Friday, January 30, 2009

EMR transition for the second wave of physicians

My practice partner is continuing on his journey through the transition. It has now been nine months for him. He is definitely not a "techie", but has now adopted the EMR, and has adapted fairly well.

There is no longer any data going into his paper charts; they are now "volume 1" of the record. All his encounters are in the EMR. He started electronic prescribing about two months ago, and is now generating almost all of his scripts through the EMR. Complicated medications continue to be a challenge for him, but he has learned to deal with the commonest issues.

He was still writing referral notes on paper at the beginning, and those were then scanned in the EMR. As well, most of his faxed repeat medications requests were authorized on the paper from the pharmacy, then faxed in and scanned. My secretaries noticed a significant increase in the volume of scanning. He is now doing his referrals via the EMR; if the drugs have been entered in the CPP, he'll just click them on the EMR, and the pharmacy rx paper no longer gets scanned in. If the meds are not in the EMR yet, it is faster for him to write "Ok" on the paper, generating a scan.

He uses flow sheets, especially diabetes and INRs. He has had no difficulties using the eMessaging or To Do notes. He really likes the remote access, and logs on both from home and from the hospital when he is working on the ward.

He is using our preventive services point of care reminders; his rate of flu shots (88%) is better than mine (86%)! He is now part of our FHN's regular preventive mailing program for the past several cycles. Our FHN administrator will be mailing the next letters in early February.

His CPPs are not finished. His practice is older, and has more complex patients with big CPPs than mine. Putting in this data certainly is a massive job, and I think it will be better for him once this is done; it is one tough slog.

He knows how to access and manage his electronic lab data and scanned data. He is now regularly using electronically generated electronic lab reqs, and is using some of our bundled reqs as well. He is less comfortable with DI reqs, but uses them.

We sometimes go over tidbits of EMR information in the evening if neither of us is too tired. That is useful, because it involves things that he has questions about and is very practical and short. He periodically asks me to show him things during the office. My office administrator is very helpful, and will show him things when he is ready as well.

We are now scanning and shredding his paper charts; we have hired a temp to do this. All of the "inactive" charts are gone, and we are now starting on the Deceased. The charts in our back closet are gone. My partner's office currently looks like a bit of a disaster zone, as there are charts piled everywhere, but I expect this to start getting better now. We are planning to move to the new office this summer, and should be completely paper-free by then.

I think that the transition is more manageable for the second wave of physicians, that is, those transitioning once office EMR processes are already in place and working well. There is more in-house knowledge and support. There is still additional stress and time during the transition for the physician, as you have to learn the EMR and put in all the data, but it is less than for the first wave (and that is a good thing). Patience, willingness to learn and to help, as well as a sense of humour all help.

It is possible to have completed most of the transition, even for non "techy" physicians, by nine months. It does require some extra support. It would have been nice to have this for the first wave.

My EMR company has now started web-based training on a regular basis. I think this is very helpful. I attended the first session; what happens is that you have a trainer and several physicians phoning in via teleconferencing. Everyone logs in to the same website, and the trainer demonstrates various aspects of the EMR. This is a good way of doing training for IT, because you can see what is happening right in front of you. The session was 1 hour, which is a good length, I think. We will be having our first user conference in May, and I've been asked to do a seminar. I'm not sure what I am going to do yet, maybe "the efficient office visit".

We will be having an EMR booster session for my FHN in mid-February. I am now familiar with the features in the new version, so that I can demonstrate the most important elements. I think we are starting to do better with our ongoing training.


Friday, January 23, 2009

What to do when your connectivity fails

We had a long, hard look at whether to change to the new ASP model run by eHealth Ontario--eHO--(previously called Smart Systems for Health Ontario, or SSHA), or to continue with our server, based at the hospital.

We decided to continue with our server for now.

There are several reasons for that decision. While I strongly believe that ASP is the way to go over the long term, I am reluctant to switch today. We now have good IT support for the server, through our own IT manager, and have bought additional hardware insurance. The server generally functions well and is closely monitored.

I cannot say the same for our connectivity, which is managed by eHO. We have had several outages in the past six weeks, and two outages this week. On Tuesday, we were off for the whole morning, as the eHO lines were down. Regular Internet was fine, so I was running on my backup line.

Trying to run a backup Internet line using the rules imposed by eHO is a daunting task. We have to use a SOFA (Small Office Firewall Appliance), through which the internet line connects to the office. I have a second, private, internet line coming to my office in case of failure. I had a private company install a failover router, so that the second line picks up when the first one fails. That itself failed the fist time SSHA's internet line went down. When SSHA was back up, the private modem interfered with the SSHA modem, so we could not re-connect properly.

What I had to then figure was how to force the two system to cooperate (a bit like what is happening between all the different players in the EMR field).

Basically, when we fail to connect to our server, we check Google. If that fails, then we know that it is the eHO lines (again). We go to the back closet, turn off the eHO modem and turn on the private internet modem. The private modem bypasses the SOFA, and is connected straight to the main router for my office.

What that means is that we have to connect via VPN (which is our bypass software). I have the VPN software installed on every computer at the office. We load the VPN, and then log on. VPN is not meant to be used in this way, so we sometimes get kicked off the EMR, but at least it works somewhat.

I have a list of instructions posted on the wall besides my router, just in case this happens when I am not there. I have shown my practice partners and my office administrator, so they know what to do. There is no help or manual to figure this out, and the way I have done it is by learning from my mistakes with each subsequent failure; I do not think that this is a good way of planning for problems.

When the eHO lines go back up, we reverse the process. We have to then wait for 5 minutes for the eHO internet lines to connect, so I either wait for a call from our IT guy letting us know that we are good to go, or we try at lunch. We can't do this in the middle of the office, as physicians are seeing patients, and staff are fielding calls and incoming patients at the front.

Today, three HydroOne transformers blew near my hospital, so all internet connections coming into the hospital are affected. We have no service at all, even through backup. We are now starting to wonder if we should have a backup line going to the server--if eHO allows this.

These issues have affected our decision on ASP. The ASP server is hosted at eHO's facility. Their service and communication (we still don't know what happened Tuesday) have been consistently less than stellar--and we are still off-line at the time I am writing this. It would be fair to say that we do not trust that organization with hosting a server managing our data; I think they will have to demonstrate improvements in reliability and communication before we reconsider.

We have to deal with eHO for the lines coming to our new office. I have just received forms for the Order Agreement, which I do not fully understand. I will need help filling those out; I am now frankly worried about whether that organization can supply the connectivity for the 80 to 100 people who will be accessing the EMR remotely in the new location. I guess we'll have to see what happens.


Tuesday, January 13, 2009

Adding more machines

My partner's tablet just spent a month in the shop getting fixed, as there were several things wrong with it (bit of a lemon). It came back after major transplants, and is now working well.

However, we were short 1 machine for a while. He took the Resident's tablet while his was away.

I had bought a very small computer for travel recently (the Acer Aspire). This machine costs $400, and runs Windows XP. During the past month, my RN and the residents used it (they don't need reading glasses). The nurse told me she likes the little machine better than the Toshiba laptop that was also available, as the Acer is much more portable. I found it somewhat surprising that something so small (and inexpensive) was actually useful; the EMR actually runs well on it.

I did not add MS Office to the Acer, as I don't need it; I downloaded OpenOffice, which is free and runs my word processing well.

We only use a fraction of the computing power on most of our machines, and most of what we use is repetitive. Much of the slowness in computers is due to adding new software (especially software that loads at start up and takes up a lot of memory), and not maintaining the hard drive. Hard drives need to be defragmented from time to time.

I don't like Vista all that much; I'm used to XP, and my network runs well with it. I'm not enough of a "techy" to be able to figure out the Vista-XP network problems (and I'm not that interested in doing it). The problem is that new computers have Vista on them. I'm going to need some additional computers for my new office, and I've been thinking of buying some good off-lease Dells, which are sold by several reputable companies. They're about $350 to $450 each. I'll put OpenOffice on the new machines.

The Family Health Team's Allied Health Professionals working in my practice all use the EMR now. The clinical pharmacist has been using it the longest and is very proficient. The dietitian uses it routinely. Our new Social Worker just started entering electronic notes; I sent her a message in the EMR, and was pleasantly surprised to receive a note back within two hours--she was logging in remotely.

What we had decided to do was to have everyone record things in the clinical notes instead of in separate areas of the chart. You can view a summary of the clinical notes which indicates which provider signed off, so it is easy to find the dietitian's notes if I need to review them. However, if a note is scanned in I'll see it because I have to review and sign it off. If something is written and signed off in clinical notes, I can't tell that there is a new entry and may not see it. What we decided to do is have our Allied Health Professionals send me a message in the EMR that there is a clinical note to review. So far, this seems to work well.

I now send a message within the EMR to our pharmacist that there is a patient to see her. As well, she now has her own schedule in my practice, along with "pharmacist appointment" that with a special colour. My staff is starting to book patients directly into her schedule. I think an e-message or direct booking are far superior to faxing a referral. I'd like to try this with the other members of our team.

I need to make sure that there are enough machines for everyone when they come in. On Fridays, the social worker and dietitian are in. My partner is in, as well as her resident; they need the Toshiba laptop and the Resident Tablet. I have an older Dell laptop in the office, as well as that new little ACER. However, if one of the machines goes down, we're now short. I just bought an off-lease Tablet for $700 (same machine as what I am using). We now have far more people in my office than when I started the EMR almost three years ago, and most machines are in use most of the time. It shows you that you really have to think about expansion when you start an EMR, and the investment in hardware does not stop; you can't see patients unless you have access to the record, and you can't have access to the record unless you have a computer.

Our fax machine bit the dust. My secretary bought a new one, a Brother MFC 7220. It came with some interesting sofware that makes faxing from the computer much easier: print the document, choose PC Fax and you have a single pop up to enter your fax number (or you can load your address book and choose a recipient from there). I can also fax from any computer on my network--the PC Fax software thinks it is a printer, and can be installed as a network printer. My staff were impressed, and I think they are going to start faxing straight from their PC very routinely. This even works over the wireless, so maybe I'll install it on the Tablets and laptops. New peripherals seem to be getting much better.

I think that eventually I'll have to replace all of my computers all at once. I'll plan for a new network then, and who knows what the technology will look like. In the meantime, what I have seems to be working.

Our residents have completed diabetic audits for six of my FHN colleagues, so now seven of us have results. 77% of the patients had data on BP, A1C and LDL within the past year available. Of those, 54% were at target for BP (<130/80), 38% had LDL <2, and 57% had A1C <7%. It is not bad, but we should figure out what happened to the 23% of patients with missing data; LDL is problematic, and we need to figure out how to improve those results.


Monday, January 05, 2009

Workflow is king: how to maximize a Peer to Peer visit

I did a Peer to Peer visit to some colleagues working in two large group practices, in another city. The visit really highlighted the value of reviewing and updating current workflows. The physicians and staff at this site did a very substantial amount of preparation, which greatly enhanced the value of the visit.

I can certainly give quick tips to my colleagues on how to use the EMR more productively. Much of this comes under the guise of “task analysis”, which relates to the speed and efficiency of data entry. For example, keeping hands on the keyboard (instead of switching back and forth to the mouse) and reducing the number of clicks and travel between clicks needed to achieve a task (especially a repetitive one) can make a large difference. For example, double clicking on the “Invoice” tab to bring up a bill is much faster than clicking “Invoice”, then “New Invoice” in a different part of the screen. I use the Tab button to go to the next cell, instead of the mouse, and I use the spacebar to fill in a checkbox, not the mouse. However, there is much more to workflow than individual data entry.

My colleagues had structured the visit over two days. The first part was a large group session, with the EMR being projected on a screen (using dummy data). They had prepared questions ahead of time, and asked me to demonstrate different areas of the chart. The benefit of having a clinician do this (instead of an EMR company representative) is that I have had the chance to think through all the various issues in actual practice and with patients, because I am familiar with both practice and EMR. As well, I am not financially tied to the company, so I have the freedom to show where the bugs are, and how to get around them.

There was a lot of interaction and many questions during that initial 1.5 hour session; I spent most of the session demonstrating the “quick tips” above. Once that was done, we went to see the scanning area, and the front area, and I spoke with a nurse and an administrator. This group had clearly decided that EMR implementation was done as a team, and wanted to make sure that I saw how different areas of the clinic functioned; this is the right approach to take. We went through what happens when a patient checks in at the waiting room, then gets their initial work up (done by a Practical Nurse), and then gets put in a room. What was really interesting was that the lead physician identified bottlenecks in flow as we were going through the clinic; the first step in solving a problem is to actually see what the problem is. At lunch, we went over the bottlenecks as a group, and brainstormed several possible changes.

For example, I saw the front secretary taking calls, checking patients in, and being handed a couple of papers by another staff member. There was a small queue of patients waiting to give her their health cards, and the phone was constantly ringing. The problems here are that incoming calls can’t always be answered and patients can’t get through on the phone; this leads to call backs and telephone tag (extra work, less patient satisfaction); as well, multitasking can make it challenging to do work well. One of the things we came up with was the concept of the “front and back”: the front secretary could direct traffic (greet patients and check them in), but not answer phones, and the back secretary could answer the incoming calls and do outgoing calls as needed. Any papers or tasks that do not have a direct impact on the front need to be given to the back secretary. We also talked about management of notes that are paid for privately; in my office, these are printed at the front (not in the physician’s office), and payment is received at the front. Payment, in other words, is directly linked to work produced (the form). What that will mean at that site is networking the front printer to all of the clinic’s PCs, and having agreement on a common workflow for the notes and payment from all clinic members. The front secretary can handle payments, unless the clinic prefers to direct patients to the back secretary for this.

For the second day, I went to the other site, and again observed different areas of the clinic. We then had several small group sessions with a projector, to go over particular problems that had been identified. For example, one of the administrators was having difficulty with large group scheduling. We sat around the table with her; there was a lot of discussion and input, ideas were flying back and forth, and we kept trying different scenarios on the projector. Within a half hour, the issue that had caused her a large amount of stress was substantially resolved. She still has the work of implementing the suggestions, but we could all see that the problem was solvable.

We then had an additional large group session. Several physicians had already tried some of the “quick tips”, and were happy with them. We discussed further improvements in charting, such as using coded entries for chronic conditions. I showed how to rapidly enter data in the CPP, as this had been a common query. This session gave everyone a chance to solidify the gains that they had made in the previous day, and to think about additional changes.

The last part of the day was a “debriefing” session with the key physicians, staff and the unit administrator. The administrator ably helped the group to decide which changes in process they were going to implement first and how, and which changes were going part of the next phase.

We have planned a return visit to my office in several months; I think a very worthwhile thing to do is for one or two of their key admin staff to spend time with our FHN administrator. We did this following another P2P meeting, and it worked well; you can’t change processes if you don’t involve all staff, and I wish the program allowed non-physician members as P2P consultants--in other words, a Team consultation.

What was done at this visit shows how to maximize the value of a consultation; the more you put in, the more you get out; have good processes in place for the consultation itself. The value to this group was largely due to the fact that they were well prepared, had clear questions and goals, and were ready to consider how to implement changes at the end. It also helps to have a cohesive group, were there is mutual respect and good communication between team members. I was very impressed with this group.

I am starting to wonder if one of the outcomes of this Peer to Peer program may well be the formation of a group of physicians familiar with both EMR and workflow analysis in primary care practices. This was not the intent of the program, but EMR implementation is so intimately tied with workflow re-design that an effective P2P physician must address both. There are already practice management consultants (through organizations such as MD Management), there are physician leadership training programs (PMI), and there are “EMR experts”; what I don’t know is whether there are “cross-overs” familiar with primary care practices—and those are the ones who may be the most useful as we transfer from paper to EMR. Perhaps Infoway should discuss this with the Practice Management people.