Monday, May 29, 2006

At the two month mark

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

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

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

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

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

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

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

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

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

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


Monday, May 22, 2006

Electronic and paper charts

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

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

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

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

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

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


Monday, May 15, 2006

Flow sheets and lab requisitions

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

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

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

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

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

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


Thursday, May 11, 2006

Power failure

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

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

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

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

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

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


Sunday, May 07, 2006

Reducing paper

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

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

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

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

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


Wednesday, May 03, 2006

Templates and handouts

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

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

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

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

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

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