Wednesday, June 17, 2009

Reviewing and changing my scanning process

I have changed my scanning process. My EMR company had provided software called "ADM" (or Advanced Document Management) in the past, but I didn't use it. The reason for that was that the quality of the images (they were in jpeg) was poor.

There are two ways to scan data in my EMR:
  1. Through the ADM program, which is separate from the EMR, and automates much of the process
  2. Directly to the EMR, through an upload and attach process in the application
I used the second method; we scan documents as pdf files, save them to a folder on the PC's desktop, and then upload and attach to each patient's file. This is a very laborious process, but the images are very clear. I prefer to have a longer process at the front of the office and to end up with better quality images.

However, I heard from several colleagues that the new ADM program was significantly better; I went to see it, and it was better. Another physician in my group came to my office to have a look at our scanning process (she was using ADM). We had a look at her scans during lunch, and figured out that some of the quality problems were due to the fact that she was not using the right software to open the files. Her scanned files were saved in tiff format; we switched to MS document imaging--it looked better and we could use OCR (Optical Character Recognition) very easily. I had found out how to associate file extensions with different programs because of a home computer problem, so I was able to do the switch for her.

The ADM software does not work out of the box. My IT guy had to install it and to tweak some other files to get it to work properly. However, once that was done, it worked. He showed us how to use it; we started and had to make a couple of changes, but now it works well.

My scanning tech can now scan papers in batches: she puts a whole stack of papers in the scanner, and scans everything into a single file. The program automatically saves it to the right area without the need for naming the file. Once it is in, the ADM software shows her what has been scanned, and she uses it to attach different pages to different patients and different areas of the chart. The software then uploads the file to the right area of the EMR.

I then see it as a tiff file attached to a patient chart in my EMR inbox (separated into lab, DI, correspondence). I can click on the file's link to open it up. Once I see it, I run the OCR process (using the little "eye" icon in MS doc imaging), which is very fast, and then I can highlight what I want and copy and paste it into the "comments" section.

OCR in tiff seems to work better than in pdf--it is easier to highlight the section you want to copy. I find that I am copying more of the letter to the EMR.

This is still problematic. OCR is not perfect, and there are always errors. You have to proofread and correct the text, which takes time. I have a saved copy of the original, so what I do is look for bad errors (numbers being wrong etc), and leave minor problems alone--example: MRI OP BRAIN.

Anything which is OCR'd and copy/pasted is now saved as part of the EMR record (not a scan), and is searchable. If you are parsimonious with what you put in, you end up with a nice summary which is easy to look at (CT chest: granuloma RUL. Echo: Normal). If you put in lots of stuff, it becomes harder to wade through the information or you have to do a text search. If you put everything in via OCR, you don't have to individually load each scanned document when printing a referral or a transfer, but you can end up with a lot of misspelled garbage, and there is no formatting--it is hard to look at.

I'm kind of in between the two. I'll copy the relevant paragraph to the EMR (diagnosis, management suggestions), and leave the rest as a scanned document. When we transfer a chart because a patient is moving to a new family physician, my secretary copies the EMR chart to a CD, but not the scanned documents. I figure the EMR really contains the relevant summaries of everything that is needed. I don't know if I should start including only the EMR summaries instead of the scanned documents when sending referrals; I guess it depends on what the referral is for.

You can see what it took for me to change my process:
  • Better software from the EMR company
  • Seeing for myself that the quality of the images had improved
  • Figuring out the file attachment problem (over lunch with a colleague)
  • Having a good IT person who could both do the installation for me, and troubleshoot it afterwards
  • Training on the new processes and revising how the secretary scans at the front and how the doctor looks at the scan
Of course, there were problems in the first couple of days: my scanning tech found the pictures on the screen too difficult to look at (until we figured out where the magnifying glass button was); there were errors in attaching scans (wrong area, wrong patient). My partner has MS Office 2007, and MS document imaging doesn't automatically install itself in that version--I had to go online to figure out how to make it load on his computer. You have to have patience with these new things. Our IT guy also figured out how to make faxes and scans automatically go into the same folder, so now the upload process is fully integrated. It doesn't matter whether the incoming is via fax or via scanner, it all looks the same.

I don't mean to imply that I like scans now; I still think that it is a waste of everyone's time to have to re-digitize documents that were originally produced in digital form. However, the hardware and software is getting better at handling this necessary evil.


Saturday, June 06, 2009

User group meeting

I went to the annual user group meeting last weekend. I believe that bringing together users is extremely valuable; we shared many tips and tricks on how to use the EMR more efficiently and effectively. We complained a lot, and laughed a lot too. I met several colleagues who were at various stages of implementation; more experienced users were extremely generous in terms of sharing what works for them.

The EMR company's executive team were there; at the end of the meeting, we discussed our "wish list". Some of the requests were:

  • Templates that can be exported and shared with others (the #1 request)
  • Increased scheduling flexibility for larger groups
  • Improved data mining and reporting capabilities
  • Better ways of entering and reporting chronic disease management data
  • Ongoing training
The head programmer demonstrated the new data mining software they are working on; this looks like it fishes data straight out of the database, and should give "power users" a lot of control over what is reported. I can't see having everyone learn database management skills, but several of us are getting more and more interested in seeing what we can do with all the data we are accumulating. Perhaps what will develop in some groups is data expertise (this does not have to be a physician), so that quality improvement projects can be started for entire groups. It will be much easier to do this for groups of physicians rather than for solo physicians. I think the formation of groups in Ontario (Family Health Groups/Networks/Organizations/Teams) is likely to bring benefits in terms of data management capabilities.

The company talked about their plans for "reportable fields". There was a lot of interest around this. As far as I understand it, this is new fields that can be inserted into templates, and that automatically go into into flowsheets, and that can be searched for later.

Altogether, I think this was a valuable meeting to attend, and I plan to attend next year. The EMR is now so central to our practices that it is worth investing time and effort to build and maintain proficiency in it.

Our last two filing cabinets were sold and picked up, and I did a happy dance over the floor space where they used to be; there is now a lot of space at the front. Our moving date to the new office looks like it will be in August (likely August 22nd), and I am trying to get rid of as much paper as possible. We still have some paper handouts, and these are getting tossed out. I'll have a look around and make sure that we are as paper-lite as possible.

The move to the new office is much more complex due to the EMR. eHealth Ontario is overseeing the internet connection in the new office, and we have to make sure that there is overlap (we need to have two SOFAs--Small Office Firewall Appliances) during the transition so that we can continue to function. We are investigating VOIP phones as a group. I have to make sure all the wiring is planned properly and that there is redundancy for the future. I have a small IT closet in the office for all the routers. I started an Excel spreadsheet of all the things we have to do, and this is growing faster than public health swine flu notices.

I took part in the CPCSSN national meeting later in the week. CPCSSN is composed of 9 different sites in Canada, and all sites are reporting anonymous EMR data on five different chronic illnesses: diabetes, hypertension, depression, Chronic Obstructive Lung Disease and osteoarthritis. I am part of the Toronto group, Nortren. There are eight different EMRs involved, so this is a very complex project. It looks like this is feasible, and primary care can be used safely and effectively for chronic disease surveilance. This likely represents an important part of the future of Public Health.

Finally, it upsets me a great deal to read about the problems currently besetting eHealth Ontario. I agree with Dr Brookstone's post, this will be a major distractor for the organization. My group has had multiple difficulties with eHO and its predecessor (SSHA), mainly centered around service provision and communication; however, I completely agree with Allan that this is a large and complex undertaking. The current chair, Dr Hudson, and the previous CEO, Sarah Kramer, have extensive knowledge and experience in this sector; I hope the executive branch of eHO will be able to maintain focus on their priorities. This news release came from our Minister of Health, David Kaplan, today:

"The board reported to me that the current uncertainty surrounding eHealth Ontario threatens to delay initiatives that are crucial to our government's plan to modernize and improve our health care system.

I am acting immediately upon its request to revoke Sarah Kramer's appointment as eHealth Ontario President and Chief Executive Officer. Ron Sapsford, Deputy Minister of Health and Long Term Care, will serve as acting President and Chief Executive Officer of eHealth Ontario until an interim President and CEO can quickly be appointed.

This decision is an important step to restore public confidence in the agency and its mandate of modernizing our health care system."