Friday, October 30, 2009

H1N1 influenza

There are increasing numbers of people with H1N1 influenza reported in the past two weeks. This feels a bit like SARS did in 2003 (my hospital was at the epicentre of the second Toronto outbreak). However, we are better prepared now, and I have electronic tools, both EMR and web based.

Public Health is running H1N1 vaccination clinics for the public. Their initial mail out about vaccine requests to family physicians almost sounded like they did not want us to order the vaccine: only order in lots in multiples of 500 doses, reconstitute vaccines with adjuvant and use the ten reconstituted doses within 24 hours. Send a report on the number of vaccines, number of males, numbers of females, ages, high risk conditions to Public Health every Monday by noon (their faxes are going to be very busy on Mondays, we may not even get through). There were also additional conditions for ordering this vaccine. I was told by a colleague who is a Medical Officer of Health that he was advising family physicians not to order the vaccine, due to the complexity of managing it.

I can understand that the requirements for this vaccine are different from the usual flu shot, and some of the problems are due to vaccine packaging, but the result is extremely long line ups for the Public Health clinics in Toronto, which are currently overwhelmed.

My Family Health Team quickly organized a common vaccination clinic for the 53 physicians and 60,000 patients registered in our practices. Our FHT executire director is pulling nurses out of offices, and most of our physicians have volunteered to man the clinic. This was all arranged by our executive team over email. All patients are being directed to the FHT clinic for H1N1 vaccinations, and we will not be running clinics in individual offices. I have added information on our clinics to our website.

We are getting more patient phone calls at the office about what to do; I post announcements on our practice website, , and my front staff is re-directing inquiries there. This is helping us to keep the phone lines reasonably free, so that patients who do need to get through on the phone can get through. I am also getting a much larger volume of emails from patients than usual, and I am able to redirect these to our website as well, so this is currently manageable. Volume of visits to the website has more than doubled, but volume of visits to the office is holding steady so far.

The EMR company has added new vaccination profiles for the H1N1 (both adjuvanted and unadjuvanted) so that we can quickly enter the data. My colleagues in Nova Scotia have reported that their Public Health authority can obtain weekly reports containing all the data needed (without patient names), directly exported from the EMR, under the authority of the NS Provincial Chief Medical Officer of Health (through the Nova Scotia Public Health Act). What a fine example of collaboration between Ministry of Health, Public Health, EMR company and physicians! I wish we had this in Ontario; it really represents a good example of the reporting power of the EMR, especially under strained conditions, but it needs to have a health care system that is less fragmented than what we currently have in Ontario. One physician said that we should be using a similar system to report routine vaccinations to Public Health, something which is currently fully paper based.

Because of the size of our FHT, we have administrative support to enter data directly in the EMR when patients come to one of our H1N1 clinics, and we will be able to generate data similar to Nova Scotia's. Hopefully Public Health will accept our reports as long as the needed data is present, without requiring it be entered in their proprietary excel format (or worse, on paper).

Just prior to the outbreak, I volunteered to program the Public Health guideline on the diagnosis and management of H1N1 influenza as an EMR template. We had enough time for several colleagues to test the template and offer feedback; it was modified to make it as useful in practice as possible, and I then added it to all three EMR enterprises for our FHT. We now have a common management tool, with clear information on when to prescribe Tamiflu available to physicians electronically, and it is currently being used. Perhaps in the future we will be able to export this to Public Health in an anonymized fashion as well.

OntarioMD announced this week that about $280 million will be made available to subsidize EMRs for the majority of Ontario physicians. The subsidy is $29,800 for those using an ASP model, and $27,100 for those using a server located in their own offices. These amounts are very similar to what physicians in my group received, and will cover about 70% of the cost of EMR. I think we will now see large scale computerization in Ontario; this step is done in conjunction with eHealth Ontario, and this is the right approach for them to take. The auditor general said that there was no traffic on the super-highway that eHO built; having data generated in the majority of physician offices will put traffic there. Once we are computerized, we quickly learn to dislike non electronic data generated on the outside. However, there have been too few of us on EMR to generate the kind of pressure needed to get other organizations to connect to us for incoming data and stop using paper-based processes for outgoing data; I think this is about to change. I expect to see a lot of changes in the next few years; I think a lot of early adopters will also be kept very busy helping our colleagues implement and use their new EMRs effectively.

I was asked by a perceptive journalist if I still expected to be writing this blog over three years after EMR implementation started in my practice. I have to admit that I did not; I thought things would be settled and going smoothly by about 18 months--how wrong I was. It now looks like I am going to continue this journal; thank you for bearing with me through these interesting times.