Thursday, July 19, 2007


Scanning continues to be an issue in EMR offices. Electronic lab results have eliminated a great deal of scanning, but DI, consult notes, and various other non-electronic data from the outside (such as forms that patients bring in to be filled) still need to be integrated into the EMR.

In my office, we keep no paper data for patients; as a result, there are 10 to 15 things that need to be scanned in daily. Here is my scanning process:

I have stacked in-boxes beside my scanner. When something comes in, it gets put into one of three boxes: correspondence, DI or lab. Mail comes in the morning. My scanning tech then scans paper from each box to a folder on the PC's desktop called "files to upload"; everything is scanned into pdf format (that gives the clearest picture). She'll do one in-box at a time, and name the file using the patient's last name: example, smith.pdf. When all the in-box has been scanned to the folder, she'll upload all the files to the EMR, and then attach each one to the proper patient. I order things via the EMR, so if there is a consult/DI request pending, that gets matched to the file that was uploaded; the consult/DI then gets taken off my outstanding list (that's how I know a letter was received).

Once an in-box is uploaded and filed, the tech deletes all the files from the folder on the PC desktop. The physical paper gets moved to the lowest in-box, which we call "pending shred". All uploaded files now appear in my Practice summary page as "unfiled", and awaiting my review. At the end of the day, if I'm happy, I take the paper and put it in the "to shred" outbox.

If a file was attached to the wrong patient, I can see that when I load the file; I can take the physical paper from the "pending shred", and put it to re-scan. Alternatively, I can save the file to my desktop, and reattach to the correct patient; I can also print the file, and put it back in the in-box. There is a high level of redundancy to avoid misfiling. We can probably get rid of the "pending shred" box.

The scanning tech will add extra information when attaching the file to each area. For example, there are drop down lists in the Lab area, indicating whether this is an ECG, a histopath report, etc. She can also put in extra comments, such as "insurance form". When there is a "match" with a pending request, the specialist's name or the name of the DI facility automatically appears in the information area. It is a good idea to work with your scanning tech to make sure that the scan is done correctly, and that extra information that is helpful to you is added; things that are done at the front save you time.

We scan everything to pdf; we tried different file formats (jpg, tiff), and pdf was by far the best. I thought about whether to scan to OCR (optical character recognition) so that text was recognized from the outset, and decided against this. The reason for that was that I needed an exact copy of the form, since the original is shredded; OCR is not 100% accurate. If I need to copy part of a note to put into comments (such as the last paragraph in a consult letter), I will use OCR on my tablet. This leaves the original form unchanged. I bought Adobe Pro; I click Document, OCR. The same thing can be done using MS Document Imaging, which comes with MS Office. To use Imaging, load the document, then Print to MS Document Imaging. Use OCR (the little eye) on the resulting file, then copy and paste to comments.

Comments will give you a very quick overview of everything when you load an area in the chart.

Here is an example of a DI area:

Signed Off DI Reports

Date Collected Date Signed Off DI Facility

Dec 30, 2006 Jan 4, 2007 North York Diagno
comments : XR left ankle normal

May 15, 2006 May 18, 2006 Unknown
comments : XR right knee There is slight prominence of the tibia1 spines and there are osteophytes on the patella. The changes are in keeping with early osteoarthritis.

I know that all this seems like a complicated process, but it works, and now it is not even time consuming. It just takes some time to get used to, and to make sure that it goes smoothly. Working with your staff and your scanning tech really helps.

I think it may be helpful for a regulatory college like our College of Physicians and Surgeons to have a look at scanning. We need some ground rules on whether it is OK or not to OCR from the outset, or whether it is preferable to save an exact copy of the incoming material. Perhaps even some rules about acceptable file formats. There seems to be a lot of confusion about the right thing to do, and we need to have some guidance here.


Sunday, July 08, 2007

Group IT maintenance

Our IT person will be starting our group computer maintenance program this month. This means updating the anti-virus protection if needed, performing manual and utility-based cleaning of the registry, services, files and folders etc (that means making sure all those things work properly), enabling the proper security services, performing internal system checks for overheating and cleanliness (CPU, Hard drive, fans), and cleaning if needed (the insides of computers get dusty and need to be vacuumed sometimes).

He will come to each office to do that. I think it is much better to have a professional come by periodically, rather than leave it as ad hoc for each practice. We decided to pay for this out of group funds. As well, he will be available for each of us as needed (we have needed him several times already), and we pay for that individually.

Our group administrator has now done house calls for almost all the practices, leading to immediate results: scanning started, use of EMR for encounters, improvements in scheduling functions. You need to have someone go to each office to see what the issues are, and to fix them. Many of the issues do not involve IT, but rather changes in work flow processes.

The pharmacist has now scheduled more of my patients; she has seen some off site (with the data entered straight into the EMR), and some at my office. We have a joint appointment for a challenging patient later this month.

We have progress on the Family Health Team's Big Office, with several physicians indicating an interest in moving there; at least two FHNs will move in as a group. It looks increasingly likely that I will move as well. I have informed my partner, and will keep him up to date on the progress of negotiations; I have told my staff as well.

This will give me a chance to think about reconfiguring my office for the EMR. My current exam rooms are 10 ft x 8 ft, and I see no reason to change that; it works. The only difference in going from paper to EMR was that I put in a $50 small stand where the printer sits. There is no paper clutter on the desk, and I don't have all the reqs that used to take up space.

The big difference will be in the front office; that is where the majority of the paper metastasizes. The filing cabinets are there, and much of the paper shuffling happens there. There is now a lot less stuff sitting on the desk at the front; most of that is from my partner's practice. I also need less waiting room area, since patients wait less (flow is better). I don't really need to allocate any space to store handouts (pretty much all the useful ones are available on-line or scanned in); I think I will reduce the amount of space for samples, since I use those less. There will need to be 1 small area to store paper reqs in case of a black-out, that can probably be shared between several offices.

My current front office and waiting room is 16 x 20 ft (320 sq ft); my small lab is 9 x 9 (81 sq ft), for the autoclave and vitals area; each of two exam rooms are 80 sq feet; the consult room is 10 x 9 (90 sq feet). If I practice in a 2 physician "pod", we will need 580 sq feet for the lab, 4 exam rooms and 2 consult rooms. No space needed for chart storage; no front desk space for files: 250 sq feet for front/reception. Without corridor space, that is 830 sq feet. I will also need some room for closets etc. I estimate we could do with 1,000 to 1,100 sq feet for two physicians, with ample space left over. I have 1450 now.


Wednesday, July 04, 2007

Fridge police

On Friday, the Fridge Police came by my office; these are the nice public health nurses who make sure that the fridge temperature is properly monitored, and within range (2 to 8 degrees), that none of the vaccines are out of date, and that vaccines are properly stored (not in the fridge door). It is important to make sure that the cold chain is preserved, so that vaccines are as effective as possible.

I can see why they are needed. However, this almost led to a disaster at my office. I was away at the cottage (no internet access) on Friday; my secretary was left to deal on her own with the unannounced visit. I use a data logger to record temperatures in my fridge. The logger is a little credit-card sized device; it sits inside the fridge and automatically records temperatures every 15 minutes. Once a week, my secretary sticks it in a cradle that is connected to a computer, and the data is downloaded to the PC. It generates both lists of temperatures and graphs; the minimum and maximum range (2 to 8 degrees) is indicated, and I can see that I am always in range. We also have a digital thermometer sitting on top of the fridge, so that the temperature is always visible when I take vaccines out.

The nurses were very upset with the fact that my secretaries were no longer handwriting minimum and maximum temperatures twice a day in a book; they threatened to impound my fridge for five days. My secretary pointed out that what we do far exceeds requirements, and that there is no opportunity to “cheat” (that is, record a false value if the temperature is out of range). She showed the nurses the graph on the computer. The problem was that the nurses had never seen a logger, and were not familiar with that technology. I am very happy to report that they decided to call their manager, who went over what I was doing, and stated that it was acceptable. My secretary got a little paper certificate stating that we’re OK.

This illustrates the issues that early adopters can face, despite the best intentions; you sometimes have to demonstrate and advocate for better workflows using IT. Public Health serves a very important role, but they seem to have particular difficulties with computerization. None of the public health lab reqs are computerizable (virology, HIV, prenatal), and they often involve obscure codes for lab requests. Because the reqs are paper-based, I cannot keep track of whether the result has come in. None of the results are sent electronically; they all have to be scanned in. There is no secure electronic access to public health labs. There seems to be no electronic way to report infectious diseases to public health; this has to be done by phone, slowly and laboriously: you have to spell the patient’s name, and personally give all their demographics. No wonder I cringe when I see a reportable illness; it's not the report, it's the process. Perhaps this could be integrated via the EMR, and sent via the secure SSHA email system, which hardly anyone is using right now. I don't mind emailing a copy of my temperatures on excel; that may lead to a reduction in unnecessary visits to my office to check my fridge.

On another note, I've installed secure access to the EMR on a computer in the doctor's lounge at my hospital, and in the physician's room on the Labour and Delivery floor (several physicians in my group deliver babies). That seems to be working well, but I have found that I can't easily log on from the lounge: doing this can develop an interest cluster of physicians and lots of questions.