Saturday, June 23, 2007


Data entry for the preventive services is proceeding; we receive stacks of paper with the date of last pap/mammogram/flu shot from the Ministry of Health, reflecting billing done for those services. The students have now transferred most of this paper-based data to the EMR. We have hired a medical student to audit charts with missing billing data; he will actually be able to do this remotely for some of the data, using the EMR; that will be done from my office. Searching for lab data (paps) is pretty simple; searching for mammograms is more difficult as not all practices are scanning yet, so mammograms won't be in the electronic charts. He'll do a first audit in the EMR, and will then visit each practice to audit paper charts for the rest of the services. The EMR audit should be a lot faster than the paper chart audit, but it will be interesting to compare the two.

Once those audits are completed, we'll be ready to send out the first reminder letters. Each physician in my group will need to review and agree to the format of their letter, and then our FHN admin will send those out for the entire group. There is no doubt in my mind that EMR-enabled group functions are now a reality, because I see them happening in front of me. The Pay-for-Performance incentives for preventive services were crucial to get this going; I think P4P may well be an important aspect of EMR implementation.

Our FHN IT person came by my office last Thursday. I showed him how my scanned handouts and reqs work: they are on the external hard drive at the front, which is shared across my network (any of my office computers can access them). I gave him a copy of my scanned handout/req folder on CD ROM, to use for any one else in my group who wishes to have them. I also have pop-up messaging for instant communication in the office, and he had a look at that. He has already installed a much faster and larger hard drive at one of my colleague's office.

Four of the nine of us are now routinely scanning to the EMR; a fifth one is just starting. The handwriting template I installed remotely on my colleague's EMR is now working, and he's now using EMR for encounters.

I think we have progress!


Friday, June 15, 2007

The big office

Plans are progressing for our Family Health Team. We now have an executive director, and are in the process of hiring social workers, dieticians and nurses. There is much talk about having one big office, with about 10 to 15 family physicians and Allied Health professionals in one location, using the same EMR software. This is very different from what most of us are used to doing.

It will be interesting, because some of us will stay in our current offices, and some will relocate. The EMR will still work, because of its distributed nature. I think one advantage of having everyone in a central location will be the ability to schedule on-going training (and ad-hoc training as well). I have a feeling there will be a room with lots of computers somewhere in there.

The pharmacist saw my first patient (without me being there), using the EMR. I think it went OK; she entered the data as an encounter in the record, and scheduled a follow-up. The medication management will present more of a challenge; to be properly searchable, medications have to be entered in a structured manner, which makes things harder at the beginning than simply scrawling something on a prescription pad. When I discontinue a drug, I enter a reason; I can always see why the drug was stopped if I choose to look later on, but I learned how to do it, and where to search. I think I will need to sit down with the pharmacist and go over some examples of drug management (auto-filling information on new drugs; changing dosages; stopping a drug and replacing it with another; renewing medications quickly; managing drug expiry dates; entering reasons for discontinuation; drug interactions and allergy alerts; drugs and flowsheets). My resident, who uses the EMR on an on-going basis, is very adept at this, and may be able to help out. I can see the benefits of co-locating, because you can transfer what you know to others more efficiently if you go over things together.

I have now been told that I will be getting a computer to let patients book their own appointments in my waiting room on July 15th; I would still like to have on-line booking and on-line patient access to their records in the future. I saw an article in this week's New England Journal of Medicine that describes a clinic with "online appointment scheduling, electronic prescription refills, general messaging capabilities, and "Web visits" with physicians". It can be done; maybe it would be easier to do in a big office than in my small practice.

I actually tried to do an electronic prescription refill when my fax line went down several weeks ago (for a narcotic prescription for a patient with severe pain), and there was simply no way to get around the regulations. True electronic prescriptions do not exist here; we are obliged to print the EMR-generated prescription on paper, or to use fax/phone technology (who decided that fax/phone is better?). I would like to have a central, secure server, where I can transmit the prescription electronically. When the patient shows up at a pharmacy, they swipe a card and enter their pin number, and the prescription downloads to the pharmacy. I have trouble imagining a banking system where your checks get treated like my prescriptions do, with no central clearinghouse, and no oversight (except for government drugs for the elderly, which are covered by the Ontario Drug Benefit). Currently, I have no way of knowing if a prescription was filled, as the information cannot navigate back to my EMR. The best information is sold by pharmacies to a private company (IMS), which then sells summaries to pharmaceutical companies. I don't know why we consider this to be acceptable.


Wednesday, June 06, 2007

EMR Enterprise: To Boldly Go.

The Enterprise function is now starting to pay dividends; I have been thinking about it for a while.

We have a FHN administrator, and an IT person for the group; there is now enough physician experience with the EMR in this group to fix most problems, and we have a central server in case we need access to different practices. You need all those pieces for things to happen.

Our administrator has started to make house calls to the different offices to see if she can troubleshoot and improve processes. She works part time at my office, and part time for the group; we discuss problems at lunch, so that helps us think about them. She took printouts of processes from my practice, to distribute them to my colleagues to use as they see fit. She spends a bit of time with staff in each practice, and works with them to see what can help.

For example, one practice is not using the scanner. They called the IT person, and it was properly connected to the PC before our admin came. However, software to scan to pdf files was missing; it came with the scanner, but was never installed. The IT person will install it, and the scanning process will be started. Our FHN admin also showed their staff person how to manage the rostering process on the computer, and how to use emessaging.

In another office, one of my colleagues would like to use the Tablet, but can't type. He asked the FHN admin if we could set up a handwriting program. I logged on to his practice remotely, and set up a template for him with vitals on top, and a drawing area for him to hand write on the bottom. His secretary called me, because the drawing area wasn't loading (it looks like an "x"). I know that this is because Java isn't installed on his machine, and I told his secretary that. She made a note; the IT person will be coming in a few days, and he'll install it, amongst other things.

We have hired students to go to each practice, and to enter all the rostering data. They are also updating the preventive services lists. Once this is finished, we can start mailing out reminder letters from a single location; the central mail-out will be ready for the next flu shot season, and we'll send out letters as a group. Each physician's letterhead will appear on top. I understand that the cost of doing this if you contract it out is $3000 per physician ($27,000 for the 9 of us per year). The cost to us of doing this in-house will be considerably less; in addition, we are getting a significant amount of help with the EMR for the funds. The $27,000 would be money well spent if we didn't have EMR, or couldn't organise ourselves; however, it does not make sense when compared to the cost of improving EMR processes. Spend money not on buying fish, but on learning how to fish.

I think that, once the EMR is going, it is very worthwhile to think of how to keep it moving forward. If there is no attention paid, some of us will likely abandon what we have already done; doing it half way is much tougher to sustain that just going back to paper--you don't know where things like your lab results are, your staff is still pulling lots of charts. There will likely be different ways of doing this for different groups. What I think will work in my group is:

1. a group administrator, to troubleshoot processes (preferably house calls at first)
2. a group IT person to troubleshoot IT hardware/non-EMR application software problems
3. a super-user physician as backup
4. remote access to the all the practices from a single log-on for group functions--the EMR enterprise part: one group, one server.

It may be easier to go forward in one big office, with all the physicians and staff located together. We don't have that in my group; like the majority of family physicians, we work in small, 1 or two physician practices. It is still possible to work as a group; I have outlined the steps we are now taking to do so.

I wonder if anyone would be interested in an "EMR implementation for Dummies" book.


Sunday, June 03, 2007

Managing change in my group

We had a FHN meeting on Tuesday to decide on further EMR implementation steps, as we continue to be at various stages in the process. The government has now started to provide a subsidy to hire a group administrator. We decided to hire one of my staff members, who is particularly adept at the EMR, to help us along.

As well, summer is a good time to get additional help, because of the availability of university and high school students. We have hired the first student to help with some data entry (finishing the roster lists; entering dates of preventive services). We decided to pay for the student out of group funds. Once the data is entered, our group administrator will manage functions such as mail-outs for drug recalls or problems, and on-going maintenance of our mailings for preventive services. The group administrator will also work with staff at the various offices to make sure that things like scanning or internal email are working smoothly.

We also agreed to use group funds to hire someone to do preventive computer maintenance; we have to decide exactly what that means. I think it probably means cleaning the computers (there seems to be a lot of dust accumulating in the back, where the fan is), making sure that the Windows updates are updated, making sure that the anti-virus system works. I found some information on this on the Microsoft website.

My lab sometimes makes mistakes and runs the wrong tests. I know this because I order labs in the EMR, and a copy of the req is automatically kept in the record. I see a Hepatitis A antibody coming in from the lab, and the req clearly shows I requested a Hep B antibody. I can't really order labs electronically; we use a copy of the Ontario lab form. This is printed and signed, and goes to the lab along with the test tubes. This means that someone has to manually enter test requests at the lab end, and it also means that there are data entry errors. Eventually, I would like to transmit orders electronically directly to the lab, or if this can't be done, have the order bar coded on the test tube. The risk of data entry errors is just too high with our current ordering system. I don't like the Ontario lab forms; having it means that the whole requisition is checked off as done when results come in. I think it would be better to have each test cross checked electronically, which means electronic lab ordering (and not an image of the current paper-based lab req on my EMR). I also need to have a pop-up on demand tell me which test tubes and how many test tubes I need, to avoid the lab return a message that a test tube wasn't sent and therefore a test was cancelled. I can't always remember that I need 1 grey top, two purple top and 1 tiger top test tubes when I draw blood. The system should help me, but it will need true electronic lab reqs to do this, not a replica of a paper-based system.