Sunday, November 30, 2008

Forms, forms, forms

We certainly had quite a bit of audience participation at the talk Dr Stephen MacLaren and I gave at the recent Family Medicine Forum conference (EMR: the first year of computerization).

Of all the family physicians in the room, about a third had implemented an EMR; none were paperless. There was a lot of interest on managing incoming and outgoing paper-based communication.

We manage incoming slightly differently: Stephen has the scanning tech use OCR (Optical Character Recognition) on the majority of the letters. The benefit is that the notes are converted to a text based document (rather than a pdf picture); this is then searchable. The drawback is that the tech has to proofread every document for accuracy prior to shredding, as the OCR process is not 100% perfect. You have to have a well trained tech, and it can be labour intensive.

I prefer to have my scans as pdf, which is essentially an image, but which preserves the original format and does not require proofreading. However, I then have to either summarize the report in "comments", or run OCR from my machine and copy/paste the text into comments.

I find that some simple reports can be summarized; for example: "Dr Smith: pt stable, monitor", or "CXR normal". Some are longer; most of the useful information in specialist reports can be found in the last paragraph, so this is what I copy and paste into the comments.

Regardless of the method used, this is unsatisfactory. Most of these reports are generated using a computer; they are then printed and mailed or faxed; then when they get to my office, they are scanned and imported into the computer.

This process is akin to writing an email, printing and mailing it, and having the recipient then either type a summary or scanning and importing the information into their in-box. Clearly no-one in business would put up with such an inefficient process for information transfer, yet this continues to be our daily reality in health care.

The process for outgoing forms is no better. Most programs continue to be wedded to forms. Both Stephen and I have attempted to replicate the look of the forms in our EMRs, so that they are ok at the other end. The information is there, but unless the format is "acceptable", the letter gets rejected. We both described the process of negotiation that is required to get the "electronic" version of the form accepted (not really electronic, but really a paper output of what our EMR generates, modified to conform to paper-based norms); Stephen has successfully negotiated with his hospital's senior management, while I have had some success with the front-line clerks. For both of us, persistence has been the key.

The friendliest department has been Diagnostic Imaging; they seem happy as long as the appropriate information is there, and it is signed. In fact, one of the XR techs at my hospital told me they like my EMR referrals because they are so clear and legible. No community or hospital-based DI facility has yet rejected an EMR generated form.

Programs (diabetes education, mental health etc) are a mixed bag. Some are progressive, some are not; it really depends on who works there. The toughest have been labs. I won't even try to send something that does not look like a provincial lab form, as I am sure that rejection rate will be 100%; I do not think that this is within the purview of the labs themselves, but rather stems from Ministry directives. The public health lab is similar. I now generate both an EMR and a paper-based form for my paps, as I consider tracking of this test to be vitally important. I think this may be the first lab component to accept electronic forms, as the paper form is proprietary (each lab has their own); the argument for improved quality of care for electronic data generation (tracking) is fairly strong.

Our colleagues continue to fear our regulatory colleges. I spoke about how I disposed of my old paper charts (scanned, backed up x 2 and verified, then the paper was shredded); I was asked what the College policy was on doing this. Here it is:

"When a physician scans his or her paper records to convert them to electronic form, the original paper records may be destroyed in accordance with the principles set out in this policy."

I think that what may be helpful to the profession are some explicit examples of what can and can't be done; otherwise we will continue to be confused. The College's intent is to protect and serve the public, and it is now always easy to balance all the different (and sometimes competing) interests. However, more clarity would help, as well some charity towards members embarking on the EMR journey; after all, these systems have been found to be beneficial to patients and to the health care system.


Saturday, November 15, 2008

The first year of computerization

I will be presenting a workshop on the first year of computerization at our national family medicine conference, in two weeks. I am doing this with a colleague, Dr Stephen McLaren.

I wanted to do this with someone who is practicing in a different setting, and is using a different EMR system. Whenever I do a workshop or presentation, I find that I learn a lot just through preparation; it was the same here.

My colleague has been using his system for almost ten years. He practices in a large group; I was in a small office of two physicians, and my partner did not wish to implement an EMR at the beginning.

When we started talking about the presentation, I think we assumed that there would be large differences in our implementation. In fact, there were far more similarities than differences. Our goals were the same, and the difficulties we encountered (especially with regards to the problems of external, non electronic data) were similar. The solutions and work arounds we came up with have differences, which fit our individual settings and styles. We even found that the challenges of dealing with our EMR companies were similar.

There are no secrets to a successful implementation; it is the same as any other large scale change: "Plan-Do-Study-Act". The first year is very hard; the rewards (increased efficiency, ability to improve quality) do not come until later, once all the data is in, and the EMR system is used consistently. I believe that there is now enough practical knowledge about what works and what doesn't to make the transition a bit easier, and that's what the workshop is all about.

Our practice team is slowly learning how to use the chart in common. This works best for those of us in the same office: my front staff and my practice RN enter everything in the EMR. We hired a new secretary in September, as well as a high school student for evening relief, and there were no training issues; they used the EMR from the start. Our Family Health Team pharmacist, who usually manages patients off site, came to my office to see a challenging patient with me, and while she was there we discussed flowsheets. I showed her how they worked, and told her that she was welcome to enter data there if she felt that it was relevant to team care; our RN, for example, routinely enters data in the diabetes and depression flowsheets. A few days later, I noticed that the pharmacist had entered information remotely into a chronic pain management flowsheet.

We have had a lot of staff changes with our dietitians and social workers, which has made implementation of a team approach more challenging; these practice team members never had a chance to start the EMR before they left. I received the first clinical message from our new dietitian, as she had a question about a patient she was to see the next day; she is enthusiastic about the technology, which is helpful. While our Family Health Team has not yet discussed where our Allied Health Workers should chart things, I think they should write in the same clinical notes as I do. I don't know if it is necessary for me to review all their notes (likely not); our clinical pharmacist sends me a message to look at her notes when she is done. We should think about whether it is better to do it this way, or better to have the physician sign off, which is what I do with my RN, or have the physician co-sign; this should all be negotiated.

I am currently attending a research conference, NAPCRG. I consider this work, so I told my practice partners that I will be checking in daily for my results. It was very busy before I left, so I did not complete some charts; I needed to go home and pack. I finished my charting from my conference. Remote access makes going to a conference a lot easier to do, and I don't feel like I am burdening my partners too much. Most of the coverage while a physician is away does not involve seeing extra patients, it involves reviewing and managing lab results and other incoming tests and consultations--these can all be done remotely.

My older partner is now six months into EMR implementation, and although he is charting pretty much everything electronically, he is not prescribing. He types the prescription into the clinical notes, and gives patients a hand written script. I asked him if he could prescribe faxed-in refill requests electronically for me while I am away; as of now, he writes "ok" on the faxed request, the secretary calls it in and the paper is then scanned. That is not useful for me, as it does not update my electronic meds. I showed him the process for managing this electronically: the secretary leaves the paper form for him, he loads the patient's chart, checks off the meds, hits the "print" button, then cancels printing. This generates the refill. He then sends an electronic message asking the secretary to call it in, with the phone number.

This process is more tedious for the doctor than writing "ok" on the paper form, but it does preserve the integrity of the data (which is lost with the paper form). I have been strongly discouraging the use of faxed/phoned refills; we have a message on our machine that we do not accept them, and we charge $25 for this service--with exceptions in some circumstances. I do not feel that phone/faxed refills, with no patient contact, represent good care; my patients are always given enough medications to last until the next appointment. There is no quick and easy way to manage phoned refills in the EMR, and there is no clinical necessity for the majority of those--they are often done for convenience.


Sunday, November 02, 2008

Space planning for my next office

Planning a new office is a good time to re-examine what I do and how I do it. This will be my third office (and my first paperless office). I have learned something new with each planning exercise, and worked on the current drawings with a space planner. There is a very useful podcast on the subject at Canadian EMR.

This office is being built for three family physicians, and is about 2,000 square feet. We teach, and have two residents in the practice. All of us are members of a Family Health Team; we have a nurse, a social worker and a dietitian seeing patients at various times.

One of the biggest differences between this office and my current office is that there is no space for filing cabinets. Instead of paper storage, I have exam rooms; there are eight of those. I work best with two available rooms; while I am seeing one patient, the next patient is put in the exam room, and a third patient is in the lab area getting their vitals done. Each physician will have two dedicated exam rooms; all three physicians are rarely in the office at the same time, so I expect to have four extra rooms available most of the time for the use of our Allied Health Professionals and students. The residents are encouraged to take extra time at the beginning for their patient encounters; the additional exam rooms ensure that this does not impede patient flow for the attending physician.

The exam rooms are mostly 8 x 10 feet. This is enough for an exam bed, a sink, a bit of counter space, and a small desk to put the Tablet on. I will also be putting a printer in each room, and have low stands for those, with space underneath to store extra printer paper and magazines for patients to read while they are waiting. I use transparent file sleeves attached to the wall for the very few paper forms that are still needed, and for my clipboards (I use clipboards to sign forms and to go over handouts with patients).

We decided to have a common consultation room; this is a major departure from my current office, where each physician has their own consult room. The shared room is far more space efficient, but does entail some loss of privacy. There is also minimal space for paper storage; paper tends to spread and fill all areas allocated to it. I designed the room for 5 people: 3 physicians with allocated desk and storage space, and two shared areas for residents, Allied Health Professionals, and the RN (with the ability to use the allocated areas when a physician is not present). In my current office, I share space in my consultation room with our RN when she is in, and with our resident (I added an extra desk for them); I find that this leads to much improved communication. I expect an increase in “corridor consultations” if all health professionals sit in the same room, and I consider this to be an important aspect of Team building.

If one of us does need privacy, for example, for a personal phone call, we can use one of the exam rooms and a cell phone. One of the things we will look into is having small wireless phones as part of our system for physicians to carry around while in the office, or having telephone jacks in exam rooms.

There is also a staff room. I find that we have an increasing amount of “back room” office work (billing, managing our preventive services, following up on OHIP numbers etc). This is often better handled away from the front desk, so that the staff person at the front can attend to patient flow in the office: checking patients in, getting vitals done(the vitals area—scale, stadiometer for height, BP machine—is right beside the front desk), putting patients in rooms. The staff room is also a good area for lunch away from the front desk or consult room, and can also be used for staff meetings.

I have not allocated space to drug samples in the lab "nurse" area. Sample storage is very space consuming, as the packaging can be wasteful. As well, we have to manage the samples: periodically, a staff member has to review expiry dates, and discard expired samples in our contaminated waste (which is very expensive). We have been asking drug reps to check and refill our cupboards, as this is not something that my staff should be doing; however, samples still expire. I also find that samples tend to spread to the space in adjacent cupboards where we still store some paper handouts. In my new lab area, there is no space for paper handouts (the best ones are all scanned in); the cupboards are for storage of clinical materials (urine dipsticks, pregnancy tests, gauze etc). We will have shelves for overflow clinical materials in the Staff room, so that only the most useful things are stored in the lab, where they are most accessible. I’m not quite sure where samples should go, but probably not in prime space.

In terms of the IT, I have a small closet for the routers, firewall, and other boxes that I want kept out of the way. My telephone system will also go in there. My wireless access point will be installed centrally in the ceiling, and tested before I use it. I plan to have network drops (RJ45 plugs) in every exam room, at the front, in the staff area, in the lab area and at each workstation in the shared consult room. These are easy and inexpensive to install when building a new office, and I prefer to have redundancy. The printers in each exam room will be plugged into the network access points. If there is only one RJ45 plug, and two devices need to be plugged in, I can use an Ethernet switch (costs $25).

You can see how I have tried to plan this office with workflow, team work, communication, and appropriate storage in mind. I have tried to think of who does what, and what the best place and flow for each member of our practice team is. I have also deliberately minimized the amount of paper-based storage; I find that if there is no place to store paper, you just naturally decrease the amount that you keep around. The basic principles for designing an EMR-based office are the same as those for a paper-chart office; the major difference is in the opportunity to decrease the wasted space allocated to paper.