Sunday, September 30, 2007

Electronic communication in the office

Communication in my office is becoming increasingly electronic. I get 5 to 10 messages from my staff per day (often a patient or a health care worker wanting to talk to me, sometimes a drug refill). Messages are linked to the patient's file (I can just click to access the entire file if needed), and no message gets lost or forgotten anymore. Most of the e-messages I send out are "Actions", or things to do, often stemming from lab results (example, please call patient and tell them that A1C is improved, now at 7.8%; or, INR is 3.8, reduce coumadin to 1 tab daily and repeat INR next wk); typically, there are 5 to 10 of those per day. The "Actions" can be assigned to a group, such as "front staff". This is very helpful if you have several people working at the front; any of my staff can do the requested action, and mark it completed, thus avoiding miscommunication.

I have been assigning complex Actions to my practice nurse, such as discussion of cholesterol results and possible courses of action, or informing a patient about a new diagnosis of impaired fasting glucose. She can often discuss things with my patients over the phone, and she records the phone conversation in the clinical notes; if needed, she will book a patient in to see her. She sends the clinical notes to me for final sign-off when she is done, so I always know what happened.

I use pop-up messaging often as well (Real Popup). This is a small application that pops up in the right lower corner of a PC whenever someone in my office sends an instant message. The message is not part of the EMR. I use this to send a quick note to the front regarding follow-up appointments (example: Mr Smith: DM 3 months). The secretary sees the popup, and gives that patient an appointment marked as "DM", so that the patient automatically gets a weight and BP done when they return, before they are shown to a room. Some of my patients have wondered how the secretary knows what they will be asking for before they even speak! My resident often sends me a popup for a quick question while she is seeing a patient; she also uses this if she wants me to come in and double check something before I see the next patient.

The office environment I have described seems complex, but it works and actually makes the office much less stressful. There is no need to duplicate messages on notes, nothing gets lost, and everything is done. This improved communication is one of the biggest benefits of EMRs.

I have now gone back to signing my prescriptions on my Tablet. So far, I have only had one phone call from a pharmacist inquiring about this, and he was satisfied when informed that it was acceptable practice according to the College of Pharmacists. I think we have progress.


Friday, September 21, 2007


It is difficult to do it all; I have some very valuable allies that have helped with EMR implementation in my group.

One of my secretaries is now working for my FHN as well, as our group admin. She has helped other offices to implement scanning: seven out of the nine of us are now scanning, and one is about to start. She regularly helps other staff with problems, and they are very comfortable contacting her, whereas contacting me would not be as easy for them.

One of my colleagues has stalled with her EMR implementation; she is in a hybrid office as I am, and so gets no help from her practice partner. She has not been able to start encounters, but would like to do so; however, she does not feel confident in her ability to enter data. I have been thinking about how to help, but it is a problem for me as I cannot spare the time to come to her practice and stay with her.

My new Practice Nurse is now getting allocated to various offices by the Family Health Team's Human Resources manager. At a recent FHT meeting, I introduced the RN to my colleague, and talked about having her come to the office. My colleague was very interested; the nurse felt that she would be able to help; the HR manager thought it was a good idea.

The nurse went to the other office yesterday. I lent her my extra laptop for the day, to make sure that there were enough PCs in that office. It helps if both the MD and the RN have access to the EMR at the same time, as each logs on personally, and permissions are different. The nurse can show the MD what she is doing, while the MD is logged on.

When she came back to drop off the laptop at the end of the day, my nurse told me that she had done several annual physicals, and had showed the physician how she entered the data in the preventive services template. She went in for some visits with the physician, and helped to enter things, and my colleague tried several encounters; she also tried a prescription. The nurse entered a diabetic flowsheet for a patient, and showed the physician how data from the Vitals template in the encounter, as well as lab data, flows automatically into the flowsheet. I really think it helps to have someone on-site; the nurse will continue to go there once a week.

While it is not always possible to have a RN to do this, often there are allies who can help. It is worthwhile thinking about some of the untapped resources present in our practices and communities.

I am now at 88% of paps, 89% of mammograms, and 100% of children's vaccinations for my preventive services. My colleagues are telling me that patients are calling in after having received the reminder letters. We are hitting some of the inevitable glitches, such as a patient who had a hysterectomy receiving a pap reminder letter; because we communicate, these problems are getting fixed (for example, telling the secretary how to tag that patient's chart as having had a hysterectomy, so they never get another letter again, and get labeled as ineligible for paps). I figure that we will have most of the problems with the initial mailing, and this will decrease with time; we have had surprisingly few issues.

The draft letters for the flu shot reminders are in, and everyone is deciding on how they will do their flu shots (clinic, RN times etc). We are now talking about holding a common clinic, since the data can be entered from any of our practice sites; I'm not sure there is enough time to organize this, but maybe next year. Our FHN admin has already organized the window envelopes and stamps, and she will mail the letters in October, as soon as we know the shots have arrived. We get a small amount of payment ($6.86) for organizing each reminder; our FHN admin has entered EMR billing lists for the flu shot reminders for each practice based on the mailing lists, and she will auto-bill after the mailing is done.


Monday, September 17, 2007

Planning an office layout for EMR

I am currently finalizing the layout for my new office. This will have 3 physicians, at least one family medicine resident, one RN, and one Allied Health Professional. The office is 1,900 sq feet.

I have been thinking about what to change. The exam rooms are 8 x 10 ft, and really do not need much modification. I will have 8 exam rooms (2 per physician, 1 for the RN, 1 for the AHP). I don't know if my new partners will prefer wired or wireless; if they prefer wired, then they will need 1 printer in each room, along with a computer stand (or they can just put the monitor on the desk table). If they prefer wireless, then they just need a stand for the printer.

I will put network "drops" (the RJ45 plugs) in each room, so there will always be a choice. If wireless, then the printers plug into the RJ 45s; this is my current configuration.

I have chosen a common consult room; I think it is very important to be able to talk to each other, especially as the new physicians start practice and EMR. I asked my nurse if she would prefer to have a consult/exam room, or would she want to sit in the common consult room: she definitely prefers to sit with us. I will also have a space for the resident in the common consult room.

When planning a new office, I think it is good to consider workflow issues, as well as people issues such as how you communicate and work with each other. EMR impacts those.

The biggest change will be at the front office. There are no charts, so the front reception area can be a lot smaller. However, my staff does more callbacks, and they need space which is more private than the open reception area. I am planning a separate staff room; we can have lunch there, but it will also have a workstation for callbacks and administrative functions that do not require a secretary to be at the front (example, uploading bills, managing our preventive services etc). I am considering buying a second scanner, so there will be two places to scan: one at the front reception, and one in the back staff room. I will still have two desktop PCs at the front.

I went to the Canada Health InfoWay Peer to Peer meeting last Saturday. I met my colleague, Dr Brookstone, who reports what happened at that meeting , along with several physicians who had been email only until now. It was good to see others who are very passionate about this subject; sometimes you do feel as if you are a voice in the wilderness, although it is getting to be less so. Our provincial bodies (in Ontario, OntarioMD) will work on figuring out how we can help others; I think this will likely mean a contact from one of us when another physician is strongly considering EMR and wishes to talk to a peer (perhaps a site visit, or a phone call to talk about the specifics of deciding to implement EMR), as well as practical help with the early implementation glitches (this worked in my practice, this didn't, here are a couple of things to try).

One of the pharmacists at the meeting told me that signing prescriptions on my Tablet is now acceptable to the College of Pharmacists; I'm going to try that again. The College states that "For a written prescription, the physician's unique signature is required to provide the authorization." The Tablet signature fulfills that criterion.


Sunday, September 09, 2007

The Diffusion of Innovations

I’ve been reading a very interesting book called “The Diffusion of Innovations”, by Dr Everett Rogers. Much of what I see as currently happening with EMR is accurately reflected in his book. Making a major change like adopting an EMR is very much a social process.

Dr Rogers found that the adoption of an innovation follows an S-shaped curve; he categorized people as Innovators (2.5%), Early Adopters (13.5%), Early Majority (34%), Late Majority (34%) and Laggards (16%). The lower elbow of the S-curve, where adoption starts to take off, is where I think we are now—right in the Early Adopter stage. This means that you may be able to get a critical mass of users now, and the adoption rate then accelerates and becomes self-sustaining (sort of like an atomic chain reaction). It is an interesting stage, because pushing things along here makes the most difference to how fast we adopt EMRs (the “turbocharging effect”).

The process of starting EMR in our practices also has several stages: thinking about it (knowledge); forming an opinion (persuasion); deciding to do it (decision); starting to use it (implementation); continuing to use it and solving problems (confirmation). According to Dr Rogers, people tend to look to their peers when deciding (persuasion and decision stages). Diffusion networks (groups of people talking to each other) are also important at the implementation and confirmation stage, because you always have to re-invent the EMR at least to some degree to fit your local circumstances; we’ve certainly done that in my group (customized templates; implementing the preventive services; getting scanning going; hiring an IT person). It helps to have a group to see how others have solved problems.

Canada Health Infoway is starting a Peer-to-Peer network, together with the provincial e-Health organizations, so they are probably thinking along the same lines. They have targeted the keeners, under various names: “champions”, “super-users”, “peer leaders”—this is the early adopters. Infoway has scheduled the first national meeting next weekend, and it will be interesting to see what they want to do with us (and for us).

My new nurse is now comfortable using the EMR; it did not take long. She starts seeing patients on her own tomorrow. We had several visits where she saw pop-up alerts for patients booked in for other problems, such as a patient with a new diagnosis of diabetes who had not returned for foot examination or urine testing, or a patient who needed to have a MMR vaccination. She is getting good at providing opportunistic preventive care. The clinical pharmacist saw one of my patients at her hospital office last week, and I saw the electronic chart being opened while in my office, which was very strange. My secretary picked up an urgent message from a patient on a Saturday: the pharmacy had not filled one of her medications. She was able to log on to the record remotely, see that the prescription had been ordered (a copy of the script was on the EMR record), and she called the pharmacy to ensure that the prescription was filled correctly. This prevented an important medication error. While Team-based care is possible without EMR, I think it works better with EMR; some of the EMR tools (alerts, reminders, legible records, e-communication) can make collaboration more seamless.

I am looking for new partners for my practice. I have been now contacted by several recently graduated physicians with impressive credentials; I had looked for a new associate a few years ago, with no response. I don’t know whether the interest is due to the EMR or to the benefits of joining a Family Health Team; probably a bit of both. I have noticed that many of the ads seeking to recruit a family physician as an associate mention that the practice is computerized; EMRs are a selling point. All these changes seem to be having an impact, and I am very pleased to personally see that new family physicians are choosing comprehensive care again.