Sunday, April 12, 2009

The three year old EMR

I now have a three year old EMR. I am way past that terribly disruptive newborn period, have dealt with the Terrible Twos, and am starting to reap some nice benefits from a maturing system. The EMR is definitely more responsive and pleasant these days, although it can still throw the occasional tantrum.

I now have three years' worth of data in my system, and am increasingly interested in using this data to improve my quality of care. My practice team went to the Quality Improvement and Innovation Partnership (QIIP) a few weeks ago; there were 50 Family Health Teams represented. My team was able to generate some statistics from our system, but few others could do this. Almost all FHTs are using an EMR, but many are newly computerized; the ability to routinely generate practice-level information (how many diabetics do I have? How many of those are at goal for their cholesterol?) is still very rare—even for those with older systems. It was a little worrisome to see that all this information cannot be put to good use because it cannot be routinely aggregated within practices.

I think that there are a couple of reasons for this

1. EMR systems were initially designed for individual patient care, replicating our paper charts. They are not designed for practice-level audits (which are critical to improving quality)
2. We do not enter data consistently; in other words, we do not have good Data Discipline. If you enter “diabetes” as T2D, NIDDM, DM2 etc, you can’t consistently look for diabetes afterwards. You have to code your diagnoses.

We have to report on a whole series of measures for QIIP, for diabetes, colorectal cancer, and office efficiencies, and I can see that this will present a whole lot of problems for all of us. Perhaps it will make us demand more and better auditing capabilities from our EMR vendors. Perhaps it will make us think more about how we enter data in our EMRs.

I will be moving to a new FHT office designed specifically for the EMR. We have just signed the lease, which is very exciting; construction will start now and I expect to move this summer. We have printed announcements on cards which we are handing out to patients, and we are asking them to regularly check my website, for updates.

We finished scanning my partner’s paper charts into the hard drive at the front, and they have been backed up to two sets of DVDs. He won’t allow my staff to shred the paper; I think many of us still need the old charts for security. I have not allotted any space in the new office for filing cabinets, so the charts will have to go to his basement or to storage when we move; then we’ll finally be paperless. I am selling the last two remaining filing cabinets on Craigslist soon.

The Allied Health Professionals (AHPs) in my office are now using the EMR routinely and consistently for all care. We decided to use eMessages in the EMR instead of faxing referrals; they check the EMR remotely on a very regular basis, and this avoids generating paper. We talked about where to enter data, and our Team’s Social Worker, Dietitian, and Clinical Pharmacist all decided to enter their reports in the Clinical Notes. They sign off when done, and send me a short eMessage linked to the patient’s chart. Both my practice partners agreed to try this system, and are much happier with it; I hear this approach is spreading to other practices in our FHT. If I have a question about a patient, I just send a message; this has greatly enhanced Team communication. For example, I routinely fire off a quick query to our Clinical Pharmacist when I have a question about the best approach for a patient’s medications; she links to and reviews the chart, and sends me back a note along with a link to appropriate on-line resources if needed.

The schedule for the AHPs was being managed centrally at the FHT’s office, using non EMR software. We all decided that it would be better if the schedule was within the EMR and in our office. I made a schedule called “Allied Health Professionals”, and when I need to refer somebody to our Dietitian, they just go to the front and book the appointment with my secretary. The Dietitian can see her own schedule both remotely and when she comes in the office, and she brings up the patient’s eChart directly from Scheduler.

AHPs in other FHT offices must be hearing about this, because I am now regularly being asked to set up them up in the EMR; everybody wants to use the EMR. I don’t mind doing this, because I can do it fast, and I think it is important to do it correctly. Our FHT’s AHPs get their initial training at the EMR company, and then some come by at lunch for a quick orientation and help with initial log in. I think the integration of all Team members will accelerate even more once we are co-located at the FHT office, and can do EMR “lunch and learn”.

My FHN colleagues are doing some very innovative things with their system. Quality Improvement initiatives and good data entry practices seem to be routinely on the agenda at our FHN meetings. For example, one of my colleagues systematically looks for patients who are overdue for their diabetic visits (using the EMR reminder system we set up last summer), and sends them a recall letter. Another physician decided to have her FHT RN recall the overdue patients and manage their visit. I think we are starting to mature as a group, along with our EMR. I updated our FHN diabetes registry (we now have 805 diabetics out of 15,000 patients), and the coding was much better than last year.

My office administrator recently received a letter from a specialist in MS Word, emailed to our office address . We talked about what to do with it, and decided to copy and paste the note into “comments” in the incoming correspondence part of the EMR; no printing, no scanning, no OCR, and no OCR-related errors. It is not quite as good as a direct electronic import into the chart like labs, but is so much better than fax; I would really like to use secure email, but the SSHA email system is very impractical so nobody uses it—you have to change your password every six weeks, you can’t have a general office email for people to send things to, it won’t forward a notification that there is something waiting for you. I don’t use it. It looks like it was designed by security experts, with no emphasis on the practical aspects of a communication system. The results are a continuing lack of electronic communication; you get the system you plan for.

Overall, I think things are coming along nicely. There certainly has been a noticeable decrease in EMR-related stress in the past few months; I think our system is now well domesticated, and we can start planning more and better things.



Anonymous said...

Thank you for publishing your Ontario EMR experience. I find your blog very informative.

Could you give some suggestions as to how to best prepare a practice for the inevitable decrease in the number of patients that a physician can see during the initial implementation period? Many physicians find this slow down untenable for their patients and indeed for their billings which can lead to a failed EMR implementation. Can an Ontario physician utilize different billing codes when he/she is "back-filling" a patients chart/medications into the EMR?

Any help on this would be greatly appreciated.

Michelle Greiver said...

The slow down is inevitable, as you said. You will see patients more slowly at the beginning, and being prepared will help (some). You have to book more slowly by blocking off parts of your schedule, not allowing double booking of patients, do more phone refills for a while. You can also schedule your lunch break to start earlier. Otherwise your waiting room gets backed up and everyone can get very frustrated.

Have a note for your patients at the front asking for their patience while you transition to EMR.

There are no different billing codes that we can use. However, going to a capitated model (such as FHN or FHO) will make this easier, as these models are less dependent on patient volume.

The transition is well worth it, but is not easy. It helps being prepared.


Anonymous said...

With regards to the secure email at eHO, I don't think I understand or agree with your statements fully. There is a very fine line between security and freedom; our modern society proves that everyday. I find it strange that your complaint is that the system seems to have been designed by security experts. I would harbour a guess that you are correct and I would then ask why that is a bad thing when the point is to have the EMR capable of being transmitted via that system? I agree that not having certain features or functionality is a hindrance to the comfort level of using the application but that should not be counted as a negative to the application fulfilling its main purpose and mandate.

My final question to you is, have you ever sent an email or called anyone at eHO to express your desire for the added features and functionality (and then followed up on your request)? If not, then you are not being part of the solution and that is a loss because your blog shows that you are insightful and fair. eHO needs to hear from more people wanting to help work to a better working solution that will benefit everyone and less of the people looking for face time and fame in the media.

Good luck on your upcoming move. :-)

Michelle Greiver said...

Thank you for your comments; my concern with eHO's email system is the fact that it is not being used. I haven't logged in for severa; months now, and my password has expired (again); it expires every 6 weeks.

I just had a look, changed my password, and found that there were no messages (other than the warning that the password will expire). The last useful message was in 2007.

There needs to be a balance between user friendliness and security, and the balance has not been achieved here. No busy family physician will keep track of an email which needs new passwords every six weeks unless there is enough value there to justify this (example, log-in to hospital). The value is not there in this system.

I did send a note to SSHA in 2007. Here was the reply

"I apologize for the delay.

1. Each staff account must be associated to an individual staff member (vs. generic to the office)
2. There is no notification system in place at this time.

Please do not hesitate to contact me with any further questions or concerns."

I think you are absolutely right, I should complain again. I will move first, and wait until the hullaboo dies down, then send a note; however, I don't even know who to talk to now at eHO!

Here is what I think will help:

1. reset the password so it lasts for a longer time (at least until the system is being used consistently)
2. enable some notification so we know to log in and check mail
3. enable an "office" email address so that messages can get routed to my staff.

I don't think this is all that complicated to do.

EMRs have been criticized for insufficient attention to workflow and usability. Secure email is needed, but the same issues apply. A very secure system that is not being used is of no value.


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