Reporting my data

OntarioMD has now announced that two new companies have been approved for ASP funding. My EMR software is one of them. This is good news for my group; our contract finishes in a year and a half, and we will be looking at whether we should then transfer to the ASP product. Doing this will mean that our software will be hosted in the SSHA Data warehouse. Other services, such as home care and some public health data, will be hosted there as well. I am sure there will be lots of bugs and difficulties, but this represents the future of health care in this province; it represents the best chance of integrating health care.

I went to the North American Primary Care Research conference last weekend. There was palpable excitement about what is happening with computerization in primary care. There were many presentations dealing with this subject.

As I look at my data over the past year and a half, I can see how valuable it is. Everything possible is going into the EMR now. It bothers me that Diagnostic Imaging reports continue to be reported on paper (despite the fact that DI is highly computerized), and that hospitals are still not connecting. That is unsafe and bad for patient care.

We also continue to receive stacks of paper from the Ministry of Health for our roster lists (list of all patients signed up with a family physician), every three month. These are generated by a computer, is there no way to receive them electronically, and match them with the EMR roster list?

It is now time for us to think about how to give our data back safely, and with full privacy protection. This data can and should be used to improve our health care system. For example, there is much talk about Wait times, and a lot of money is being poured to improve this. I don't really know how good the data is. In my EMR, we routinely collect wait time data as part of everyday care. When I send a patient for Diagnostic Imaging, the requisition is generated in the EMR (with a time stamp). This is the same for a specialist referral. When the specialist's office notifies us of the date, my secretary calls the patient and enters the date into the EMR. When the letter or DI report comes back, it is matched with the req (so we know it has been received), and that date is stamped in as well. I think it is now possible to start reporting on wait times from primary care, which is what is most relevant to patients. I think the public has a right to know, physicians and other health care providers should know, and our government (which funds health care) would want to know. If you don't know there is a problem, it is very difficult to fix it.

I do not think most of my colleagues would have much of a problem with this, provided privacy is strictly safeguarded. I think there is large value for patients as well, with the same caveat. I know I have several colleagues who are thinking the same thing. It is time to get going on this.

One of my colleagues was mentioning the fact that proprietary requisitions seem to be proliferating. Every specialist and hospital program wants their own, usually based on a paper form. This is not the way to go. I generate generic requisitions for DI, and have started generating EMR based reqs for Diabetes education. I simply append their form on the top, with "see attached". That seems to work. Dr Brookstone in BC has managed to get programs in his area to post their reqs on a secure website, but it takes work to make sure this is regularly updated. It is better than what we have here, which is nothing. I think it should be the responsibility of programs to make sure they are accessible when needed. Give up on proprietary forms (health is not proprietary), and make all programs accessible from a common area. Toronto211 is a good example for community and social services, we need something like that for medical programs.

It is time to ensure that the necessary data is there, both for our patients and for our health care system. I can see this is starting to happen now.

Michelle

Back to paper

Due to personal circumstances, my practice partner had to suddenly be away and unavailable from his practice for the past week.

What that meant was that I was looking after two practices, one EMR and one paper-based. This was a somewhat rough way to compare the two systems. The picture above shows what the front of the office looked like after four days, and there were more charts piled up on my partner's desk. He is very meticulous, and wants to look at everything, so nothing got filed away; we must have had well over 150 charts out.

The logistical problems for my staff were tremendous: trying to find a chart to attach a result to quickly became very challenging: labs often send a partial result first, then a final result; this leads to two separate chart searches. My secretaries stacked the charts in alphabetical order, so that there was some chance of finding the right file.

I had trouble finding data in the paper chart. Looking for previous results meant having to thumb through several papers instead of doing a simple search or clicking a checkbox to get a list of results. Labs, consultation notes and Diagnostic Imaging reports were all mixed together. The CPP was up to date, but drug prescriptions were often very hard to follow, as they were in the clinical notes. There was no easy way to refill prescriptions, those had to be written by hand. My partner keeps excellent notes, and has handwriting that is much more legible than mine, but the logistic challenges were still large.

I know that many of my colleagues who have gone to EMR have stated that they would never go back to paper. Having had to go back to paper for a week, I can unequivocally say that no, absolutely not, under no circumstances, and no way would I go back to paper. It doesn't work.

Having said that, EMR does present its own challenges. My resident is on block time (in my office most of the time) and was a great help in the past week. However, her Tablet went on the fritz on our busiest day (Thursday). It suddenly refused to load the EMR software properly. I have a backup laptop for those occasions, but had lent it to my Nurse who takes it to my colleague's office Thursday afternoons. My resident went back to paper (since she was seeing my partner's patients), and my secretary called the EMR company. They had to "remote" into the Tablet (that means they take control of it from a remote location). Apparently, the hosts had disappeared; I don't know what that means, it sounds like something from the hospitality industry. They reintroduced the hosts, and the Tablet was fixed and happy. This took about 45 minutes.

I have been asked what I do when my Tablet crashes. Computers crash, and they usually do so at the worst times. If mine crashes in the middle of a patient encounter, I either leave it to reboot in the room (if I'm doing something else such as examining the patient), or I put in my consult room to reboot and I go take the backup laptop. The backup laptop is left turned on and ready to go; I just log in. You really have to have some redundancy; however, as noted above, even the best laid plans sometimes do go astray.

I do not pretend that EMR systems are free of problems and aggravation (they are not); however, the past week has made it very obvious to me that EMR is far superior to paper. Just try asking your kids to function without the Internet--asking a computerized doc to go back to paper will lead to the same reaction.

Michelle

The Efficient EMR

I am currently in the office three days a week (I am taking a course at the University of Toronto Mondays, and do research projects on Fridays). My roster size is at 1,320 patients and I have about 100 to 150 unrostered patients. That makes a practice of about 1,450 patients.

In my FHN, the average practice is about 1,200 patients. I have a slightly larger than average practice.

If a patient is not too particular about the time of the appointment, they can almost always be fitted in within a few days, and often the next day. The only appointments that are troublesome are full check-ups booked in the morning (so that a patient can get fasting blood work done at my office on the same day). If they can get their blood done prior to the visit, the appointment can be scheduled much sooner; we mail them the requisition along with a list of labs (only ones that do electronic results) and weblinks to lab locations. This is in the Handouts section of my EMR.

The university provides hotspots for students, so I log on to my practice on Mondays; I am usually logged on remotely Fridays as well. I can review results and reports, and assign needed actions to my staff or my practice nurse.

What that tells me is that there is less need for my patients to come in personally for minor problems. If they do need to come in, they can usually be see fairly quickly. Much of this increase in efficiency has been gained by using the capabilities of the EMR (remote access, e-communication), along with having the entire practice work as a team. It helps to have excellent staff. I am starting to see some improvements with my new nurse coming on board, and expect to see more as other Allied Health Professionals join us. My Family Health Team now includes dietitians (I've made several referrals already), and I met our new Social Workers yesterday. The RN and our Clinical Pharmacist already enter data directly into the electronic chart-in-common; the other AHP's will get training; for now, their notes are done on paper and are scanned in.

If I can look after a full roster on reduced hours, this tells me that I may be able to expand my practice if I go back to my regular hours. This is part of the payback for EMR and for adding extra people to primary care. I will have to decide whether I should do more research or see more patients.

I have now taken on a new physician as a partner; she will start in December, and will have an EMR practice from the beginning. We are already starting to keep a list of people wanting to join her practice. I think most of the pain happens during the transition; once an EMR is established (meaning that all the new processes work), it is much easier to add a new member to a practice. I have seen this with my resident. That bodes well for the next generation of physicians, provided that they do not start a paper-based practice.

My nurse will be giving my patients flu shots on a drop-in basis every Monday afternoon, once the shots are available. We will be doing a mail-out to my older patients to notify them of this. We are doing the mailing as a group, just as we did for the other preventive services: the letters are already in everyone's EMR; our FHN admin will print and mail them as soon as we have confirmation that the shots have been delivered to our offices. Several of my colleagues have also decided to have the RN run the flu shot clinic in their office.

It is increasingly difficult for me to remember what it was like to run a paper-based office; I am pretty sure that I would find the inefficiency and lack of communication difficult to tolerate. I no longer believe that paper-record based medical care has a future.

Michelle

Electronic communication in the office

Communication in my office is becoming increasingly electronic. I get 5 to 10 messages from my staff per day (often a patient or a health care worker wanting to talk to me, sometimes a drug refill). Messages are linked to the patient's file (I can just click to access the entire file if needed), and no message gets lost or forgotten anymore. Most of the e-messages I send out are "Actions", or things to do, often stemming from lab results (example, please call patient and tell them that A1C is improved, now at 7.8%; or, INR is 3.8, reduce coumadin to 1 tab daily and repeat INR next wk); typically, there are 5 to 10 of those per day. The "Actions" can be assigned to a group, such as "front staff". This is very helpful if you have several people working at the front; any of my staff can do the requested action, and mark it completed, thus avoiding miscommunication.

I have been assigning complex Actions to my practice nurse, such as discussion of cholesterol results and possible courses of action, or informing a patient about a new diagnosis of impaired fasting glucose. She can often discuss things with my patients over the phone, and she records the phone conversation in the clinical notes; if needed, she will book a patient in to see her. She sends the clinical notes to me for final sign-off when she is done, so I always know what happened.

I use pop-up messaging often as well (Real Popup). This is a small application that pops up in the right lower corner of a PC whenever someone in my office sends an instant message. The message is not part of the EMR. I use this to send a quick note to the front regarding follow-up appointments (example: Mr Smith: DM 3 months). The secretary sees the popup, and gives that patient an appointment marked as "DM", so that the patient automatically gets a weight and BP done when they return, before they are shown to a room. Some of my patients have wondered how the secretary knows what they will be asking for before they even speak! My resident often sends me a popup for a quick question while she is seeing a patient; she also uses this if she wants me to come in and double check something before I see the next patient.

The office environment I have described seems complex, but it works and actually makes the office much less stressful. There is no need to duplicate messages on notes, nothing gets lost, and everything is done. This improved communication is one of the biggest benefits of EMRs.


I have now gone back to signing my prescriptions on my Tablet. So far, I have only had one phone call from a pharmacist inquiring about this, and he was satisfied when informed that it was acceptable practice according to the College of Pharmacists. I think we have progress.

Michelle

Allies

It is difficult to do it all; I have some very valuable allies that have helped with EMR implementation in my group.

One of my secretaries is now working for my FHN as well, as our group admin. She has helped other offices to implement scanning: seven out of the nine of us are now scanning, and one is about to start. She regularly helps other staff with problems, and they are very comfortable contacting her, whereas contacting me would not be as easy for them.

One of my colleagues has stalled with her EMR implementation; she is in a hybrid office as I am, and so gets no help from her practice partner. She has not been able to start encounters, but would like to do so; however, she does not feel confident in her ability to enter data. I have been thinking about how to help, but it is a problem for me as I cannot spare the time to come to her practice and stay with her.

My new Practice Nurse is now getting allocated to various offices by the Family Health Team's Human Resources manager. At a recent FHT meeting, I introduced the RN to my colleague, and talked about having her come to the office. My colleague was very interested; the nurse felt that she would be able to help; the HR manager thought it was a good idea.

The nurse went to the other office yesterday. I lent her my extra laptop for the day, to make sure that there were enough PCs in that office. It helps if both the MD and the RN have access to the EMR at the same time, as each logs on personally, and permissions are different. The nurse can show the MD what she is doing, while the MD is logged on.

When she came back to drop off the laptop at the end of the day, my nurse told me that she had done several annual physicals, and had showed the physician how she entered the data in the preventive services template. She went in for some visits with the physician, and helped to enter things, and my colleague tried several encounters; she also tried a prescription. The nurse entered a diabetic flowsheet for a patient, and showed the physician how data from the Vitals template in the encounter, as well as lab data, flows automatically into the flowsheet. I really think it helps to have someone on-site; the nurse will continue to go there once a week.

While it is not always possible to have a RN to do this, often there are allies who can help. It is worthwhile thinking about some of the untapped resources present in our practices and communities.

I am now at 88% of paps, 89% of mammograms, and 100% of children's vaccinations for my preventive services. My colleagues are telling me that patients are calling in after having received the reminder letters. We are hitting some of the inevitable glitches, such as a patient who had a hysterectomy receiving a pap reminder letter; because we communicate, these problems are getting fixed (for example, telling the secretary how to tag that patient's chart as having had a hysterectomy, so they never get another letter again, and get labeled as ineligible for paps). I figure that we will have most of the problems with the initial mailing, and this will decrease with time; we have had surprisingly few issues.

The draft letters for the flu shot reminders are in, and everyone is deciding on how they will do their flu shots (clinic, RN times etc). We are now talking about holding a common clinic, since the data can be entered from any of our practice sites; I'm not sure there is enough time to organize this, but maybe next year. Our FHN admin has already organized the window envelopes and stamps, and she will mail the letters in October, as soon as we know the shots have arrived. We get a small amount of payment ($6.86) for organizing each reminder; our FHN admin has entered EMR billing lists for the flu shot reminders for each practice based on the mailing lists, and she will auto-bill after the mailing is done.

Michelle

Planning an office layout for EMR

I am currently finalizing the layout for my new office. This will have 3 physicians, at least one family medicine resident, one RN, and one Allied Health Professional. The office is 1,900 sq feet.

I have been thinking about what to change. The exam rooms are 8 x 10 ft, and really do not need much modification. I will have 8 exam rooms (2 per physician, 1 for the RN, 1 for the AHP). I don't know if my new partners will prefer wired or wireless; if they prefer wired, then they will need 1 printer in each room, along with a computer stand (or they can just put the monitor on the desk table). If they prefer wireless, then they just need a stand for the printer.

I will put network "drops" (the RJ45 plugs) in each room, so there will always be a choice. If wireless, then the printers plug into the RJ 45s; this is my current configuration.

I have chosen a common consult room; I think it is very important to be able to talk to each other, especially as the new physicians start practice and EMR. I asked my nurse if she would prefer to have a consult/exam room, or would she want to sit in the common consult room: she definitely prefers to sit with us. I will also have a space for the resident in the common consult room.

When planning a new office, I think it is good to consider workflow issues, as well as people issues such as how you communicate and work with each other. EMR impacts those.

The biggest change will be at the front office. There are no charts, so the front reception area can be a lot smaller. However, my staff does more callbacks, and they need space which is more private than the open reception area. I am planning a separate staff room; we can have lunch there, but it will also have a workstation for callbacks and administrative functions that do not require a secretary to be at the front (example, uploading bills, managing our preventive services etc). I am considering buying a second scanner, so there will be two places to scan: one at the front reception, and one in the back staff room. I will still have two desktop PCs at the front.

I went to the Canada Health InfoWay Peer to Peer meeting last Saturday. I met my colleague, Dr Brookstone, who reports what happened at that meeting , along with several physicians who had been email only until now. It was good to see others who are very passionate about this subject; sometimes you do feel as if you are a voice in the wilderness, although it is getting to be less so. Our provincial bodies (in Ontario, OntarioMD) will work on figuring out how we can help others; I think this will likely mean a contact from one of us when another physician is strongly considering EMR and wishes to talk to a peer (perhaps a site visit, or a phone call to talk about the specifics of deciding to implement EMR), as well as practical help with the early implementation glitches (this worked in my practice, this didn't, here are a couple of things to try).

One of the pharmacists at the meeting told me that signing prescriptions on my Tablet is now acceptable to the College of Pharmacists; I'm going to try that again. The College states that "For a written prescription, the physician's unique signature is required to provide the authorization." The Tablet signature fulfills that criterion.

Michelle

The Diffusion of Innovations

I’ve been reading a very interesting book called “The Diffusion of Innovations”, by Dr Everett Rogers. Much of what I see as currently happening with EMR is accurately reflected in his book. Making a major change like adopting an EMR is very much a social process.

Dr Rogers found that the adoption of an innovation follows an S-shaped curve; he categorized people as Innovators (2.5%), Early Adopters (13.5%), Early Majority (34%), Late Majority (34%) and Laggards (16%). The lower elbow of the S-curve, where adoption starts to take off, is where I think we are now—right in the Early Adopter stage. This means that you may be able to get a critical mass of users now, and the adoption rate then accelerates and becomes self-sustaining (sort of like an atomic chain reaction). It is an interesting stage, because pushing things along here makes the most difference to how fast we adopt EMRs (the “turbocharging effect”).

The process of starting EMR in our practices also has several stages: thinking about it (knowledge); forming an opinion (persuasion); deciding to do it (decision); starting to use it (implementation); continuing to use it and solving problems (confirmation). According to Dr Rogers, people tend to look to their peers when deciding (persuasion and decision stages). Diffusion networks (groups of people talking to each other) are also important at the implementation and confirmation stage, because you always have to re-invent the EMR at least to some degree to fit your local circumstances; we’ve certainly done that in my group (customized templates; implementing the preventive services; getting scanning going; hiring an IT person). It helps to have a group to see how others have solved problems.

Canada Health Infoway is starting a Peer-to-Peer network, together with the provincial e-Health organizations, so they are probably thinking along the same lines. They have targeted the keeners, under various names: “champions”, “super-users”, “peer leaders”—this is the early adopters. Infoway has scheduled the first national meeting next weekend, and it will be interesting to see what they want to do with us (and for us).

My new nurse is now comfortable using the EMR; it did not take long. She starts seeing patients on her own tomorrow. We had several visits where she saw pop-up alerts for patients booked in for other problems, such as a patient with a new diagnosis of diabetes who had not returned for foot examination or urine testing, or a patient who needed to have a MMR vaccination. She is getting good at providing opportunistic preventive care. The clinical pharmacist saw one of my patients at her hospital office last week, and I saw the electronic chart being opened while in my office, which was very strange. My secretary picked up an urgent message from a patient on a Saturday: the pharmacy had not filled one of her medications. She was able to log on to the record remotely, see that the prescription had been ordered (a copy of the script was on the EMR record), and she called the pharmacy to ensure that the prescription was filled correctly. This prevented an important medication error. While Team-based care is possible without EMR, I think it works better with EMR; some of the EMR tools (alerts, reminders, legible records, e-communication) can make collaboration more seamless.

I am looking for new partners for my practice. I have been now contacted by several recently graduated physicians with impressive credentials; I had looked for a new associate a few years ago, with no response. I don’t know whether the interest is due to the EMR or to the benefits of joining a Family Health Team; probably a bit of both. I have noticed that many of the ads seeking to recruit a family physician as an associate mention that the practice is computerized; EMRs are a selling point. All these changes seem to be having an impact, and I am very pleased to personally see that new family physicians are choosing comprehensive care again.

Michelle

DHCP blues

One of my front computers stopped connecting to my network last Thursday; this was kind of bad, because it is connected to the scanner--no scanning. When a computer fails at the office, it is always a bit of a crisis, and someone has to fix it.

In my office, I'm usually the first line of defense (I think every office has one of those, often by default). Most of the time, what I do is reboot the computer, and that often fixes things. This time, it didn't work. Then what you have to do is look to see if you can easily identify the problem; clicking on the "repair" button for the network didn't work.

This is when you call your IT person; every group should identify a professional IT person that they can call (not another physician or their neighbor's teenaged son). He came by that afternoon, and had a look at the machine. He tested the network card, connected the computer directly to the routers and did other things; I can't say exactly what, because I was seeing patients instead of taking care of the problem--which is the way it should be.

He finally identified the issue as a "DHCP server not working; must be replaced". He said that this is bad; he pointed to the router boxes in my IT closet. He assigned a static IP instead of a dynamic IP address to the computer, and said that this would fix it temporarily (whatever that is, it worked and the computer reconnected to the network). This reminds me of being in the garage with the car not working, and the mechanic tells me that the crankshaft is unglued; please just fix it.

Now that the problem was identified, I had to figure out who to call; the boxes in the back belong to SSHA (Smart Systems for Health), and we also go through the EMR company. I sent an email to SSHA, the EMR company, and OntarioMD. My very helpful contact at OntarioMD said to call the SSHA helpline, which is what I did; they took down the information, and gave me a 6 digit number for tracking purposes. On Monday, a new SOFA (Small Office Firewall Appliance), which is the box that had gone bad, arrived by courier. The IT person installed it for me, tested it, and now things are working again.

I am writing this to show the processes I am currently using to deal with IT problems. My computer systems are very complicated, since they involve internal hardware and software, EMR software, and hardware/software managed by an outside agency (SSHA). I am better at dealing with this than at the beginning, but it is still stressful. In order to deal with potential non EMR computer problems, it helps to have:

-a person in the office responsible for low level issues
-an IT person to call in for more difficult problems
-if you have things belonging to an outside agency, have their helpline number and keep the identification number for their hardware (they will ask you for it)

To give you a picture of my office last Thursday, my new nurse was in, my resident was in, my secretary was training a high school student for evening work, and the IT person was working on the broken computer. It was a little crowded and chaotic. There was no way I could work on fixing the computer.


On another note, my group's preventive services project is now finished, and we have mailed letters to all patients who are overdue for paps, mammograms, and 18 months vaccines. It took the students two months to complete the audits for all nine of us, and to enter everything in the EMR. The total cost for the nine of us was $6,500: $4,500 for wages and $2,000 for printing, envelopes and stamps. We mailed 1,433 letters (out of a 12,000 patients roster in my group), so 12% of patients were overdue for one of those services. List maintenance and periodic mail-outs are going to be much easier now that we have the initial audit and computer entry done; our FHN admin person is going to look after this.


Plans are progressing for the big FHT office. A space planner came by my office: although about 15 t FHT physicians will be located there, each group will have their own individual practice space within the large office. Several of the FHT nurses, dieticians, social workers, as well as the FHT admin staff will be also be located there. I have been thinking about how I would like to work; my partner can't move to the big office since he's not part of the FHT, and isn't computerized. I think I would be happiest in a group practice, with two other colleagues. It is time for me to take on some new associates; I will be asking my FHN colleagues for permission to add two new physicians.

There will be no filing cabinets.

Michelle

Practice nurse

Things are progressing for the Family Health Team. We've hired a dietician and several practice nurses. The nurses have been coming to family practices to shadow us.

I have started working with a nurse for the past few days. It is an interesting experience for both of us, since I've never had a nurse in my office, and she comes from an emergency room background.

I asked our FHT physician advisor if I could have a copy of the nursing scope of practice. The advisor is one of my family practice colleagues who has worked for the ministry; he is also a FHT member, and is knowledgeable about these issues. It looks like a nurse can do most things, but can't prescribe.

When our new nurse came in, I registered her in the EMR, and set her Permissions as "Nurse". By default, she is not allowed to prescribe or bill.

I gave her my resident's Tablet, and logged her in. I would come into the exam room, and introduce her. As she shadowed me, she would load a patient's record on the Tablet, so she could see what I was doing as I was doing it. After a couple of days, she had a good idea of the structure of the record, where things are kept, how to access the CPP, how to do an encounter and how to load templates. Patients seemed comfortable with having her in.

Yesterday, she started seeing patients before I came in. The EMR logs who does what, so it keeps her notes under her name. She does not sign off encounters, but instead sends them to me with the heading "Nurse saw patient". I can then modify and complete the record, and sign it off.

The Fall will be hectic for me. I have been doing a part time Masters of Science at the University of Toronto as I'm very interested in the effects of EMR on medical practice and wanted some extra education on policy and research topics. This is my third and final year; I will be taking a course in biostatistics, which will keep me away from my office on Mondays from September to December. I have been trying to figure out how to schedule things so I can still cover my practice, and will be adding extra hours on Tuesday afternoons and some Wednesday mornings. However, I think this will not be enough.

The nurse may be able to help here. I am getting some idea of what she does, and I think she can triage many problems over the phone or through an office visit. I think we will schedule her in on Monday afternoons and Tuesday mornings. She can see patients Monday, and shedule a follow up for those needing to see me urgently (which may not be a majority) on the following day. Having worked in Emerg, she is very comfortable triaging patients who require emergent treatment. She cannot prescribe; if she thinks a prescription is needed (example, positive quick strep), we can collect the pharmacy's phone number and I will authorize the script when I return from my course in the late afternoon. My practice partner is present in the office on Mondays, but I don't want to burden him with this, as he has not joined the FHT and therefore would not benefit from having a nurse; however, he is still there for emergencies.

There are hotspots at the university, and I will also log-on Mondays at lunchtime. While logistically challenging, I think this will work, and is a good opportunity to try interprofessional care in an EMR primary care environment, and to see what roles the practice nurse can take.

My Master's thesis is on the Effect of EMRs on Preventive Services with Pay for Performance Incentives. I recently received some funding for this; I will study two cohorts, one using EMRs and the other one on paper records, to see whether the introduction of EMRs had an additional effect beyond P4P.

Michelle

of Time and EMRs

After almost a year and a half of using an EMR, I think it saves me time. There is no question that it saves a lot of administrative time for my staff: there is no pulling of charts, things don’t get misfiled, and accessing data is a lot faster when patients call for results. That is partially counter-balanced by the need to scan and file non-electronic data, but still accounts for net time-savings.

However, saving physician time is less obvious; I think the EMR can help to save time, but you have to organize yourself to do this. I was away for two weeks, with essentially no Internet access. When I returned, there were 52 labs, 26 Diagnostic Imaging reports, and 58 correspondence reports waiting for me. There were also 10 staff messages. I had budgeted time on the day before I came back to go through everything; it took about four hours to review all the reports, and to send appropriate messages for my staff. The time savings here happened because I was able to review the data by logging in from home instead of having to go to the office. Prior to EMR, I sometimes tried to do this while booking a full complement of patients on my first day back, which was inevitably a disaster.

I do not routinely finish recording patient encounters during or right after I see patients. Much of the numerical data (vital signs) is now entered by my staff before I see the patient. Some of the data, such as a note that a patient is in for a routine diabetic visit or a routine BP visit, is quickly entered using a drop down list as I start the encounter; the reason for that is that it takes only two clicks and does not interfere with the interview. I usually will not load a template, such as an Upper Respirator Infection, when I see the patient, because I don’t want to fill in this data instead of attending to my patient's needs; instead, I’ll use free text to write “URI x 2 days”. The free text reminds me to load and fill the template later. If there are significant abnormal findings, I’ll note those in free text. The templates are especially useful for noting normal findings. I’m not sure I save time; however, my records are more complete.

When I am finished seeing a patient, I’ll often go on to the next patient instead of completing the encounter. I don’t like to make my patients wait, so the visit takes precedence over record completion; I note the abnormal/significant results during or right after the encounter, and the rest waits. The alternative is booking fewer patients so I can finish recording encounters.

Because of this, I have routinely have uncompleted visits at the end of the day. I allot one hour to complete my records, return phone calls, review and file reports, and finish insurance or other forms. The difference with EMR is that I can leave for home if I’m tired and not finished by then, and I don’t lug charts home. I find that it is not as painful to finish completing charts after I have supper with my family. Prior to EMR, I had some charts left for completion for a couple of days (which I know is less than ideal); this no longer occurs. It is unusual for me to have a practice summary showing more than one or two tasks undone at the end of the day; most often, there are none; everything has been done.

The difference here with EMR is the ability to complete tasks more quickly, and to have fewer pending reports. My patients have commented on how fast we get forms back to them.

Electronic lab reports seem to come in overnight, mid-morning and mid afternoon. I’ll review them before I start my office, so that I can send a message to my staff if needed. I’ll review them again at lunch, and before I leave the office in the afternoon. Non-electronic reports get scanned in the afternoon, so I’ll review those at the end of the day. If it is a bit quieter, I’ll do that between patients. Time savings for me stem from the fact that lab results go automatically into flow sheets (no duplication), and from having the ability to look at trends easily. Actually reviewing reports takes the same amount of time; there are no EMR savings there.

Inter-office messaging is much more efficient. For non-urgent message, my staff writes an e-note which is automatically attached to the patient’s chart. A little “M” appears at the bottom of my screen to let me know I have pending messages. I check those periodically, and will often send a note back for my staff to call the patient. We also have pop-up messaging for instant communication, and my secretary can always knock on the exam room door if needed. This has led to quicker turn-around to return messages, and fewer phone calls in the evening for me, as the majority of messages can now be handled by my staff. In order to save time here, you and your staff have to use e-messaging consistently, and you have to work with and trust your staff to return messages appropriately.

I think the conclusion is that we have to work with our EMRs and figure out where they will save us time; this won’t happen by itself. One of the best ways to do this is to find out what our colleagues are doing; I am starting to see some forums for exchanging ideas, such as the new EMR Advisor on our provincial website, OntarioMD.

I can see that if I didn't work on my office procedures when the EMR came in, I was just in for endless frustration. Investing time up front to figure out how to do things better and faster with EMR is definitely worthwhile.

Michelle

Scanning

Scanning continues to be an issue in EMR offices. Electronic lab results have eliminated a great deal of scanning, but DI, consult notes, and various other non-electronic data from the outside (such as forms that patients bring in to be filled) still need to be integrated into the EMR.

In my office, we keep no paper data for patients; as a result, there are 10 to 15 things that need to be scanned in daily. Here is my scanning process:

I have stacked in-boxes beside my scanner. When something comes in, it gets put into one of three boxes: correspondence, DI or lab. Mail comes in the morning. My scanning tech then scans paper from each box to a folder on the PC's desktop called "files to upload"; everything is scanned into pdf format (that gives the clearest picture). She'll do one in-box at a time, and name the file using the patient's last name: example, smith.pdf. When all the in-box has been scanned to the folder, she'll upload all the files to the EMR, and then attach each one to the proper patient. I order things via the EMR, so if there is a consult/DI request pending, that gets matched to the file that was uploaded; the consult/DI then gets taken off my outstanding list (that's how I know a letter was received).

Once an in-box is uploaded and filed, the tech deletes all the files from the folder on the PC desktop. The physical paper gets moved to the lowest in-box, which we call "pending shred". All uploaded files now appear in my Practice summary page as "unfiled", and awaiting my review. At the end of the day, if I'm happy, I take the paper and put it in the "to shred" outbox.

If a file was attached to the wrong patient, I can see that when I load the file; I can take the physical paper from the "pending shred", and put it to re-scan. Alternatively, I can save the file to my desktop, and reattach to the correct patient; I can also print the file, and put it back in the in-box. There is a high level of redundancy to avoid misfiling. We can probably get rid of the "pending shred" box.

The scanning tech will add extra information when attaching the file to each area. For example, there are drop down lists in the Lab area, indicating whether this is an ECG, a histopath report, etc. She can also put in extra comments, such as "insurance form". When there is a "match" with a pending request, the specialist's name or the name of the DI facility automatically appears in the information area. It is a good idea to work with your scanning tech to make sure that the scan is done correctly, and that extra information that is helpful to you is added; things that are done at the front save you time.

We scan everything to pdf; we tried different file formats (jpg, tiff), and pdf was by far the best. I thought about whether to scan to OCR (optical character recognition) so that text was recognized from the outset, and decided against this. The reason for that was that I needed an exact copy of the form, since the original is shredded; OCR is not 100% accurate. If I need to copy part of a note to put into comments (such as the last paragraph in a consult letter), I will use OCR on my tablet. This leaves the original form unchanged. I bought Adobe Pro; I click Document, OCR. The same thing can be done using MS Document Imaging, which comes with MS Office. To use Imaging, load the document, then Print to MS Document Imaging. Use OCR (the little eye) on the resulting file, then copy and paste to comments.

Comments will give you a very quick overview of everything when you load an area in the chart.

Here is an example of a DI area:

Signed Off DI Reports

Date Collected Date Signed Off DI Facility

Dec 30, 2006 Jan 4, 2007 North York Diagno
comments : XR left ankle normal

May 15, 2006 May 18, 2006 Unknown
comments : XR right knee There is slight prominence of the tibia1 spines and there are osteophytes on the patella. The changes are in keeping with early osteoarthritis.


I know that all this seems like a complicated process, but it works, and now it is not even time consuming. It just takes some time to get used to, and to make sure that it goes smoothly. Working with your staff and your scanning tech really helps.

I think it may be helpful for a regulatory college like our College of Physicians and Surgeons to have a look at scanning. We need some ground rules on whether it is OK or not to OCR from the outset, or whether it is preferable to save an exact copy of the incoming material. Perhaps even some rules about acceptable file formats. There seems to be a lot of confusion about the right thing to do, and we need to have some guidance here.

Michelle

Group IT maintenance

Our IT person will be starting our group computer maintenance program this month. This means updating the anti-virus protection if needed, performing manual and utility-based cleaning of the registry, services, files and folders etc (that means making sure all those things work properly), enabling the proper security services, performing internal system checks for overheating and cleanliness (CPU, Hard drive, fans), and cleaning if needed (the insides of computers get dusty and need to be vacuumed sometimes).

He will come to each office to do that. I think it is much better to have a professional come by periodically, rather than leave it as ad hoc for each practice. We decided to pay for this out of group funds. As well, he will be available for each of us as needed (we have needed him several times already), and we pay for that individually.

Our group administrator has now done house calls for almost all the practices, leading to immediate results: scanning started, use of EMR for encounters, improvements in scheduling functions. You need to have someone go to each office to see what the issues are, and to fix them. Many of the issues do not involve IT, but rather changes in work flow processes.

The pharmacist has now scheduled more of my patients; she has seen some off site (with the data entered straight into the EMR), and some at my office. We have a joint appointment for a challenging patient later this month.

We have progress on the Family Health Team's Big Office, with several physicians indicating an interest in moving there; at least two FHNs will move in as a group. It looks increasingly likely that I will move as well. I have informed my partner, and will keep him up to date on the progress of negotiations; I have told my staff as well.

This will give me a chance to think about reconfiguring my office for the EMR. My current exam rooms are 10 ft x 8 ft, and I see no reason to change that; it works. The only difference in going from paper to EMR was that I put in a $50 small stand where the printer sits. There is no paper clutter on the desk, and I don't have all the reqs that used to take up space.

The big difference will be in the front office; that is where the majority of the paper metastasizes. The filing cabinets are there, and much of the paper shuffling happens there. There is now a lot less stuff sitting on the desk at the front; most of that is from my partner's practice. I also need less waiting room area, since patients wait less (flow is better). I don't really need to allocate any space to store handouts (pretty much all the useful ones are available on-line or scanned in); I think I will reduce the amount of space for samples, since I use those less. There will need to be 1 small area to store paper reqs in case of a black-out, that can probably be shared between several offices.

My current front office and waiting room is 16 x 20 ft (320 sq ft); my small lab is 9 x 9 (81 sq ft), for the autoclave and vitals area; each of two exam rooms are 80 sq feet; the consult room is 10 x 9 (90 sq feet). If I practice in a 2 physician "pod", we will need 580 sq feet for the lab, 4 exam rooms and 2 consult rooms. No space needed for chart storage; no front desk space for files: 250 sq feet for front/reception. Without corridor space, that is 830 sq feet. I will also need some room for closets etc. I estimate we could do with 1,000 to 1,100 sq feet for two physicians, with ample space left over. I have 1450 now.

Michelle

Fridge police

On Friday, the Fridge Police came by my office; these are the nice public health nurses who make sure that the fridge temperature is properly monitored, and within range (2 to 8 degrees), that none of the vaccines are out of date, and that vaccines are properly stored (not in the fridge door). It is important to make sure that the cold chain is preserved, so that vaccines are as effective as possible.

I can see why they are needed. However, this almost led to a disaster at my office. I was away at the cottage (no internet access) on Friday; my secretary was left to deal on her own with the unannounced visit. I use a data logger to record temperatures in my fridge. The logger is a little credit-card sized device; it sits inside the fridge and automatically records temperatures every 15 minutes. Once a week, my secretary sticks it in a cradle that is connected to a computer, and the data is downloaded to the PC. It generates both lists of temperatures and graphs; the minimum and maximum range (2 to 8 degrees) is indicated, and I can see that I am always in range. We also have a digital thermometer sitting on top of the fridge, so that the temperature is always visible when I take vaccines out.

The nurses were very upset with the fact that my secretaries were no longer handwriting minimum and maximum temperatures twice a day in a book; they threatened to impound my fridge for five days. My secretary pointed out that what we do far exceeds requirements, and that there is no opportunity to “cheat” (that is, record a false value if the temperature is out of range). She showed the nurses the graph on the computer. The problem was that the nurses had never seen a logger, and were not familiar with that technology. I am very happy to report that they decided to call their manager, who went over what I was doing, and stated that it was acceptable. My secretary got a little paper certificate stating that we’re OK.

This illustrates the issues that early adopters can face, despite the best intentions; you sometimes have to demonstrate and advocate for better workflows using IT. Public Health serves a very important role, but they seem to have particular difficulties with computerization. None of the public health lab reqs are computerizable (virology, HIV, prenatal), and they often involve obscure codes for lab requests. Because the reqs are paper-based, I cannot keep track of whether the result has come in. None of the results are sent electronically; they all have to be scanned in. There is no secure electronic access to public health labs. There seems to be no electronic way to report infectious diseases to public health; this has to be done by phone, slowly and laboriously: you have to spell the patient’s name, and personally give all their demographics. No wonder I cringe when I see a reportable illness; it's not the report, it's the process. Perhaps this could be integrated via the EMR, and sent via the secure SSHA email system, which hardly anyone is using right now. I don't mind emailing a copy of my temperatures on excel; that may lead to a reduction in unnecessary visits to my office to check my fridge.

On another note, I've installed secure access to the EMR on a computer in the doctor's lounge at my hospital, and in the physician's room on the Labour and Delivery floor (several physicians in my group deliver babies). That seems to be working well, but I have found that I can't easily log on from the lounge: doing this can develop an interest cluster of physicians and lots of questions.

Michelle

Progress

Data entry for the preventive services is proceeding; we receive stacks of paper with the date of last pap/mammogram/flu shot from the Ministry of Health, reflecting billing done for those services. The students have now transferred most of this paper-based data to the EMR. We have hired a medical student to audit charts with missing billing data; he will actually be able to do this remotely for some of the data, using the EMR; that will be done from my office. Searching for lab data (paps) is pretty simple; searching for mammograms is more difficult as not all practices are scanning yet, so mammograms won't be in the electronic charts. He'll do a first audit in the EMR, and will then visit each practice to audit paper charts for the rest of the services. The EMR audit should be a lot faster than the paper chart audit, but it will be interesting to compare the two.

Once those audits are completed, we'll be ready to send out the first reminder letters. Each physician in my group will need to review and agree to the format of their letter, and then our FHN admin will send those out for the entire group. There is no doubt in my mind that EMR-enabled group functions are now a reality, because I see them happening in front of me. The Pay-for-Performance incentives for preventive services were crucial to get this going; I think P4P may well be an important aspect of EMR implementation.

Our FHN IT person came by my office last Thursday. I showed him how my scanned handouts and reqs work: they are on the external hard drive at the front, which is shared across my network (any of my office computers can access them). I gave him a copy of my scanned handout/req folder on CD ROM, to use for any one else in my group who wishes to have them. I also have pop-up messaging for instant communication in the office, and he had a look at that. He has already installed a much faster and larger hard drive at one of my colleague's office.

Four of the nine of us are now routinely scanning to the EMR; a fifth one is just starting. The handwriting template I installed remotely on my colleague's EMR is now working, and he's now using EMR for encounters.

I think we have progress!

Michelle

The big office

Plans are progressing for our Family Health Team. We now have an executive director, and are in the process of hiring social workers, dieticians and nurses. There is much talk about having one big office, with about 10 to 15 family physicians and Allied Health professionals in one location, using the same EMR software. This is very different from what most of us are used to doing.

It will be interesting, because some of us will stay in our current offices, and some will relocate. The EMR will still work, because of its distributed nature. I think one advantage of having everyone in a central location will be the ability to schedule on-going training (and ad-hoc training as well). I have a feeling there will be a room with lots of computers somewhere in there.

The pharmacist saw my first patient (without me being there), using the EMR. I think it went OK; she entered the data as an encounter in the record, and scheduled a follow-up. The medication management will present more of a challenge; to be properly searchable, medications have to be entered in a structured manner, which makes things harder at the beginning than simply scrawling something on a prescription pad. When I discontinue a drug, I enter a reason; I can always see why the drug was stopped if I choose to look later on, but I learned how to do it, and where to search. I think I will need to sit down with the pharmacist and go over some examples of drug management (auto-filling information on new drugs; changing dosages; stopping a drug and replacing it with another; renewing medications quickly; managing drug expiry dates; entering reasons for discontinuation; drug interactions and allergy alerts; drugs and flowsheets). My resident, who uses the EMR on an on-going basis, is very adept at this, and may be able to help out. I can see the benefits of co-locating, because you can transfer what you know to others more efficiently if you go over things together.

I have now been told that I will be getting a computer to let patients book their own appointments in my waiting room on July 15th; I would still like to have on-line booking and on-line patient access to their records in the future. I saw an article in this week's New England Journal of Medicine that describes a clinic with "online appointment scheduling, electronic prescription refills, general messaging capabilities, and "Web visits" with physicians". It can be done; maybe it would be easier to do in a big office than in my small practice.

I actually tried to do an electronic prescription refill when my fax line went down several weeks ago (for a narcotic prescription for a patient with severe pain), and there was simply no way to get around the regulations. True electronic prescriptions do not exist here; we are obliged to print the EMR-generated prescription on paper, or to use fax/phone technology (who decided that fax/phone is better?). I would like to have a central, secure server, where I can transmit the prescription electronically. When the patient shows up at a pharmacy, they swipe a card and enter their pin number, and the prescription downloads to the pharmacy. I have trouble imagining a banking system where your checks get treated like my prescriptions do, with no central clearinghouse, and no oversight (except for government drugs for the elderly, which are covered by the Ontario Drug Benefit). Currently, I have no way of knowing if a prescription was filled, as the information cannot navigate back to my EMR. The best information is sold by pharmacies to a private company (IMS), which then sells summaries to pharmaceutical companies. I don't know why we consider this to be acceptable.

Michelle

EMR Enterprise: To Boldly Go.

The Enterprise function is now starting to pay dividends; I have been thinking about it for a while.

We have a FHN administrator, and an IT person for the group; there is now enough physician experience with the EMR in this group to fix most problems, and we have a central server in case we need access to different practices. You need all those pieces for things to happen.

Our administrator has started to make house calls to the different offices to see if she can troubleshoot and improve processes. She works part time at my office, and part time for the group; we discuss problems at lunch, so that helps us think about them. She took printouts of processes from my practice, to distribute them to my colleagues to use as they see fit. She spends a bit of time with staff in each practice, and works with them to see what can help.

For example, one practice is not using the scanner. They called the IT person, and it was properly connected to the PC before our admin came. However, software to scan to pdf files was missing; it came with the scanner, but was never installed. The IT person will install it, and the scanning process will be started. Our FHN admin also showed their staff person how to manage the rostering process on the computer, and how to use emessaging.

In another office, one of my colleagues would like to use the Tablet, but can't type. He asked the FHN admin if we could set up a handwriting program. I logged on to his practice remotely, and set up a template for him with vitals on top, and a drawing area for him to hand write on the bottom. His secretary called me, because the drawing area wasn't loading (it looks like an "x"). I know that this is because Java isn't installed on his machine, and I told his secretary that. She made a note; the IT person will be coming in a few days, and he'll install it, amongst other things.

We have hired students to go to each practice, and to enter all the rostering data. They are also updating the preventive services lists. Once this is finished, we can start mailing out reminder letters from a single location; the central mail-out will be ready for the next flu shot season, and we'll send out letters as a group. Each physician's letterhead will appear on top. I understand that the cost of doing this if you contract it out is $3000 per physician ($27,000 for the 9 of us per year). The cost to us of doing this in-house will be considerably less; in addition, we are getting a significant amount of help with the EMR for the funds. The $27,000 would be money well spent if we didn't have EMR, or couldn't organise ourselves; however, it does not make sense when compared to the cost of improving EMR processes. Spend money not on buying fish, but on learning how to fish.

I think that, once the EMR is going, it is very worthwhile to think of how to keep it moving forward. If there is no attention paid, some of us will likely abandon what we have already done; doing it half way is much tougher to sustain that just going back to paper--you don't know where things like your lab results are, your staff is still pulling lots of charts. There will likely be different ways of doing this for different groups. What I think will work in my group is:

1. a group administrator, to troubleshoot processes (preferably house calls at first)
2. a group IT person to troubleshoot IT hardware/non-EMR application software problems
3. a super-user physician as backup
4. remote access to the all the practices from a single log-on for group functions--the EMR enterprise part: one group, one server.

It may be easier to go forward in one big office, with all the physicians and staff located together. We don't have that in my group; like the majority of family physicians, we work in small, 1 or two physician practices. It is still possible to work as a group; I have outlined the steps we are now taking to do so.

I wonder if anyone would be interested in an "EMR implementation for Dummies" book.

Michelle

Managing change in my group

We had a FHN meeting on Tuesday to decide on further EMR implementation steps, as we continue to be at various stages in the process. The government has now started to provide a subsidy to hire a group administrator. We decided to hire one of my staff members, who is particularly adept at the EMR, to help us along.

As well, summer is a good time to get additional help, because of the availability of university and high school students. We have hired the first student to help with some data entry (finishing the roster lists; entering dates of preventive services). We decided to pay for the student out of group funds. Once the data is entered, our group administrator will manage functions such as mail-outs for drug recalls or problems, and on-going maintenance of our mailings for preventive services. The group administrator will also work with staff at the various offices to make sure that things like scanning or internal email are working smoothly.

We also agreed to use group funds to hire someone to do preventive computer maintenance; we have to decide exactly what that means. I think it probably means cleaning the computers (there seems to be a lot of dust accumulating in the back, where the fan is), making sure that the Windows updates are updated, making sure that the anti-virus system works. I found some information on this on the Microsoft website.


My lab sometimes makes mistakes and runs the wrong tests. I know this because I order labs in the EMR, and a copy of the req is automatically kept in the record. I see a Hepatitis A antibody coming in from the lab, and the req clearly shows I requested a Hep B antibody. I can't really order labs electronically; we use a copy of the Ontario lab form. This is printed and signed, and goes to the lab along with the test tubes. This means that someone has to manually enter test requests at the lab end, and it also means that there are data entry errors. Eventually, I would like to transmit orders electronically directly to the lab, or if this can't be done, have the order bar coded on the test tube. The risk of data entry errors is just too high with our current ordering system. I don't like the Ontario lab forms; having it means that the whole requisition is checked off as done when results come in. I think it would be better to have each test cross checked electronically, which means electronic lab ordering (and not an image of the current paper-based lab req on my EMR). I also need to have a pop-up on demand tell me which test tubes and how many test tubes I need, to avoid the lab return a message that a test tube wasn't sent and therefore a test was cancelled. I can't always remember that I need 1 grey top, two purple top and 1 tiger top test tubes when I draw blood. The system should help me, but it will need true electronic lab reqs to do this, not a replica of a paper-based system.

Michelle

Dealing with structural and mechanical failures

What a week! I returned to work on Tuesday after the long week-end, only to be greeted by a truly awful smell in my back closet. It turns out that a sewage pipe in the condominium building above my office had leaked. I have been worried about water leaks for a long time because we are at the bottom of a condo. My routers and SOFA (Small Office Firewall Appliance--the blue box that SSHA sends physicians) are located on a shelf in the closet. I don't think they'd appreciate being exposed to a load of crap.

We built a canopy above the equipment several months ago; this saved the day. The building manager sent a plumber and cleaners over pretty quickly. I guess it could have been worse; replacing all the routers would not have been easy. I could be up and running with my back-up internet line and VPN access pretty quickly; the problem would have been the SSHA equipment--it took a long time to arrive when we first ordered it. I wonder if they have expedited delivery for problems like this, where practice continuity is at stake.

My partner was away this week. I saw one of his patients and had to talk to him about further investigations. While talking, I had to flip through the pages to look for an old XR; I could not find it. I am getting used to the organization and speed of the EMR--dealing with a paper chart is becoming frustrating.

We also had a paper-side failure a bit over a month ago: our fax line went dead (I think my office is jinxed). It took Bell three days to come and fix it. Of course, all the XR reports and consult notes come by fax; I think of the fax as the main paper-side (or non-EMR) external communication conduit. One of the issues with fax is that people don't always look at the verification when they send something, to make sure that the fax went through successfully. We notified the hospital, but I'm sure we lost some data.

I order Diagnostic Imaging via the EMR, unless a proprietary form is required (example: MRI). The EMR tracks outstanding DIs. I had a look at those, to make sure that there was nothing that I was truly worried about. While I was at it, I put alerts in the charts of all patients with overdue DIs. A couple of patients have already told me they never went--mostly bone density XRs. I gave them a duplicate of the req. We called the hospital for 3 patients, and they faxed over the results; these would have been lost without EMR tracking.

We had another medication problem this week, for Avandia. I have four patients on this drug. I had a look at the original article, and our clinical pharmacist e-mailed some very helpful information and analysis to my group. I've reproduced the letter that went out to my patients below; I'm getting used to this process! As well, I installed the letter and set up the Avandia mailing list for one of my FHN colleagues in another office, remotely, so I know this can be done. We can think about managing this as a group, with a common letter and mailing, in the future.

Here is the letter:

Dear ....

I am writing you this letter because you have been prescribed a medication called Avandia (or Rosiglitazone) to lower your blood sugar.

A study reviewing the effect of Avandia has just been published; it found that patients taking this drug had a somewhat higher risk of having a heart attack than patients who were not taking the drug. About 4,700 patients would have to take this drug for 6 months to 4 years to cause one extra heart attack. The full study can be accessed at http://content.nejm.org/cgi/content/full/NEJMoa072761

Diseases of the heart and blood vessels are the commonest cause of serious illness and death in people with diabetes; preventing this is a very important part of your care. This is the reason why I prescribe aspirin, cholesterol medications and blood pressure medications.

Because of this report, I am asking you to make an appointment to see me to discuss this drug. Several other medications for blood sugar have been found to be safer; I would like to review your medications with you.

EMR in the waiting room

I have been talking with OntarioMD and my EMR company about establishing on-line patient access to the chart and to my scheduler. Because our server is hosted at the hospital, there are additional security layers. Allowing and managing access is going to be very complicated; there are several organizations involved. I think this is something that may have to wait a bit.

I was told by my EMR company that giving patients access to the scheduler in my waiting room does not present the same logistic problems, and could be done fairly easily. This would be a simple scheduler, with booked spaces greyed out and available spaces blank.

When I look at flow in my office, I often see a little traffic jam at the front. My secretary is busy on the phone, and patients are waiting to book their next appointment. When they book, they can't see my scheduler, and it usually involves some negotiations because my secretary does not know the patient's timetable. Many people book airline flights on line; I don't think booking a medical appointment is going to be all that complicated. If it is done in the office, my staff can help as well.

The EMR company will lend me a PC, and will also give me a one pager for patients. I will put the PC in my waiting room, with the monitor visible to the secretary and to the patient. I will need a pad of paper and some golf pencils so people can write down their appointments. There will need to be some type of patient registration before they can use the scheduler; I'm not sure how that will work yet. We'll try it out and see if it works, sometimes in June. I don't know if there are other offices allowing patient self-booking in the waiting room.

In the future, maybe I can use my waiting room for something more interesting than waiting. Maybe patients can self-check in with a card swipe, and verify their information. If I need a patient to fill out a form (example, a Benign Prostate Hypertrophy questionnaire to see how things are, or a PHQ-9 questionnaire for depression), maybe that can be programmed to pop up when the patient checks in. They can go to another PC in a more private area, and fill that out. Perhaps I could have pre-programmed health information for their health condition for them to look at while they wait. This would also be really good for research; you could have questionnaires administered in the waiting room.

There has been some talk of having several FHT physicians all move to a big office, together with several of the Allied Health Professionals we'll be hiring. I think this type of set-up would work better in a big office.


We have a FHN meeting on May 29th. Several of my colleagues have experienced the same type of hardware/software issues that I have, which involve computers rather than the EMR software itself; at one office, the cleaners accessed the internet at night, and introduced a virus on a PC. We are looking at hiring someone to serve as a "Geek squad", to be on call for these type of issues, and to make sure the computers are properly maintained. We can use group funds for this, but I'm not sure what it will cost; we are going to get a quote.

I have been asked if I get paid by the EMR company for things like giving a tour of my office to colleagues, or for articles that have been published in the press. I talked to them about this pretty early on. I think it is reasonable for people to get paid for their time; what I decided to do instead is to have them deposit the money in a "research fund". I can think of several colleagues who have really good ideas; the fund will not be large enough to support a big research project, but perhaps it can supply a bit of seed money when required--sort of like planting for the future.

Michelle

Having an IT administrator

Managing my office IT continues to require my time. One of my UPS (Uninterruptible Power Supply) devices failed. The computer crashed.

I called the company, and it turns out that the UPS device I bought can only handle one PC, and I had two PCs at the front connected to it. The voltage was too high. They sent me another UPS, and I connected it to the second PC; it works now. I phoned the company to pay for the second unit, but they won't accept that. I have to ship the other unit back, and then reorder a new unit. That makes no sense to me; I am not a travel agent for UPS devices. I'll just wait a bit and see if the company gets upset at me and allows me to pay for the second unit.

I have a bank branch downstairs at work. I wonder whose responsibility it is to deal with this type of issue there; I would bet that it is not the bank manager's. They also seem to have a huge amount of redundancy, certainly more than what I have. They probably have some very good remote IT support; do they have some in-branch support?

We probably need to think about the minimum level of redundancy in each practice; I have written about this before. Maybe we should have one admin person in each group (FHG, FHN, FHT) whose job it is to become familiar with each practice's IT set-up, and to deal with minor but annoying problems. These problems can become major very quickly if they are not dealt with; the physician is often the IT troubleshooter by default, but I don't think we are the best person for this. It would be good to have the IT administrator monitor each PC periodically to make sure that Windows updates are up to date, and that anti-virus programs are working and are scanning periodically. Computers should be restarted periodically. We were told to install IE 7 on every PC, which has not been done at my office. We should probably have the IT person develop some policies about routine PC maintenance.

I am looking at having a PC in the waiting room to let patients book their own appointments. I've noticed that this is a source of back-ups at the front; my secretary is on the phone, and patients are waiting to book their next appointments. The secretary does not know what time is good for the patient, and the patient can't see my schedule and does not know what times are available. This does not seem like the best booking method.

I've found out how to generate some numbers for my practice. I can generate clinical reports in html format, but this just gives me lists of patients (and not how many patients have a condition). I save these reports, and then open them up in Excel. I then use Data, Sort, and it gives me a number. For example:

All active pts in my practice age 20 and over: 987
code 278 (obesity): 226 pts (I code all BMIs of 30 and over as 278)
250 (diabetes): 95 pts
250 AND 278: 43

9.6% of my pts are diabetic
23% are obese
45% of diabetics are obese

Diabetics in my practice are more likely to be obese than non-diabetics.

Michelle