Friday, September 29, 2006

Distributed information

My Tablet is back from the repair shop. The problem was that a small cable was getting caught when I twisted and closed the screen. They replaced it, but it took a whole week.

While the machine was getting its vasectomy reversal, I was using the backup laptop. What was interesting was that most of the functions that I use no longer reside inside my machine, so it wasn't as bad as I thought. Of course, the EMR isn't even in my office. My scanned old charts are on a networked external hard drive. The scanned paper requisitions (public health, Diabetes Education referral etc) are on the front machine. I still had some trouble, because my payroll program and Quicken (which I use for the practice's bookkeeping) are on the Tablet. These are backed up to a USB key, but I would have had to reinstall the programs on another PC. I guess the information is getting distributed to all kinds of different places; the laptops or PCs used to access the data do not actually hold that data inside. This is what they mean by "thin clients".

I received a report for someone who is another doctor's patient; her physician is part of my group. What I did is I scanned the report and uploaded it directly to the patient's chart. I sent a brief message so that the other office would be aware of what I did; I received a message from my colleague saying that the report was there, and it was no problem. I guess we can scan and upload from any office for any patient in this group.

This is interesting, because the government recently approved our application to become a "Family Health Team", or FHT. What that means is that we get some extra money to hire other health care workers, such as social workers or mental health workers, for our group. They will need to have remote access to the EMR as well; that way they can see and enter information directly into the patient's chart. We'll have to figure out what type of access each person can have. The location where the patient is seen no longer really matters, since access to the chart can be from anywhere.

I don't know yet how this will function, or who exactly we need to hire. I think it may help to have the occasional face to face team meetings, but I'm not sure how much of that we need. I find I work quite well with our home care coordinators or our Regional Geriatric Program, and contact is mostly over the phone. I have a feeling much of the communication will be over the internal EMR email, which is much more efficient. We'll probably get together if we decide to plan a new program, like an asthma clinic for patients identified as needing group education; otherwise, I don't really think I want more meetings, I have enough of those already. I think the key to this team approach will be the Distributed EMR.


Friday, September 22, 2006

Electronic lab requisitions

I've started using electronic lab requisitions, and electronic Diagnostic Imaging requisitions. The lab reqs replicate the look of the paper Ontario lab requisitions, but the patient information is pre-filled. I had to think about that one, because if that's all there was, there is really no advantage to having electronic lab reqs; in fact, it is faster to just pick a blank req from my pile, tick off the couple of lab tests that I want, and have my secretary put on a label.

However, I found that I could pre-fill a series of lab tests, giving me a list of "favourite" lab forms. I made a series of them: full check up for diabetics, full check up for hypertensives, full check up for people age 40 and over, Methotrexate blood work, first prenatal exam. That is akin to standing orders, and will save me time; it will also increase quality, because now I can't forget to do a microalb/creat ratio for diabetics. I can add additional tests to each req if needed, but I have all the basics covered.

If I generate a lab req electronically, there is a record of what I ordered in the patient encounter; when the results come in, they match against the requisition, so I can see if they were received. However, the match is against the entire req; that is, individual results do not reconcile (the system can't see if the TSH I ordered was done, but it does see whether a batch of lab tests for that requisition came in). That probably stems from the fact that the req is a replica of a paper-based process; individual tests are not coded electronically.

All public health forms (such as HIV or viral studies) are paper-based, and require their own paper requisitions. I have stamped the forms and scanned them in to my system to be printed as needed. All public health results come in on paper only and have to be scanned in. I know public health is very underfunded, but it seems to me that this is one area that would really benefit from better information systems, especially if we have another crisis.

I have a couple of favourite DI reqs, such as bone density requisitions for my hospital, and CXR for the local facility. Saving time in EMRs often comes from automating things that are done repeatedly.

It is interesting being connected. Last week, a patient came in because of a delay: she likely has severe OA of her knee, and she's in her early 50s. The surgeon won't see her until she has a MRI; however, there is a long waiting list for MRIs at my hospital because of high demand. Her MRI isn't until late November, so her ortho appointment was delayed until January; she's in pain. I loaded up the Ontario wait time website, which I've put on my EMR's list of internal websites, and we found a nearby facility with a median wait of only 12 days. I asked my patient to call them, and find out how to refer; a referral sheet came the next day and we faxed it over.

Eventually, I would prefer to send everything electronically (lab reqs, DI, prescriptions, public health, referrals), much like I do my banking. We're still a long way from this.


Friday, September 15, 2006


My Tablet failed. It is still usable, but when I flip the screen and shut it to turn it into a slate, the screen goes dark just as it is about to be shut. I phoned IBM; we have an extended 3 year warranty, but it does not include on-site service. They sent me a box so I can ship the Tablet to them. I'm not going to do that; I don't know how soon it will come back.

This brings me to the issue of redundancy. What do you do if some of your hardware or software fails? It was hard to plan well for that at the beginning of EMR, because I was too busy just keeping my head above water. Now that things are smoother, I have managed to put in some safety valves.

I do not know of any manual that outlines exactly what we should plan for; perhaps practices are too individual for that. I figure that it is good to identify things that you can't do without, the so called "mission criticals", and plan for what happens if they did fail. In any case, here is what I have done in my practice.


Practice data is the most "mission critical" thing there is. In my FHN, we have the server at the hospital, so they back it up nightly (as part of their routine back-up systems for the whole hospital's IT), and keep a spare copy at a second hospital site. The data has been validated, which means that they've looked at it to make sure that the copy is good. If the server fails, the most we can lose is a day's data. We had server failures early on in the project, so we know what to do if that happens: write notes on paper and scan into the EMR later; do prescription refills when the system is working again. Things are much more stable now, but if there is a problem, we know what to do.

There is also local data. The scanned charts in my external hard drive have been backed up to 2 DVDs, 1 copy at my office and 1 at home. As new charts get added from the inactive files, we back them up to DVDs weekly. The local data on my Tablet (patient handouts, clinical cheat notes, reports from committees I sit on, etc) gets backed up to an external hard drive at my home (sometimes).

Internet connection

I have a back-up internet connection to access the server via VPN in case SSHA fails. That required paying someone from Nightingale to come and do it properly; the office network is sufficiently complicated that I cannot manage this myself.


I have a spare laptop to use in case my Tablet really breaks; I carry it around, it can get dropped. The laptop is used by my resident a half day a week, so I know it is properly configured and ready to go. When not in use, it is attached to a laptop lock beside the vaccine fridge.

The Tablet has a stylus to write on its screen; I use the stylus instead of a mouse. These are always getting misplaced; I have two spares, 1 in each exam room.

There are two desktop PCs at the front. If one fails, we can still function, and can use the laptop temporarily.

As far as the screen problem on my Tablet, IBM gave me the name of several local companies that they use. I am responsible for the cost of the "housecall" (about $95/hour) if I choose to have someone come to my office, and they will pay for the repair. I phoned around, and there is a very reputable company close to where I live. They told me that if I bring the Tablet to them, there is no extra charge. That's what I will do.


Friday, September 08, 2006

Having a resident in an EMR practice

After five months of use, the EMR is starting to pay significant dividends. We had no chart pulls this week; my practice is now paperless. All the old charts of active patients have been scanned and shredded, and we have now started scanning charts of inactive and transferred patients. I had to look at an old chart from home today, and just clicked on the file from the backup DVD of my practice; there it was. Amazing.

My desk was completely clear at the end of the week, despite having been away for two weeks, and I have no backlog. I feel as if I'm bragging!

My resident has now been given remote access to the EMR. I have taken on a few new patients recently; they have been specifically assigned to her, so she can build a "mini-practice" while working under supervision. She is only in my office one half day every week, so we were talking about how she can manage lab tests for her patients, because these are coming back before the week is up. We decided to do this: I will look at all results as they come in, and will deal with all urgent reports (such as INRs). She will log on remotely periodically. If results are abnormal, but not urgent, she will deal with them as she sees the result, and put a note in the EMR. She cannot sign off on lab reports, so I will always see the comments. We will use the internal messaging in the EMR to communicate about patients, because this is much more secure than email. This remote lab review would work very well for a family physician who has a very part-time practice. I have a "dummy patient"chart that my resident can use to practice, so she can see how templates and other more advanced aspect of the EMR work.

I printed and scanned a diabetic flow sheet so that you can see what it looks like in practice. Lab results and vitals go in automatically, and I enter the last four items manually; notes and meds are also for manual entry as required. Flow sheets are customizable, so you can put in the parameters you need. I have made flow sheets for diabetes, for asthma, for depression, for INR management, and for BP/wt loss. I'll probably make more; they are especially useful for chronic disease management.

No way I'd ever go back to paper.


Tuesday, September 05, 2006

Back to reality

I am back from vacation, and my office is getting very busy after the summer hiatus.

During my absence, my (non-EMR) partner looked after my patients. He had some problems, as he could not see CPPs or previous encounters on the EMR, so my staff had to print a lot of things for him. I looked at the Permissions in my System Set up module, and realized that I could have given him access to read-only forms of my CPPs and encounters. I'll know better for next time.

My resident saw several of my patients, and entered the data for me to sign off later (which I did remotely).

I had been away for two weeks; I told my staff that I would have no access to the Internet for the first week, but that I would access the EMR the second week. My partner still looked after urgent lab result, and saw patients that needed to come in. However, I could deal with most incoming lab/reports remotely, and sent several messages to my staff. It was about 3 hours of work over the week.

When I came back this morning, after a two week absence, I had about 45 minutes of work (mainly forms to fill out). There were no stacks of charts and papers to review.

There are pros and cons of doing things this way during vacation. You have to be willing to give up some of your vacation time. You cannot deal with more urgent things remotely, unless you commit to logging on daily, which is not always possible or even desirable during vacation. On the other hand, there is much less chaos and pressure when you come back, as most things have been taken care of and filed away.

We received two record transfer requests while I was away. We printed the chart from the EMR, using the "print whole chart" feature; the CPP and encounters were printed very quickly, but it did not print the scanned documents (these are not OCR'd and pasted in the record, so you have to load them to see them). It looks like you still have to load scanned material to print individually, so printing a whole chart is not as quick as I expected. However, the old paper chart is now a pdf document, and that simply gets transferred to a CD ROM to mail out--size of chart no longer matters.

I do the bookkeeping for my practice (on Quicken). I have now registered for on-line business banking, and did my first electronic reconciliation today (much faster and easier). I plan to switch to on-line payments as much as possible. I think having an EMR has made me think of what other paperwork I can reduce.