Friday, January 19, 2007

Having fun with the EMR

Now that the transition is essentially over, the EMR is not just efficient, it is also fun. Everything is always done; everything is tracked; there is little to no loose paper flying around

My secretary was commenting on how efficient we have become. There was a call from a specialist's office, as they needed copies of some Diagnostic Imaging reports for one of my patients, from October. It took her under 30 seconds to load the chart, locate the reports, and fax them over, all without leaving her desk. Because of the enormous gains in efficiency, they have time to do more call backs to patients about test results. As a result, my staff are becoming much more knowlegeable about tests; I no longer put in normal ranges for fasting sugar when I send an e-note to call a patient, because they know this. They are becoming more like clinical assistants.

I am starting to use a lot of flowsheets; I have found that this is the best way to correlate several things (BP and medication changes; Asthma exacerbations; CHF: weight, eGFR, medications). This is a list of my current flowsheets:

Active Flowsheets:
Flowsheet Name Description
Asthma flowsheet Flow sheet for management of asthma
CHF flowsheet
Depression flowsheet
diabetic flow
INR Flowsheet for INR
Weight loss, BP

I have figured out how to make results from several different labs mesh together, so that they go into one common flowsheet.

I have also made a couple of "history builders"; these are a type of template where you click on a link, and a series of phrases comes up, which you then save to the record. This is the builder called "normal neurological exam":

"Pupils are equal and reactive to light and accomodation. Fundi are grossly normal, with no papilledema. Cranial nerves II-XII are intact. Neck is supple. Motor examination reveals normal gait and normal strength bilaterally. Reflexes are equal bilaterally and within normal limits. Sensory examination is normal with respect to touch."

If there is something abnormal, you can always change it before saving. It saves a lot of typing. I have a two part Builder for BCP counseling; the first link is if I did STI counseling, and the second is for discussion of BCP benefits and side effects.

I probably should do one to document discussion of Steroid side effects. This is good for anything where there is standard counseling.

I had a look at my activity log; I've reproduced a bit of it below, without patient identification. This gives me a pretty good idea of what I am doing during my day.

9:47 AM Greiver, Michelle

Edit Encounter

9:51 AM Greiver, Michelle

Add Medications

9:52 AM Greiver, Michelle

Add Lab Requisition

9:54 AM Greiver, Michelle

Add Clinical Notes Subjective/Objective

9:54 AM Greiver, Michelle

Add Assessment

9:54 AM Greiver, Michelle

Edit Plan Notes

9:54 AM Greiver, Michelle

Sign off Encounter

I have my email loaded, which can be distracting at times. However, it does make sending links like the BP Action Plan from the Heart and Stroke Foundation, or the excellent self-care depression booklet very easy to do. I have the links inside the EMR, load them up, ask for permission from my patient, and then copy/paste the URL into an email to my patients. This is a really great way to extend the education done at the office; the EMR tracks the fact that a link was sent.

Some abnormal blood results came in for one of my resident's patient. I sent her an email to please log on to the EMR and have a look at the results. She had a look, and emailed me a very appropriate management plan. I am still responsible for the patient's care, and will manage any urgent reports, but this gives my resident the ability to look after her own patients even if she is only here one half day a week. Continuity of care in residency is now a reality. My group is talking about adding a nurse practitioner, since we are becoming a Family Health Team. Team based care can involve the same processes me and my resident are now using.

I know that the transition to EMR is challenging, having been there. However, now that I am paperless, I have found that the EMR is making my practice more fun, more efficient, and definitely more interesting. And I still expect more.



Anonymous said...

Strangely, I had a patient come into my EMR equipped office today and tell me that she works for Nightingale. I mentioned your name and she lauded your praises. I am finding that the main difficulty is not in harnessing the power of the EMR but getting my 9 colleagues in the office to do the same. I have been an early IT adopter and tried to do everything through the EMR but I have people at different stages. There are a 3 of us doing prescriptions, notes, reviewing labs, remotely faxing consults (basically everything) on the computer. We then have others that use the EMR only for prescriptions and still paper chart everything. Then we have others that refuse to use electronic labs. And others don't use the remote faxing. My staff find the situation confusing and inefficient. Some of the doctors don't seem particularly interested in changing or investing time to learn the process. Barriers mentioned are: time, lack of computer knowledge, poor typing skills. I end up feeling frustrated. Any suggestions on encouraging change in others?

Michelle Greiver said...

I have the same issue, on a smaller scale, at my office; my practice partner will not adopt EMR and continues to be fully paper based. We discussed this extensively at the beginning, and agreed to share the scheduling and billing modules (front office).

I think you will continue to have hybrid practices for now. There is little to no point in trying to push colleagues who do not want to go to EMR; the value is in helping those that do. It's a bit like the stages of change model. I think you likely know your practice partners well enough to guess where they are at.

What we'll need to do is to make sure that the hybrid practices work as well as they can.
1. Billing/scheduling through single system
2. in a 9 physician office, it may be possible to split into 3 groups of 3, and assign staff to be EMR (3 physicians), dual (3), and paper only (3); there will be some overlap depending on your practice staffing arrangements, but there should be a way to assign primary responsibility to staff. It may be worthwhile getting a MD management practice consultant in for advice.

In the future, you may well see practice rearrangement, when leases come up. Physicians adopting EMR may well prefer to join others that are like-minded.

I hope this helps. We can try to change what we can, and have to accept (and manage) what we can't.