Friday, June 23, 2006

At the three month mark

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

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

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

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

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

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

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

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

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

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

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

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



Unknown said...

As I started a similar job like yours, I will make some comments. I'm the medical responsible for the implementation of an EMR in my region, in Quebec. We had started the process for nearly one month in two clinics. but for some parts only, billing/scheduling/patient indexing and since one week: prescription.

We too had problems with the internet. Our ISP decided to work on their equipment and they cut the internet without any warnings... Hopefully we had a spare internet connection and we remove the primary one with the spare. But I think there's a piece of equipment that do this job alone. It's always checking the two connections, and if one goes bad, switch on the good one. Have heard about that ?

I take this time to say that you site is very helpful for me, since we are in a similar process for our region. But I'm very impress by the support that you have for you implementation.

Continue your nice job !

Eric Paradis MD

Michelle Greiver said...

Hello, Dr. Paradis, and thank you for the comments. It looks like your start-up process is similar to what we did: billing/scheduling/demographic data first, EMR a month later. Like you, I started the EMR with prescriptions, then did referral letters and clinical notes soon after. Scanning then came in.

I didn't know that there is a piece of equipment that checks internet connection for you. I don't know if I can use that,though, because we access the server via the government's SSHA system. It has to go through their firewall appliance, which won't work with other ISPs. I will have to ask.

It is a problem with these systems; they are very complex. Sometimes it is not obvious who is responsible for what, or who to ask.

As far as the support, I've gotten a lot of help from my colleagues in my group, from the software company, and from SSHA. This is too much for one physician in a small practice to manage; without help and support (especially at the beginning), you're sunk.

Good luck with your implementation!