Monday, August 24, 2009

New office

I love my new office! We spent the weekend moving in, unpacking, hanging things on walls, and installing and testing all the IT we have. Our IT guy spent several days at the office making sure that everything works. I now have a new and very fast internet line from eHO: our IT guy, the Family Health Team's IT guy and the IT guys from eHO worked together to make sure it was ready for this week--it takes a whole village to raise an EMR. The telco company was there installing our phone and fax systems; the alarm configured their system as well. We met the lab technician next door. I went downstairs to say hello to the pharmacist in our building. Our office manager seemed to be five places at once, as she masterfully directed this symphony.

We reopen tomorrow.

This office was planned from the outset as a paperless practice. I now own a large number of redundant power bars--our old office had too few power outlets. We have a lot of grommets (the little holes in desks and countertops you put cables through); the grommet guy came by today to put more in where we wanted them.

The office really has very little paper; my partner was very good about getting rid of his at the end, and we shredded everything before leaving. We found some paper prescription pads; those were shredded, except for two pads in case of EMR outage. We are not ordering Rx pads with the new address.

Here is the basic plan for patient flow:

1. EMR schedule reviewed by MD (and RN if she is there) in the morning--the "huddle". Additional instructions for staff pre-work added if needed (example, take bp).
2. patient checks in; secretary verifies demographics. If there are alerts (example, print depression questionnaire and give to pt; give pt bottle for urine sample), she completes the requested action. Scheduler shows pt is In.
3. Pt is shown into clinical area; the initial area is the central nursing station, where the BP-tru, height, weight and waist circumference are done by a member of the front staff. There is a computer there, all vitals are entered directly into the computer
4. Pt gets put into exam room; scheduler shows which room (1 to 8)
5. MD/RN sees that pt is in room on Scheduler; loads chart, reviews notifications (example, due for FOBT), sees alerts and reviews CPP/lab/Diagnostic Imaging, loads chronic disease flowsheet as needed, then enters room and greets patient
6. After exam, pt goes back to central Nursing station, gets lab req/urine sample bottle if needed, talks to receptionist on duty in that area and books follow up appointment if needed. MD/RN can send pop-up message if a specific type of follow up is needed (example, diabetes--wt and BP--in 3 months). No little line up to talk to a busy front receptionist.
7. Pt goes back out through waiting room. Scheduler shows patient is Out.

We have a large staff room for back office work. We have two scanners, one in reception and one in the staff room. There are two fax machines; faxes come straight into a PC, but in case the PC fails, the fax machine will print the document. Outgoing faxes can be done from either machine. The secretary at the front reception will be there mainly to greet patients and manage flow; the second secretary at the side reception will be responsible for scanning/uploading, and for managing outgoing patients at the central nursing station (which is right beside the reception). There are two PCs at reception (front and side); 1 PC at Nursing station; 2 PCs in the staff room; a phone beside each PC.

There is a common consult room for the 3 physicians, and the RN has space there as well; there is some room for residents and medical students to sit and discuss cases, and they have space in the staff room to type their charts. Two of the physicians have desktop PCs in the consult room; all physicians have tablets or laptops to take into the exam rooms. The consult room has 3 additional portable computers ready to go, for the RN or other Allied Health Provider to use, or in case one of the MD's computers crashes or fails. The common room has 1 outbox for faxes/papers with action needed, and 1 outbox for scans; front staff periodically check this during the day. Each MD has an inbox on their desk. There is a shredder in the room, so that paper documents can be disposed of immediately if needed. There is a shredder in the reception area and in the staff room as well.

If a provider needs to have a private conversation, he or she can go into any exam room; rooms have phone jacks, so one of the phones can be plugged in. We have increased our phone lines to three incoming lines, 1 private line, and 1 fax line--hopefully this will reduce the number of missed calls and messages left because all lines were busy.

I'm sure this won't work out perfectly as planned, and we'll have to work out kinks over time. We've been talking about flow a lot over the past few months, and I have looked at a fair amount of literature on this. I think the basic plan is sound; I'll start to find out tomorrow.


Monday, August 17, 2009

Of concrete blocks and EMRs

I am moving to my new office on August 22nd, next Saturday (or at least that was the plan). A 20 foot block of concrete fell from the third floor on the back entrance of the building where my new office is located last Friday.

We thought the building would be closed for several weeks; the city evacuated it that day. Two Family Health Team practices had already moved in, and the FHT head office is in the building.

Over the weekend, physicians made contingency plans. The practices that had already moved in are all using EMR through remote access. A call was put out to host fellow family physicians; all that was needed for them to access their records was internet access. These physicians had switched their phone system to VOIP, so were able to port the phones to other offices if needed.

Several physicians had hired a private company to scan all their old paper records; the company generously offered to make the copies available to the physicians if needed (paper charts were trapped inside the building). Secretaries were able to access the scheduler remotely to phone patients with appointments. Labs continued to come in electronically. The main issues was with the fax machines, as these were located inside the building, and incoming information could not be accessed or uploaded to the EMR.

It was very stressful, but also very interesting to realize how portable the information now is; this was good demonstration of disaster recovery. Had my colleagues still been using paper, their patient records would have been completely inaccessible. We also continue to need to work to decrease the amount of data coming in by fax.

I updated our practice website with the information; it was not clear over the weekend what would happen.

Finally, we received word on Monday morning that the building was re-opened; access was through the underground parking, which had been reinforced. Everyone was to stay away from windows until notified otherwise. We could move next weekend, although with some restrictions.

We had developed a communication plan for my practice should the move be cancelled. Our summer students were going to call all patients booked after August 21st. We were going to update our voicemail system and website. I thought about sending out an "allpatient" email relating the issue; although we have started collecting emails, this is still at an early stage, and we cannot do mass emails for now. It may be good to try at some point in time, we may need the ability to send something quickly out to all registered patients in the event of an outbreak. I don't know if there are any rules yet around mass emails from physicians; this is likely coming, we probably should start thinking about what is appropriate and what is not.

Email communication with patients itself is becoming more difficult to manage. Although I have communicated by email with patients for over 10 years, I am not sure that I should continue to allow this type of communication. We have been discussing email at QIIP, and here is what they said:

"A clinic email address for general inquiries would be adequate and admin staff could manage the inbox. However, for services like prescription renewals, medical advice (non urgent of course) or any other service that involves a healthcare professionals, a more secure line of communication is necessary. "

Our medico-legal insurer, the CMPA, has also recommended stricter rules for email; I have added a link to their disclaimer on my email signature. Email security and encryption is impossible for me to manage; a proposed solution is to only allow patient email through a portal, such as It costs $240 per year, and each patient must pay $20 per year. I am not sure at the present time. I like the fact that this is secure, but I'm not sure about the payment. As well, my email has now been widely disseminated; I don't know how I would manage a switch to a portal instead of "plain" email. I also frequently email patients links directly from an encounter (for example, the DASH diet for patients with hypertension), and I'm not sure if I can continue to do this through a portal. I'll have to think about that one.


Sunday, August 09, 2009

Summertime data entry

I am now back from vacation. Our summer students did a lot of work while I was away.

In the previous post, I mentioned that we have missing data on smokers; we also found inconsistencies in terms of how the data was entered if the patient was a non-smoker. In this EMR program, a non-smoker is indicated through a check-box; most patients had this data entered correctly, but some had "non-smoker" entered as free text. Our summer student was able to identify all the free text "non-smokers", by looking for terms such as "ex-smoker", "x-smoker", "quit smoking", "non-smoker", "non smoker", and entered the correct information in the check box. We now have a more accurate list of non-smokers for my group.

As well, the summer student put in an alert in all the charts of all active patients age 15 and over who did not have any information about smoking in their Cumulative Patient Profile; while my partner was away this week, I saw one of his patients with an alert, and just added the information. We'll see if this approach works.

Our summer students verified our lists of preventive services, and double checked all patients. They also checked the lists of rostered patients sent by the Ministry of Health for my group, and updated the information in the EMR.

Our FHN administrator oversaw the work while I was away. I have a lot less supervision to do now. The main problem I have is that the students did the work so fast that it was completed ahead of schedule!

The move to the new office is now less than two weeks away. I am very happy that we are not moving our paper files, this considerably decreases the amount of stuff that needs to be moved. I have discarded some old textbooks that hid in my office; I no longer look at them as they are obsolete. We have gotten rid of the vast majority of paper handouts, and now print as needed. My partner continues to have paper in his office and exam rooms; he is currently away, and will need to sort what needs to come and what can be discarded when he returns. We have a common consult room, and there is very little storage space for paper--all opportunities to retain and use paper have been deliberately minimized in the new office. The first two group practices have already moved in on the 7th floor as of last week; I went to visit them, and they are happy so far. Our new offices are much brighter and better laid out, and are taking advantage of the fact that we are paperless.

I had a look at the FHT office, which is being built next door to mine; it will be interesting to work so closely with a large group of Allied Health Professionals. The fact that we are co-located will no doubt lead to multi-disciplinary medical education sessions; we need to start thinking about how to do this.

Speed of access at my current office continues to be an intermittent problem; I have been told that this will be fixed in the new office. We have had several service interruptions in the last two weeks as well, where I had to switch over to my backup internet line. I am not sure what the issue is, but it is always aggravating when things slow to a crawl, and this has been happening all too often recently. We lost service completely a few weeks ago; eHealth Ontario arranged to have a technician come over, and we found out that somebody had pulled out our internet line in the basement! The technician felt that this wasn't vandalism, but rather an error by somebody who didn't realize what this line was; he added a label on the line warning that it should not be removed. We need a stable, fast line; this is key to a well functioning EMR that runs remotely. This function is the core business of eHealth Ontario.

I continue to move towards more prepared, pro-active care. In the past several months, my practice team has decided to help patients prepare for their annual physicals. What that means is that we mail a letter to them asking them to do their blood tests before they come in. The first few letters were sent too late and patients did not have time to do the blood tests; we then decided to send a letter at least a month prior to the appointment. As things evolved, I added a reminder for my new location, added several lab locations, and then also added a space for the secretary to put in the date of the upcoming appointment. They usually phone the patient to remind them of the upcoming appointment, but we decided not to do this anymore, since a reminder letter is being sent. I then added a comment about self management (I got the idea from an article in Family Practice Management) , and then I added the preventive care questionnaire from a Practice Based Small Group module.

Now, once a week, I look at all the upcoming physicals 6 weeks from now, and then print the lab reqs for what I want. My secretary then prints the reminder letter, and mails it to all patients. The majority of patients have all their blood tests done by the time they come in; I ask what they think of this approach, and they feel that it is much better. We have a look at their lab together when they come in, and I print it for them. If there is a problem, my nurse calls, and asks them to do the follow up lab before they come in. I think this works very well, and illustrates the multiple cycles of Plan-Do-Study-Act we are using in my office to try to improve things.

Here is the letter


**We are moving to our new location, 240 Duncan Mill Road, suite 705, Toronto, M3B 3S6 on August 22nd 2009**

We are sending this letter to remind you about your upcoming physical; Please bring all your medications with you (including all over the counter medications and vitamins); please think about your self management goals and what you would like to accomplish at the visit.

APPOINTMENT DATE AND TIME:____________________________

Please have your lab tests done at least a week before you come for your complete physical; all the results will then be available for you at your appointment and can be reviewed with you.

Please make sure you fast for 12 hours before doing the tests. You can have water, and you can take your regular pills (except for medications that lower blood sugar).

You can also have this done at any CML or LifeLab locations. Please make sure you take the attached requisition when you go.

CML locations:

Address: 4430 Bathurst St. -
Cross St: Sheppard Ave. W. Phone: 416 - 636-2040
Hours: Monday to Thursday: 9:00am to 6:00pm Friday: 9:00am to 2:00pm

Address: 5927 Bathurst St.
Cross St: Drury; Phone: 416 225-1629
Hours: Mon to Thurs: 8:00am to 8:00pm Friday: 8:00am to 6:00pm Saturday: 8:00am to 1:30pm

Lifelabs locations:

149-1333 Sheppard Avenue
Toronto M2J 1V1 Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m. - 5:00 p.m.
Fri. 8:00 a.m. - 4:00 p.m.
Sat. 8:00 a.m. - 12:00 p.m. Toll Free :1-877-849-3637

4800 Leslie Street, Toronto M2J 2K9; Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m.-5:00 p.m,
Fri. 8:00 a.m- 4:00 p.m.

217-4949 Bathurst Street, Toronto M2R 1Y1
Phone : 416-675-3637
Hours of Operation : Mon. Tue. Thu. 8:00 a.m. - 4:00 p.m.
Wed. Fri. 8:00 a.m. - 2:00 p.m.
Sat. 8:00 a.m. - 12.00 p.m. Toll Free :1-877-849-3637

Preventive Health Questionnaire for Adolescents & Adults

Please complete this questionnaire before you come for your check up.
We will be pleased to help, if you have any problems or questions.

Please circle the most appropriate answer for each question: Y = Yes; N = No; X = Not applicable or Don’t know

General Safety
Do you always:
• Wear a seat belt when you ride in a car or other motor vehicle? Y N X
• Wear a helmet when you ride on a bicycle,motorcycle, or all-terrain-vehicle (ATV)? Y N X
Do you:
• Have a smoke detector on each floor of your home? Y N X
• Regularly test each smoke detector? Y N X
Do you regularly protect your hearing against excessive noise? Y N X

If you are over 64 years old:
• Do you have hazards (such as loose carpets, exposed extension cords, and
stairs with no handrails) in your home that could cause you or someone else to fall or be injured? Y N X

Dental Hygiene
Do you (every day):
• Brush your teeth with a fluoride toothpaste? Y N X
• Floss your teeth? Y N X
• Have you seen a dentist in the past year? Y N X

Stress Management
During the past month:
• Have you often felt “down,” “blue,” depressed, or hopeless? Y N X
• Have you often had little interest or pleasure in doing things? Y N X

Physical Activity & Exercise
Does your daily physical activity add up to at least 30 to 60 minutes? (Include each 5- to 10-minute interval of activity or exercise.) Y N X

Pre-Conception Care
If you are planning to be, or could get pregnant, are you taking a folic acid
supplement? Y N X

Potential Risk Behaviours
Do you smoke? Y N X
If you are a smoker:
• Would you like to quit? Y N X
• Have you ever tried to quit before? Y N X
• Are you interested in medication to help you quit? Y N X
• Are you interested in a smoking cessation program to help you quit? Y N X
• Do you have a “quit date” in mind? Y N X

Do you ever:
• Try to cut down on drinking or drug use? Y N X
• Feel annoyed if someone mentions your drinking or drug use? Y N X
• Feel guilty about drinking or using drugs? Y N X
• Drink or use drugs as soon as you get up in the morning? Y N X
• Use alcohol or drugs when you are involved in activities such as driving,
boating, cycling, or swimming? Y N X

If you are sexually active, do you:
• Take precautions to prevent an unplanned pregnancy? Y N X
• Always use a condom to protect yourself from sexually transmitted infections (STIs)? Y N X
• Avoid high-risk sexual behaviour? Y N X

Are you eating the right number of calories (enough to maintain a healthy body weight) every day? Y N X
Do you limit your intake of fat and cholesterol? Y N X
Do you emphasize grains (such as cereals, whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet? Y N X
Do you take in enough calcium and vitamin D for a healthy body and bones?

Thank you for taking care of yourself and helping to prepare for your visit.