The Enterprise module: functioning as a group

I am now beginning to explore the enterprise module. This is the area for group functions, and is one of the most powerful features of the EMR.

I think of "enterprise" functions as things that we should be managing as a group, rather than individually, such as

• quality improvement projects (example, meeting targets in diabetes; protocols that the whole group agrees on)
• Shared care, such as prenatal care or palliative care
  
• Services that one physician is willing to provide for the group (example, IUD insertion)
  
• Allied health professionals attached to the whole group rather than to individual physicians

It is very clear that the majority of family physicians in Ontario practice solo, see the ICES Primary Care Atlas, chapter on Characteristics of Primary Care. This will not change much in the next few years, because it is too difficult to break leases, there are staff issues to consider, etc. However, practicing solo no longer means automatic isolation; my group is now linked through our common EMR.

I have started to use this. A couple of my colleagues wanted a copy of my diabetes flow sheets, and I just installed those on their office application. I helped another colleague remotely with the process of doing consultation letters. I figured out how to access the different schedulers. We have started talking about how to do shared prenatal care across the whole group, and about what would be best practices.

The team pharmacist has started logging on remotely to learn about the application; there were a couple of things that I needed to change in her permissions (the pharmacist profile), and that has been done. These permissions are set for the group so they don't need to be replicated.

My filing cabinets are gone; it is amazing how much space I have at my office. If my partner ever decides to go EMR, we will not need a single filing cabinet for charts. I am now trying to decide if the space should go to a third associate, or whether I should use it for some of the new allied health professionals we will be hiring for our Family Health Team. I am leaning towards the latter; there is still so very little inter-professional health care in Canada that there will be much to learn and invent in small family practices. If, for example, a social worker works out of my office some of the time, his or her schedule is always immediately available to the whole group through the single log-in. Any of our group's support staff can book the appointment and see the location without having to call. I think it will also be interesting for me to have lunch-time conversations whith whoever we hire.

This, in my mind, is what lies beyond the EMR transition: EMR ver2 can let us do as a group what we cannot achieve individually.

Michelle

Paperless!

On Monday, we scanned and shredded the very last paper file in my practice. My secretary made one last DVD back-up, and that's it. We filled 20 gigabytes of hard drive; I now see external hard drives with 500 gigs, so storage is not an issue for any practice. Next week, I am taking my staff out to celebrate.

I found a buyer for all my filing cabinets, and they are gone as of next Monday.

It is interesting for me to look back at this diary; a year ago at this time, we were just about to switch over to the new system for billing and scheduling.

My husband went to see a specialist a few days ago. He came home and told me that there was a wall of paper files behind the secretary; the specialist wrote everything by hand, and also gave him a prescription scribbled on a little piece of paper. When he went back to the front to make an appointment, the secretary was on the phone with a patient, and was flipping back and forth in a paper book to try to find where the appointment was (which took a while).

While this is the current "normal" in health care, and is not too far removed from my practice of only a year ago, it does not have to be thus. We now have the tools to do better.

I had a couple of computer experts from a company called DM Link in the office today. This is something new that SSHA (the Ontario Government agency charged with connecting the health care system) has set up. I think one of the issues in small practices is that we are not IT experts, and can't configure or maintain these systems by ourselves. The EMR companies are mainly concerned with software, not hardware. The computer guys went around and made sure that all my computers had anti-virus working properly and that Windows updates were up to date (they said that this was a problem in a lot of offices). They also did an inventory and put labels on my routers so that I would know what things are. They wrote down my system configuration, and will send me a hard copy so I know what I have and how it works. They had a look at my routers, and made sure that the UPS device was properly set up so that power would not be interrupted in the event of an outage. I had a couple of questions, and they answered those as well; they even set up my printers to work faster.

This type of housecall is very helpful. Having some professional help and review from people who know what they are doing, and have a checklist to make sure everything works will likely save a lot of grief down the road. The whole thing took about two hours. SSHA has come in for a lot of (deserved) criticism in the recent past; however, this undertaking looks like the right approach.

Michelle

Working with your EMR company

After 10 months, I have a fairly good idea of how to work with the EMR company. My most common contact with the helpdesk is by email; if I can't get a good answer, I contact the helpdesk manager. Phone calls to helpdesk are rare, because I find this inefficient; it is more useful for things that are urgent or that are not getting resolved by email.

Some things are more of a "wish list", and I know that I may or may not get them. They get sent to the development team. As an example, I use "profiles", with the assessment ICD, medication and follow up preprogrammed (cystitis-595, Septra DS bid x 3 days, push fluids); I would like to have a bill pre-programmed as well. I think if there are lots of physicians asking for the same thing, it is more likely to happen. The on-line group that I belong to is monitored (we sometimes have a reply from someone at the company), so ideas from there likely percolate to development. We are getting an upgrade at the end of the month, so I'll find out then about the extra things.

My husband works in the coatings industry; they use a very large company for their corporate database, SAP. He tells me that despite millions spent on implementation, there are still problems, and upgrades are very expensive. His company also bought a colour computer to help with color matches; it took a year to get that working properly, and several sister companies never did get theirs working.

It is still not clear to me what the critical elements are for a successful transition. In the Compete study in Hamilton, 25% of physicians abandoned the EMR at the end of 3 years, and there were still 22 chart pulls per day after 18 months. I think there are also transition problems in South Western Ontario, at the DELPHI project. These projects provided a lot of support and help. It is unrealistic to expect 100% adoption (or to have everything working within half an hour); it looks like the major issue is the management of all the changes, and surviving the turbulence. There are other physicians like me who have managed the change, I wonder if we could help our colleagues. Some of the information will be company-specific, but some can be translated across all EMRs.

The EMR provided an unexpected finding for me this week. When managing depression, I have an alert in the chart for my staff to print a PHQ-9 questionnaire before I see the patient. Often, patients don't return for follow-up. A couple of days ago, I saw a lady for a sore shoulder, and she handed me a PHQ. She was seen for depression 6 months ago, but did not return for follow-up visits and did not get treated. Her alert remained in the chart, and so a questionnaire was printed for her when she came in. Her PHQ is now completely normal--she got a better job and fired the bad boyfriend. Now I wonder what the natural history of depression in primary care is; perhaps I'll get to find out a bit about what it is in my practice.

I am finding some creative uses for the EMR. I have put information on the home BP machine that I recommend in my list of prescription favourites, so now it prints as a prescription. Maybe I should do an exercise prescription next.

I guess with EMR,
You can't always get what you want,
But if you try sometimes you just might find
You get what you need

Michelle

The non-EMR physician in a wired office

My practice partner seems to be happier. There was a lot of disruption during the EMR implementation, almost none of which benefited him personally. I think he tolerated this because he knew it was important to me. I was pretty careful with the financial aspect; I showed him everything, we agreed on the extra amount that I would put in for common computer expenses (such as networking), and if I had a bill that was clearly EMR related, I paid for it myself. The disruption is now over, and the office is running smoothly again (although with a split personality).

He still does not want to go EMR. He does not type fast, and is not all that comfortable with computing. Even with an office that is now fully configured for EMR, he just can't see making that step; I think the change is just too big. It is sometimes difficult for him to see my patients when I'm away, because he can't easily navigate an electronic chart. My staff helps, by printing CPPs for him. He knows where CPPs are, and knows how to look at encounters. I try to help by managing my lab and reports remotely when possible.

The resident in my practice spends half her time with him, and half with me, so that some of her patients are on paper, and some on EMR. We put alerts in the demographics so that the secretary knows whether to pull a paper chart for her. It is creaky, but it works for now.

I wonder what will happen as more parts of the system and more physicians go electronic. There may be a time when labs no longer issue paper reports, perhaps as a cost saving measure. At a family medicine meeting yesterday, almost half of the physicians put up their hands when asked if they were looking to computerize soon. My hospital will be going to Computerized Physician Order Entry this year. Their PACS Diagnostic Imaging system is working well--it is probably not a very big step to integrate the report with the EMR. Plans to link our community-based EMR with the hospital system are proceeding apace. I think we're just about to move past the early adopter phase.

It really is a different way of working. Here I am, writing this from home, with my email and my practice both loaded up on my computer. A specialist just called me a few minutes ago to discuss a difficult case; I had all the data in front of me--and I'm getting used to practicing this way.

And, of course, those of us who have successfully transitioned become IT enthusiasts. I wonder if my partner is becoming tired of hearing about EMR this and EMR that; living with a true believer is not a peaceful thing.

Michelle

Life after the transition

I sometimes look at one of my scanned non-electronic old charts, and I have trouble believing that I practiced that way for 20 years. Even though I tried to be organized, the record is still scattered (all the diagnostic imaging, consult letters, and lab reports are mixed together). I used flow sheets for diabetes and INR management, but nothing else. Trying to follow on-going vitals like BP or weight meant laboriously looking through the clinical record. I had to calculate every BMI myself with a PDA. I sometimes forgot to record medications, especially skin creams. Doing audits for quality of care was possible, but time-consuming.

Now, things work. Because I have e-messaging in the EMR, and pop-up messaging for instant communication, I seldom need to come to the front, and can just alternate between my two exam rooms. I often return calls between seeing patients (because I have more time) instead of having the calls pile up at the end of the day. Sometimes I do not need to phone personally; I just send an e-message to my secretary, and she handles the return call. I sometimes go to the front just because I like talking to my staff.

I have been told that my transition was faster than that of most of my colleagues. Many things went right in my practice. My staff helped me; they often came up with suggestions, and were willing to try new things and to help me fix things that didn’t go right at fist. I was very committed to doing this, and was willing to put in time and money. I knew I would have initial problems (although I did not know what they would be), and was determined to solve as many things as I could, as quickly as I could. I knew just enough about IT, and could learn enough as I went along to be able to fix most things fairly quickly. The fact that my partner did not go along was disconcerting at first, but may have helped me: I did not have to spend much time helping him, and could concentrate on my own practice. Perhaps a definite “no” at the beginning is better than a half-hearted “yes”, although this may not always be possible with government funding (they fund entire groups, which must all agree to go EMR with the same software, rather than individual physicians).

One of the most helpful things was scanning and shredding the old charts. This accelerated the transition, as going back was no longer possible (there were no charts), and it made the use of EMR the default in practice. This is not for the faint of heart; we began scanning 3 months after EMR start-up. It does immediately reduce chart pulls, and demonstrates the efficiency of IT on a daily basis. The cost was minimal; hiring a summer student to do this is worth it.

I keep being asked if I am happy with my software, because many of my colleagues are now looking to computerize. This is a loaded question: the current market is crowded and competitive; what I answer may influence some people. It is impossible for me to judge other EMR applications because I don’t use them, and thus I can’t compare them to what I have. What I will say is that I use the software I have daily, for almost everything I do in practice, and that I like it. I will not say that it is better or worse than other applications.

One of the things that I like is that it does coding for diagnoses well. This was not a selling point for any EMR; I don’t remember it even being mentioned at the beginning. When I read Dr Nicola Shaw’s book, Computerization in Canadian Primary Care, one of her key points (repeated several times) was “learn to code”; I can’t say I paid any attention at the time.

When I enter a diagnosis at the end of an encounter, putting in the code directly in the code field (example, 401) is faster than entering most words, like “hypertension”. Sometimes I don’t remember the code, and I have to use the drop-down list to help me choose one. For example, for cancers I start to type “neop”, and all the cancer names drop down, with their ICD number in front: I pick the relevant one. ICD organizes the cancers by body systems, so all the digestive cancers are numbered consecutively from mouth to anus. After a while, you know where things are.

Sometimes I can’t find what I’m looking for, then I have to go look at the paper list of ICD codes I have from the Ontario Medical Association. I have a copy on my desk, and a scanned copy in my computer. This is the slowest method. After a while, I learned some of the common things, like 307 for a tension headache, or that ADHD is called “Hyperkinetic disorder” in the ICD drop-down.

A benefit of coding is that the ICD number flows directly into my bill (code once, use many times) and I can look for things in my EMR; every previous MI is coded as 410. As the government moves towards more pay-for-performance, we’ll need to identify and keep registers of patients with certain conditions. Using free text for diagnoses will make that difficult; free text for on-going medical conditions in the CPP is especially bad.

In the near future, we’ll start using primary care EMR data for health care system planning (because the data will be there, in usable, electronic form). We need to know how many people with diabetes there are, how many people with congestive heart failure etc, and what is happening with them. The free text diagnoses will not be good for that; it is much easier to look for all 401 than for all HT, HTN, hypertension, high BP, incr BP etc etc. Free text diagnoses are a relic of paper records; all EMRs should make diagnostic coding the default, and make it as easy to do as possible. If you are thinking of buying a system, ask your vendor to demonstrate this; it will not happen unless we ask for it.

Michelle

Communicating electronically

In my practice, we now frequently talk electronically. One advantage is that messages are archived in the patient's chart. For example:

Oct 18, 2006

to: staff

Greiver, Michelle

Call pt re results

A1C above goal (8.5%, should be 7% or less). blood sugar not controlled. pls make appointment Completion Notes:'pt informed will call for app'

This is very efficient. Patients are now routinely informed of important follow-up results that are normal, which didn't happen in the past. Several patients have said that they really appreciated the information.

I recently installed a small pop-up program for instant messaging inside the office, Realpopup http://www.download .com/RealPopup/ 3000-2085_ 4-10367875. html. This was suggested by a colleague in my on-line users group, Dr Paul Hasson; the program is small and free. I used to give patients a note to present at the front if they needed follow-up, example "DM, 3 months". Now I just send a pop-up to the front, and the note never gets lost or forgotten. Yesterday, my secretary sent me a pop-up that there was a pharmacy on the phone, line 1, so I just went and got it. This is good for small, instant messages that don't need to be archived to the EMR.

Email with patients is becoming a bit more frequent; this month, there were 8 messages. I recently wrote an article about emailing patients; in the EMR, recording the email involves cutting and pasting it into an encounter (easier and more complete than recording a phone call).

While email is not secure, this does not seem to be a problem for most patients. One of my patients lives in the Far East, and needed his chart (he has complex medical problems). The chart had been scanned into pdf. I told him that I could mail it, or email it to him if he preferred, provided he was aware of the low security and gave me permission. We had communicated previously by email, and identification was not an issue here. He asked me to email it, and we sent a 200 page file electronically that day.

Another patient needed a back to work form emailed; I had to print the note for my signature (I don't have an uploaded signature), we scanned and emailed.

I have secure email via SSHA's ONEmail system; however, it periodically needs a new password, I don't look at it very often, and it won't forward a message to let me know that there is mail for me. I don't know anyone who uses it, because it is not very useful right now. It will probably be good for secure messaging between health care providers, but not for patients since the information goes outside of the system.

I probably should think about setting up an "office" email address for general enquiries; perhaps this should be through SSHA.

I connected the second PC at the front to the fax line (I used a line splitter). Now we can fax from both PCs. If there is a simple fax (a single pdf file, or a lab result from the EMR), my staff can fax straight from the computer, by using the "print, fax" command. No paper is printed.

I found out that I can copy and paste all the decision tools from MedCalc on the EMR. MedCalc is free on the OntarioMD site. I used the PDA version very often, but with this one, you do the calculation on-line, and the result is transferred to text or xml format, to copy into the EMR clinical record. Here is an example of what an atrial fib risk calculation looks like on the clinical notes:


"Decision Tool: Atrial Fibrillation Five Year Risk of Stroke or Death

Age: 60 (4 points)
Systolic Blood Pressure: 120-139 (1 point)
0 points for: Diabetes: No
0 points for: Smoker: No
6 points for: Prior MI or CHF: Yes
0 points for: Significant murmur: No
0 points for: LVH on EKG: No

Total Score = 11 points
Result Interpretation: 11 points : 20 %

References:

Wang TJ, Massaro JM, Levy D, et. al., A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study, JAMA, 2003 Aug 27;290(8):1049-56, PubMed ID number: 12941677"


It looks like it is possible to integrate a great variety of clinical prediction rules fairly quickly into EMR at the point of care. I think I'll try that in practice.

Michelle

Having fun with the EMR

Now that the transition is essentially over, the EMR is not just efficient, it is also fun. Everything is always done; everything is tracked; there is little to no loose paper flying around

My secretary was commenting on how efficient we have become. There was a call from a specialist's office, as they needed copies of some Diagnostic Imaging reports for one of my patients, from October. It took her under 30 seconds to load the chart, locate the reports, and fax them over, all without leaving her desk. Because of the enormous gains in efficiency, they have time to do more call backs to patients about test results. As a result, my staff are becoming much more knowlegeable about tests; I no longer put in normal ranges for fasting sugar when I send an e-note to call a patient, because they know this. They are becoming more like clinical assistants.

I am starting to use a lot of flowsheets; I have found that this is the best way to correlate several things (BP and medication changes; Asthma exacerbations; CHF: weight, eGFR, medications). This is a list of my current flowsheets:

Active Flowsheets:

	Flowsheet Name	Description
	Asthma flowsheet	Flow sheet for management of asthma
	BP
	CHF flowsheet
	COPD
	Depression flowsheet
	diabetic flow
	INR	Flowsheet for INR
	Osteoporosis
	TSH
	Weight loss, BP

I have figured out how to make results from several different labs mesh together, so that they go into one common flowsheet.

I have also made a couple of "history builders"; these are a type of template where you click on a link, and a series of phrases comes up, which you then save to the record. This is the builder called "normal neurological exam":

"Pupils are equal and reactive to light and accomodation. Fundi are grossly normal, with no papilledema. Cranial nerves II-XII are intact. Neck is supple. Motor examination reveals normal gait and normal strength bilaterally. Reflexes are equal bilaterally and within normal limits. Sensory examination is normal with respect to touch."

If there is something abnormal, you can always change it before saving. It saves a lot of typing. I have a two part Builder for BCP counseling; the first link is if I did STI counseling, and the second is for discussion of BCP benefits and side effects.

I probably should do one to document discussion of Steroid side effects. This is good for anything where there is standard counseling.

I had a look at my activity log; I've reproduced a bit of it below, without patient identification. This gives me a pretty good idea of what I am doing during my day.

	9:47 AM	Greiver, Michelle			Edit Encounter
	9:51 AM	Greiver, Michelle			Add Medications
	9:52 AM	Greiver, Michelle			Add Lab Requisition
	9:54 AM	Greiver, Michelle			Add Clinical Notes Subjective/Objective
	9:54 AM	Greiver, Michelle			Add Assessment
	9:54 AM	Greiver, Michelle			Edit Plan Notes
	9:54 AM	Greiver, Michelle			Sign off Encounter

I have my email loaded, which can be distracting at times. However, it does make sending links like the BP Action Plan from the Heart and Stroke Foundation, or the excellent self-care depression booklet very easy to do. I have the links inside the EMR, load them up, ask for permission from my patient, and then copy/paste the URL into an email to my patients. This is a really great way to extend the education done at the office; the EMR tracks the fact that a link was sent.

Some abnormal blood results came in for one of my resident's patient. I sent her an email to please log on to the EMR and have a look at the results. She had a look, and emailed me a very appropriate management plan. I am still responsible for the patient's care, and will manage any urgent reports, but this gives my resident the ability to look after her own patients even if she is only here one half day a week. Continuity of care in residency is now a reality. My group is talking about adding a nurse practitioner, since we are becoming a Family Health Team. Team based care can involve the same processes me and my resident are now using.

I know that the transition to EMR is challenging, having been there. However, now that I am paperless, I have found that the EMR is making my practice more fun, more efficient, and definitely more interesting. And I still expect more.

Michelle

Managing my hardware

I am starting to own a lot of hardware and software.

EMR is so important to my local residency program that preceptors are offered a subsidy if they buy a laptop for the use of medical students/residents. I just bought an extra Tablet. I am very happy with my Tablet, and I think it is a good idea for my resident to have access to one; it will likely be a very common form of medical data entry.

The new Tablet arrived recently. I then realised that I didn't know how to access my wireless network--it is not a simple home network, there are a lot of security features. That meant an email to the EMR company. I also had to put my printers on the Tablet (they are accessed wirelessly via IP ports), and I had to configure access to the server. This is a lot of work, so I ended up sending the Tablet to the helpdesk. They did tell me how to access my wireless, and I will keep this information.

One of my FHN colleagues has a folder with all the passwords, and a list of all the printers and computers in her office. This is a good idea, I think I will do the same. I think it is still better to have someone else do the work of setting up a new computer, but it is wise to keep all that information safe someplace. I probably know a bit too much about networking for my own good (that is, just enough to get into trouble); I know how to fix an IP port for a printer, because I've had printers change their IP address.

I think many offices will end up with at least one person very familiar with common IT problems, mostly through experience, so many things will be fixed quickly on site once the transition is over. I have an office manual, which is updated periodically; I have started to put EMR information in there, and I will add information on common problems. I think that, as we move towards a Family Health Team, or group practice, it would be good to assign one staff person to be a resource for the entire group; maybe we should give him or her a blackberry.

I have started taking digital photos to put in the EMR; I had an extra camera at home, which I brought to the office. The Tablet has a SD card slot, so I can just remove the memory chip from the camera and put it straight into the computer. I then attach the picture to the patient file.

Because I carry the Tablet with me all the time, it is becoming highly customized for my needs. I have found that I access some extra information within the EMR (example: templates), some on the internet (example: CDC travel advice), and some locally on my Tablet (example: "cheat notes" for common conditions). I have stopped using my PDA at the office, since I can access everything on the Internet; I use the on-line version of ePocrates. The PDA is backed up to the Tablet, so I have access to my phonebook and calendar on my desktop. I needed a Gestational calculator, so I downloaded one from Medical Algorithms and made a couple of changes, such as a field for "today's date", and changing from a standard Excel file to a template, so it can be reused. The Gestational template is at http://ca.briefcase.yahoo.com/mgreiver@rogers.com, click on Shared, and you will see the file to download. I have it in a folder on my desktop, and just save data for each pregnant patient as an Excel file in the folder; because of the "Today" field, the gestational age is automatically calculated when the patient is seen. I print the excel if referring a patient for prenatal care.

Finally, I have been told that some of my templates will now be shared with my colleagues. Once they are shared, I can no longer modify them. The templates include the age-based preventive health tables; this was the tables on paper records, and this is what they look like on EMR (click on preventive health in the shared folder; it is a big file because of all the screenshots, and will take about 20 secs to download). The last screenshot shows what the template looks like when saved to the patient record.

I bought a temperature logger for my fridge. My filing cabinets are now advertised on Craigslist.

Michelle

The cost of EMR

My cost to start the EMR was approximately $30,000, half for software and half for hardware. This is comparable to buying a new car (not a SUV), but does not depreciate as quickly. There are additional costs to the EMR, such as my upgraded VPN router (which cost $1,000 for parts and labour); as well, I have a backup internet line, at $500 per year. I have not had significant additional hardware costs beyond the router; however, I do expect to put in additional things, such as an automatic temperature logger for my fridge vaccine (about $100 for sensor and kit). The cost for scanning and shredding my charts was $300 for hardware (DVD reader, external hard drive), and about $1200 in labour costs for a student. My staff continued to scan and shred after the summer, during quieter office times, and I have a student coming in the evening to do this. Total labour costs to completely get rid of old paper charts are in the $1500 to $2000 range.

Once our 3 year EMR contract runs out, I expect yearly support and maintenance costs to be in the order of $3,000 per year.

It is difficult for me to say whether this makes business sense without government subsidies. There is a cost to continuing to carry paper records: The approximately $4500 in yearly rental costs taken up by filing cabinets and papers; the cost of the cabinets themselves (my 6 drawer end-file cabinets cost $1,054 each, new); the time for staff to manage the paper; the cost of inefficiency (lost files etc).

As well, there is the cost of managing preventive services on paper. The maximum incentive payment for reaching targets for five preventive services in Ontario is $11,000 per year. Doing this on paper is very difficult; either the physician or their staff has to do the audits, or it has to be contracted out to a private company for a fee. I understand that there is a company that does this; I have heard that the cost per physician is anywhere from $800 to $3,000 per year. Now that I have finished doing my CPPs, the EMR keeps track of preventive services for me. It generates a list of patients overdue, to print letters; I expect to look at the list about once a month--I may now assign this task to one of my staff. The letters are personalized and are very easy to print; a copy is automatically kept in the patient's record. I expect to see more pay-for-performance incentives in the future.

Private bills are much easier to manage with EMR. I print things like notes for massage therapy or sick notes at the front printer, where the patient collects and pays for the note at the same time. We have a PinPad at the front, so people can pay by credit or debit card. As well, the notes are all templated, and are much easier to generate than with paper records. A copy of the note is always and automatically generated in the electronic record; there is no longer any need to photocopy for the file.

Many of my colleagues are now contracting out block billing and private bills to outside companies. I contracted out block billing in the past, at an annual cost of approximately $2500. I have to figure out how to do the block billing, but the private bills are certainly done more easily and efficiently in the EMR.

Having said all that, I strongly believe that government subsidies are needed to kickstart the EMR process. In Ontario, there was a recent lottery, where physicians in FHGs (Family Health Groups, receiving fee-for-service payment) could apply to receive the $28,600 subsidy. They allocated $15 million to this initiative; 2100 physicians out of the 4,000 FHG physicians applied. If a physician gets funded and already has an EMR (provided it is from one of the approved companies), the funding is still given, provided the EMR continues.

There is now lots of physician interest. The initial cost continues to be a barrier, and governments can certainly do a lot to address this. However, I think a reasonable business case can now be made for EMR, if the ongoing cost of paper is taken into account. Additionally, it appears that if there is funding down the line, this funding will be retroactive.

Michelle

At the nine month mark: a new year, a new beginning

I have just finished the last CPP. It took me nine month to enter almost 1,500 CPPs into the EMR; sometimes I got bogged down, when things were very busy, and didn't do any for a while. That's about 166 CPPs per month, on average. Done!!!!

During the transition, if I saw a patient whose CPP hadn't been entered yet, I used the scanned record on my networked hard drive to look up the information. As the year progressed and I entered more CPPs, this became less and less necessary. I expect that I will seldom need to access the information now, but it is still good to have it so easily available if needed.

Doing this work was not fun, but it does have some benefits. One of the things I learned was to code the information very consistently; I expect this to have large dividends. I tried to look up all my patients with COPD (491), and there they are. All patients with osteoporosis are coded as 733. All patients with Coronary Heart Disease are coded as 410, 412 or 413. Practice-based audits of medical conditions are now a reality.

My audits are still limited; in my EMR, I can do audits for diagnoses, immunizations, medications, and family history. I would like to expand that, for example, to "Coronary heart disease AND (LDL >2.5)", or "Stroke NOT (ASA OR Plavix)". There are still technical limitations, not the least of which being that the labs do not use common nomenclature for test results. However, all EMRs are essentially big databases; databases make things searchable, and keep track of related data. The entry point is the coded diagnosis; I know my data is in there and is searchable--it sits in a Microsoft SQL database. 2007 will likely bring much more audit capability.

One big difference between paper and EMR is that adding data in EMR increases the value of the data. On paper, there is often little to no added value; in fact too much data just leads to chart mitosis, and chart #2 gets retired to the basement.

In the new year, I would like to donate my data to organizations that can do some good with it, with privacy protection. During SARS, there was no way for public health to gather data quickly and make some sense of it; most data was on paper. What if there was some way to quickly see if there were geographic clusters of fevers? What if the latest information on symptoms is transmitted electronically straight into the EMR? What if we could report a suspected case by clicking a checkbox on the record? I think the EMRs could be of much benefit to public health.

There are public institutions that I would trust with my data, such as ICES or CIHI. In the UK, primary care EMR records have been an invaluable source of public health research data, through the GPRD; in fact, they even pay GPs for good quality data. Another plus for the EMR.

It would not surprise me if a private company or a commercial research organization asked for aggregated practice data (like IMS already collects for GP prescribing, from pharmacies). I don't know what the rules and regulations are, but I would like to see a lot of safeguards.

There are early signs of bridges between the electronic islands. Labs are pretty good; local hospitals are starting to work with their family physicians for data transmission. The LHINs are interested in integrating all this information. However, I still have no idea of how to exchange information with specialists; I think we'll have to re-think the consultation process. The letters coming back to us will have to be structured differently: the "action" part on the top (diagnosis, rx changes, follow up), coded, and entered in fields so that they can be integrated into the electronic record. The body of the letter is less important, and that can be left as text. Same for DI reports, they should have a field right on top for diagnosis, a check off box for "normal", "abnormal, see text" etc. Screening tests like mammograms need to be integrated with our electronic Health Maintenance lists--for example, the incoming electronic mammo report would be linked to, and automatically update, the patient record.

I am looking forward to 2007; I am now completely done with the transition, and I wonder what the next steps will be.

Michelle

Insurance companies

I dislike insurance companies. At times, it seems like their purpose is to make family physicians' lives miserable by inundating us with time consuming, difficult to fill, paper forms (multi-axial diagnoses; precise time of return to work; lenthy functional enquiries; detailed descriptions of amount of weight that a patient is able to lift; repeated requests for the same data, etc). I have noticed that, for the past several years, they are refusing to pay for the forms they request. Often, the request is urgent, detracting from patient care.

I wonder if I can use the EMR to make the process less burdensome. My notes are now typewritten and legible, which is both a good and a bad thing. I have tried sending a printout of relevant visits, to see if the adjustors would be happier with that than with the usual illegible note. However, I received a note recently from a large company, stating that a life insurance application was denied because the patient has "anxiety disorder and OCD and hypochondriasis". In fact, what had happened was that I coded the visit as ICD9 300 because there was no specific diagnosis. I have to have a code to bill OHIP, and this is what I have used as a "catch-all" in the past. Non-specific problems are very common in family practice.

I wrote another letter to the insurance company stating that it was not OCD etc, it was just an ICD9 300, and suggesting they familiarize themselves with ICD coding in primary care. I received a letter back asking for an explanation of the visit, what the subjective and objective findings were etc. I think I will have to think twice about sending real encounter reports to the insurance corporations.

What does seem to work is the initial medical report for life insurance applications (Keyfacts and others). I send the typed CPP, which is well organized and legible; they also often ask for serial BP measurements, which the EMR readily produces. As well, I can reproduce my flowsheet for diabetes. I should note that these companies do pay for the reports.

The insurance reports are a significant source of stress for me and my colleagues. I wish there was some way that the Corporations could support EMR implementation by making the reports "fit" with the EMR, that is, by accepting legible, typed CPPs and flowsheets, along with a simple statement of diagnosis and prognosis. This would be much easier for me to do, and would likely contain more accurate information for the Corporation. My depression flowsheets, for example, contain serial PHQ9 scores, accompanied by medication changes and notes about therapy type; this would not be difficult to interpret, and follows accepted guidelines. All my diagnoses are ICD9 coded, which will help in standardization. I can't say this is perfect, as noted above; however, I am very careful with ongoing conditions in the CPP. Perhaps these corporations could even pay for the EMR report; this would be another incentive to computerize.

Fat chance.

Michelle

Working as part of a team

The EMR is allowing me to think about working as a part of a team.

My resident did a chart audit of my diabetic patients using remote access to the EMR. It did not take her that long for 70 patients, because the data was in the flowsheets, but I would like to have automated audits in the future. The results are not bad; (2003 audit results are in brackets):

% meeting targets (July 2003 results)
BP <140/90=83% (65%)
BP <130/80=66%
LDL <2.6=63% (50%)
LDL <2.0=40%
HbA1c <8.4=81% (74%)
HbA1c <7.0=48%

There is a new clinical pharmacist in our family medicine teaching unit at my hospital. She can do consultations for our patients who need extra help with their meds. What I was thinking of doing is identifying patients from the audit who need intensification of their meds (sugar, bp, lipids) and referring them to her.

Because I am paperless, I will not do this as a paper based referral. I will give the clinical pharmacist access to my EMR as a team member, just like my resident has. Because I don't know exactly what the scope of practice for a pharmacist is, I will configure the EMR permissions together with her. The EMR has detailed permissions (permission to view, permission to sign off, permission to prescribe etc, for each part of the EMR); we will need to discuss this on set up so that she has appropriate permissions, not more and not less than needed. I figure that, as the family physician, I am the custodian of the primary care record (I don't want to call it a chart, it is becoming increasingly different from a paper chart); therefore I need to think about who can and should have access and input for this record. The "pharmacist" profile, once set, is then available to my whole group. I have an extra RSA security fob for the pharmacist, and this will log and identify her for every chart access just like every member of the team.

Once this is set up, we will mail letters to the identified patients to let them know that the pharmacist may be contacting them. She can access their chart remotely from anywhere with internet access, and call to set up an appointment anywhere convenient; it does not have to be at my office. When she sees the pt, she will be accessing their EMR chart live, and she can enter information directly in their clinical record, live. That is, it is a fully shared chart, with remote access. If we continue, she can also access the chart later for monitoring and callback. The EMR has detailed audit capabilities, so I am able to find out what each team member is doing, and who accesses the chart. If the patient needs to see me for follow-up, the pharmacist has access to my schedule, and can book the appointment.

She is coming to my office Thursday; we'll give it a try.

Michelle

Efficient and effective processes

I had a flu clinic last Monday, and will be having another one on December 11. Here is the process for the clinic: I set up a separate schedule, called "flu shot clinic", with appointments at 5 minute intervals. When patients came in, my secretary swiped their card, and entered them in the flu clinic schedule. She then sent them to the back area, where I was standing next to the vaccine fridge, and I gave them their shot. When she had time, she opened their electronic chart, clicked the button that enters the flu shot in my preventive list, and then entered the full flu shot (the lot number and dosage are pre-set in the EMR, there was no need for her to reenter the same information every time). When the clinic was finished, I changed my pre-set billing code to G591 (the Ontario code for influenza vaccination), clicked the button to auto-bill the entire schedule, clicked send, and it was done. We were finished within 5 minutes of the clinic closing. There were no charts pulled or put back. My preventive services list was automatically updated.

The EMR allows for very efficient processes, with a high degree of automation for things that are repetitive. However, this doesn't happen by itself; you have to figure out how to make the EMR work for you.

As another example, I bought an Automated BP machine (the BP Tru) in the summer. My staff is trained on it and they know how to use it. If I get a patient that requires additional BP readings (perhaps because their last BP was above 140/90), I will often ask them to come on a Friday. I am not in the office Friday. My secretary takes their BP using the BP Tru, and enters the average reading (which the machine produces out of several BP readings) in the EMR. I see it remotely, and will send back a message if needed. The current guidelines say that if office BP is between 140/90 and 160/100, you need 4 to 5 visits to diagnose HT. I can get several visits done pretty easily this way. I also use home BP (Lifesource monitor) extensively. I also use the Friday BP visits for diabetic BP slightly above 130/80, for verification. The EMR generates lists and graphs of Blood pressures, so it is easy to follow them. Having my staff help me, and using automated electronic equipment and EMR has improved my quality of care.

My secretary tells me that I won't have a single paper chart belonging to me in the office by 2007. We are currently scanning the Inactive Patient charts, and that is the last of it. I will put 4 filing cabinets for sale on Craigslist over the holidays. I was trying to figure out how much we pay for the space for these: each filing cabinet is 1.5 ft x 3 ft. I have an exam room that is not usable because of filing cabinets, that is 9 ft x 9 ft. I also have to figure out some space to walk around the cabinets. In addition, I no longer store handouts or chart aids (they are scanned into the computer, or accessed from the Internet). This must be about 150 sq feet for my office; at $30 rent per sq foot in my area, that is $4,500 per year for paper storage. I wonder what an office designed with no paper from the start would look like.

Interestingly, I seem to be going through more paper since starting the EMR. However, I look at it as "good paper". For example, when a patient is in for their annual physical, they are usually sitting on the exam table. I have the Tablet sitting beside them, with the screen turned so they can see it. I load the CPP, and point to it as I talk, to verify the information. When that is finished, the last step is for me to say: "I will print a copy for you to have on hand, in case you need to use it". That is now routine. As well, I'll often print a copy of the flowsheet for diabetic patients, so they can see how their results compare with recommended results. I am certainly printing lots of handouts, such as calcium/vitamin D recommendations during full checkups. The storage cost for Good Paper is essentially nil, because they are just blank sheets ordered from the office supply store as needed.

Michelle

Tips and Tricks meeting

We had our Tips and Tricks meeting on Friday, at the company's training room. We all wanted to be there together with computers, so that we could log on remotely to our own practices, and figure out how to improve things. We made the agenda ahead of time, and I ran the session.

Here is the agenda; most of it involves how to be more efficient, based on real world practice conditions:
___________________

Tips and tricks: how to do things faster and better in the EMR

The patient encounter

Using the Summary page as your default

Clinical

Drop down lists to save time

Templates: Rourke, preventive health, smoking cessation

Medications

Rapid prescribing of new drugs

Loading previous drugs and doing repeats quickly

Assessments

How to record them fast

Follow-ups

How to make sure you remember what to do for next visit

Plan

Using drop down lists for speed

Billing

Within the patient encounter; how to make the bill quicker

Preventive services

How to generate your reports (and your bonuses)

Using the Summary page to remind you when a service is due

How to send letters to patients who are overdue

Flowsheets

How to use them.

Programming one

Examples of some: INR, diabetes, depression

Reports

How to generate a Diabetes report

Review of preventive services reports

Scanning old charts

How to get rid of all your paper records (forever).

_______________________

This took about 2.5 hours. It is a good idea to do something like this several months after EMR start-up, as most of us have had a taste of it, but are not using it to its full potential. It has now been 8 months for my group, and I understand it takes an average of 18 months for the EMR to work well. For keeners like me, it is probably 6 months.

I was speaking with a colleague who had been using EMR for 10 years in his 7 physician practice. 2 physicians never went to EMR, so hybrid practices like mine may be more common than people think. It is interesting that he does not scan; paper copies are kept in a paper chart, so there are still duplicate charts after 10 years. He does not feel that he is using the EMR to its full capacity. Nonetheless, he would never go back to paper, and this is something that I hear universally from people that have made the transition.

I found a very active on-line group for my EMR, and have joined it. I have found several useful tips in the messages.

I seem to have a bit more time at the office; I think I am now more efficient because of EMR and so I can do extra things. On Tuesday, I looked at my list of overdue consultations, and found 7 that were very overdue. We faxed a note to the specialists, with the initial consult request and a letter asking their secretary to tick off what happened (pt never showed, pt cancelled, pt seen and report attached etc). Within two hours, 5 reports came back: 2 with consult notes attached, and 3 stating that the patient cancelled or rebooked for a later date.

My preventive services reports are working. I have given flu shots to 109 out of 213 eligible patients (age 65 and over), which is 51.17%. It says that right at the bottom of the report, and tells me what my bonus code is. On Monday, we have our first flu shot clinic, so my report will look better after that. We sent out letters to all the patients. The reports tell me that we have also sent out 35 letters to patients overdue for a mammogram, and 33 to patients overdue for a pap smear. Several of those patients have had the service because of the letter.

I like this organized approach to prevention; because my group has a common remote server, we are looking at doing this as a group once everyone is on-board with the EMR. We can have a group administrator responsible for things like quality audits, reminder letters/phone calls etc. This is very difficult to do if you have single server boxes in individual offices with no sharing of charts. I am becoming very opinionated about this subject as I see how the EMR functions; the single in-office server is OK for large group practices in a single location, but not for distributed small practices like us.

I tried going through VPN at my office on Monday, which was kludgy at best. The SSHA connection came back on, and we switched to that at noon. They tell me that the problem with VPN is my office router, so I have someone coming to install and test a new super-router on Friday. I have a regular Shelob's lair of wires in my back closet, and several boxes with blinking lights. Managing a small office network is not a job for amateurs; it is worth spending a bit of money for extra help at times.

Michelle

Managing waiting times, managing data

We now have a Joint assessment centre to expedite assessments for hip and knee surgery, run in common by the surgery departments of 3 local hospitals. Because the surgery depends on how functionally impaired people are, the assessments are done by a physiotherapist or orthopedic nurse practitioner. This frees up the surgeon's time. The patient can choose the first available surgeon (from 3 hospitals) or a surgeon of their choice--but then they have to wait longer. The Centre opened November 1st.

When I received the announcement, the referral form and letter were scanned into my network. I saw a patient who fit their criteria last week. I printed the letter of introduction and a blank referral for my patient, and a referral for me to fill out. I sent this the same day (with very little hand-written data, it is mostly check-boxes), along with the CPP and a printed copy of my clinical notes indicating what the problem is (which saves having to rewrite the whole thing).

I wish more specialists took this approach, rather than continue to use individual waiting lists.

I am continuing to use the on-line waiting times sites to refer my patients for MRIs, and this has made a difference.

I have to think carefully about what happens to my data. It continues to bother me that so much data needs to be scanned in because it is not integrated with the EMR; this can be a real problem for shared care with a specialist. A local internist sees one of my patients for mild hypertension (I am not sure why). Periodically, he orders blood tests, DI such as bone densities, and changes her meds. In the past, on the paper chart, this was just irritating. In the EMR, it is more of a problem. The blood tests he orders have to be scanned in, and do not show up on electronic summaries (he does not use one of the electronic labs). The changes in meds have to be entered in the CPP instead of just flowing in from my encounter. I have to enter his BP values so they show up on my graphs. It is no longer just irritating, it is now more work (for no better care).

I finally called the specialist and explained why I no longer wanted my patient to see him. I explained that I am using an EMR, and that it is important that the data flow in electronically. He agreed to stop seeing the patient.

I think the primary care EMR will be the core of the eventual Electronic Health Record (EHR) for most patients. When a patient comes back from a hospital, I ask them to tell the institution to send me a report. I show them their EMR, and explain that records get scattered all over the place in our health care system; the only way to ensure information is not lost is to get their data into the EMR.

There are 4 large labs in my area. 3 are electronic and flow into the EMR, and 1 is not. If I get a result from the non-electronic lab, that chart is flagged, so that the patient can be told not to use that lab in the future.

I have now been told that my hospital's software and my EMR will be able to share data, in mid 2007.

I think we can have a say into how the data is managed. We can sometimes direct patients where their data is more likely to follow them.

My group continues to have problems with SSHA (Smart Systems for Health), which is the government agency that provides Internet access for doctors and hospitals. Their lines have been slow at times, and are sometimes unreliable. I had my SSHA internet access cut off on Friday, and I switched to my back-up internet line, which is actually faster. I am not sure government should be in the business of providing Internet access; I may just stay on the back-up line.

Michelle

Guidelines in the EMR

I have been thinking about how to put guidelines in the EMR so that I can use them in practice more effectively. This is a recent review in BMJ : they found that

1. integration with charting
2. computer-based generation of decision support
3. automatic provision of decision support as part of workflow
4. provision at time and location of decision making
5. request documentation of reason for not following recommendation

were associated with more use of the recommendations in practice. Some of these things I can do now, some I can't.

The integration with charting is pretty easy for simple recommendations. For example, I made a template for the GAC recommendations for sinusitis. It has checkboxes for symptoms, and a text box for recommendations (copied and pasted from the website). I had a patient with sinusitis, loaded the template, and showed her the recommendations (no XRs, no antibiotics). These can just be saved to the clinical record, since the amount of writing on the record doesn't really matter anymore. I guess that takes care of point 3 and point 4 as well.

I copied and pasted below a slightly more complicated template I made to help me with the management of patients with chest pain. I used a "history builder", which is where you click on snippets of phrases to put them in the record, then a table, a textbox, and a drop-down list (the table didn't format properly when I copied it for here):

chest pain Updated By:(Michelle Greiver)

chest pain

chest pain

Patient complains of retrosternal chest pain; The pain is worse with exercise or stress; Patient states pain is better with rest or NTG.

number of symptoms 3

Simple Table

	Risk of heart disease
	Age (yrs) Men, 0-1 sympt Women, 0-1 sympt Men, 2 sympt Women, 2 sympt Men, 3 sympt Women, 3 sympt 30-39 4 % 2 % 34 % 12 % 76 % 26 % 40-49 13 % 3 % 51 % 22 % 87 % 55 % 50-59 20 % 7 % 65 % 31 % 93 % 73 % 60-69 27 % 14 % 72 % 51 % 94 % 86 %

Risk of heart disease (%) 76

Test suggestions:

Risk <20%: observe, reduce risk factors Risk 20%-80%: cardiac stress test, unless contraindications Risk >80%: refer, stress test for prognosis, consider angiogram

Test chosen: Cardiac stress test;

I don't really see how the computer can generate automatic decision support in the current EMRs. The decision support tools are all "outside", on the web or on PDAs, and not integrated. Nor does the EMR request a reason for not following recommendations, even if I choose to bypass an alert that a patient is allergic to that medication. I am not sure how well accepted such a request would be.

I think more advanced functions, like context-specific suggestions, will be in EMR ver2. In the meantime, I can use what I already have. I programmed the new Rourke well baby record, using pieces that were in the EMR for the old record. I also pasted the Rourke patient education recommendations to a website. When parents are in, I ask if I can email it to them; they then have access to all the great links from the Rourke. I also printed a copy for a new mom who doesn't use email.

One of my front computers crashed on Tuesday; we had a blue screen with a note to get support. Dell sent a technician to replace the motherboard (didn't work), then the Intel chip and memory (didn't work), and now I think they are going to reload Windows. We are using the laptop as a back-up, so there are still two computers at the front. Some redundancy is good to have.

Michelle

Helping others in my group

One of the benefits of starting EMR as a group, rather than individually, is that we can help each other. At our recent meeting, it was clear to me that I was the furthest along, although others had good ideas. Because the nine of us work in 7 different practice locations, we don't meet all that often; we use email, and recently also the EMR's internal messaging system. We decided to have a "Tips and Tricks" afternoon at the company's training room, and this will be on November 24th.

The plan is for us to log on remotely to our practice EMR during that meeting, so that we can make changes (such as new flow sheets) directly. My group's IT lead physician will help me set an agenda; I will circulate this prior to the meeting to see if there is anything people want to add. We've invited the other FHN's IT lead, so that she can bring things back to her group; her FHN includes one 6 physician group practice and one 3 physician group, so it is not as scattered all over the place as ours.

Some practices are not using the scanner. EMR not only involves software, it also involves learning how to use new (and sometimes unfamiliar) hardware quickly and effectively in a busy office. I did a brief demonstration of how to use the scanner during the meeting; I talked to my staff the next day, and they offered to help as well. Probably the best way to show how we use the EMR is to have a staff member from another office visit my practice on a Friday (since I'm not there Fridays); this happened today.

I have been away at a conference for the past two days. In the evening, before supper, I have been logging on to my practice, and signing off lab work, and scanned reports. I received several messages from my staff, wrote a couple of prescriptions, sent notes to my staff to call patients about their results, and wrote some lab reqs. I also had an email from a patient who was worried about his lung function test; it had been scanned in the EMR, I saw it, and sent him a note that it was normal. One of my patients had received a flu shot at another office in my group; they entered it in the EMR chart, and sent me an internal message to let me know.

This work for my practice took about 45 minutes. I consider going to a conference part of work, so told my staff that I would be logging on daily. It is extra for me, but really does take a load off my practice partner; a big part of covering for another physician is reviewing all the paper that comes in. I am much more efficient at reviewing results for my own patients, because I know them. It is becoming more important for me to let my staff know whether I will be logging on when I am away, and I have to be explicit about this. If I do log on, my partner is only responsible for looking after critical results.

A couple of physicians in my FHN are part of our palliative care group. I wonder if I should ask the nurse coordinator to direct my patients to them when I refer. They would have access to the chart. It would not always be possible to use the EMR during a housecall, since not everyone has high speed internet; they would have to print the CPP ahead of time, and then scan notes in afterwards. However, if there is access, then all the changes are live in the common chart. They could even write a prescription in the EMR during the housecall, and have their secretary print and fax it to the patient's pharmacy (just like I am doing from my conference). I would always be able to know what is happening, and if I made any changes, my colleague would know. Any home care, specialist, or test report that came would be scanned in, and would thus be available to the team. I should talk to my colleagues about this.

Michelle

Managing Flu shots with the EMR

Computers are good at making lists of things. As of October 1st, my EMR automatically generated a list of patients age 65 and over, since they are due for a flu shot. I have two lists

1. a Report list, which shows how many patients I have that are 65 and over, how many received a flu shot, and the percentage who have been vaccinated
2. a Letters to send list; this shows me the list of everyone who has not been vaccinated so I can generate a personalized letter for them. The list has buttons that you click on to generate letters
   

I wrote a letter inviting my patients to come in for the shot. We run two flu shot clinics in the evening, and the letter also includes the date and time for those. We bought window envelopes; the letters get folded so that the address shows in the window, so that we don't have to print labels.

When a patient gets a flu shot, I have a button that I click on in my Summary sheet. That removes the patient from the Letters to send list, and marks them as vaccinated in the report. Then I start the encounter; in it, I click on the drop down list for vaccines, and click on "influenza". I've preprogrammed information on lot number, expiry date, and route of administration, so that all gets automatically recorded. If the lot number changes, I can update the saved information.

If a patient gets a flu shot outside of my office, I just click on the button in my Summary sheet.

The vaccines are late this year. I've had to defer the clinics; we'll have one on November 27th, for high risk patients, and one on December 11th for everyone. I've posted this all over my office, and put it on my website. I've been telling people to look at my website to find out when the clinics are.

I was talking with my staff: after 6 months of use, we now have very little that is still managed outside of the EMR. All clinical notes, prescriptions, phone calls and inter-office messages are recorded in the EMR. Requisitions (DI and lab) are now generated in the EMR, with the exception of pap reqs (my lab has still not authorized this), public health reqs, and some specialized reqs (Diabetes education, MRIs). All letters and consult notes are in the EMR. Everything that comes in is scanned and then shredded.

I figured out how to upload faxes without printing and then scanning. What we do is view the fax, then click File, Print, Print to pdf. That transforms the fax into a nice, very legible pdf file, which is then saved to the "charts to upload" folder on the desktop. It is then uploaded to the patient chart along with the scanned files, which are saved into the same folder. I taught my scanning tech how to do it, and we have had no problems.

An 18 page old chart came by fax. Rather than printing it to paper, we saved it as a pdf file to the external hard drive where all my old charts are kept.

My friend at IBM told me to download a copy of Adobe Reader, and archive it. That way, I can make sure my files are readable in the future. I saved a copy to DVD.

My scanner sent a message that it needed a new pin roller; this is something that you replace after 100,000 pages. I guess we scanned that many. We're now scanning all the files of deceased patients. I think by the time this is over, I'll manage with a single filing shelf.

We had a meeting for my group of physicians last Tuesday. I think I've gone the furthest; most people have entered CPPs, some are prescribing in the EMR. We're going to go to Nightingale's computer training room at the end of November to share tips and tricks. We're starting to receive the montly EMR subsidy from OntarioMD, which is $600 per month for 3 years. I've also received a $2,500 bonus for entering over 600 CPPs.

My own family physician has retired. I will be going to one of the physicians in my group, for two reasons. That person is an excellent family doctor; as well, my chart will be on our server, so that I can access my own data. I've already entered my demographics, my CPP, and uploaded a couple of reports. I'm healthy now, so accessing my data is not that important; however, if I get sick, I want to know what is happening to me. I've made it so that I can.

Michelle

Lights out

Thursday was a terrible day. Our server went down at 2:30; then a transformer blew, and the electricity went out for my street at 3:30, for the rest of the day.

With no electricity, I could not even access my old charts, which are stored on my external hard drive. The data on those is already a couple of months old, but at least there is some information there. This is a risk of going fully paperless: if there is a major power interruption, I am stuck.

Having been through a couple of server problems earlier on, I had some idea of what to do: jot brief notes on paper; only give prescriptions that are not recurring (such as antibiotics), or recurring prescriptions for patients who were on only one medication and knew what it was (such as birth control pills). All complex renewals to be faxed to the pharmacy once the system was working again. It was difficult to function: people were asking me what the result of their tests were, and I could not tell them. None of my fancy recall systems were working: I had no flowsheets for a diabetic that came in; I could not remember exactly why I had asked an elderly patient with multiple problems and cognitive impairment to come in (and neither could he). I ended up rescheduling some appointments.

I work late on Thursdays; without access to the scheduler, we had no way to even call patients to ask them not to come if they were booked after sunset. My secretary brought some flashlights. One of my exam rooms has a window and faces West, so I saw patients there while there was still light.

The server came back on at 6:30 pm (which was of no use to me at the office, without electricity). I went home after seeing my last patient in the dark, and completed my charts remotely. I left for a conference the next day.

My group is very unhappy with this server interruption. We will be meeting with the company to discuss what happened: service interruptions can come from the hospital, from SSHA (which provides our internet access), and from the server itself. Since start-up, we have had interruptions caused by all three. Having a centrally managed server has advantages (managed backups, managed security, centralized upgrades, ability to securely share patient data between several providers), but also introduces complexity to the system. Along with this complexity come multiple possible failure points. I think my group is an early adopter of an enterprise-level system; down the line, it is probably the right way to go, but this week it just felt like a lot of birthing pains.

Michelle

Tracking patients, tracking reports

The EMR allows tracking of several things. I've already mentioned tracking of lab results, which is not perfect, but is much better than what I had before (nothing). It tracks DI reports, and also consultation requests. I have three folders for tracking requests to the outside (lab, DI, consults).

I had a look at my consultation requests folder recently. The largest number are for derm referrals (I probably over-use this); Second was for ENT. When I send a consult, I can put in a "date expected" in a drop down field; if the date is exceeded, the request is highlighted in red. One of my patients had a rather serious medical problem, and no report was received. We sent in a note to the specialist, and they told us that she had cancelled. This lady comes in fairly often, so I will ask her what she would like to do. When a report is received, I click off "received"; in the future, perhaps we can do audits to see what actual times between referral and report are.

There are therefore a couple of advantages to this

1. you can get a sense of what your referral pattern is like
2. you can track patients to see what happened
3. you may be able to get a sense of waiting times. That might be useful for wait time management for our health care system in the future

I also track "follow-ups" in my office. When someone needs a follow up (1st rx for HCTZ: needs K+; 1st rx for ACEI: needs K+, creatinine; etc), this shows up in my Summary screen when I load up the chart, to remind me. However, it also shows up as a list of Follow-ups, so I can see which ones were missed. A common miss seems to be the follow up for depression therapy, after a patient was given a first script for a SSRI. They don't book the follow up appointment with my secretary when they come out, and they don't come back. Guilt and hopelessness are features of depression, so it is no wonder this happens. Right now, I don't have the resources to do something about this; however, once we have the FHT going, I wonder if it might not be good to assign a mental health worker to phone these people. Same thing for people who have missed more than one of the recurring DM follow-ups.

There are problems with doing this, such as how much is the physician's responsibility and how much is the patient's. Tracking does make recalls for chronic disease management possible; we already do it for preventive services, such as influenza or pap smears. We'll have to decide how much is possible to do, which problems to target, and how to do it.

Michelle