Friday, October 27, 2006

Managing Flu shots with the EMR

Computers are good at making lists of things. As of October 1st, my EMR automatically generated a list of patients age 65 and over, since they are due for a flu shot. I have two lists
  1. a Report list, which shows how many patients I have that are 65 and over, how many received a flu shot, and the percentage who have been vaccinated
  2. a Letters to send list; this shows me the list of everyone who has not been vaccinated so I can generate a personalized letter for them. The list has buttons that you click on to generate letters
I wrote a letter inviting my patients to come in for the shot. We run two flu shot clinics in the evening, and the letter also includes the date and time for those. We bought window envelopes; the letters get folded so that the address shows in the window, so that we don't have to print labels.

When a patient gets a flu shot, I have a button that I click on in my Summary sheet. That removes the patient from the Letters to send list, and marks them as vaccinated in the report. Then I start the encounter; in it, I click on the drop down list for vaccines, and click on "influenza". I've preprogrammed information on lot number, expiry date, and route of administration, so that all gets automatically recorded. If the lot number changes, I can update the saved information.

If a patient gets a flu shot outside of my office, I just click on the button in my Summary sheet.

The vaccines are late this year. I've had to defer the clinics; we'll have one on November 27th, for high risk patients, and one on December 11th for everyone. I've posted this all over my office, and put it on my website. I've been telling people to look at my website to find out when the clinics are.

I was talking with my staff: after 6 months of use, we now have very little that is still managed outside of the EMR. All clinical notes, prescriptions, phone calls and inter-office messages are recorded in the EMR. Requisitions (DI and lab) are now generated in the EMR, with the exception of pap reqs (my lab has still not authorized this), public health reqs, and some specialized reqs (Diabetes education, MRIs). All letters and consult notes are in the EMR. Everything that comes in is scanned and then shredded.

I figured out how to upload faxes without printing and then scanning. What we do is view the fax, then click File, Print, Print to pdf. That transforms the fax into a nice, very legible pdf file, which is then saved to the "charts to upload" folder on the desktop. It is then uploaded to the patient chart along with the scanned files, which are saved into the same folder. I taught my scanning tech how to do it, and we have had no problems.

An 18 page old chart came by fax. Rather than printing it to paper, we saved it as a pdf file to the external hard drive where all my old charts are kept.

My friend at IBM told me to download a copy of Adobe Reader, and archive it. That way, I can make sure my files are readable in the future. I saved a copy to DVD.

My scanner sent a message that it needed a new pin roller; this is something that you replace after 100,000 pages. I guess we scanned that many. We're now scanning all the files of deceased patients. I think by the time this is over, I'll manage with a single filing shelf.

We had a meeting for my group of physicians last Tuesday. I think I've gone the furthest; most people have entered CPPs, some are prescribing in the EMR. We're going to go to Nightingale's computer training room at the end of November to share tips and tricks. We're starting to receive the montly EMR subsidy from OntarioMD, which is $600 per month for 3 years. I've also received a $2,500 bonus for entering over 600 CPPs.

My own family physician has retired. I will be going to one of the physicians in my group, for two reasons. That person is an excellent family doctor; as well, my chart will be on our server, so that I can access my own data. I've already entered my demographics, my CPP, and uploaded a couple of reports. I'm healthy now, so accessing my data is not that important; however, if I get sick, I want to know what is happening to me. I've made it so that I can.


Saturday, October 14, 2006

Lights out

Thursday was a terrible day. Our server went down at 2:30; then a transformer blew, and the electricity went out for my street at 3:30, for the rest of the day.

With no electricity, I could not even access my old charts, which are stored on my external hard drive. The data on those is already a couple of months old, but at least there is some information there. This is a risk of going fully paperless: if there is a major power interruption, I am stuck.

Having been through a couple of server problems earlier on, I had some idea of what to do: jot brief notes on paper; only give prescriptions that are not recurring (such as antibiotics), or recurring prescriptions for patients who were on only one medication and knew what it was (such as birth control pills). All complex renewals to be faxed to the pharmacy once the system was working again. It was difficult to function: people were asking me what the result of their tests were, and I could not tell them. None of my fancy recall systems were working: I had no flowsheets for a diabetic that came in; I could not remember exactly why I had asked an elderly patient with multiple problems and cognitive impairment to come in (and neither could he). I ended up rescheduling some appointments.

I work late on Thursdays; without access to the scheduler, we had no way to even call patients to ask them not to come if they were booked after sunset. My secretary brought some flashlights. One of my exam rooms has a window and faces West, so I saw patients there while there was still light.

The server came back on at 6:30 pm (which was of no use to me at the office, without electricity). I went home after seeing my last patient in the dark, and completed my charts remotely. I left for a conference the next day.

My group is very unhappy with this server interruption. We will be meeting with the company to discuss what happened: service interruptions can come from the hospital, from SSHA (which provides our internet access), and from the server itself. Since start-up, we have had interruptions caused by all three. Having a centrally managed server has advantages (managed backups, managed security, centralized upgrades, ability to securely share patient data between several providers), but also introduces complexity to the system. Along with this complexity come multiple possible failure points. I think my group is an early adopter of an enterprise-level system; down the line, it is probably the right way to go, but this week it just felt like a lot of birthing pains.


Saturday, October 07, 2006

Tracking patients, tracking reports

The EMR allows tracking of several things. I've already mentioned tracking of lab results, which is not perfect, but is much better than what I had before (nothing). It tracks DI reports, and also consultation requests. I have three folders for tracking requests to the outside (lab, DI, consults).

I had a look at my consultation requests folder recently. The largest number are for derm referrals (I probably over-use this); Second was for ENT. When I send a consult, I can put in a "date expected" in a drop down field; if the date is exceeded, the request is highlighted in red. One of my patients had a rather serious medical problem, and no report was received. We sent in a note to the specialist, and they told us that she had cancelled. This lady comes in fairly often, so I will ask her what she would like to do. When a report is received, I click off "received"; in the future, perhaps we can do audits to see what actual times between referral and report are.

There are therefore a couple of advantages to this
  1. you can get a sense of what your referral pattern is like
  2. you can track patients to see what happened
  3. you may be able to get a sense of waiting times. That might be useful for wait time management for our health care system in the future
I also track "follow-ups" in my office. When someone needs a follow up (1st rx for HCTZ: needs K+; 1st rx for ACEI: needs K+, creatinine; etc), this shows up in my Summary screen when I load up the chart, to remind me. However, it also shows up as a list of Follow-ups, so I can see which ones were missed. A common miss seems to be the follow up for depression therapy, after a patient was given a first script for a SSRI. They don't book the follow up appointment with my secretary when they come out, and they don't come back. Guilt and hopelessness are features of depression, so it is no wonder this happens. Right now, I don't have the resources to do something about this; however, once we have the FHT going, I wonder if it might not be good to assign a mental health worker to phone these people. Same thing for people who have missed more than one of the recurring DM follow-ups.

There are problems with doing this, such as how much is the physician's responsibility and how much is the patient's. Tracking does make recalls for chronic disease management possible; we already do it for preventive services, such as influenza or pap smears. We'll have to decide how much is possible to do, which problems to target, and how to do it.