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.



Anonymous said...

I totally agree with your comments about security. When we think about security, we need to think about both the costs and benefits. What people tend to do instead is to use fear-mongering rhetoric when discussing security issues, and people rarely get around to discussing what the costs of security are. As you point out, if security makes a system too difficult to use, it will completely derail the system, making it useless to everyone. We need to have more open disussions about the realistic risks associated with security breaches, and balance the appropriate security measures with system usability.

Michelle Greiver said...

Thank you. I have walked into a company's office and seen email passwords on post-its, stuck on the computer screen. When I asked, it was because the password changes every 6 weeks, you can't re-use passwords etc. People just can't remember the thing, can't manage the security, so it gets completely bypassed. Security experts need to think about how people function too.

I am not saying that security is a bad thing, on the contrary. I am saying that we need some common sense, a balance, and an estimation of risk vs benefits of security measures. "Intelligent risk management", if you wish.

As an example, when an ambulance is called, the paramedics have to start CPR, whether it is appropriate or not. We now have a new form that patients can sign, authorizing no CPR (Do not rescuscitate); if someone has terminal cancer, they may make the choice of DNR. The form has a serial number on it, and can only be ordered from the Queen's printer, on pads of paper. A downloaded form is not to be used; if it is signed and witnessed, but does not have the serial number, it is not valid. This is yet another example of really good security measures, ensuring that almost no one will use the document.