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.



Gabriel said...

As you know, I've been following your EMR implementation as your are about 3 months ahead of my own implementation. I'm finding that much of the installation and training work is now done after 1 year. I'm interested in the next challenge and wondered about studying out patient's qualitative experiences with EMR. The studies I've looked up so far focus more on physician experiences. I'd be interested to know what patient perceptions of the EMR are. For example, does computer use impair patient physician communication? Do patients feel that they are getting a higher level of care (preventative manouevres or otherwise)? Do patients save time by having their physicians have faster access to lab results? It would also be interesting to see if things such as keyboard entry (mine) or tablet entry (yours) make a difference. Would you be interested in something like a survey study? I wish I had thought about it before we implemented the EMR as it would have been neat to have a prospective study.

Michelle Greiver said...

Hi Gabriel

I think that's a really interesting area of research, and those are really good questions. I don't know if you have done research before. You likely have several research projects there; choose one that is of particular interest to you. You will need to do a literature search first on your area. If you have access to a medical librarian at your hospital, they can be invaluable; otherwise, try the College of Family Physicians,
They give you 5 free searches a year. Once you've done that, and if you would like to bounce ideas off me, please email me.

I don't think my data entry is all that different from yours; I use mainly keyboard entry, as I find that it is the fastest way to get data in. I use the Tablet's pen as a mouse, because I don't like the little red button in the middle of the keyboard.