Friday, April 13, 2007


I've been asked how I do housecalls with EMR. I did a housecall on Wednesday.

I review the chart before going. I print the CPP (which has the patient's date of birth, health card number, address and phone number on top). I take that to the housecall; it helps to have the address, I don't have to copy it from the chart.

During the housecall, I may make a brief note on paper; when I get back to the office, I document the visit in the EMR. For simple prescriptions, I give the patient a written script (entered in the EMR later); for more complicated prescriptions, I ask for the pharmacy number; I print from the EMR to fax it in later. I have an ethernet cable in my laptop bag, in case there is internet access where I am going.

On Wednesday's housecall, I had to call an ambulance. It was good to be able to give the ambulance attendants a printed CPP with all the information on it. It would be better if the CPP was securely available on-line when needed, but this can't be done yet.

I found out from a colleague that I can stop the paper lab reports; this does not have to be done as a group. It was was surprisingly easy to do--just two emails and a faxed letter.

I continue to be amazed at the satisfaction that I am getting from the paper Bgone process, and others are telling me the same thing. My consultation room is uncluttered, and my exam rooms are much neater. When drug reps come in, I no longer accept pads of patient handouts; I will take a single page if it looks interesting, and will scan it in later if it is really useful. The reps now manage the sample cupboard, they put the drugs in the cupboard (and never on the counter). A rep came in on Tuesday carrying two cases of enormously over-packaged samples; this was promptly rejected. My practice team is much more conscious of office space usage, and I think I feel more Green.

I've put patient instructions on my saved favourite DI reqs, so that these are always printed along with the req. As well, our Total Joint Assessment Centre has specific requirements for knee and hip XRs; I've saved those as a favourite DI req, so I know that the appropriate XR will automatically be done in the future. I've emailed samples of electronically generated Diabetes Education Centre reqs and MRI reqs to both centres, and have asked if I can use those instead of the scanned standard reqs. If I generate those electronically, they are part of the chart, all the demographics are automatically entered, there is no bad handwriting, and the referral can be tracked. They will have a look and let me know; there is a good relationship between the hospital and family physicians, so things like this often happen.

Very good



Gabriel said...

It is funny how close our EMR implementations seem to be mirroring one another. There seems to be a common group of problems / features to be implemented that have been conquered in a similar sequence, even though we are using different EMRs. I wonder if other EMR users find a similar situation. I am currently trying to work with my hospital to end the avalanche of diagnostic imaging and consultation reports that flood my hospital inbox. Currently, we are taking the piece of paper and then scanning it into the EMR. Since the reports were generated and stored electronically there must be a way to bypass the need to print things out on paper. I hope that we can get reports electronically generated into PDF format that we can download from an electronic mailbox on the hospital server. Then we would cut and paste the information into the EMR. Have you tackled this problem yet?

Michelle Greiver said...

I agree with you, there are common issues with all EMR implementations. I do not think any EMR vendor can truthfully claim that their product is easier to implement than others. I have found evidence of both success and failure with the same software in the literature.

My group has been talking to the hospital about linking their system with ours. There has been some progress, and they have said that this will be done this year; I'm not sure about that, but it does look like it will happen.

I don't know how it will be done, but here are some ideas. Each patient is uniquely identified by health number/date of birth/name; these are in discrete fields in the hospital's database. The data needs to flow in electronically, and be automatically attached to the chart using the unique identifier. Ideally, this would be the same process as the lab data, with an electronic consult letter/DI report that cannot be modified, but to which you can add comments.

It would be good if there were fields for diagnosis (with a checkbox to accept into CPP) and medications (same). I think that this is less likely to happen at the beginning, but perhaps in time.

Information systems become more valuable when more people use them (example: fax, email). We are slowly getting there with EMRs.


Michael Milne said...

For housecalls, an EMR should be designed to allow access through a VPN and a wireless broadband connection. There are some techical issues that because of the design of some EMRs may prevent this. There are also other issues that an EMR vendor needs to consider when your data is bouncing off cell towers.

Medscribbler is designed to give real-time access for housecalls. We have a group of doctors who do nothing but housecalls. They are all linked together and to the main database located at their main office with the secretary. They can even write notes as they drive - not a recommended driving policy - that a collegue 50 miles away can read as soon as the save button is pushed.

Michelle Greiver said...

Thank you. Acess via VPN is exactly what I do during a housecall, if broadband internet access is available. The problem is that sometimes it is not.

I know there are more and more hotspots, so that may be the solution in the future, although I can't believe hotspot access will be free. In Toronto, I think we have this downtown, and it is free for now, but only for 6 months.

It does not matter if you access the EMR via wired or wireless. Once you enter your data, it is available to all members of the group, same as described in your note. This is the same for all current EMR applications. I agree with not using the application in the car; you can use it at Starbucks, but privacy may be a condern.