Friday, August 18, 2006


Yesterday was my last day at the office for two weeks, and I was covering two practices. Thursdays are my late days, when I see patients into the evening. It was busy. I ended up with 29 charts that needed completion by the end of the day.

Before EMR, I would stay on and complete my charts. I cannot take 29 charts home when going on vacation, because my partner would have no access to them. Yesterday, I just shut my computer, and went home; I was too tired. I finished my charts from home today in about an hour, meaning it took about 2 minutes per file to chart and bill. I don't know if that is faster than on paper, but it was certainly less stressful than staying even later at the office to complete the paperwork.

During patient encounters, I had completed pieces of the record that I would be likely to forget, such as blood pressure measurements or positive findings. As well, all my prescriptions were already recorded, since prescribing and recording happen at the same time. I had volunteered for a study on errors in family practice a few years ago, and found that a common error for me was failing to note a prescription in my record (if I prescribe several repeat medications, and then add a "less important" drug such as cortisone cream, the cortisone cream may not get recorded). This was worse when I was busier. The study found that office processes (such as not finding the chart) were the commonest source of errors, followed by medication errors. With EMR, the risk of lost charts is essentially gone, while the risk of medication errors is lessened (automatic allergy and drug interaction alerts, consistent recording of all drugs in the record, decreased risk of refill errors).

Late Wednesday night, my lab called me regarding a critical result. While I was talking to my patient, I recorded the information on her chart. Remote access to my charts is proving to be truly invaluable.

We tried the automatic blood pressure machine, and really liked it; we are using it consistently for annual check-ups. We decided how to implement staff monitoring of blood pressures for diabetics: at the end of appointments I give my diabetic patients a "ticket" (I have a pad of paper for this on my desk), which says "DM, 3 months". The appointment then gets labeled with a colour assigned to diabetic follow-ups, and when the patient returns, my staff weighs them, takes their BP and enters the information in the EMR before they see me. I guess I'm using this as an example of how processes get thought about and changed at my office.

We should have the rest of my active charts scanned in by the time I return from vacation, in September. I took a back-up DVD home with me, to lock away in my cabinet. In September, we'll start scanning inactive/transferred charts. It is odd for me to think that I can carry my entire practice with me in a couple of DVDs.



Anonymous said...

HI, Michelle

I also use Nightingale. I was wondering how you had implemented your "preventative health tables" into the EMR and how you are integrating this and tracking your preventative care in your new CPP. Do you use the Flowsheets for this? I have been pondering how to best track preventative care in the EMR?

Michelle Greiver said...

What I've done is use their Template Designer (either in System Setup or in Enterprise if you want to share with your group).

I took the tables pretty much as you see them on my website, , and put each recommendation as a checkbox. You can see the Well baby templates in System templates as an example of how to do that.

Under the tables, I put in a brief functional enquiry, then vital signs,and then physical exam.

When I do a check-up, I load the whole thing and go through it. If there is something I missed, or that I want to reemphasize, I'll put it in Past Medical History in the CPP, so I can do it next time.

This is good for the first (or intake) full check up. I'm using these for now, to document the first check up in the EMR. For subsequent check ups, I don't need the full tables, as most of the manoevres don't need to be repeated (I don't need to ask about seatbelts five times, unless it is a problem). I will make templates for follow up physicals, with things that I want to go over yearly (such as diet, exercise, asking about falls in the elderly etc).

Nightingale told me that they will be putting the preventive tables in the System templates, so you can have a look at them then.

Hope that helps; pls let me if you have found other ways to implement preventive care, I'd be interested.