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.



Anonymous said...

Regarding emailed consult letters: I just wanted to let you know that email is not yet a verifiable medium for communication unlike a fax. In other words the sender would have no way of knowing if an email was received and the receiver would have no way of knowing that something was sent in error. Nonetheless, software like Winfax or Rightfax allows for the same verification protocols that makes the delivery ("service" in legal speak) of a faxed document legally binding without having to print the document. The faxed documents are represented on your screen as images (most often the tif image format) that could be attached to the EMR record without having to waste paper. Another upshot of network electronic faxing is you can easily delete all the nasty unsolicited fax advertising that tends to clog-up a paper based system.

I hope this is helpful?

E. Barrington

Ian Furst said...

We use email referrals (and send letters) and just put them on PDF's and disclaimers at the bottom then we send a confirmation (done automated as data is entered in the EMR with date and time stamp). the email is sent, the EMR sucks it in through exchange and as the data is entered the EMR sends an autoemail back through exchange with username, date, time and reference.

I'll still need to get down to see you're system Michelle -- sounds like the adoption of EMR is going smoothly. I'm surprised by the time the recall is taking (and work involved). Recall/treatment planning are regular routines of dentistry so the tools are an integral part of the dental EMR but based on you're post the seem kind of labour intensive for you. Once you've entered the info once, is it easy to maintain year to year or do you have to keep entering it? If so, do you think it will last?

Michelle Greiver said...

I have to disagree with you; I am getting verification for my faxes. I get an email saying the fax was successful, who it was sent to etc.
Here is an example:

Fax Delivery Number: 1416xxxxx
Fax Recipient: To:xxxx
Sent at: 05/21/2008 03:57:08 PM (GMT-4:00)
Pages: 2
Duration: 87

The verification comes in within a few minutes. One fax didn't get through, and I got a note that it wasn't sent. The verification is electronic; I don't attach it to the EMR, as it is not useful information, but I leave it in my inbox in case I need to search for it in the future.

Basically, we need to get rid of the fax and go to electronic communication. The system needs to help us do that; so far, this is not happening. I've gone electronic from my side, and I'm waiting for the other side.

Ian, I print the referral to pdf, and email it to fax. I would email it to the receiver's email if I was able to, but I can't because they don't use email.

The labour for the recalls was due to the transition. We went from a paper-based system to an electronic system, and had to figure out how to enter all the data in the EMR. That is what took all the work. Now that it is done, the recalls are going pretty smoothly.

As well, much of the business of dentists is based on recalls, so they are well set up for this. Family medicine has not been traditionally based on recalls (we leave it to the patient to do this); most of our visits are initiated by patients or are booked as follow-up when the patient leaves the office. We have had to figure out recall systems for preventive services since we now have software that is capable of doing this.


Anonymous said...

Re emailed v. fax. It sounds like you office is using a fax interface through your computer already, which does indeed make the document service verifiable and therefore legal. My point is that standard email does not enjoy the same legal strength simply because it's not reliable and no standard system has yet been adopted thus far to remedy this real problem. Email is great tool, but use it at your peril in a clinical setting.

E. Barrington

PS - I send all my physician contacts a link to your blog because I think it's one of the best EMR resources available. Thanks for your great work.

Anonymous said...

Hi Michelle:

I follow your blog religiously and have found it to be a great help in our transition to EMR. Thank you for your great insights and ideas.

I read with great interest how you are sending faxes from your EMR without printing it out first. We are using Practice Solutions in which we can print documents as PDFs. Can you go over step by step (for us who are IT challenged) how to electronically send these PDFs as faxes without needing to print them out? Also how can incoming faxes be converted to PDFs or OCRed and be pasted directly into the EMR without printing them out first?


Michelle Greiver said...


I don't think using outgoing fax via email is for most people. It did take a fair amount of set-up.

Here is how to do it:

To send faxes electronically via email, you have to buy an internet fax service. I use "myfax". To send a pdf file, you click on the "Email" icon on the top, then your email program (like MS Outlook Express) loads. I put in the fax number with a "1" in front, followed by example I also save the fax numbers as email addresses in the email program.

You may also have to "collate", or put a bunch of pdf files together first. I have Adobe pro in my Tablet, use File, create files, from multiple files.

Frankly, I think this process is likely too "fiddly" for most people.

Your secretary can also directly send a file from her computer, as long as the PC's modem is connected to a fax line. File, Print, to fax, and then just follow the directions. You can assign that to her as an "office action".

When faxes come in, to convert them to pdf, use File, Print. When given a choice of printer, choose "adobe acrobat". If your faxes come in the same PC that your scanner is in, you have the adobe acrobat printer installed there. --If you only have the Acrobat Reader (not Adobe Standard or Pro, which come with many scanners), you cannot do this--. Then save to your upload folder, and attach to the EMR.


Anonymous said...

Thank you for your detailed reply.