Tuesday, May 27, 2008

Generating new ideas

I am sometimes asked about how I think of new things. The EMR is a powerful driver for new processes, because if you do things the old (paper-based) way, it does not work very well.

Very few things are completely new and world-changing like Google; my new ideas are small re-combinations of older things. This ability to figure out things is very human; machines certainly can't do this, and most animals probably don't either--at least my cat does not appear to.

Usually, I start with something that bothers me. For example, printing something and then re-digitizing it so it can be faxed seems silly; how do I fax directly from my Tablet? I don't have a fax server, and installing one does not seem practical. I can email; perhaps there is a way to combine email and fax.

The next step is to google "internet fax", and many sites pop up. Wikipedia gives me a quick run-down of how it works, and it seems reasonable. I give it a try, and it works.

I now have to figure out how to collate documents: many of my faxes consist of several documents (a consult letter, labs, scanned diagnostic images). I have to put all these into a single file, so I can email it to fax; if I don't do that, I have to save all the files to desktop, then attach a whole bunch of documents to the email-fax. That is too labour-intensive, and won't work.

When I write a consult letter, I sign it on the Tablet, then I print it. I have Adobe Pro; I can print it to Adobe and it saves it exacly, including my signature. I look at the Help in Adobe, and it tells me that I can create a document from multiple files; that seems pretty easy to do. I open three files, and try it, and it saves it as a single document. That works, and it is fast.

On top of the document, there is an email icon. I click that, my email program loads and I enter the fax. It works and is faster than printing and putting the letter at the front with a sticky.

Now I have a bunch of fax numbers saved in my address book. Sending a fax is now the same as sending an email. I still put long, complex faxes at the front, but most of the smaller notes go straight out from my Tablet.

That is how I do new things; it consists of figuring out what the issues are, trying things in small incremental steps, and solving problems along the way. Being curious and persistent helps.

If you like trying new things, the EMR is a gold mine for this, because it is early in its life-cycle. Bonus for innovators. If you prefer to let someone else start new things, but are open to trying them out for yourself, there are now enough innovations that you can help yourself from the menu. The on-line helpgroups for your EMR are a good place to look; provincial organizations like our EMR Advisor in Ontario also have good suggestions.

As another example, I am trying out new templates to help me with the clinical management of various conditions. At our recent Practice Based Small Group educational meeting, the module suggested a 3 question screener for suspected dementia. It seemed like a good idea, and you can see the resulting template at the top. I put a drawing area in the template, and the patient can draw the clock directly in the Tablet. It is saved as part of the record. I put this template in our Enterprise section, so it is available to everyone in my FHN.
The ability to try new things is a real EMR asset; the speed of communication also allows for a potentially very rapid spread of new ideas. I kind of like that.

Wednesday, May 21, 2008

Preventive services results for our group

We now have my FHN’s results for our preventive services:

Children’s vaccinations: 98%;
Pap smears: 74%
Mammograms: 75%
Influenza vaccinations: 71%

We mailed out 7,666 reminder letters in the past year. Our FHN admin is emailing individual and group results to each physician.

The results are OK. I think they are not as accurate as they could be, because it was hard for us to figure out how to keep our patient rosters up to date at the beginning, so some patients are on the list and shouldn’t be. We are now much better at it: most practices fax the monthly update to our FHN administrator, and she enters the changes in the EMR. As a result, our patient databases are becoming much cleaner. I received a note that the Ministry of Health will soon be sending us our patient Roster lists electronically, so that will help--if it does happen and if the EMR company programs an interface for it.

I expect that our preventive results will be better in the second year because we are better organized and we have worked out the initial problems. I think this was a good experience overall for my group; I am now getting requests from several colleagues to start a Fecal Occult Blood screening program.

We are about to do our next mailing; this is now routinely happening every three months. We are also organizing a system to phone patients who have already received two letters and have not responded yet.

The five new physicians joining our FHN will be part of this, once they implement the EMR; my two practice partners have started, and we will do their initial mail out this month. Having a project that you do as a group is a good idea: it will make you function as a group (groups don’t really happen unless you do things in common), and these projects can be used to help with EMR implementation, because they add value to the EMR.

The diabetes project is going faster than expected. Most of the flowsheets have now been put in; the work is all being done remotely, since we no longer have to go to each practice to get data from paper charts. We are now going to start putting in automated reminders for diabetes care.

I have now visited five practices in my FHT. There are different things happening at each practice, but I am starting to see a couple of things that are common. Several of my colleagues wanted the vitals and current medications to load automatically into the encounter. I showed them how this is set up in Preferences, and we changed it while I was there.

I installed several batched lab requisitions at some practices, as well as requisitions for Diagnostic Imaging. For other colleagues, I went over how to prescribe using the favourites list, and how to quickly enter ICD codes for assessments. I re-worked saved letters and handouts to make them a better fit, after asking what my colleague needed; several people will now be doing sick notes directly from the EMR.

At several of the practices, I also spoke to the front staff. I have a CD with my scanned requisitions and patient handouts, and I installed this on a networked folder on the front computer.

I can see that this type of individualized assistance is of value. I was able to fix some annoying problems fairly quickly, and I think everyone was happy with the experience. I spent 1.5 to 2 hours at each practice, and the visits were pre-booked: the physicians cancelled appointments to make sure that we could sit together. I don’t expect that everything we discussed will be done, but I know that some things will, because we changed the Preferences and practiced together; if two or three common things work better, I think that’s pretty good.

It was interesting that while I was at their office, several colleagues told me that the computer made them feel “stupid”. You really have to wonder why this is happening to intelligent, very competent physicians. I think we have a lot of experience and knowledge about caring for patients, and we don’t have the same for computers. I reminded my colleagues that the amount of education and training we receive in Information Technology is several orders of magnitude less than what we receive in medicine; we are physicians and not IT specialists, after all. I don’t expect my lawyer to solve my computer problems. The stupidity lies on the side of the machines: if they worked perfectly, we wouldn’t have to deal with their frequent mood swings and reboots. My patients are used to hearing me vent at my stupid Tablet.

I went to another group on Tuesday evening, as part of the “official” Peer to Peer program. The issues were somewhat similar; their administrator was there, and we discussed work flow issues for different conditions, such as diabetes; I have now posted several entries on workflow at EMR Advisor. I showed how to make new templates using pieces of old templates. This took about two hours, which I think is about the right amount of time; more than that and everyone gets a headache.

Little pieces of integration are starting to happen on their own. I am receiving the occasional email about patients; I received a note from a specialty clinic asking if we would prefer to receive consultation letters via email. Even if the “System” makes it difficult, electronic communication is starting; perhaps we can use “going green” as an excuse to avoid paper and fax.


Saturday, May 10, 2008

First week on EMR

My practice partner has just completed his first week on EMR. The student pre-entered his CPPs for this week's patients.

My partner started doing some encounters. He is taking his Tablet into the examining room, and typing things in. He still has the paper charts with him, and I expect this will last for several months. He has prescribed a few medications, starting from the first day; this is more challenging for him, and he is still writing many scripts on paper. The medications that auto-load from the CPP into the encounter, as well as those that are in his list of favourites, are easier for him to do, so he has started with those. Prescribing using the drug database is much more challenging.

Interestingly, he noticed that the dosage of acetaminophen in Tylenol #3 was 300 mg, and he sent me an e-message about this. Dosage of regular tylenol is 325 mg of acetaminophen, and we both assumed this should be the same in T3. I had to look it up in the CPS (our drug bible), and in fact, it is 300 mg in the T3; a new pair of eyes is a powerful thing!

My partner is comfortable entering coded diagnoses in his encounters, and is now doing this fairly routinely. Family physicians generally know the ICD9 codes, because we use those in billing. Having the diagnostic codes will help once he goes on to the more complex aspects of the EMR, such as searching his whole practice for health conditions.

Our staff is scanning incoming documents for him. He still wants to have a look at the paper, so these are left in an area at the front for him. However, the secretaries are no longer pulling charts for scanned documents or electronic labs; this has immediately cut down on clutter at the front. If he wants to see a paper chart, he asks for it (verbally, or via e-message). Once he is done with the paper report, it is shredded.

Faxes come in to the front computer, and are uploaded to the EMR without printing; what we do is print the fax to pdf, save to the "Files to upload" folder, and then upload to the EMR. My partner has asked that the faxes be printed for him for now, so his faxes are both printed and uploaded at the same time.

He is spending more time at the office because of the EMR; we had discussed this, and he is prepared for the extra time investment. Our staff is trying to book him very lightly. He sometimes asks me for help if he is not sure what to do, and I am very happy to assist; our staff members are also very supportive.

We went over how to use a Tablet in the previous week. He is a bit tentative with the stylus, but is getting used to it. He has the same Tablet that I do (a convertible, with a keyboard), so I was able to show him how to use the Tablet effectively.

Overall, he says that the first week was OK. I think starting with basic things like putting in an encounter and assessment, and trying some prescriptions, works well. My partner is getting used to the way the CPP looks, and has entered some data in it.

What helps a lot in this case is the fact that the office is familiar with the EMR, so he is not starting from zero. There is a lot of on-site knowledge and support from both his practice partner and his staff; there is no need to call the helpdesk, which can take a lot of time. We are able to handle glitches and questions pretty quickly, so that if he has a problem, it gets solved. The questions he asks help him to figure out what the system does (and doesn't) do.

We have started to scan his old charts; I have ordered a second scanner, so we can do all the charts in the summer, and he is getting a student to do this job. He goes to a senior's clinic off-site, and he does not want to drag the paper charts with him any more. Those charts have been scanned in, and backed up to his Tablet. He will be logging in remotely while at the Senior's clinic.

I now have received the lists of diabetics back from my FHN colleagues, so we have a diabetes registry. There are 801 patients on this registry. I have a summer student now; he is currently entering the data for the preventive services for the new FHN physicians (rostering, checking off patients who have received the service). This is going much faster than last summer, because we are used to the system. Once he is done with that, he will be putting in electronic flowsheets and reminders for all diabetics on our common register. I have notified my FHN colleagues that this will start happening in the next few weeks.

I am currently trying out Internet faxing. Our system continues to be fax-dependent; even though secure email exists, no-one is using it. The way Internet fax works is that I upload the documents via email to a fax server, and it then transmits the information to fax at the other end. It is electronic (fast and easy to use) from my end, and paper-based fax (slow and non-secure) from their end. This may be one way to bypass the paper system. A problem is the cost: $14 per month includes 100 outgoing pages; I sent out 35 pages the first day. I then figured out how to avoid a cover page, which will reduce the number of pages I produce.

Something that happened once transmission was easier is that I am sending out more information. I had a lab result that I thought might possibly be useful to the geriatrician who co-manages a fragile patient with me; I emailed it to his fax. I would not have done this by plain outgoing fax, because you have to print it, put a sticky with the fax number on it and bring it to the front, then the secretary faxes it. I was off site at the Senior's clinic when I saw the result, and just emailed it. Make transmission of information easier to do, and it is more likely to happen; too much security can mean a loss of information, and there is little attention paid to the downside of security measures. Make a system too secure and too difficult to use, and the result is that nobody uses it; this is what has happened to our SSHA email system. Of course, fax is neither secure (everyone can see the pages that come out, sometimes you fax to the wrong number), nor fast or particularly easy to use--we're just used to it. It is time to consider abandoning our fax addiction.