Sunday, April 13, 2008

EMR housecall

I have now done the first two “EMR housecalls”.

At the first office, I could see that the Tablet was running out of power very quickly. Rechargeable batteries do not last forever; after a year and a half or so, they no longer hold their charge. My colleague has a spare battery, and I asked her to put it in and charge it overnight. I think this must be a common problem for my FHN, as we all bought Tablets at the same time; we have an upcoming FHN meeting, and I will mention this.

My colleague was interested in starting to use the EMR-based lab requisitions. I asked her to tick off what she normally would do at a complete check-up and a check-up for diabetes, and installed those as “lab favourites” while she went to see a patient. When she was between patients, we tested this; I also showed her where the pending lab reqs are kept; sometimes a patient loses the req, and the secretary can print an extra one. This seemed to be a common problem at her office, and the secretary was especially happy to find out how to reprint. I also showed my colleague how the system indicates that lab tests were ordered, as part of the encounter. I showed her how to do her own favourite reqs, and we did one for Fecal Occult Blood testing (a common req due to our new provincial colon cancer program). I configured Diagnostic Imaging reqs for her, and she will now start ordering these electronically.

She wasn’t sure of how to add a patient’s health care number to consultation requests. This was causing difficulties, as her secretary had to enter those manually; I put it in her letter templates and printed an example for her. She was happy with that.

Her scanning system is the same as mine; our FHN admin had shown her secretary what our processes were. I showed her how to use MS Document Imaging to quickly copy a part of the scanned pdf document, then paste it into comments. She practiced this, and I wrote it down for her; it will save her a lot of time.

I installed a shared (networked) folder on the front computer, and made sure it was accessible from the Tablet and from the back computer. I have copied all my handouts and scanned requisitions on a CD, and will give those to her at our upcoming FHN meeting. Her secretary will copy it to the shared folder, so that they can both access it from anywhere.

At the second office, we went over things with three colleagues during lunch. They had thought carefully about what was bothering them. We went over “preferences”, which is where you set how you want the system to work for you. For example, I showed them how to default all the currently active medications in the encounter; this makes it very easy and fast to prescribe, requiring only checking the tick-box, then “Sign and Print”. I also showed them how the system handles “active” and “inactive” medications: there is an “expire by” area on the top of the prescription. My long term prescriptions all have “expire by 1 year”, so they don’t drop off the active list. For short term prescriptions, such as antibiotics or skin creams, the expire by is 1 week (these expiry dates are all saved in favourites, so that I don’t have to remember them). The short term drugs stay in the CPP and show up in new encounters for 1 week and then they’re off. I showed my colleagues additional places where expired medications are kept, as well as rapid methods to remove drugs from the active list. We also went over tricks in prescriptions, such as how to prescribe glucometer strips using three keystrokes.

My colleagues were not sure of how to do sick notes; I showed them how to do a template for letters, and we put a sick note template in. We practiced doing one together on a test patient, which is very simple once the template is in; there is a copy of the note kept in the system. They are now comfortable writing sick notes and letters for massage therapy very quickly. I also suggested that they print the notes at the front desk, so that payment could be managed by the secretary; we put a footer regarding payment at the bottom of the note template.

They use desktop computers, and there is very little desk space in the exam rooms because of the keyboard. I suggested buying some plastic sleeves that could be attached to the walls, some of the paper on the desk can be stored there; as well, a couple of clipboards can be placed in the top sleeve, and these can be used to hold papers to sign prescriptions, or to discuss handouts. There are no printers in the exam rooms, so they walk a lot. Installing a small printer in each room may work; there is space for that.

I think there was considerable enthusiasm by the end of lunch; they had lots of ideas and thoughts about how to improve EMR processes. I was impressed by their rapid grasp of new ideas and their willingness to implement new things.

One of the physicians emailed me with an idea: we could have meetings at the hospital to learn how to better use the EMR. We could use a projector tied to a laptop; one physician would act as a facilitator. Each physician would bring their own laptop and would log on to their own EMR application to try things out.

I think this may work; in fact, I was at a conference for my University Department on Friday. At lunch, a colleague who is using another EMR told me that her group of 22 physicians does exactly that: they hold monthly “EMR learning” meetings, and use exactly the same process. It has helped them a lot. EMR companies do not really offer much broad-based ongoing training, and we really need that.

At the departmental meeting, a physician who had come to visit my office with his whole office team a few months ago came by to say hello. He told me that things were running much more smoothly for him and that he was much happier. It was the processes we outlined that made the difference, although he was the one responsible for implementing them. He was now paperless, and ready to send all his paper charts to the basement.

I think that this type of individualized physician to physician dialogue on EMR is helpful. There is no one better able to say what works and what doesn’t than a physician in his or her own practice. Having a peer who has solved many of the same problems do an EMR housecall is valuable because it adds an extra pair of informed eyes and ears. I don’t expect that everything I suggest will be done; I think each practice is best placed to choose what they would like to implement, when and how. I was asked to do a follow-up housecall in a few months; the problem for me will be managing my time. I just don’t know if there are enough of us around to do this on a wide scale; however, I can see that even a couple of hours will help: each housecall took 1.5 hours.

My practice partner has now chosen May 5th as his EMR start date. Two students are coming by next Thursday morning: they will start entering his CPPs for him. I will give them a bit of training and supervision for the first few entries. My office staff is now booking him very lightly for the month of May; it is important to do that, because he will be much slower at the beginning.



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Anonymous said...

We realized also that physician peer to peer teaching is the best way to learn an EMR and start a peer to peer network. We may also do so web learning modules and if these are developed I will try to get the NS government to share them.

Mike Wadden

Michelle Greiver said...

Thanks, Mike. It would be helpful to share those modules if you think they are good. I think the more sharing, the better.

Peer to Peer is not the only way to support EMR implementation, but I think it is an important aspect of it, and complements other strategies. So far, the main strategy seems to be "just put EMR in and physicians will adopt". It doesn't work.