Friday, February 29, 2008

Helping my practice partner start the transition

My partner has been away in the past week. I had a look at his computer, and made sure that he has access to all the scanned documents on the front computer. These now include all the requisitions for programs at our hospital, and all the documents that I had previously scanned.

As well, I configured things for him within the EMR software. He has access to all the handouts, to outside links for patient education, to pre-made DI requisitions, and to ready-made consult requests. Many of those things (such as our phone book) can be shared, but some cannot. It took me about an hour to organize this, and I consider it time well spent; this work will ease his transition. We sent an email to notify the labs this morning, and the first electronic results already came in this afternoon. Things move much more quickly now than they did when I started. As of today, my partner has hybrid charts; he will need to decide how quickly he moves to fully electronic--that is where the biggest gains are.

I think I will put in some medications favourites for him; I have a list of drugs that I commonly use, and I will ask him to pick some. Maybe I will sit with him periodically at lunch, and we'll have a look at things together.

I sent him an e-message while he was away, and made a dummy chart for him to practice on. The flow sheets are programmed and are ready for him to use; I have a pretty good selection of useful templates as well. I have profiles and billing short cuts that are ready to use.

Setting all this up made me think about how much I now know about EMR, and how much work I did. When you first start, most of this is just not in the application; it can't be, since practices differ, and different physicians use different diagnostic facilities, have different referral patterns etc. I had to put in things at the beginning without really knowing how the software works. In retrospect, it was actually easier for me to start by myself, and to have a hybrid practice for a while. The new physician who joined me helped me to work out the bugs of having several physicians in the office on EMR instead of just one. She now requires no assistance from me, and is using many of the advanced features of the EMR, after only three months. I think things actually worked out well.

My secretary has started scanning in the paper charts for my partner's deceased patients. These are going into the networked hard drive at the front, same as mine. We have made new folders for his patients. He had a look at several charts from his computer, and I think he was happy with the excellent quality of the scans. We showed him how to use the "pages" tab on the left side of the pdf file (this produces thumbnail pictures) to quickly find what he is looking for. We have started shredding the paper charts that have been scanned in.

He now has a lot of work to do; all his CPPs will need to be entered in. I think he is considering hiring a student to do part of this work, which is not a bad idea. I will talk to him about coding his ongoing medical conditions in the paper CPP; he can enter the ICD code besides each condition, and that will help the student with accuracy. He will need to review each CPP that was entered.

There is still some uncertainty about when we move to the big office; I think this will most likely be in late Fall. It will be tight for him to complete the transition before the move; I have not allocated any space for paper chart storage. Starting now is not too early.


Sunday, February 17, 2008

EMR for the non-believer

My practice partner will be implementing the EMR. This is not because he strongly believes that it will make a difference. He is doing it because EMR comes as part of a package: we have decided to continue practicing together; he is joining my FHN; he will be joining the FHT; he wants to move with us to the big office. EMR comes as part and parcel of all of those, and the benefits to him of going in this direction outweigh the risks of staying put. This is called "relative advantage", and I think this calculation is increasingly tilting in favour of Electronic Records.

I do not think that doing this type of calculation makes you a "bad" physician, or an "IT laggard". I think it is a realistic assessment for many of my colleagues, given the initial difficulties with implementing EMR. I also think that it is up to our health care system to help us; EMR subsidies are important. Other possible rewards are giving incentives for quality of care (such as the preventive care incentives in Ontario) that are easier to track and measure through EMR. I would like to see more of this; these incentives will drive the programming of EMR systems towards making sure that we can measure and improve what we do. This programming is still in its infancy.

Another very important aspect is making sure that we are connected: reduce the amount of scanning due to non-EMR data, help to ensure that other parts of the system accept EMR generated forms. This is not something that can come from physicians, it must come from the top (leadership). If a private Diagnostic Imaging facility can send me reports directly into my EMR, I am more likely to refer there. I wonder at which point competition will come into play; I would prefer to remain within the public system, but will use private facilities if their care is better because they are connected.

What I am trying to say is that there is a very important role for government, and for policy-makers. There is a role for incentives that favour adoption at the same time as quality of care; we also need policies that promote effective and efficient information transfer, instead of the current status-quo of outdated forms and processes.

I just went to a conference on the management of mental health issues, which I attend annually. At the conference, several of my colleagues told me that they were about to adopt an EMR, or were in the early transition; this is a change from a year ago. A physician who started using an EMR two months ago told me that his staff are unhappy, and that it is hard for him because everything is taking so much longer. He had a realistic assessment of this, however, and told me that he knew the early slogging was tough, and that things would get better; he wasn't giving up. EMR even came up in one of the small group meetings (these are run by a psychiatrist and a GP psychotherapist); a family physician said that prescribing some of the complex psychiatric drugs was now better because of the automatic interaction and allergy checking. I do not think that the GP psychotherapists are adopting these systems; these physicians restrict their practice to talk therapy, and I cannot see EMRs as having a relative advantage for them. There will likely be corners of the medical system with late or non-adoption; however, these will run the risk of being disconnected from an increasingly inter-connected system.


Monday, February 11, 2008

On-line Support group

I have an on-line support group for my EMR. We have about 70 members; some are more active, some less. There is also an area where you can post useful files, such as an excel gestational calculator template, or examples of EMR processes. The support group is monitored by the company, and sometimes we have replies or comments from them. When someone posts an entry, I get a copy by email; there are anywhere between ten and 50 entries or so per month, so it is not overwhelming.

Occasionally, a new user posts a question, and the replies have been very helpful and generous. I have noticed recently that comments are switching towards data extraction: my colleagues are asking for more Reports (procedures, labs, social history); we are talking about how to enter data in the EMR so that we can get good quality information on our practices. It seems to me that we are now starting to head into "phase II", which is the interesting part of EMR implementation: there is enough data in that we are now thinking about getting data out.

In my own group, I have noticed more clinical queries (or Reports); we can share queries as a group, so you see who programs and runs queries. Some of my colleagues re-use my queries for their own patients (and I am happy to see this happening); there are also new queries being done. I think our coding is becoming better in the second year of implementation; we are now used to entering the ICD diagnostic code routinely for every encounter, and this is no longer an issue. The payback is being able to search for diagnoses consistently. What this means is better data quality in the charts.

My new partner was asking me how to do a referral for audiology; I set this up for her, and showed her how to generate the request as part of the encounter. She told me that most lab/DI/allied health requisitions at her previous office were still done on paper pads. This is rare here; we use EMR reqs whenever possible, or scanned reqs if we have to. I do not think physicians are wedded to paper forms; I see my new partner using EMR forms, because these have been set up in the system. The work for EMR is all upfront: do it once to set it up, re-use it forever. For paper forms, there is no set-up; the work is all back-loaded and on-going: store and find the forms, stamp them with your name, write the patient's name on the form, or send to the front to label. I prefer EMR.

My new partner is not familiar with our local specialists, so I asked her how she was referring. She uses our EMR phone book. We have two phone books: one local (just for my practice), and one shared with all my FHN colleagues at any of our seven locations; I don't use the local one. In our shared phone book, information on the specialist's referral preferences (fax then patient phones, etc) is entered in Notes, and is shared with everyone; there is also a field where you indicate specialty. My new partner told me that she just searches for the specialty, and sees who we refer to. This is a good way to use aggregate information collected by the group; it made me realize that we now have a fairly extensive phone book. The information is used in referral letters as well as on the electronic lab reqs (the address of the specialist we are cc-ing to automatically appears on the req). I have access to a provincial database of physicians in the EMR, but our local phone book is better, because it is more up to date and has extra information.

My current practice partner has now decided that he is going go EMR. I have started showing him some of the really cool things in the system, as he starts to prepare for his transition. He will need to decide whether he prefers desktop or wireless, so I have asked him to try using the resident's Tablet so he can get an idea of both set-ups. We will need to figure out how to make the transition as easy for him as possible; I have printed a list of my medication favourites, and have asked him to pick out some of his commonest prescriptions. I will enter those for him, so he can see how it is done, and can start prescribing. We'll get lab and DI favourites set up for him. I expect that it will be harder for him than it was for our younger colleague; I have a fair idea now of what the likely start-up issues are, and having EMR processes already in place will help.

As for me, my encounters now start with a look at my reminders, the vitals are pre-entered by my wonderful staff, and the on-going meds are already all pending in the encounter, just waiting for a click and signature. I have access to the vast resources of the Internet at a click. One of my patients needed a referral to an addiction centre near him; I googled DART. We were both looking at the site on my Tablet, and decided together which centre he would be referred to. I think that the EMR helps me to be a better physician, and I like that.


Friday, February 01, 2008

Snow storm

The weather is just awful today, so I am working at home. My labs all came in at 9:30 am. An INR is slightly abnormal, so I've just sent a note for my secretary to call the patient and adjust his coumadin dose. She can log in remotely from home if she cannot make it to the office.

My husband is working in our home office as well. He is accessing his office via VPN, as I am. His large database is in Cleveland, but the results for queries are near instantaneous. I guess many large companies are functioning via remote access (the common database is somewhere else), but they have made sure that the pipeline is big enough. We still have a long way to go with SSHA; I heard that there were outages last week in several locations on Ontario, making it impossible for practices to access medical records. I think this would be unacceptable in a business environment (my husband's multinational company could not function); I really don't see why this is acceptable in a medical environment, with people's health at stake. We have been promised good access at the new clinic; we'll have to see if SSHA does come through.

A blood sugar just came in as elevated for another patient, confirming a new diagnosis of diabetes. I've just called the patient to let her know. This lady has other serious health issues, as well as limited English and literacy; I had recently asked our FHT RN Case Manager to see her. The RN Case Manager does not have access to the EMR yet; the referrals are done by fax. I've just notified the Nurse of the lab results by email, without using the patient's name: "recently referred pt -initials- has new dx DM II". Once the RN has access, I will e-message her within the EMR, which is much better. I will probably need to send her an email to let her know that she has a message in the EMR.

It is taking a while to establish all the EMR connections within our team. Each FHN requires its own log-in, and there are two different EMRs to learn. All together, it is complex. I would like it done yesterday, as the benefits are so glaringly obvious, but I know I have to have some patience. We have a bit of IT support for the FHT, but it is limited at present; I am worried about what will happen when all of us move into the big office--will we have enough support to run all these machines and software? I can run my office as our FHN has its own IT person, but I don't know what will happen to the rest of the group. We probably should really start thinking about coordinated IT support.

My resident is now talking about joining me after graduation; I know of several young physicians who have joined EMR/FHN practices recently. I think the current primary care environment is much more attractive for new physicians.

My new partner is functioning well in the EMR environment. After a month and a half, we have worked out most of the initial bugs, and she now has remote access.

She is getting a fair number of old charts from her previous practice: we scan those to the networked external hard drive (I have made a folder for her) after she has seen them. Some of her old charts arrived on CD; we simply drag the file to the external hard drive; the patient can have the CD back immediately if they wish, as the process takes next to no time.

She is getting some lab/DI reports for patients who are not registered in her new practice at my office; we don't know if these patients will transfer here. Rather than starting a new chart, we scan those to a folder; if the patient does come in, we start an electronic record, and the files are then uploaded to the EMR.

She told me that scanning was very slow in her previous office; up to 3 months. It made it very difficult at times to know where results were (on loose paper waiting to scan? in a paper chart? attached to the electronic file?) leading to a lot of wasted time. The reason for the slowness was that scanning was only done in the evening, and the clerk did not have enough time to do everything. This does not work; in my office, scanning takes 1 day, or at the most two. It is really worthwhile investing in a good, fast scanner, and making sure that you have enough personnel to do it properly.

My practice partner is actually talking about converting to EMR! He can't type (using 2 fingers), which will present a problem. I think what would work for him is dictation:

Favorite Notes:

The Subjective/Objective part can be dictated (dragon dictate, other). The Vitals are now often entered ahead of time by my staff. If not, these don't take long to put in.

The medications should be typed in. However, once his list of favourite meds is done, it will only take a few keystrokes to enter, as the rest is auto-filled:

Drug Name

amoxicillin 500 mg Refill: 0
Direction: Take 1 Tab(s) PO TID for 10 Day(s);

The Assessment requires typing the 3 ICD-9 digits (if you know them), or a couple of keystrokes to get the drop down list:


ICD - Description




The Plan notes can be dictated as well:

Plan Notes

Favorite Notes:

His CPPs are very organized and legible, we can hire someone to type these in for him. This combination of some typing and some dictating will likely work.

He may not be able to get to the office today. If my secretary can get in, he can call her for results, but otherwise it will be difficult for him to access anything. In Canada, we have snow storms; the EMR certainly makes it easier for us to cope with our weather.