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.


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