Sunday, June 22, 2008

Research and Quality Improvement

I have been interested in research for several years, and have a couple of projects under my belt (Using a PDA for the diagnosis of angina; Cognitive Behavioural Therapy in primary care; effect of incentives on preventive services). I think EMRs have enormous value for research that is relevant to family medicine and useful for patient care; beyond that, the data in EMRs can certainly contribute information to run our health care system more effectively and efficiently.

The issue will be how to collect data from our practices; you want to fully protect the privacy of both patients and physicians, yet ensure that you still collect enough useful data for analysis.

I am a co-investigator in two studies that have recently received funding:
  1. Canadian Primary Care Sentinel Surveillance Network (CPCSSN), and
  2. Development of an Electronic Medical Record primary care research database, at ICES
These represent two different way of collecting EMR data for research. The CPCSSN sites will collect data on some chronic conditions locally from many different EMR systems in Canada; the data will not contain patient identification. All this data will then be amalgamated at the national site.

The benefit is that you can collect data from several different EMR systems (as we have a tower of Babel of EMR systems in family medicine). The drawback is that you depend on local investigators to try to collect data from their EMRs, and that you are pretty limited in terms of what you collect. You have to say what you collect at the beginning; if you forgot or just couldn't get something important, you don't have it in your database.

For the ICES study, we will explore anonymization software; this will allow, in the future, collection of the entire EMR database while protecting privacy. All names and identifiers are scrambled; after this is done, no one has access to the scrambled data, except for an ICES analyst. Researchers only have access to data after it is analyzed (once they obtain permission), and only for larger groups of patients, never for a single record. In other words, what you get is things like x% of patients in this geographic area have diabetes, y% were prescribed a cholesterol drug, and z% have a cholesterol level that is at goal.

The benefit is that you have a fairly complete description of care; if the database is mirrored (sent automatically to a second server), data collection is on-going and is pretty much live. The drawback is that the anonymizers will have to be programmed for each EMR software, since they all work differently. You will only get data from a select group of physicians, and there will have to be some extrapolation and assumptions if you say that the data represents an entire population.

Because the practices in my group are run remotely out of a single server, we can collect data without having to personally go to each office and access the server. In fact, the amount of bothering physicians, staff or patients is pretty much zero. Ideally, that is the way it should be--we're busy enough during the transition without imposing more work related to research. We will have posters informing patients, and giving them the option of opting out.

I do not know which way is best, and I think these two projects will test both approaches. We will start small, and go slowly and carefully; it may well be that we need a variety of approaches for data collection.

It is very interesting to me that some of the ground work that makes this possible started out of our group Quality improvement initiatives. We wanted to use our common EMR to improve our preventive services, and our diabetes care. Out of that came the realization that data could be collected remotely, and we also learned how to do it.

Research is difficult and time consuming. You also have to go through a Research Ethics Board, and there are lots of forms to fill out. I am not saying this is a bad thing, although sometimes it is very bureaucratic and it doesn't always make sense. Quality Improvement does not require all this overhead; in fact it works better when you have a goal, try small things, see if they work, then fix problems and keep going. This is called a Plan-Do-Study-Act cycle (PDSA); much of what I learned about collecting data in my group's EMR was through that process. For Research, you have to plan thoroughly, apply for your grant, hope it gets accepted, then implement and hope it works. This is not a great way to start something with as many unknowns as EMR data collection. We probably need to re-think the interface between Research and QI.

As for me, I think I probably have something to contribute to this nascent EMR research enterprise. I have now finished the coursework for my Masters, and am writing my thesis (on the Effect of EMRs on preventive services in a Pay-for-Performance environment). I have asked my University department for a second day of research, and will take Wednesdays for this, as of September. I'll practice three days a week, and devote two days (and some evenings and weekends) to research. I have asked for permission to join ICES; we'll see how things go.


Friday, June 06, 2008

FHN staff meeting

Our FHN administrator organized a meeting for staff at all of our FHN practices, earlier today. She asked me to attend, which I was happy to do.

Every practice was represented (7 offices), most with more than one staff member. It was very gratifying to see that both my colleagues and their staff considered this to be important enough for time off to attend.

The first problem we had is that my office is too small! We really need a boardroom, which we don't have. Much of the discussion involved the EMR, so everyone crowded around the three computers in the front office area.

Interestingly, one of the first questions was about what a FHN is. In Ontario, we have a regular alphabet soup of primary care reform (FHN, FHT, FHO, FHG, CCM). Don't ask. I explained that the main difference between independent Fee for Service practice and a Family Health Network is in the payment (largely capitated, or one set fee per patient per year) for FHN, and piecework for FFS. As well, in a FHN, patients roster, or identify a particular family physician as their physician.

We did not find much change in our practice when we became a FHN. I think capitation is supposed to decrease small visits for minor problems, and encourage visits for prevention and chronic disease management; I'm not really sure this works. One of the main reasons we joined was that the government said they would subsidize EMRs for physicians joining FHNs.

Our FHN administrator went over the rostering process, and why it is important to keep rosters up to date, using the monthly update list. The roster list in the EMR drives the preventive services; only rostered patients get recall letters (that is the way the government set it up). I think that it really helps if people know why they are doing things. Maintaining the list ensures that letters are sent to appropriate patients and not to those who don't need them (patient moved, switched physician etc). We went over the process for de-rostering patients, both with the paper form from the ministry, as well as tracking in the EMR.

We showed the list of preventive reminder letters, and showed everyone how to easily access it in the EMR. Our administrator showed how phone calls are tracked, and reminded everyone that patients are now getting called if they have already received two letters and have not answered yet.

Staff member were very enthusiastic about participating in the FHN preventive services program. We discussed the fact that reminders do make a difference in cancer prevention, and they know they are taking part in a good program.

We discussed efficient messaging in the office, as well as pop up messaging. We have a summer student that will go around and install the pop up software, as well as fix computer glitches as needed. Several offices were interested in having electronic faxing installed, so that they could import faxes straight to the EMR without having to print and scan.

Finally, our FHN administrator took everyone's email address. It is not sufficient to email physicians, some things need to go to their staff as well.

Overall, it was a very productive and interesting hour and a half (included lunch). I think there is a lot of value in involving practice staff, not just physicians.

My practice partner is progressing quickly. He now writes some prescriptions, and has done several consult requests in the EMR. He uses office messaging and "to do" notes consistently. He is starting to write electronic encounter notes more and more often. The Tablet goes in with him consistently. He is using INR and diabetic flowsheets. All incoming reports are getting scanned in, and no charts get pulled; his labs are electronic. My staff still pull his charts for him for patients coming to the office, and I expect this to continue for several months, until there is enough data in the EMR. His first preventive services mail-out went out last week.

It has been a month on EMR for him, so I think this is not bad. There is still a ton of extra work for him, mainly the CPPs. We occasionally go over things quickly after the office, and I'm there to troubleshoot minor problems. He does not have to call the Helpdesk, which is a big difference from when I started. It makes a big difference once the EMR is up and running; adding extra physicians is not quite as tough.

We are getting two new residents in the practice in July; it will be interesting to see how they pick up the EMR. I was lucky to have an exceptional resident for the past two years; she bore with us during the transition with good grace, and is pretty expert at the use of the EMR now.