Tuesday, November 10, 2009

H1N1 vaccination clinic and EMR

Our H1N1 vaccination clinics are now running at full capacity, five afternoons a week. All Family Health Team physicians have volunteered to staff the clinics. Family Health Team RNs have been withdrawn from their regular duties in our offices, and are staffing the vaccination clinics.

We are running this at a single location for all 53 physicians in the FHT, and this was all organized in a few days. We are currently vaccinating high risk patients in our FHT. The clinic has one administrator, three nurses and two physicians. We vaccinate about 360 people in 3 ½ hours.

The clinic is two doors down from my office, and I see the line up in the corridor when I poke my head out the door. The waiting time is about 40 minutes, and nobody has to wait outside in the cold. Patients getting vaccinated are in a different location than those coming in to see their family physician for the flu, so this approach limits viral transmission. We have had very good feedback on our clinic from patients getting vaccinated.

The vaccination team holds a debriefing session at the end of each clinic. They review their processes, identify bottlenecks, and quickly implement changes.

We use the EMR to record data, because otherwise we would have to keep enormous amounts of personal information on paper (the consent forms, the name of each patient getting the vaccine, their ages, gender, and risk category). The FHT, as an organization, does not have a mandate to hold personal information, nor do we have storage facilities for this at our central FHT office. In Ontario, all patient data has to be kept for a minimum of ten years; for children, until they are 28 years of age.

The first issue that we ran into is that we do not have an integrated EMR for all FHT physicians. There are two EMR software applications being used; the larger one, which my group uses, is split into three databases (or enterprises), one for 14 physicians, one for 9 physicians and one for 20 physicians. The physical location of the offices does not matter for data entry, as it is all done remotely—we log in to a server located off site. The other EMR, serving 10 physicians, uses software on servers located in individual offices, so there are actually a larger number of individual databases for fewer offices. You have to have a different log on for each database, and you have to establish remote access.

In a FHT-wide program, especially where speed is key, you cannot have multiple different log-ins. What I mean by that, is you can’t have Mr Smith, who is in Dr A’s practice, having demographic data and H1N1 immunization entered in Dr A’s database, then Mrs Jones, in Dr B’s practice, comes, and the clerk has to enter demographic data by logging into a different database etc. It doesn’t work because it is too complicated, is too much additional work, and slows things down too much.

We decided that all data entry was going to be done in the 20 physician database. Here is the process:

1. the patient checks in, the clerk swipes the health card
2. if the patient is already in the current database, the system recognizes this and automatically registers the patient. If not, then the swiped card automatically adds data to the EMR (name, date of birth, health card number, gender), and the patient is entered as new
3. patients are sequentially added by the software to the schedule, so that the clerk can see who is next in line when calling patients in.
4. The clerk gives the patients the screening form, and the patient waits until called in to see the nurse.
5. When checking in, the nurse reviews the data; an encounter is opened, which contains the screening questions as checkboxes, all defaulted to no (most patients are all “no”). If there is a “yes”, the nurse changes that, and notifies the physician
6. The patient signs the consent electronically on a signature pad, and this is saved to the EMR.
7. The physician sees the patient and gives him or her the H1N1 vaccine. Lot numbers and dosages are pre-set as defaults. The dosage is changed if this is a pediatric injection.
8. The encounter, screen, consent, signature, and vaccination are all electronically saved in the EMR.
9. The patient goes to wait for 15 minutes in our post vaccination room, which has chairs and a television. They are given a paper to inform their family physician of the vaccination. If there are any reactions, these can be entered in the correct field of the EMR, so that the data can be extracted later.

The first day that we had the clinic, the waiting time was longer. The rate-limiting step was the screening; the initial EMR screening template used drop down lists, so all information had to be individually entered, which slowed things down. Once it was changed to checkboxes defaulted to “no” for all screening questions, this was much faster. The change was implemented at the end of the very first clinic.

One early challenge for us was not setting up and managing the clinic, it was communicating with Public Health. They had a great deal of difficulty letting us know if we would receive vaccines so that we could run our clinics and take some pressure off their own, overwhelmed vaccination program—and a few days later we heard that a private clinic downtown had been sent vaccines for their “executive physicals”. I understand that this will be investigated.

The vaccine supply chain at Public Health runs well for our regular supplies; it appears to have been initially overwhelmed by this large scale H1N1 program. I cannot tell where the internal problem was; I hope that processes similar to our daily debrief and rapid improvement cycles have been implemented. The problem at the present time, as I understand it, is vaccine shortages due to manufacturing problems.

We do have ongoing issues with our local Public health unit; as an example, we do not have an efficient method of reporting issues to them (usually this is by fax or by phone). For those of us on EMR, the issue is even worse, as they insist on paper-based proprietary lab reqs and will not accept anything generated out of an EMR; I cannot track HIV tests in my practice to ensure that I have received the result. I think the Public health unit does an excellent job in many areas, such as their “safe dining” restaurant program; however, they do less well when communicating and collaborating with family physicians.

The EMR company has programmed software to extract the data that public health needs in an excel format; we should be able to extract information such as age, gender, vaccine lot number, adverse reactions so we can report for our large clinic. This is a much better way to report than duplicating the information on a piece of paper for each patient. Perhaps we’ll eventually have a secure electronic method for forwarding these data; wouldn’t it be nice to be able to automatically send data on child vaccination to public health.

I am pretty proud of this Family Health Team for doing such a great job of organizing and managing this project. I think there are a couple of early conclusions that I am coming to:

1. This couldn’t have been done without a good organizational structure. Primary care has traditionally been composed of individual offices, often working in isolation; we are now moving towards more organized groups (Family Health Groups, Organizations and Networks, Family Health Teams)
2. EMRs are part of this new organizational structure. Newly forming groups should consider having one common database for all offices if they want to run projects in common in the future. This can be done with many of the EMR applications being sold
3. Local Public health units need to consider primary care as an integral partner. The experience with SARS shows that these new diseases often show up in our offices first. Talk to us, work with us, we can help you.
4. The IT infrastructure at Public Health may need to be revisited. They receive large amounts of data, and they need robust systems to analyze and manage the information. During SARS, information was tracked via yellow sticky notes on the wall; I hope it is different now. Upgrade Public Health lab to electronic reporting standards. Work on having EMR data from family practices reported electronically to the local Unit.

I think this H1N1 vaccination clinic is a beautiful example of a large, geographically dispersed primary care team banding together to provide needed services, quickly and efficiently. The EMR in this case is an important facilitator, but the key aspect was leadership and group cohesiveness. Family Health Teams are a fairly recent initiative from our provincial Ministry of Health, and our experience shows the value and benefit of this approach. I hope the FHT program will be expanded and offered to more of my colleagues in family practice.