Wednesday, March 29, 2006

Getting faster

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

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

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

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

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

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

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

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

It's a start.


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.


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.


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.


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.


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.