Saturday, December 30, 2006

At the nine month mark: a new year, a new beginning

I have just finished the last CPP. It took me nine month to enter almost 1,500 CPPs into the EMR; sometimes I got bogged down, when things were very busy, and didn't do any for a while. That's about 166 CPPs per month, on average. Done!!!!

During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.

Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.

My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.

One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.

In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.

There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.

It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.

There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.

I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.


Friday, December 15, 2006

Insurance companies

I dislike insurance companies. At times, it seems like their purpose is to make family physicians' lives miserable by inundating us with time consuming, difficult to fill, paper forms (multi-axial diagnoses; precise time of return to work; lenthy functional enquiries; detailed descriptions of amount of weight that a patient is able to lift; repeated requests for the same data, etc). I have noticed that, for the past several years, they are refusing to pay for the forms they request. Often, the request is urgent, detracting from patient care.

I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.

I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.

What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.

The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.

Fat chance.


Friday, December 08, 2006

Working as part of a team

The EMR is allowing me to think about working as a part of a team.

My resident did a chart audit of my diabetic patients using remote access to the EMR. It did not take her that long for 70 patients, because the data was in the flowsheets, but I would like to have automated audits in the future. The results are not bad; (2003 audit results are in brackets):

% meeting targets (July 2003 results)
BP <140/90=83% (65%)
BP <130/80=66%
LDL <2.6=63% (50%)
LDL <2.0=40%
HbA1c <8.4=81% (74%)
HbA1c <7.0=48%

There is a new clinical pharmacist in our family medicine teaching unit at my hospital. She can do consultations for our patients who need extra help with their meds. What I was thinking of doing is identifying patients from the audit who need intensification of their meds (sugar, bp, lipids) and referring them to her.

Because I am paperless, I will not do this as a paper based referral. I will give the clinical pharmacist access to my EMR as a team member, just like my resident has. Because I don't know exactly what the scope of practice for a pharmacist is, I will configure the EMR permissions together with her. The EMR has detailed permissions (permission to view, permission to sign off, permission to prescribe etc, for each part of the EMR); we will need to discuss this on set up so that she has appropriate permissions, not more and not less than needed. I figure that, as the family physician, I am the custodian of the primary care record (I don't want to call it a chart, it is becoming increasingly different from a paper chart); therefore I need to think about who can and should have access and input for this record. The "pharmacist" profile, once set, is then available to my whole group. I have an extra RSA security fob for the pharmacist, and this will log and identify her for every chart access just like every member of the team.

Once this is set up, we will mail letters to the identified patients to let them know that the pharmacist may be contacting them. She can access their chart remotely from anywhere with internet access, and call to set up an appointment anywhere convenient; it does not have to be at my office. When she sees the pt, she will be accessing their EMR chart live, and she can enter information directly in their clinical record, live. That is, it is a fully shared chart, with remote access. If we continue, she can also access the chart later for monitoring and callback. The EMR has detailed audit capabilities, so I am able to find out what each team member is doing, and who accesses the chart. If the patient needs to see me for follow-up, the pharmacist has access to my schedule, and can book the appointment.

She is coming to my office Thursday; we'll give it a try.


Sunday, December 03, 2006

Efficient and effective processes

I had a flu clinic last Monday, and will be having another one on December 11. Here is the process for the clinic: I set up a separate schedule, called "flu shot clinic", with appointments at 5 minute intervals. When patients came in, my secretary swiped their card, and entered them in the flu clinic schedule. She then sent them to the back area, where I was standing next to the vaccine fridge, and I gave them their shot. When she had time, she opened their electronic chart, clicked the button that enters the flu shot in my preventive list, and then entered the full flu shot (the lot number and dosage are pre-set in the EMR, there was no need for her to reenter the same information every time). When the clinic was finished, I changed my pre-set billing code to G591 (the Ontario code for influenza vaccination), clicked the button to auto-bill the entire schedule, clicked send, and it was done. We were finished within 5 minutes of the clinic closing. There were no charts pulled or put back. My preventive services list was automatically updated.

The EMR allows for very efficient processes, with a high degree of automation for things that are repetitive. However, this doesn't happen by itself; you have to figure out how to make the EMR work for you.

As another example, I bought an Automated BP machine (the BP Tru) in the summer. My staff is trained on it and they know how to use it. If I get a patient that requires additional BP readings (perhaps because their last BP was above 140/90), I will often ask them to come on a Friday. I am not in the office Friday. My secretary takes their BP using the BP Tru, and enters the average reading (which the machine produces out of several BP readings) in the EMR. I see it remotely, and will send back a message if needed. The current guidelines say that if office BP is between 140/90 and 160/100, you need 4 to 5 visits to diagnose HT. I can get several visits done pretty easily this way. I also use home BP (Lifesource monitor) extensively. I also use the Friday BP visits for diabetic BP slightly above 130/80, for verification. The EMR generates lists and graphs of Blood pressures, so it is easy to follow them. Having my staff help me, and using automated electronic equipment and EMR has improved my quality of care.

My secretary tells me that I won't have a single paper chart belonging to me in the office by 2007. We are currently scanning the Inactive Patient charts, and that is the last of it. I will put 4 filing cabinets for sale on Craigslist over the holidays. I was trying to figure out how much we pay for the space for these: each filing cabinet is 1.5 ft x 3 ft. I have an exam room that is not usable because of filing cabinets, that is 9 ft x 9 ft. I also have to figure out some space to walk around the cabinets. In addition, I no longer store handouts or chart aids (they are scanned into the computer, or accessed from the Internet). This must be about 150 sq feet for my office; at $30 rent per sq foot in my area, that is $4,500 per year for paper storage. I wonder what an office designed with no paper from the start would look like.

Interestingly, I seem to be going through more paper since starting the EMR. However, I look at it as "good paper". For example, when a patient is in for their annual physical, they are usually sitting on the exam table. I have the Tablet sitting beside them, with the screen turned so they can see it. I load the CPP, and point to it as I talk, to verify the information. When that is finished, the last step is for me to say: "I will print a copy for you to have on hand, in case you need to use it". That is now routine. As well, I'll often print a copy of the flowsheet for diabetic patients, so they can see how their results compare with recommended results. I am certainly printing lots of handouts, such as calcium/vitamin D recommendations during full checkups. The storage cost for Good Paper is essentially nil, because they are just blank sheets ordered from the office supply store as needed.