future. I was thinking of buying one of those electronic ear thermometers, so that my staff can check and enter temperatures before I see the patient. Maybe I should buy an electronic blood pressure cuff, so that can be done and entered ahead of time as well; or perhaps I shouldn't--it might be good to leave some work for me!
I should probably do a template for chart forms that I use very often, such as the Preventive Health tables. I can see that I fill out most of the tables at the initial full check-up, and then only go over parts of it at the following preventive exams. I seem to be asking about dental care (flossing), mood, diet and exercise (amongst other things) every year, but I don't need to ask about seat-belts repeatedly. I'll make one big template for the first check up, and then a smaller one for on-going preventive maintenance.
My scanner hasn't been installed yet. Once that is done, we'll start scanning (and shredding, if I see that it works well). I've notified the labs, so I should start getting electronic lab results in about two weeks.
It's a start.
Michelle
Wednesday, March 29, 2006
Friday, March 24, 2006
First EMR steps
We had our first EMR class on Tuesday. I have to admit that it looked overwhelming at first; there seems to be so much to learn. We learned about the basic set up of the electronic patient chart, how to generate electronic lab and XR requests (and make sure that they are tracked), and how to document a basic patient encounter. I'm sure I forgot 3/4 of it; it's a good thing we have notes and handouts to take home.
After I got back to the office, I thought that I might as well start trying a couple of things. My Tablet is still sitting in my consultation room, wired to the network. I excused myself during a patient encounter, went to my consultation room, and generated a prescription from the EMR. It took about 5 minutes, and it was probably good that my patient did not seem me fumbling around. I had to read it carefully after I printed it; a local pharmacist told me that he had been seeing several odd-looking prescription instructions from physicians who have recently switched to EMRs. It looked reasonable, so I signed it and gave it to my patient. The good thing was that the drugs on the prescription were now stored in my list of "favourite drugs", so prescribing will be faster next time. As well, I did not copy the medications in the paper chart, as this would be duplicate entry. The meds were automatically entered in the Patient's electronic cumulative patient profile. The pharmacist won't have to call me about an illegible prescription anymore.
By Thursday night, I'd written 39 electronic prescriptions; I'm getting better at it. However, I've turned off the automatic drug interaction software. I couldn't figure out how to accept and print a prescription if there are interactions that don't matter; since we have the EMR2 seminar next Wednesday, I will ask then. I can see how some potentially useful (but irritating at the beginning) parts of the EMR can be bypassed; workarounds must be very common. I should probably take a refresher course in a few months.
I've also started documenting patient encounters in the EMR. I often write charts at the end of the day, so I thought I'd try a couple then. I type faster than I write. That actually wasn't too bad. I found a couple of useful templates (pre-made forms), and used those for patients presenting with a cold, for a couple of well-baby visits, and for complete check-ups. On Thursday evening, I wrote about 1/4 of the charts electronically. By the time I start using the EMR in the exam room with patients, on April 3rd, I'll still be slow, but not a total neophyte.
I tried entering my first Cumulative Patient Profile (CPP), which took me about 20 minutes of my lunch hour. I should have started with a simpler CPP, not a patient with complex medical conditions. I am very picky about my CPPs, want a lot of detail in them, want to do it right, and I'd like to make sure I can search them in the future. I'm going to start slowly with CPPs, and maybe do one to three daily. Some data, such as medications, will be entered directly from the clinical encounter.
The software offers a lot of customization for the CPP: you can set up categories and sub-categories for many things. For example, for "smoking", I set up a "never" category, a "social smoker" category in addition to the pre-set category of number of cigarettes/day and age quit. It is more time for me now, but will pay off in the future once this is all set. It reminds me of my electronic financial program, Quicken; I also had to find out how to do everything at first, and now I can't imagine doing my home or office bookkeeping without it. I bought my first copy of Quicken in 1993.
I typed my first consultation letter in the EMR. I signed it on the Tablet's screen, which was kind of interesting.
My front staff is calling the helpdesk less often. I've called a couple of times; once, the nice man at helpdesk took over my computer remotely; it was very strange to see the mouse moving about via an unseen hand.
My wireless router was delivered this week. I expect it will be installed sometimes next week; maybe I'll try unhooking the Tablet and bringing it into the exam room once that is done.
Michelle
After I got back to the office, I thought that I might as well start trying a couple of things. My Tablet is still sitting in my consultation room, wired to the network. I excused myself during a patient encounter, went to my consultation room, and generated a prescription from the EMR. It took about 5 minutes, and it was probably good that my patient did not seem me fumbling around. I had to read it carefully after I printed it; a local pharmacist told me that he had been seeing several odd-looking prescription instructions from physicians who have recently switched to EMRs. It looked reasonable, so I signed it and gave it to my patient. The good thing was that the drugs on the prescription were now stored in my list of "favourite drugs", so prescribing will be faster next time. As well, I did not copy the medications in the paper chart, as this would be duplicate entry. The meds were automatically entered in the Patient's electronic cumulative patient profile. The pharmacist won't have to call me about an illegible prescription anymore.
By Thursday night, I'd written 39 electronic prescriptions; I'm getting better at it. However, I've turned off the automatic drug interaction software. I couldn't figure out how to accept and print a prescription if there are interactions that don't matter; since we have the EMR2 seminar next Wednesday, I will ask then. I can see how some potentially useful (but irritating at the beginning) parts of the EMR can be bypassed; workarounds must be very common. I should probably take a refresher course in a few months.
I've also started documenting patient encounters in the EMR. I often write charts at the end of the day, so I thought I'd try a couple then. I type faster than I write. That actually wasn't too bad. I found a couple of useful templates (pre-made forms), and used those for patients presenting with a cold, for a couple of well-baby visits, and for complete check-ups. On Thursday evening, I wrote about 1/4 of the charts electronically. By the time I start using the EMR in the exam room with patients, on April 3rd, I'll still be slow, but not a total neophyte.
I tried entering my first Cumulative Patient Profile (CPP), which took me about 20 minutes of my lunch hour. I should have started with a simpler CPP, not a patient with complex medical conditions. I am very picky about my CPPs, want a lot of detail in them, want to do it right, and I'd like to make sure I can search them in the future. I'm going to start slowly with CPPs, and maybe do one to three daily. Some data, such as medications, will be entered directly from the clinical encounter.
The software offers a lot of customization for the CPP: you can set up categories and sub-categories for many things. For example, for "smoking", I set up a "never" category, a "social smoker" category in addition to the pre-set category of number of cigarettes/day and age quit. It is more time for me now, but will pay off in the future once this is all set. It reminds me of my electronic financial program, Quicken; I also had to find out how to do everything at first, and now I can't imagine doing my home or office bookkeeping without it. I bought my first copy of Quicken in 1993.
I typed my first consultation letter in the EMR. I signed it on the Tablet's screen, which was kind of interesting.
My front staff is calling the helpdesk less often. I've called a couple of times; once, the nice man at helpdesk took over my computer remotely; it was very strange to see the mouse moving about via an unseen hand.
My wireless router was delivered this week. I expect it will be installed sometimes next week; maybe I'll try unhooking the Tablet and bringing it into the exam room once that is done.
Michelle
Monday, March 20, 2006
Staff turn-over
I came back from March Break holidays to find out that one of my staff is leaving, as of next week. This is not due to EMR implementation (although this can be an issue); she has found another job, for which she is eminently qualified, and is very upset about having to leave now. As well, one of my other secretaries will be away most of April for family and personal reasons. I was planning to switch to entering patient data on the EMR as of April 3rd.
I have 3 part-time medical secretaries and 1 student in the evening, for two family physicians. This will leave us very short-staffed in April. We had an office meeting today to decide what to do. The staff member who will be staying in April offered to work full time for that month; as well, I have an extra person familiar with the office who can fill in on a casual basis in the afternoons. What we will do is have the casual worker come in daily in the afternoon to do filing/faxing and office work, leaving my secretary time to do the phones and booking.
In May, we'll all look at scheduling, and decide if we need to hire an extra person, or see if the rearranged schedule with a filing clerk in the afternoons works.
I now have to decide if I still want to start EMR on April 3rd. After thinking about it, I see no reason not to; I can certainly start to enter patient data in the EMR instead of the paper chart. We had already blocked off some appointments in April so as to give me time to enter data; slower scheduling then will be better for my secretary as well. I will likely wait a month before introducing EMR functions that require changes at the front, such as scanning documents into the chart. I am going to the EMR training sessions tomorrow morning and next Wednesday, and may as well start to apply what I will learn.
I have emailed Nightingale to find out about training if we hire an extra person. I would like new hires to get training, but this will have to be modified, as the new person will not have to learn about all the customization features; the program will already be customized to fit our practice. I am not sure if we should do this in-house; the answer will likely become more clear to me as we start using the EMR.
I don't think having an EMR will limit the opportunity to hire staff. The ability to deal with several requests at once, people skills, a solid dose of common sense, and some computer ability will continue to be key requirements. The rest can be dealt with through training.
Let's see how things go. I'm looking forward to tomorrow's training session.
Michelle
I have 3 part-time medical secretaries and 1 student in the evening, for two family physicians. This will leave us very short-staffed in April. We had an office meeting today to decide what to do. The staff member who will be staying in April offered to work full time for that month; as well, I have an extra person familiar with the office who can fill in on a casual basis in the afternoons. What we will do is have the casual worker come in daily in the afternoon to do filing/faxing and office work, leaving my secretary time to do the phones and booking.
In May, we'll all look at scheduling, and decide if we need to hire an extra person, or see if the rearranged schedule with a filing clerk in the afternoons works.
I now have to decide if I still want to start EMR on April 3rd. After thinking about it, I see no reason not to; I can certainly start to enter patient data in the EMR instead of the paper chart. We had already blocked off some appointments in April so as to give me time to enter data; slower scheduling then will be better for my secretary as well. I will likely wait a month before introducing EMR functions that require changes at the front, such as scanning documents into the chart. I am going to the EMR training sessions tomorrow morning and next Wednesday, and may as well start to apply what I will learn.
I have emailed Nightingale to find out about training if we hire an extra person. I would like new hires to get training, but this will have to be modified, as the new person will not have to learn about all the customization features; the program will already be customized to fit our practice. I am not sure if we should do this in-house; the answer will likely become more clear to me as we start using the EMR.
I don't think having an EMR will limit the opportunity to hire staff. The ability to deal with several requests at once, people skills, a solid dose of common sense, and some computer ability will continue to be key requirements. The rest can be dealt with through training.
Let's see how things go. I'm looking forward to tomorrow's training session.
Michelle
Wednesday, March 08, 2006
Week 1
Here we are, one week after switching to the new system for billing and scheduling. We've been calling the helpdesk often, whenever we're not sure of something. The scheduling part is working well. We're starting to figure out the ins and outs of the phonebook in the software application; my staff is switching from rolodex to computer. I've started putting in patient recalls, like abnormal pap smears.
I took my Tablet home over the weekend, to try it out. It works well as an electronic book because it is comfortable to hold and read while lying on a couch. I was at a meeting, took it out, and found a cluster of people around me; the tablet definitely has a high coolness factor. I showed it to a couple of patients, and told them that I would be using it in the exam room next month. I am starting to think that a wireless network and PC Tablet is definitely the way to go for EMR. I've bought a wireless mouse, and will probably buy a numeric keypad (I find entering numbers for billing much slower without the keypad).
On Friday, I received remote access to the hospital's database from home or office. I can now see XR reports, lab data, medications and consultation notes for inpatients and patients in Emergency. I'm not sure how I will put that into the EMR, perhaps cut and paste. There needs to be integration between the two systems, perhaps as an "import data" function.
Since Monday, I've looked a the CDC website twice to see if one of my patients needed malaria prophylaxis; I've printed two asthma management plans for patients from the FPME website; and I've printed contact information on the Alzheimer's society for a patient from the Toronto 211 site. I'm starting to develop a list of favourite websites at the office. The Tablet still sits in my consultation room, wired to my network and printer, so I go there to look up and print things. I can see that once I'm wireless and unbound, I'll be doing a lot more of this; that will come after I start using the EMR, April 3rd.
All in all, no major start-up glitches, and we're still sane. I'll be taking a week off for March break, and come back for the EMR training sessions afterwards.
Michelle
I took my Tablet home over the weekend, to try it out. It works well as an electronic book because it is comfortable to hold and read while lying on a couch. I was at a meeting, took it out, and found a cluster of people around me; the tablet definitely has a high coolness factor. I showed it to a couple of patients, and told them that I would be using it in the exam room next month. I am starting to think that a wireless network and PC Tablet is definitely the way to go for EMR. I've bought a wireless mouse, and will probably buy a numeric keypad (I find entering numbers for billing much slower without the keypad).
On Friday, I received remote access to the hospital's database from home or office. I can now see XR reports, lab data, medications and consultation notes for inpatients and patients in Emergency. I'm not sure how I will put that into the EMR, perhaps cut and paste. There needs to be integration between the two systems, perhaps as an "import data" function.
Since Monday, I've looked a the CDC website twice to see if one of my patients needed malaria prophylaxis; I've printed two asthma management plans for patients from the FPME website; and I've printed contact information on the Alzheimer's society for a patient from the Toronto 211 site. I'm starting to develop a list of favourite websites at the office. The Tablet still sits in my consultation room, wired to my network and printer, so I go there to look up and print things. I can see that once I'm wireless and unbound, I'll be doing a lot more of this; that will come after I start using the EMR, April 3rd.
All in all, no major start-up glitches, and we're still sane. I'll be taking a week off for March break, and come back for the EMR training sessions afterwards.
Michelle
Thursday, March 02, 2006
Going live
We've fully switched. The 2 label printers and the card swipe are now installed. We're printing little labels to put on test tubes, and big labels for lab requisitions. We're all getting used to billing and scheduling in the new system. Checking people in today was slower than usual, so it was good to book lightly.
We tried clinical messaging (sending short emails back and forth between different people in the practice), which was kind of fun. I think that this is something that I will use more often in the future, as I stop using the paper charts. My secretary told me that I could probably start retiring simple paper charts fairly early on: once I enter the CPP, we can scan a couple of lab reports (eg, last pap), and then retire the chart by putting it in the back closet. We'll have to mark the chart as retired by putting a stripe on it; I'll put a note in the electronic chart that the paper chart is retired, and does not need to be pulled.
I used the tablet today, but only as a laptop. We don't have the wireless router installed yet, so I'm leaving the tablet on my desk, and accessing the internet through the wired network. I don't like the little red button mouse that sits in the middle of the keyboard, so I'm going to buy a wireless mouse for the tablet. Maybe I'll leave a wireless mouse in each exam room.
I've synced my PDA's calendar and address book to the internet so that I can access them from the tablet PC. I'm not sure how much I'll continue to use the Palm once I start carrying the tablet around; probably a lot less.
I noticed that there is a bar code on the vaccine boxes. Perhaps I could get one of those bar code readers like they have in the grocery stores, so that the vaccine lot number and expiry date can be entered automatically in the patient's chart. I run a flu shot clinic in the fall; last October, I vaccinated about 100 people in a couple of hours. Being able to scan the vaccine in would save a lot of repetitive data entry.
Michelle
We tried clinical messaging (sending short emails back and forth between different people in the practice), which was kind of fun. I think that this is something that I will use more often in the future, as I stop using the paper charts. My secretary told me that I could probably start retiring simple paper charts fairly early on: once I enter the CPP, we can scan a couple of lab reports (eg, last pap), and then retire the chart by putting it in the back closet. We'll have to mark the chart as retired by putting a stripe on it; I'll put a note in the electronic chart that the paper chart is retired, and does not need to be pulled.
I used the tablet today, but only as a laptop. We don't have the wireless router installed yet, so I'm leaving the tablet on my desk, and accessing the internet through the wired network. I don't like the little red button mouse that sits in the middle of the keyboard, so I'm going to buy a wireless mouse for the tablet. Maybe I'll leave a wireless mouse in each exam room.
I've synced my PDA's calendar and address book to the internet so that I can access them from the tablet PC. I'm not sure how much I'll continue to use the Palm once I start carrying the tablet around; probably a lot less.
I noticed that there is a bar code on the vaccine boxes. Perhaps I could get one of those bar code readers like they have in the grocery stores, so that the vaccine lot number and expiry date can be entered automatically in the patient's chart. I run a flu shot clinic in the fall; last October, I vaccinated about 100 people in a couple of hours. Being able to scan the vaccine in would save a lot of repetitive data entry.
Michelle
Wednesday, March 01, 2006
Switching to the new system for billing and scheduling
We are switching tomorrow. Actually, we've already switched. The computers got installed and configured yesterday, which took most of the day. The installer worked while patients were being greeted, checked in, and seen--somehow it was OK. Once this was done, we started re-entering patient appointments in the new scheduler software.
It is interesting being connected to the Internet. I actually did send an email link to the DASH diet while my patient was getting dressed; I was able to look up malaria prophylaxis on the CDC website for a patient going to the Philippines pretty quickly. I also got an email query from a patient, and I cut and pasted that into the "phone record" area in the EMR; that seems somewhat better than laboriously recording a phone conversation in my usual chicken scratch.
The tablet PC came today; I'll start using it everyday so I can get a good feel for it. It is about 3 lbs, which isn't too bad, since I'll be carrying it around all day.
My dedicated staff members stayed very late yesterday and today to make sure the schedule was completely transferred. We also started billing from the new system today; the government may get some odd bills. A card swipe arrived today, along with a label printer. Our project manager came by to make sure everything was OK. We get a trainer at the office for the morning, but I think we are comfortable with the basics.
We'll spend this month getting to know the administrative functions of the software. After March break, I go back for two sessions of EMR training.
Michelle
It is interesting being connected to the Internet. I actually did send an email link to the DASH diet while my patient was getting dressed; I was able to look up malaria prophylaxis on the CDC website for a patient going to the Philippines pretty quickly. I also got an email query from a patient, and I cut and pasted that into the "phone record" area in the EMR; that seems somewhat better than laboriously recording a phone conversation in my usual chicken scratch.
The tablet PC came today; I'll start using it everyday so I can get a good feel for it. It is about 3 lbs, which isn't too bad, since I'll be carrying it around all day.
My dedicated staff members stayed very late yesterday and today to make sure the schedule was completely transferred. We also started billing from the new system today; the government may get some odd bills. A card swipe arrived today, along with a label printer. Our project manager came by to make sure everything was OK. We get a trainer at the office for the morning, but I think we are comfortable with the basics.
We'll spend this month getting to know the administrative functions of the software. After March break, I go back for two sessions of EMR training.
Michelle
Monday, February 27, 2006
Birth pains and other glitches
My office switches over to the new system for billing/scheduling on Thursday. My colleagues in the FHN have been switching one practice at a time, since last Wednesday. We've encountered some problems.
There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.
I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.
The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.
I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.
I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.
I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.
Michelle
There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.
I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.
The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.
I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.
I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.
I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.
Michelle
Monday, February 20, 2006
Skinny labels
We had two more training sessions last week. The first one dealt with billing, both to the provincial government and for private bills. The second session dealt with scanning documents and managing security. There is a high level of security with the RSA security fobs (see Glossary) , and we have different passwords for everything (logging in at the office, logging in from home via VPN, logging in to manage security fobs, logging in to server to submit claims to the government). These passwords are proliferating like yeast spores.
Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.
We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.
Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.
We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.
Michelle
Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.
We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.
Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.
We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.
Michelle
Wednesday, February 15, 2006
Communicating on-line
I've started to communicate with everyone at my office via email. I've also changed my email software to web-based mail, so I can access mail from both home and office.
My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.
The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.
We have now put up signs letting patients know about the change, and asking for their patience.
My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.
Michelle
My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.
The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.
We have now put up signs letting patients know about the change, and asking for their patience.
My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.
Michelle
Sunday, February 12, 2006
Evidence-based programming
I've been playing around with the training software at home; I think this will work.
I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).
It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.
I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.
As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.
I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.
I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.
Michelle
I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).
It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.
I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.
As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.
I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.
I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.
Michelle
Wednesday, February 08, 2006
Starting to train
We had our first training session today, for four hours. They train 8 people at a time; we all had a computer in front of us, the trainer shows us things via a projector and then we practice. We had a mix of physicians and staff members. There was a very wide range of comfort with computers, from one "super-user" who had already been using the software in another office, to someone who had never used a mouse or email (and was not too thrilled about all this nonsense).
We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.
The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.
We go back in one week for more training. The computers should come in in the next 10 days.
Michelle
We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.
The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.
We go back in one week for more training. The computers should come in in the next 10 days.
Michelle
Sunday, February 05, 2006
Doing things differently
The EMR will allow me to do things differently. How differently will depend on what me and my staff decide to change; it won't happen by itself.
One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:
"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:
I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."
I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.
One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:
Michelle
One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:
"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:
I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."
I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.
One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:
"I use a Hoboware temperature recording device in my vaccineYou can get the Hoboware here. You need the logger, software and cable. Although there is a cost, it will make your staff's life easier because they no longer have to record fridge temperatures twice a day. This is something I will definitely do.
fridge. It is connected by a USB port to a nearby computer.
It records temperatures every 30 minutes continually, and
these readings can be downloaded to the computer when desired.
I use one of those cheap temperature displays for looking at,
but nobody needs to write down temperatures.
You can't continually display the temperature over USB because
it sucks the battery too quickly, so we left the cheap
thermometer attached, but nobody needs to write down temperatures
anymore.
I have been doing this for 18 months and it works well. Public
Health here is quite pleased.
You don't need to download the temperatures every day. Once
weekly seems adequate. Glancing at the external temperature when
opening the fridge is good enough for every day."
Michelle
Tuesday, January 31, 2006
Networking my office
The network installer came on January 27th, a Friday. It is not a good idea to install on a Monday, as those days are too busy.
I had to choose between a wired and wireless network. I've heard various opinions on problems with safety, speed and stability of wireless. It is difficult to know, as the technology changes so fast. It seems to me that wireless is a reasonable option now; security can be properly configured if done by a professional. In any case, having a tablet means having a wireless network, since the tablet is portable.
I ended up choosing to have both. Each wired "drop" (or plug in the wall that connects to your network) costs $150. This is a one time capital cost, it would be difficult for me to arrange for someone to come in to do a single line through the ceiling. I ended up having wired network connections (or RJ45 outlets) in every examining room, at the front, and beside my scale. I will also have a wireless router.
Another way to think about this is to have wired connections for all desktops computers (ie, the front computers for your staff), and wireless for the tablet. I also put in an extra RJ45 outlet in the front for the credit/debit card pinpad; you can have those run through the broadband connection, instead of tying up your phone line. Two companies that supply pinpads are Moneris and Paymentech.
I am thinking of buying some network printers. These are not expensive anymore. They can use the network cable (Ethernet) instead of USB, and I'll put one in each exam room. Then I can use my tablet to access my network wirelessly, and print prescriptions and handouts in the room.
Our contract includes some nice desktop computers, with extensive warranties. It is good to get those for "mission critical" areas, for example for your front staff. If that computer breaks down, you want it fixed, fast. As well, the tablet includes a very good warranty. I will probably buy some inexpensive eMachines in the future for less critical areas, for example, where the scales and vaccine fridge are, so that weights and fridge temperatures can be recorded. Perhaps I can find a thermometer with software that automatically sends the temperature to the computer.
I also work at a satellite office, in a residence for seniors, once a week. I had the network installer put a network connection there as well. The building's front office has broadband (which they're letting me use), and I can access my server via VPN. I won't have to trudge charts back and forth from my office anymore.
Our first training session will be February 8th.
Michelle
I had to choose between a wired and wireless network. I've heard various opinions on problems with safety, speed and stability of wireless. It is difficult to know, as the technology changes so fast. It seems to me that wireless is a reasonable option now; security can be properly configured if done by a professional. In any case, having a tablet means having a wireless network, since the tablet is portable.
I ended up choosing to have both. Each wired "drop" (or plug in the wall that connects to your network) costs $150. This is a one time capital cost, it would be difficult for me to arrange for someone to come in to do a single line through the ceiling. I ended up having wired network connections (or RJ45 outlets) in every examining room, at the front, and beside my scale. I will also have a wireless router.
Another way to think about this is to have wired connections for all desktops computers (ie, the front computers for your staff), and wireless for the tablet. I also put in an extra RJ45 outlet in the front for the credit/debit card pinpad; you can have those run through the broadband connection, instead of tying up your phone line. Two companies that supply pinpads are Moneris and Paymentech.
I am thinking of buying some network printers. These are not expensive anymore. They can use the network cable (Ethernet) instead of USB, and I'll put one in each exam room. Then I can use my tablet to access my network wirelessly, and print prescriptions and handouts in the room.
Our contract includes some nice desktop computers, with extensive warranties. It is good to get those for "mission critical" areas, for example for your front staff. If that computer breaks down, you want it fixed, fast. As well, the tablet includes a very good warranty. I will probably buy some inexpensive eMachines in the future for less critical areas, for example, where the scales and vaccine fridge are, so that weights and fridge temperatures can be recorded. Perhaps I can find a thermometer with software that automatically sends the temperature to the computer.
I also work at a satellite office, in a residence for seniors, once a week. I had the network installer put a network connection there as well. The building's front office has broadband (which they're letting me use), and I can access my server via VPN. I won't have to trudge charts back and forth from my office anymore.
Our first training session will be February 8th.
Michelle
Monday, January 30, 2006
Choosing training and go live dates
We held a meeting in December to confirm hardware choices, and to decide on training dates. The training schedule was complex, as there were 7 offices, 9 physicians, and support staff; training sessions are from 9 am to 1 pm or from 2 pm to 6 pm. We had picked our preferred dates, as well as preferred "go live" dates, and emailed them to the company as well as to our It lead ahead of time. At the meeting, we confirmed the dates (with a bit of bargaining around).
"Go live" day for me is Thursday March 2nd, 2006. On that day, we will stop using my old billing program, and will switch to the new billing and scheduling software. I blocked off half of my appointments. We will be getting a trainer at the office from 9 am to 1 pm.
We have two training sessions of 4 hours each scheduled for my staff, and for me and my partner in February. We will learn billing, private invoices, reconciliation and scheduling. We also have an extra 3 hour session to learn how to manage the RSA security fobs. These are small key fobs that you carry around; they display a random number, and you enter that along with your password. There is one for every physician, and one for each staff member (we also got one extra one, in case someone forgets to bring theirs to the office). These are included in the purchase price, and they provide very good security. The company will also teach us about the electronic lab interface (we will switch from paper to electronic data for labs), and how to manage scanned documents.
We had completed all the paperwork for OntarioMD, and received the initial subsidy of $4,500.
The next step will be to set up the network.
Michelle
"Go live" day for me is Thursday March 2nd, 2006. On that day, we will stop using my old billing program, and will switch to the new billing and scheduling software. I blocked off half of my appointments. We will be getting a trainer at the office from 9 am to 1 pm.
We have two training sessions of 4 hours each scheduled for my staff, and for me and my partner in February. We will learn billing, private invoices, reconciliation and scheduling. We also have an extra 3 hour session to learn how to manage the RSA security fobs. These are small key fobs that you carry around; they display a random number, and you enter that along with your password. There is one for every physician, and one for each staff member (we also got one extra one, in case someone forgets to bring theirs to the office). These are included in the purchase price, and they provide very good security. The company will also teach us about the electronic lab interface (we will switch from paper to electronic data for labs), and how to manage scanned documents.
We had completed all the paperwork for OntarioMD, and received the initial subsidy of $4,500.
The next step will be to set up the network.
Michelle
Sunday, January 22, 2006
Thinking about how to convert my data from paper to electronic
I had been thinking about how to convert from paper-based data to computer-based data. I found these resources to be very helpful:
Dr. Dermer suggests converting during quieter office times; Fall is not a good time, as we are especially busy due to flu shots. During the summer, everyone is away, so that is not a good time either. We are going to train in February, and start using the EMR in March.
Scanning all my old charts is not going to be very useful. You can't easily search the scanned images, and it would be a lot of work. Dr. Dermer suggests thinking of charts as "volume 1" (paper), and "volume 2"(EMR), which makes a lot of sense to me. I will be entering my Cumulative Patient Profile (CPP), which is the summary report at the front of the chart into the EMR, and almost nothing else. All new lab results and other reports will go into the EMR after the start date.
I had been thinking about hiring someone to enter the CPP on the computer, but have decided to do it myself. It is the most important part of the chart, and needs to be done properly and reliably. I have made sure that my CPPs are well organized, which will help with data entry.
The IT trainer from myNightingale had asked me for a test diskette with data from my old billing program. He needed to test it to see if transferring demographic data (patient names, dates of birth, addresses, health card numbers etc) would work. I was able to give him that, and he said we should have no problem with this data. Scheduling and billing data are more of a problem; they cannot be transferred. We will print the schedule and manually transfer it to the new system, but I'm not sure what we will do with billing yet. The trainer told me that he will get a "final cut", which is the demographic data on the last day we use the old system, and transfer it to the new system so it is ready for "go live day".
Michelle
- Computerization and going paperless in Canadian primary care, a book by Dr. Nicola Shaw, which I bought from the CMA's website
- Implementing an electronic medical record in your practice, available here. The "rapid but cautious" article by Dr. Mark Dermer is especially useful
Dr. Dermer suggests converting during quieter office times; Fall is not a good time, as we are especially busy due to flu shots. During the summer, everyone is away, so that is not a good time either. We are going to train in February, and start using the EMR in March.
Scanning all my old charts is not going to be very useful. You can't easily search the scanned images, and it would be a lot of work. Dr. Dermer suggests thinking of charts as "volume 1" (paper), and "volume 2"(EMR), which makes a lot of sense to me. I will be entering my Cumulative Patient Profile (CPP), which is the summary report at the front of the chart into the EMR, and almost nothing else. All new lab results and other reports will go into the EMR after the start date.
I had been thinking about hiring someone to enter the CPP on the computer, but have decided to do it myself. It is the most important part of the chart, and needs to be done properly and reliably. I have made sure that my CPPs are well organized, which will help with data entry.
The IT trainer from myNightingale had asked me for a test diskette with data from my old billing program. He needed to test it to see if transferring demographic data (patient names, dates of birth, addresses, health card numbers etc) would work. I was able to give him that, and he said we should have no problem with this data. Scheduling and billing data are more of a problem; they cannot be transferred. We will print the schedule and manually transfer it to the new system, but I'm not sure what we will do with billing yet. The trainer told me that he will get a "final cut", which is the demographic data on the last day we use the old system, and transfer it to the new system so it is ready for "go live day".
Michelle
Wednesday, January 18, 2006
Choosing hardware
My practice partner decided he wasn't quite ready for EMR. However, he agreed to switch to the new system for billing and scheduling, as our current system was over 10 years old, and was DOS based. We would therefore have a hybrid office, but with a single billing and scheduling system; having two computer systems would have been very difficult for our front staff.
I made a point of trying to keep everyone at my office as up to date as possible. This is a big change, and it helps if people know what is happening.
My group held one more meeting in October, and we decided to sign the contract. We met the company's IT trainers, and we set up dates for them to visit each practice. Our FHN lead reminded everyone to send in the SSHA and EDT applications. We discussed the cost of the server (shared with the other FHN); this is approximately $1,500 per physician. We started to think about hardware: we had a choice between a wired network with desktop PCs (or "workstations") in each room, and a wireless network with tablet PCs for the physicians. Please see the glossary for a definition of Tablet PC.
We each gave a check for the software to our FHN lead physician, to deposit in our group account. The contract is for the entire group, so the FHN pays for the software, not each individual physician.
The two IT trainers came to my office a week later. They spoke with my staff and me, and had a look at my practice's physical layout. I thought I would prefer to have two workstations at the front desk (as I have two staff members there), and a tablet PC for myself. I use a Palm PDA very often, and had gone to FutureShop to try the Tablet PC: it felt like a large PDA, and I thought I'd be comfortable with this method of data entry. My partner chose one desktop PC for his consultation room, and did not need any computers in his exam rooms. I wanted a printer in each room (to print prescriptions, because electronic transmission of prescriptions is not allowed, and to print handouts). Printers are very inexpensive, and can be plugged into the Tablet as needed. The trainers had a look at my existing computers and equipment; most of it was very outdated, and little could be salvaged.
Once everyone had a site visit, the company asked us to email them our thoughts about the hardware we needed. For my practice, this was:
Michelle
I made a point of trying to keep everyone at my office as up to date as possible. This is a big change, and it helps if people know what is happening.
My group held one more meeting in October, and we decided to sign the contract. We met the company's IT trainers, and we set up dates for them to visit each practice. Our FHN lead reminded everyone to send in the SSHA and EDT applications. We discussed the cost of the server (shared with the other FHN); this is approximately $1,500 per physician. We started to think about hardware: we had a choice between a wired network with desktop PCs (or "workstations") in each room, and a wireless network with tablet PCs for the physicians. Please see the glossary for a definition of Tablet PC.
We each gave a check for the software to our FHN lead physician, to deposit in our group account. The contract is for the entire group, so the FHN pays for the software, not each individual physician.
The two IT trainers came to my office a week later. They spoke with my staff and me, and had a look at my practice's physical layout. I thought I would prefer to have two workstations at the front desk (as I have two staff members there), and a tablet PC for myself. I use a Palm PDA very often, and had gone to FutureShop to try the Tablet PC: it felt like a large PDA, and I thought I'd be comfortable with this method of data entry. My partner chose one desktop PC for his consultation room, and did not need any computers in his exam rooms. I wanted a printer in each room (to print prescriptions, because electronic transmission of prescriptions is not allowed, and to print handouts). Printers are very inexpensive, and can be plugged into the Tablet as needed. The trainers had a look at my existing computers and equipment; most of it was very outdated, and little could be salvaged.
Once everyone had a site visit, the company asked us to email them our thoughts about the hardware we needed. For my practice, this was:
- 2 workstations for the front, 1 for my partner
- 1 tablet PC for me
- 1 network printer for the front
- 4 printers
- 1 card swiper
- 2 label printers
- 1 scanner
Michelle
Sunday, January 15, 2006
Signing the contract and thinking about implementation
We were getting to the final nuts and bolts of the contract. Our IT lead had kept us informed via email. At the meeting, we went over a couple of points on the contract offer, with the regional manager from myNightingale; it looked like we were going to sign.
We went over the Scope of Work document, which we each had to fill. Most of what we had to write in there was impossible for us to understand. Our IT lead had asked the OntarioMD specialist what we needed to write in, and just dictated this at the meeting. That is the only way this document is going to get completed.
We were also thinking about implementation. The company had emailed us a description of how they were planning to implement:
4. start training
We were going to start using the billing and scheduling (or "practice management") software first. Then, we were going to go back for the two EMR training sessions, and have the physicians start using the EMR a month after the staff starts. This is called a "staged implementation".
We now had to go back to our practices and talk to our non-FHN partners, as they needed to decide if they were going to use the same software. It was October.
Michelle
We went over the Scope of Work document, which we each had to fill. Most of what we had to write in there was impossible for us to understand. Our IT lead had asked the OntarioMD specialist what we needed to write in, and just dictated this at the meeting. That is the only way this document is going to get completed.
We were also thinking about implementation. The company had emailed us a description of how they were planning to implement:
- workflow analysis: they send people to each office. They talk to the physicians and staff and find out what happens in the office
- training and implementation plan: this tells us how we will do
- billing,
- scheduling,
- training for staff (course is mostly standardized, but can be customized--although I'm not sure how exactly this can be customized)
- EMR training for physicians
- IT assessment for practices and the hospital (what machines go in, wiring, etc)
- decide on wired or wireless network
4. start training
- 2 sessions on practice management (billing, scheduling)
- 2 sessions on EMR
- each session is 4 hours
We were going to start using the billing and scheduling (or "practice management") software first. Then, we were going to go back for the two EMR training sessions, and have the physicians start using the EMR a month after the staff starts. This is called a "staged implementation".
We now had to go back to our practices and talk to our non-FHN partners, as they needed to decide if they were going to use the same software. It was October.
Michelle
Saturday, January 14, 2006
Getting SSHA broadband in the office
After some prodding from our IT lead physician, we sent the documents to SSHA so we could each get a broadband connection. My office received an ADSL connection; SSHA shipped me a DSL modem, as well as a Small Office Firewall Appliance (SOFA). The SOFA is about the same size as the modem, and provides additional security. Instructions on how to connect the whole thing came with the shipment; the modem connects to the phone jack, and the SOFA connects to the modem. If you need help, there is a 1-800 number to call.
My internet connection did not work. After an hour of being connected, the modem started to smoke and smell bad, and then shut off. My OntarioMD IT transition specialist put me in touch with someone at SSHA, and they sent me a second modem. Perhaps the problem was that I have two phone lines at the office, so I bought a line splitter; putting DSL over a dedicated phone line (such as a fax line) is a better idea. The second modem fried as well, shortly after installation--a critical hardware failure.
SSHA then told me that they would install cable internet. This came about three weeks later. You have to make sure that you contact SSHA well ahead of time, as it takes time for the installation, as well as time to solve problems. The cable internet connection now works.
Some physicians in our group (including me) had never switched to Electronic Data Transmission (EDT) to submit billings, and were still using diskettes. We had to send in a form to the Ministry to switch to EDT. The two forms are on the Ministry of Health's website, Form 1 and Form 2.
Our IT lead physician was proceeding with the contract negotiations. OntarioMD told us that they would release the first installment of the subsidy ($4,500 per physician) once they had our Letter of Intent, Vendor Contract Declaration, and Scope of Work. The OntarioMD IT specialist will help with the forms; the first two are done for the group, and the last is done by each physician (we did it together at one of our meetings).
The cost over 3 years for software and hardware was going to be approximately $30,000 (depending on how many computers in the office etc), fairly close to the subsidy. The greatest costs are hardware, training, and support, not software.
Our IT lead called a meeting so we could decide on next steps.
Michelle
My internet connection did not work. After an hour of being connected, the modem started to smoke and smell bad, and then shut off. My OntarioMD IT transition specialist put me in touch with someone at SSHA, and they sent me a second modem. Perhaps the problem was that I have two phone lines at the office, so I bought a line splitter; putting DSL over a dedicated phone line (such as a fax line) is a better idea. The second modem fried as well, shortly after installation--a critical hardware failure.
SSHA then told me that they would install cable internet. This came about three weeks later. You have to make sure that you contact SSHA well ahead of time, as it takes time for the installation, as well as time to solve problems. The cable internet connection now works.
Some physicians in our group (including me) had never switched to Electronic Data Transmission (EDT) to submit billings, and were still using diskettes. We had to send in a form to the Ministry to switch to EDT. The two forms are on the Ministry of Health's website, Form 1 and Form 2.
Our IT lead physician was proceeding with the contract negotiations. OntarioMD told us that they would release the first installment of the subsidy ($4,500 per physician) once they had our Letter of Intent, Vendor Contract Declaration, and Scope of Work. The OntarioMD IT specialist will help with the forms; the first two are done for the group, and the last is done by each physician (we did it together at one of our meetings).
The cost over 3 years for software and hardware was going to be approximately $30,000 (depending on how many computers in the office etc), fairly close to the subsidy. The greatest costs are hardware, training, and support, not software.
Our IT lead called a meeting so we could decide on next steps.
Michelle
Wednesday, January 11, 2006
Choosing an EMR company: we decide
We decided to have a demonstration at the company's head office. All of us got together one July evening, with some of our staff, and tried the software. At the end, it seemed pretty clear that we were going to go with myNightingale.
Now came the hard work of negotiating a deal, and a Service Level Agreement (SLA). The SLA is a separate document outlining support and maintenance (such as what happens in case of catastrophic failure, how fast the company responds to requests, etc). Documents relating to the SLA can be found here, under "Contract Negotiations", and here, under "Systems Management Guidelines". Our IT lead started on this, and had some help from a lawyer. It helps if your group has a bit of money in reserve to pay for this. The FHN receives some money each month for being on-call, and we hold this in a common account. We used this to pay the lawyer, and to reimburse the IT lead physician for the time she put in. You don't have to have a lawyer review the software agreement or the SLA, but there is a lot of fine print. It is worthwhile doing.
Because of the fact that we are in 7 different offices, we decided to go with a "Configuration 3" set-up (for an explanation of configurations, please see the glossary). This means that we have a server (or main computer) at the hospital, with all of us accessing our data via broadband. There are some advantages to doing this: we contract with the hospital's IT department to do regular back-up and maintenance, and they keep a copy of all data off site (they do this as part of their regular hospital back-up procedures, so there are already processes set up for this). The EMR company works with the hospital to maintain and upgrade the server as needed. We no longer have to worry about back-up management, or database software issues.
The other FHN wanted to do this as well, and we agreed to share one single server, which cut the cost of the server hardware in half. If more FHNs decided to join us in the future, or if more physicians join our FHN, there is ample room on the server to accomodate them (this is called scalability).
The head of the hospital's IT agreed to have the server in the hospital. Having the hospital work with us is very helpful; perhaps having our server inside the hospital will help us to share our data. If a patient is in the Emergency room, or is admitted, appropriate data from their community-based chart should be available inside the hospital. Conversely, when a patient is discharged, I should have access to their hospital data.
We had to solve the problem of having non-FHN physicians on the server as well. If a physician has data on a different server, you have to log out and log back in to see their patients. That would not work very well in my office, where I am a FHN member, and my partner is not; my staff would have to continually log out and log in to switch between us. We had to get permission from OntarioMD to have non FHN physicians on our server, which they granted.
We were now ready for final negotiations. It was September.
Michelle
Now came the hard work of negotiating a deal, and a Service Level Agreement (SLA). The SLA is a separate document outlining support and maintenance (such as what happens in case of catastrophic failure, how fast the company responds to requests, etc). Documents relating to the SLA can be found here, under "Contract Negotiations", and here, under "Systems Management Guidelines". Our IT lead started on this, and had some help from a lawyer. It helps if your group has a bit of money in reserve to pay for this. The FHN receives some money each month for being on-call, and we hold this in a common account. We used this to pay the lawyer, and to reimburse the IT lead physician for the time she put in. You don't have to have a lawyer review the software agreement or the SLA, but there is a lot of fine print. It is worthwhile doing.
Because of the fact that we are in 7 different offices, we decided to go with a "Configuration 3" set-up (for an explanation of configurations, please see the glossary). This means that we have a server (or main computer) at the hospital, with all of us accessing our data via broadband. There are some advantages to doing this: we contract with the hospital's IT department to do regular back-up and maintenance, and they keep a copy of all data off site (they do this as part of their regular hospital back-up procedures, so there are already processes set up for this). The EMR company works with the hospital to maintain and upgrade the server as needed. We no longer have to worry about back-up management, or database software issues.
The other FHN wanted to do this as well, and we agreed to share one single server, which cut the cost of the server hardware in half. If more FHNs decided to join us in the future, or if more physicians join our FHN, there is ample room on the server to accomodate them (this is called scalability).
The head of the hospital's IT agreed to have the server in the hospital. Having the hospital work with us is very helpful; perhaps having our server inside the hospital will help us to share our data. If a patient is in the Emergency room, or is admitted, appropriate data from their community-based chart should be available inside the hospital. Conversely, when a patient is discharged, I should have access to their hospital data.
We had to solve the problem of having non-FHN physicians on the server as well. If a physician has data on a different server, you have to log out and log back in to see their patients. That would not work very well in my office, where I am a FHN member, and my partner is not; my staff would have to continually log out and log in to switch between us. We had to get permission from OntarioMD to have non FHN physicians on our server, which they granted.
We were now ready for final negotiations. It was September.
Michelle
Sunday, January 08, 2006
Choosing an EMR company: unexpected difficulties
Our IT lead physician arranged a meeting for our group with the OntarioMD IT transition specialist assigned to us. Each FHN has access to a transition specialist to help with the process and the (often very complicated) forms we have to do.
Our transition specialist told us how the subsidy program works, and showed us a power point presentation about the program. She explained what the different configurations for the server are.
Our FHN has some problems. There are 9 of us, working in 7 different offices. Three of us work in a two physician practice with a non-FHN partner. We did not know how the EMR would work in this case.
The transition specialist explained that the non-FHN partners would not be eligible for the IT subsidy. The FHN negotiates as a whole, so there is only one IT contract for the whole group. Our non-FHN partners would not be negotiating with us, and we each would have to make separate agreements with them. This introduced the possibility that some practices would have a mix of physicians using and not using EMRs.
We knew about the other FHNs decision on software; our IT lead wanted to explore a few more options before deciding on a demonstration, and we agreed to do this.
We were also told to apply now for free broadband access from SSHA, as it takes from 2 to 4 months for them to install this. We were given forms to fill and fax back to SSHA. The forms include authorization for both cable and ADSL (over phone line) broadband, and you have to fill out both. SSHA decides which one should go in your office. At the same time, we were also given forms to fill for the rVPN (remote Virtual Private Network); this enables access to the practice software from other places (for example, home or cottage). I have put a link to a glossary on the right side if you find all these acronyms to be confusing.
Michelle
Our transition specialist told us how the subsidy program works, and showed us a power point presentation about the program. She explained what the different configurations for the server are.
Our FHN has some problems. There are 9 of us, working in 7 different offices. Three of us work in a two physician practice with a non-FHN partner. We did not know how the EMR would work in this case.
The transition specialist explained that the non-FHN partners would not be eligible for the IT subsidy. The FHN negotiates as a whole, so there is only one IT contract for the whole group. Our non-FHN partners would not be negotiating with us, and we each would have to make separate agreements with them. This introduced the possibility that some practices would have a mix of physicians using and not using EMRs.
We knew about the other FHNs decision on software; our IT lead wanted to explore a few more options before deciding on a demonstration, and we agreed to do this.
We were also told to apply now for free broadband access from SSHA, as it takes from 2 to 4 months for them to install this. We were given forms to fill and fax back to SSHA. The forms include authorization for both cable and ADSL (over phone line) broadband, and you have to fill out both. SSHA decides which one should go in your office. At the same time, we were also given forms to fill for the rVPN (remote Virtual Private Network); this enables access to the practice software from other places (for example, home or cottage). I have put a link to a glossary on the right side if you find all these acronyms to be confusing.
Michelle
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