Friday, November 23, 2007

Adding a new physician

A colleague will be joining me in my practice on December 3rd. She has joined my Family Health Network (lots of paperwork), is coming on staff at my hospital (paperwork), will be using my EMR (paperwork) and will be receiving the OntarioMD subsidy (paperwork). I wonder if we could combine all this paper into one giant Sequoia. We also notified the labs so she can start receiving electronic labs from the outset.

I have been thinking about how to make it easier for her to start the EMR. It took a little while to register her properly on the system. I already set up her preferences for her, so that the system works from the beginning; these large systems are highly customizable, but the downside of that is that you have to set things up. When you first start, you don't know much about the options available, and it may not be intuitive. I have a good idea of how things run efficiently, so I put that in and she can always change it later. I've set up things in the EMR like lab favourites (1st prenatal etc) for quick lab ordering, quickfill for DI ordering, physiotherapy reqs, basic form letters, referrals etc. It takes a while to start a new physician, it is more complex than adding staff, a resident, or Allied Health; it is important to try to do it properly.

My secretaries know quite a bit about this, so they will help as well, and my nurse can assist.

She bought new machines, but the Vista system does not seem to see the Window XP machines on my network, so her computers can't access all my scanned documents. I will need to call my IT guy to have a look. In the meantime, I will lend her one of my machines so that things work from the beginning. There is a learning curve for the EMR, and it helps if everything is already set up and if you have some help and advice from the outset. I think one of the things that make the initial transition so hard is that you have to deal with everything at once: the hardware never works properly at first, and the software is terra incognita.

She has been using another software application in the practice she is leaving, and does not like it all that much. I'm not sure what the issues were, probably some combination of process problems and computer issues. I'd like to see if I can do a bit better, but I'm sure there will be glitches. I'm hoping to have everything running smoothly within 6 months, which I think is reasonable, and is certainly shorter than the 18 months that has been quoted for a transition from a full paper-based practice. It will be easier for the next generation of physicians.

I've just had a quick look at my overdue lab reqs: there are nine reports that were done but results were never received, from June to mid-November. We will have to call the lab and request copies. I cannot track paps that have not been received, because the lab will not accept electronically generated reqs (mine will only take their own proprietary form). I scanned the pap req in, and print it as needed, but that makes it non traceable. I have had a patient come back and ask for her pap result, which was missing. We called the lab and had them fax it; I can also look results up on line, but that doesn't help me if I don't know that the report is missing. Whether by fax or online, results do not flow into the EMR: we have to scan in.

I wonder why results go missing, and what can be done about it. We sometimes had paper lab reports delivered to us that belong to a different doctor, which explains missing labs on paper. It is more difficult for me to understand why electronic labs go missing; perhaps a technician miscodes the physician's name when the lab form is received. It is time for bar codes, which my system can do. There should be some way of having labs track missing results systematically, especially for the electronic labs.


Monday, November 12, 2007

the structure of the chart

I have now used electronic charts for more than a year and a half. The way I look at the chart has changed substantially, because the chart is now much better organized and it is much easier to find data.

However, I look at my "plain" clinical encounter notes less often. In the past, much of the data was located there; for example, I'd have to search to find previous blood pressures or weights. Now, I click a link or look at my flowsheets.

There has been debate about "the patient's story" in the chart; in the past, that mostly meant ongoing longitudinal data in the encounter notes (legible or not). Now, the story tends to be all over the chart; the data is more easily accessible, but it is also more scattered. Some of it is only accessible in electronic form.

Much of my chronic disease management is captured in my flowsheets; the encounter is a poor format for following chronic diseases. For lab follow-up, I am less likely to write "hemoglobin was 88, now it is 97", because that is clickable in the electronic lab. I do put in assessments in encounters, although this is more likely for in-person encounters (for billing) than for phone conversations. I put in reasoning for treatment or investigations, so I can see what I was thinking. However, I will often not put in "DXA ordered"; the DXA (bone density XR) order is a link within the encounter. If I print the chart, the link will show a DI was ordered, but you will need to access the electronic version to see what it was for. Similarly, my lab requests show up in the encounter as a link, and not as discrete blood tests.

The data is generally richer and more extensive (because much of it flows in automatically), but some of it is standardized because of templates, such as a low back examination or a visit for a cold. My annual check ups also are standardized. This probably reflects an attempt to provide good care for everyone, but it does make the record less individual. I am probably conscious of the fact that there will be patient access at some point in the future (and I fully support this), which may make me a bit more cautious about what I write.

I think we may need to start thinking about "the patient's story" in a less linear manner. I am not saying that the clinical encounter document is not important, but it does seem to me that it is assuming less importance; I look at it less. I'm not sure if that's a good or bad thing.


Saturday, November 03, 2007

Peer to peer

I have often received requests to visit my practice; I think that there are still so few computerized offices in my area that people want some idea of how the EMR works in a real life setting. I also get requests from physicians who have recently started an EMR, so that they can see how things flow in my office and get ideas for their own practice. I have had visits from people in academia who are interested in the EMR transition.

I recently went to visit Alan Brookstone in BC, and got a chance to tour the recently opened PROOF office. This is a regular medical office, set up for EMR, so that physicians can test hardware and applications in a real setting that mirrors their own practices (waiting room, exam rooms etc). There is demand for this; having something organized and easily available will make it much more accessible.

I don't know if we can get something similar in my area; it will take someone to organize it. In the meantime, I have started passing requests to visit my practice on to OntarioMD. We have the new InfoWay Peer to Peer Network, and it says that one of the things we are supposed to do are "individual demonstrations of Electronic Health Records technology". To me, that means "come see my office". At OntarioMD, we have Practice Management Consultants (PMCs), who help with the process of choosing the EMR and receiving funding. I passed the last request on to my local PMC, and she arranged to meet with the physician's group to discuss things such as the subsidy and what their needs are. Once they are ready, she will then arrange for them to come to my office. I think that this is a much more efficient way to do things, and it also provides my colleagues with much more than a simple visit could.

I wish I could make an organized inventory of work flows that I use. I did not find such a thing, and had to invent many things as I went. I am sure many of my work flows are similar to other physicians'. I was watching my colleague, Dr Stephen McLaren, speak about this subject. The video will take a bit of time to download, but it is well worth the wait. This type of practical, day to day work flow advice is invaluable; maybe we should have some type of document on work flow (paper, or CD or internet based and searchable), with "how to" sections. There are enough power users now that we could have screen shots of different EMR systems so that the document is reasonably vendor neutral; I think it is important to have screen shots so that you can see how it is actually done.

All EMR systems have their strengths and weaknesses. I have been talking to users of other systems, and I am starting to see what those are. It is helpful for us to talk across platforms, because we will then go back to our own vendors and work with them to improve our products. In terms of choosing a system today, my advice is the same as Dr McLaren's: there are enough larger, established products now on the market; do not pick a small vendor--you will be a pioneer, there are no established peer networks for support, and your vendor is more likely to fail.

I am not saying that the cavalry is here to save your implementation; I am saying that there is much more available now than a year and a half ago, when I started. For those of my colleagues at the tipping point of deciding to computerize, your peers who have done it can tell you that the time is now.