Friday, January 18, 2008

Planning my new office

Thinking about my new office presents challenges. I may have to change some of my technology (phone, fax), and rethink some of my practice processes (again).

For example, should I consider VOIP (internet-based phone)? What about Internet faxing? A fax line costs $50 per month; Internet fax costs about $10 per month, there is no need for a fax machine, and it is always on (without the need to leave the computer attached to my fax on). Long distance is free. My secretaries are already faxing directly from the computer more and more often. We can use the scanner to fax things that are paper-based. On the other hand, I don't know if Internet fax is secure, and I have not seen how it works. I really don't know anything about VOIP.

We will have many physicians and allied health workers in the new office; there will be 5 practices, each with 3 to 6 physicians. Our Allied Health Professionals will have their central offices there. The FHT administrative offices will be there as well. All of us will be on the same EMR system, and the plan is that physicians will be able to access it remotely for booking. EMR training for our AHPs has just taken place. We will need significant Internet bandwidth to take care of all this, and probably someone on-site to manage the IT. It is exciting, but also more than a little scary to me; it feels just like before we embarked on the EMR project, with many more questions than answers.

My group is now starting to think about what to do when our EMR contract expires, in 2009. We can choose to remain on the hospital-based server, or go to ASP. Our provincial subsidy ends after three years, so we no longer have to comply with the provincial stipulations (use SSHA's internet lines, use a Certified EMR etc). Many of my colleagues in Ontario are going to be in the same boat.

The benefits of staying with our current server are that it is a known quantity. However, it will need to be upgraded (we are taking on new physicians, and the amount of data going in is increasing).

The benefits of going with the SSHA ASP is that provincial healthcare data is going there, so there is a better chance of linking with the rest of the system. Hospitals and Home Care are sending data there. However, much of this is still theory, not fact. The drawbacks are that we have to continue to deal with SSHA; this has not been a physician-friendly (or even customer-friendly) organization in the past.

The benefits of going with the company's ASP (which is not Certified, we could not do this under the terms of our current contract) is that we can access over regular internet (faster than SSHA). This is much simpler and easier.

I am leaning towards the SSHA ASP. I know the problems with SSHA; however, I do think this type of structure gives the best chance of having the data follow the patients. As well, we need to have our data professionally managed and backed up; I was speaking with someone who had been at at physician's office, and saw a sign asking people for patience, as they had lost two months of data. I worry about the small servers in solo or small family practices; not all of us are good at backing up our data. Data loss happens, not everyone is careful; while there are risks in large data centres, I think the cumulative risks in many small, unsupervised practices are likely greater.

I was looking at CanadianEMR, and saw that the results of the 2007 National Physician Survey are now available. It looks like 19% of family physicians are now using a combination of paper and EMR records; that may well represent people currently transitioning to EMR. 12% of us are using EMR only; that must be those who have completed the transition. The total for EMR (full or partial) is 31% of family physicians; for all physicians under age 35, it is 45%. These are much higher rates of adoption than previously reported, and the numbers may mean that we are now in the "early majority" phase of EMR adoption.


Sunday, January 13, 2008

the New Normal

On Friday afternoon I had a meeting at the hospital. After the meeting, I went to the doctor’s lounge to get a coffee and to log on to my EMR from one of the Lounge computers.

I had several things to review. I had told one of my patients to stop her blood pressure medication a month ago (she had several BP readings in the 110-120 range). I asked her to drop by in a month to get a reading done by my secretary on the Automated BP machine. My secretary had started the Encounter, and entered her blood pressure, which was now above goal. The fact that the patient had come in was visible on the Dashboard as I logged in; I viewed her BP, and reviewed her Hypertension flow sheet to remind myself of what I had done. I re-started her medication and signed the prescription electronically, then sent a message to my secretary to call and let my patient know, and to fax the signed script to the pharmacy.

Lab tests had come in. One of my diabetics had an elevated A1C (blood sugar level). This patient had come in the previous week; my EMR has reminders to check diabetic parameters every 3 months, and he had not been in for 6 months; Summary immediately showed me that a diabetic visit had been missed. I explained why it was important to manage his diabetes, and that I wanted to work with him on preventing complications. His blood pressure was above goal (I increased his BP meds), and his weight had increased. He told me that from now on he will be making his next appointment prior to leaving the office (decreasing the risk of missed visits), and I sent a pop-up to the front for him to return and get wt/BP rechecked in a month. I also asked him to get fasting blood for cholesterol and sugar done in the next few days.

When I saw his A1C on Friday, I called him, and asked him to start on a new medication. I explained the side effects. Summary showed me that he did make an appointment in a month, and I told him that I would review the medication again with him at that time. I asked him to give me his pharmacy number, prescribed and signed the new medication on the Encounter (which also automatically placed it in the CPP), made a comment on the flow sheet, and sent a message to my secretary to phone the prescription in.

A holter monitor had also come in for another patient with palpitations. This showed Atrial Fibrillation (irregular heart beat). Fibrillation is a risk factor for stroke; we use coumadin (a blood thinner) for stroke prevention. I phoned my patient and asked her to make an appointment for Monday; a discussion of fibrillation and coumadin management is something that requires an office visit. When she comes in, I will use the MedCalc 3000 atrial fib stroke risk calculation, import this into the EMR, and give her a handout. The handout will be logged into the visit.

While this was going on, I was simply sitting at one of the Lounge workstations, a specialist colleague was dictating a routine hospital encounter beside me, and others were discussing their weekend plans. It was not until a few hours later that I thought about how extraordinary my New Normal really is.

This is how I practice now: remote access from anywhere; ability to manage problems over the phone or at the office, depending on what is most appropriate; immediate recording of phone encounters into the chart; alerts and flow sheets to enable improved chronic disease management; enhanced communication with my practice team; ability to delegate tasks; implementation of evidence-based tools into encounters; and more. What I see in my practice is not just more efficient care, but better, timelier care as well.

I think this should be Normal for everyone in the Health Care system. It cannot be individual physicians’ sole responsibility to pay for and implement EMRs, as is the case for too many of my colleagues; patients and our System benefit even more than physicians. It truly is time for our Governments to look at rational Health Care IT funding.

I have been thinking about what else I can do. We will be having our national Family Medicine conference in Toronto this Fall (FMF 2008). I spoke with a colleague I respect about doing a workshop together, on EMR implementation issues. He uses a different EMR, works in a larger group office, and has been very successful in resolving challenges with computerization. We also invited one of our experienced Practice Management Consultants at OntarioMD as an additional resource. I think having a mixture of experienced users from different settings, along with a consultant, is likely to result in an interesting and productive workshop. The submissions are peer-reviewed (and there is always lots of competition), so I do not know if this will be accepted. If it is, I will post the date when available.

I now write occasional blog entries for OntarioMD, in the EMR advisor section. They recently asked me if I would be interested in answering EMR questions from colleagues, a sort of “Dear Abby” approach; I thought I’d try, so they put a link to do this on top of my entries. I don’t promise I’ll answer everything, but I’ll do my best, and will ask experts when I don’t know.