Sunday, December 30, 2007

My Team: multidisciplinary care

The New Year will mean more Team-based care for me. A part of it will be the move to the Big Office, but much of it will stem from the on-going development of our Family Health Team: we are now deciding what programs to launch, and how to go about this.

The reason for FHTs is to increase access (more patients rostered, improved access for current patients), to create Teams so that care can be better coordinated, and to increase activities directed at health promotion and disease prevention.

We now have nurses, a RN case coordinator (for tough problems that need system navigation), dietitians, social workers and a clinical pharmacist. We are planning on hiring a clinical psychologist as well. The Social Workers were an immediate hit, and are now so busy that there is a bit of waiting time to see them. We do not have Nurse Practitioners, because there are very few of them, and they’ve all been hired by the other FHTs.

We have a board of directors (mostly family physicians), and an executive director, as well as admin support staff. We have identified several areas that we would like to focus on. Our Allied Health Professionals are getting a full week of in-service training in early January, followed by EMR training the following week.

I’ve been asked to talk about Medical Directives during the in-service training; this is something that we can now start thinking about as a group. Medical Directives allow AHP’s to do delegated act, for patients who fit criteria. For example, I would like to have a directive that will allow my nurse to do a quick strep (or throat swab) for patients who have a positive sore throat score, without asking me for permission first (nurses are not allowed to order diagnostic tests independently). Things like that are easier to do if you use EMR templates; I’ve seen my nurse use the sore throat template correctly several times (it is visible on the EMR Encounter as soon as entered), before I go in to review the history with her; she knows when to do a quick strep, and she has no difficulty in interpreting it correctly. We’ll have to start thinking about what makes sense, and is likely to improve access and quality of care.

There has been some thinking about how to use the EMR; we may go to a centralized booking system for the Allied Health Professionals, accessible remotely. I don’t know how well that will work; I have a feeling several offices will prefer calling rather than logging on to book. We have two EMR systems in our FHT (I heard that in Hamilton they have six!), and some AHPs will work mainly in one system, while others will be assigned to the other. This will be easier for AHPs working inside family practices; I’m not sure how it will work for those assigned to programs.

I have not been actively involved with our FHT board or planning committee, but I am the beneficiary of their work. One physician in particular has been instrumental in bringing this project to fruition, after years of hard work (and lots and lots of meetings for him). It is always like that: there have to be people with vision and dedication to make projects like this happen, and sometimes they are not recognized or rewarded. This is true for some of our EMR pioneers. It is gratifying to see that our provincial government has decided to re-invest in primary care; I think this will pay large dividends.

There will be significant changes related to Team-based care in 2008 for me and my FHT colleagues. I expect that, by the end of the year, my practice will have dramatically changed from what it was as of my first entry in December 2005. Although the upcoming changes may not always be directly related to EMR, IT will be a large component of the final transformation. I am planning to post regular updates on this last part of the journey here.


Monday, December 24, 2007

Year 2: looking back, looking forward

A year ago, I had just finished entering the last of my CPPs into the EMR. It has now been a year since I have been fully electronic.

This is a log of a routine diabetic visit; I have erased the date and the patient's name:

10:41 AM

View Summary

10:43 AM

Add Encounter

10:43 AM

Add Clinical Notes Templates

10:44 AM

Edit Clinical Notes

10:44 AM

Edit Clinical Notes Templates

10:45 AM

Add Medications

10:45 AM

Add Medications

10:45 AM

Add Medications

10:45 AM

Add Medications

10:46 AM

Add Lab Requisition

10:47 AM

Add Immunization

10:48 AM

Sign off Encounter

I view Summary as my entry screen, by default; this lets me see if there are any outstanding issues for a patient. In this case, she was overdue for her flu shot, which was the first thing I did (the two minutes between Summary and start Encounter). The active medications are auto-loaded into my Encounters, and they are batch printed (that's why they are all stamped on as being at the same time, this is the time they are printed). I sent the patient for an A1C (lab req), and recorded her flu shot. Log lets you get a quick snapshot of how your encounter goes; it doesn't include everything (I also looked at the diabetic flowsheet and the CPP), but it is pretty good.

I keep looking for ways to improve efficiency; the EMR software application is so large and complex that there is still lots to find and use. One of my colleagues was telling me that he feels he uses only about 5% of the functionality; I probably use more, but there is still lots to discover.

My new partner has been using EMR from day 1. I can see that there are some things that are still challenging, such as learning to prescribe more complex drugs (example, gardasil, at 0, 2 months, and 6 months, to be given in physician's office), or doing referral letters. The basic encounter was pretty easy for her to learn. Periodically, we sit down for a few minutes and I show her things. She did not go for EMR training, as it did not seem necessary; she is learning it as she uses it. I will buy a new Windows XP PC for her, because I just can't make Vista connect to my XP network properly. There were a couple of start-up problems: for example, we had to figure out how to make sure that encounters that are started for her by my front staff (they put the vitals in) are sent electronically to her and not to me. Her off-site access does not work; it seems to be a problem with her router blocking the VPN, and that needs to be solved.

She decided that she preferred desktops (wired) as opposed to wireless. Because I have network "drops" in every room, it was very easy to accomodate her. She has her own exam room (the room where paper charts used to be stored), and this now has the desktop with a local printer attached. The printer is the same brand as what I use in the rest of the office, so that we don't have to manage cartridges from different companies. We share an exam room, and she just leaves the laptop in there on the days that she is using it.

Overall, adding a new physician in my office was a lot of paperwork and some extra EMR work (configuring the machines, learning to work with two EMR physicians instead of one), but this is much less than initial EMR start-up, and is manageable. It has not been as difficult as I thought it would be, although there are still things that we need to fix. It helps a lot that my new partner is so easy to talk to, we can solve problems. I expect that, once she gets going, she will be teaching me things.

My son moved out of residence this year, and moved in with two other university students. They have a brief "house meeting" every two weeks, do discuss outstanding issues. He keeps minutes. This is working very well for them; it sounds like a good idea, and I think I will try that with my new partner.

I have been talking to several colleagues about joining me, as I will have a three physician office in the big FHT office; I do not yet have a third partner yet.

While there has been progress, there is still a lot that remains undone. What bothers me the most is the lack of action on the "electronic island"; we are still not connected to the hospital or to outside agencies beyond the labs, there has been no decrease in the incoming data that needs to be scanned, and there has been no progress on decreasing the number of proprietary (non-electronic) outgoing forms. There seems to be lots of talk, but there is no change in my practice.

As an example, we are now being forced to send out proprietary public health forms for Chlamydia urine PCR; up to a month ago, the Ontario lab req was accepted. If you make it more difficult for me to screen for chlamydia, I am less likely to screen (a decrease in quality of care).

There is nothing that a front line clinician like me can do to improve this. Because the health care system is still so fragmented, it is difficult to know who to talk to about these issues, and each problem has to be solved in isolation. We certainly have lots of organizations dedicated to decreasing fragmentation (the LHINs, Canada Health Infoway etc), but I cannot say that their work has percolated down to my practice. Maybe next year.

On the other hand, EMRs are spreading. I have now started the study that I will be writing up as part of my Master's thesis (effect of EMRs on preventive services). We are recruiting colleagues in family practice in my area, and have recently sent out letters of invitation. 26 physicians out of 130 have already replied; of those 15 have or are planning to implement an EMR, and 11 are not planning EMR.

In my own Family Health Team (composed of 6 Family Health Networks), all 40 physicians have or will have EMR by next year. Our Allied Health Professionals are getting EMR training the second week of January. I expect to have more EMR integration at the FHT level next year: by that, I mean that our social workers and dietitians will enter data directly into the EMR. My practice nurse and our clinical pharmacist already do this.

We are getting ready to start renovations on the big FHT office. My own office at the new location will be just over 2,000 sq feet; plans to move in later in 2008 are on track. There was a good article on office planning in a recent issue of Future Practice, by Dr Kendall Noel; just like him, I really like the fact that my patients can see the computer screen--it allows them to participate more in their own care. Almost all of my physicals are now done collaboratively with my patients: I point at what I am looking at on the screen (and I often ask patients age 50 and over if they need their reading glasses--because I'm starting to need those more routinely). It is important that you don't have your back turned to your patient while entering data. It is simpler to do this with wireless because the computer is portable, but the new flat screens make this a lot easier to do with desktops: they take up much less space, and it is easier to place them where they make the most sense.

For the next year, I look forward to planning the big move; this will make my practice fully electronic, as all physicians will be on EMR. I look forward to working as part of a Family Health Team. Now that I have lots of data in, I want to learn to use the capabilities of the EMR to systematically improve care: that will mean doing audits to figure out what patients need, deciding what to do, and using the Team to put our plan into action.

I would like to thank readers of this blog for your company through this journey, and wish everyone a good and peaceful 2008.


Sunday, December 16, 2007

Divorce, EMR style

At a recent OntarioMD meeting, several of my colleagues who are early adopters talked about being on their second EMR system. I've also heard from colleagues who are not happy with their system, and my new partner is now on her third EMR system because of changing to new practices.

I think going electronic is a bit like a marriage; you use the darn EMR all the time, sometimes it works and sometimes it drives you crazy. If it drives you crazy enough, then you get a divorce, which is difficult and expensive, but is sometimes necessary. No guarantees on whether the next partner will be any better.

There is no way that the electronic data from my partner's previous practice can get transferred to the new EMR. Her previous office manager is printing the charts of patients who are following her; she has to then re-enter the CPP. We are scanning the old charts that are arriving into the office's external hard drive. This is the current state of affairs.

In Ontario, all approved EMR applications will now have to be portable; in other words, you will be able to transfer data to a new EMR vendor if you switch. This document has what must be portable on page 40 and on. It is a bit difficult for me to understand, but it looks as if most of the CPP, lab and clinical notes are in there. I can't imagine that is will be easy or seamless, since EMRs store things in all kinds of different ways, and in all kinds of different databases. I'd like to see this in action; I think the most important piece will be the CPP.

In my EMR, I now see a Data Export and Data Import piece, so they are getting ready for this.

Having some data that is similar across EMRs is a good idea; perhaps one of the unintended (or maybe intended?) consequences of this initiative is that there will be a common CPP that can be transferred back and forth to hospitals, home care, and specialists when needed.

It is interesting that I have not heard of instances where the divorce was back to paper; the difficulty is with the initial transition to EMR. There is no reversion back to paper, but there is failure to launch EMR.

My Family Health Team is getting ready for the big move; about half of the physicians in the Team will move their practice to the same premises as our Allied Health Professionals. This looks like it will definitely be happening in 2008; I will be moving, along with my new partner and a third physician. Our AHPs will be getting EMR training early in the new year. It will be interesting to see how things get integrated. I've been asked to talk to the FHT Allied Health about medical directives in the new year, so now I have to think about what I would like them to do.

Three of the practices that are moving are now on EMR, and two will be transitioning after the move. On the Master Plan, there is space allocated for high density filing for the non-EMR practices only; I cannot see much wasted chart areas in the EMR practices. I will not be moving any paper charts to the new office; others in my FHN who are moving are now disposing of their paper as well. One physician has moved files to her home, another to a storage company, RSRS (and she is quite happy with the service). I think we are starting to witness the beginning of the end of paper records.


Friday, December 07, 2007

Being irritated

We just got a new version of my EMR software. The colours are all different, the layout is somewhat different, my label machine didn't work and I get error messages with some of my bills. We got the new Ontario lab reqs, and I had to reprogram my saved lab favourites. I don't really like new software versions, it seems they never work quite right at the beginning and it takes a while before everything settles down again. Even giants like Microsoft can't quite get it right (Vista is very buggy).

I fixed the label machine; the billing error message is annoying but the bill goes through. I'm getting used to the new layout, and there have been some improvements, such as making the DI and lab areas of the charts easier to access without leaving the encounter. There have been some changes in the prescriptions that I haven't quite figured out yet; on the other hand, one of my FHN colleagues found that the EMR can now print a "non-prescription prescription" when drugs are stopped. That's useful, because I give this note to the patient so they know what has been stopped, and they can pass it on to their pharmacist.

I figure that if I'm irritated, I might as well be an oyster and see if I can make something out of it. I figured out a much faster way to get my lab and DI reqs into the record, which I hadn't seen before. I also followed up on my colleague's comment on the previous post, and now auto-load a pap requisition into the record, so that the pap can be tracked; while I was at it, I emailed the general manager of my lab company to ask him if it would be possible to send him my computer-generated req instead of the proprietary pap form. I sent him an example of a requisition, which is reproduced below. Maybe they'll agree this time.

Some of our lab processes are unnecessarily complicated; for example, a first prenatal exam involves generating a req for prenatal blood work, a second lab req with "IPS, part 1"(Integrated prenatal screening), along with a special Genetics form for the IPS; an Ultrasound req for Nuchal translucency; and a special public health lab form for HIV and other public health labs. That's five forms, plus the handout on IPS that I give patients.

I generated EMR form favourites for the two labs and the US, and they're now clicked into the encounter and batch printed. The special IPS form and the public health form (with my own information pre-entered, and all the public health blood tests pre-checked) are now together as a single file; Adobe Pro lets you put several pdf files together. I also include a letter of explanation that says: "book your ultrasound between 11 and 14 weeks; take the special IPS form, along with the lab requisition that says "IPS I" and the ultrasound requisition to the ultrasound place. The technologist will keep the ultrasound requisition, and write the results in the special IPS form. Take that form and the IPS I lab requisition to the lab on the same day; they will take your blood and keep both forms."

The single file with this letter, the IPS form and the Public Health lab form is then printed. That's one print for the EMR forms, and one print for the rest (instead of 6 load and prints--or having to look for a bunch of forms). Also, I'm much less likely to forget one of the forms, which I've done in the past.

This is my EMR pap req:

Cytopathology Requisition

Dr. Michelle Greiver

212, 5460 Yonge Street

North York, ON

M2N 6K7



(416) 222-3011


(416) 221-3097


Lab company



Patient: Dummy2, Patient

123 any street

Toronto, ON

M1M 2M2

Date of Birth:

Oct 1, 1947


(416) 222-2222

Date Created:

Dec 7, 2007

Priority: Routine

Tests requested:

Date of LMP:

December 2 2007



LMP 2 weeks ago. Cervix appears normal

Physician OHIP number: