Friday, October 26, 2007

Reporting my data

OntarioMD has now announced that two new companies have been approved for ASP funding. My EMR software is one of them. This is good news for my group; our contract finishes in a year and a half, and we will be looking at whether we should then transfer to the ASP product. Doing this will mean that our software will be hosted in the SSHA Data warehouse. Other services, such as home care and some public health data, will be hosted there as well. I am sure there will be lots of bugs and difficulties, but this represents the future of health care in this province; it represents the best chance of integrating health care.

I went to the North American Primary Care Research conference last weekend. There was palpable excitement about what is happening with computerization in primary care. There were many presentations dealing with this subject.

As I look at my data over the past year and a half, I can see how valuable it is. Everything possible is going into the EMR now. It bothers me that Diagnostic Imaging reports continue to be reported on paper (despite the fact that DI is highly computerized), and that hospitals are still not connecting. That is unsafe and bad for patient care.

We also continue to receive stacks of paper from the Ministry of Health for our roster lists (list of all patients signed up with a family physician), every three month. These are generated by a computer, is there no way to receive them electronically, and match them with the EMR roster list?

It is now time for us to think about how to give our data back safely, and with full privacy protection. This data can and should be used to improve our health care system. For example, there is much talk about Wait times, and a lot of money is being poured to improve this. I don't really know how good the data is. In my EMR, we routinely collect wait time data as part of everyday care. When I send a patient for Diagnostic Imaging, the requisition is generated in the EMR (with a time stamp). This is the same for a specialist referral. When the specialist's office notifies us of the date, my secretary calls the patient and enters the date into the EMR. When the letter or DI report comes back, it is matched with the req (so we know it has been received), and that date is stamped in as well. I think it is now possible to start reporting on wait times from primary care, which is what is most relevant to patients. I think the public has a right to know, physicians and other health care providers should know, and our government (which funds health care) would want to know. If you don't know there is a problem, it is very difficult to fix it.

I do not think most of my colleagues would have much of a problem with this, provided privacy is strictly safeguarded. I think there is large value for patients as well, with the same caveat. I know I have several colleagues who are thinking the same thing. It is time to get going on this.

One of my colleagues was mentioning the fact that proprietary requisitions seem to be proliferating. Every specialist and hospital program wants their own, usually based on a paper form. This is not the way to go. I generate generic requisitions for DI, and have started generating EMR based reqs for Diabetes education. I simply append their form on the top, with "see attached". That seems to work. Dr Brookstone in BC has managed to get programs in his area to post their reqs on a secure website, but it takes work to make sure this is regularly updated. It is better than what we have here, which is nothing. I think it should be the responsibility of programs to make sure they are accessible when needed. Give up on proprietary forms (health is not proprietary), and make all programs accessible from a common area. Toronto211 is a good example for community and social services, we need something like that for medical programs.

It is time to ensure that the necessary data is there, both for our patients and for our health care system. I can see this is starting to happen now.


Sunday, October 14, 2007

Back to paper

Due to personal circumstances, my practice partner had to suddenly be away and unavailable from his practice for the past week.

What that meant was that I was looking after two practices, one EMR and one paper-based. This was a somewhat rough way to compare the two systems. The picture above shows what the front of the office looked like after four days, and there were more charts piled up on my partner's desk. He is very meticulous, and wants to look at everything, so nothing got filed away; we must have had well over 150 charts out.

The logistical problems for my staff were tremendous: trying to find a chart to attach a result to quickly became very challenging: labs often send a partial result first, then a final result; this leads to two separate chart searches. My secretaries stacked the charts in alphabetical order, so that there was some chance of finding the right file.

I had trouble finding data in the paper chart. Looking for previous results meant having to thumb through several papers instead of doing a simple search or clicking a checkbox to get a list of results. Labs, consultation notes and Diagnostic Imaging reports were all mixed together. The CPP was up to date, but drug prescriptions were often very hard to follow, as they were in the clinical notes. There was no easy way to refill prescriptions, those had to be written by hand. My partner keeps excellent notes, and has handwriting that is much more legible than mine, but the logistic challenges were still large.

I know that many of my colleagues who have gone to EMR have stated that they would never go back to paper. Having had to go back to paper for a week, I can unequivocally say that no, absolutely not, under no circumstances, and no way would I go back to paper. It doesn't work.

Having said that, EMR does present its own challenges. My resident is on block time (in my office most of the time) and was a great help in the past week. However, her Tablet went on the fritz on our busiest day (Thursday). It suddenly refused to load the EMR software properly. I have a backup laptop for those occasions, but had lent it to my Nurse who takes it to my colleague's office Thursday afternoons. My resident went back to paper (since she was seeing my partner's patients), and my secretary called the EMR company. They had to "remote" into the Tablet (that means they take control of it from a remote location). Apparently, the hosts had disappeared; I don't know what that means, it sounds like something from the hospitality industry. They reintroduced the hosts, and the Tablet was fixed and happy. This took about 45 minutes.

I have been asked what I do when my Tablet crashes. Computers crash, and they usually do so at the worst times. If mine crashes in the middle of a patient encounter, I either leave it to reboot in the room (if I'm doing something else such as examining the patient), or I put in my consult room to reboot and I go take the backup laptop. The backup laptop is left turned on and ready to go; I just log in. You really have to have some redundancy; however, as noted above, even the best laid plans sometimes do go astray.

I do not pretend that EMR systems are free of problems and aggravation (they are not); however, the past week has made it very obvious to me that EMR is far superior to paper. Just try asking your kids to function without the Internet--asking a computerized doc to go back to paper will lead to the same reaction.


Friday, October 05, 2007

The Efficient EMR

I am currently in the office three days a week (I am taking a course at the University of Toronto Mondays, and do research projects on Fridays). My roster size is at 1,320 patients and I have about 100 to 150 unrostered patients. That makes a practice of about 1,450 patients.

In my FHN, the average practice is about 1,200 patients. I have a slightly larger than average practice.

If a patient is not too particular about the time of the appointment, they can almost always be fitted in within a few days, and often the next day. The only appointments that are troublesome are full check-ups booked in the morning (so that a patient can get fasting blood work done at my office on the same day). If they can get their blood done prior to the visit, the appointment can be scheduled much sooner; we mail them the requisition along with a list of labs (only ones that do electronic results) and weblinks to lab locations. This is in the Handouts section of my EMR.

The university provides hotspots for students, so I log on to my practice on Mondays; I am usually logged on remotely Fridays as well. I can review results and reports, and assign needed actions to my staff or my practice nurse.

What that tells me is that there is less need for my patients to come in personally for minor problems. If they do need to come in, they can usually be see fairly quickly. Much of this increase in efficiency has been gained by using the capabilities of the EMR (remote access, e-communication), along with having the entire practice work as a team. It helps to have excellent staff. I am starting to see some improvements with my new nurse coming on board, and expect to see more as other Allied Health Professionals join us. My Family Health Team now includes dietitians (I've made several referrals already), and I met our new Social Workers yesterday. The RN and our Clinical Pharmacist already enter data directly into the electronic chart-in-common; the other AHP's will get training; for now, their notes are done on paper and are scanned in.

If I can look after a full roster on reduced hours, this tells me that I may be able to expand my practice if I go back to my regular hours. This is part of the payback for EMR and for adding extra people to primary care. I will have to decide whether I should do more research or see more patients.

I have now taken on a new physician as a partner; she will start in December, and will have an EMR practice from the beginning. We are already starting to keep a list of people wanting to join her practice. I think most of the pain happens during the transition; once an EMR is established (meaning that all the new processes work), it is much easier to add a new member to a practice. I have seen this with my resident. That bodes well for the next generation of physicians, provided that they do not start a paper-based practice.

My nurse will be giving my patients flu shots on a drop-in basis every Monday afternoon, once the shots are available. We will be doing a mail-out to my older patients to notify them of this. We are doing the mailing as a group, just as we did for the other preventive services: the letters are already in everyone's EMR; our FHN admin will print and mail them as soon as we have confirmation that the shots have been delivered to our offices. Several of my colleagues have also decided to have the RN run the flu shot clinic in their office.

It is increasingly difficult for me to remember what it was like to run a paper-based office; I am pretty sure that I would find the inefficiency and lack of communication difficult to tolerate. I no longer believe that paper-record based medical care has a future.