EMR housecall

I have now done the first two “EMR housecalls”.

At the first office, I could see that the Tablet was running out of power very quickly. Rechargeable batteries do not last forever; after a year and a half or so, they no longer hold their charge. My colleague has a spare battery, and I asked her to put it in and charge it overnight. I think this must be a common problem for my FHN, as we all bought Tablets at the same time; we have an upcoming FHN meeting, and I will mention this.

My colleague was interested in starting to use the EMR-based lab requisitions. I asked her to tick off what she normally would do at a complete check-up and a check-up for diabetes, and installed those as “lab favourites” while she went to see a patient. When she was between patients, we tested this; I also showed her where the pending lab reqs are kept; sometimes a patient loses the req, and the secretary can print an extra one. This seemed to be a common problem at her office, and the secretary was especially happy to find out how to reprint. I also showed my colleague how the system indicates that lab tests were ordered, as part of the encounter. I showed her how to do her own favourite reqs, and we did one for Fecal Occult Blood testing (a common req due to our new provincial colon cancer program). I configured Diagnostic Imaging reqs for her, and she will now start ordering these electronically.

She wasn’t sure of how to add a patient’s health care number to consultation requests. This was causing difficulties, as her secretary had to enter those manually; I put it in her letter templates and printed an example for her. She was happy with that.

Her scanning system is the same as mine; our FHN admin had shown her secretary what our processes were. I showed her how to use MS Document Imaging to quickly copy a part of the scanned pdf document, then paste it into comments. She practiced this, and I wrote it down for her; it will save her a lot of time.

I installed a shared (networked) folder on the front computer, and made sure it was accessible from the Tablet and from the back computer. I have copied all my handouts and scanned requisitions on a CD, and will give those to her at our upcoming FHN meeting. Her secretary will copy it to the shared folder, so that they can both access it from anywhere.

At the second office, we went over things with three colleagues during lunch. They had thought carefully about what was bothering them. We went over “preferences”, which is where you set how you want the system to work for you. For example, I showed them how to default all the currently active medications in the encounter; this makes it very easy and fast to prescribe, requiring only checking the tick-box, then “Sign and Print”. I also showed them how the system handles “active” and “inactive” medications: there is an “expire by” area on the top of the prescription. My long term prescriptions all have “expire by 1 year”, so they don’t drop off the active list. For short term prescriptions, such as antibiotics or skin creams, the expire by is 1 week (these expiry dates are all saved in favourites, so that I don’t have to remember them). The short term drugs stay in the CPP and show up in new encounters for 1 week and then they’re off. I showed my colleagues additional places where expired medications are kept, as well as rapid methods to remove drugs from the active list. We also went over tricks in prescriptions, such as how to prescribe glucometer strips using three keystrokes.

My colleagues were not sure of how to do sick notes; I showed them how to do a template for letters, and we put a sick note template in. We practiced doing one together on a test patient, which is very simple once the template is in; there is a copy of the note kept in the system. They are now comfortable writing sick notes and letters for massage therapy very quickly. I also suggested that they print the notes at the front desk, so that payment could be managed by the secretary; we put a footer regarding payment at the bottom of the note template.

They use desktop computers, and there is very little desk space in the exam rooms because of the keyboard. I suggested buying some plastic sleeves that could be attached to the walls, some of the paper on the desk can be stored there; as well, a couple of clipboards can be placed in the top sleeve, and these can be used to hold papers to sign prescriptions, or to discuss handouts. There are no printers in the exam rooms, so they walk a lot. Installing a small printer in each room may work; there is space for that.

I think there was considerable enthusiasm by the end of lunch; they had lots of ideas and thoughts about how to improve EMR processes. I was impressed by their rapid grasp of new ideas and their willingness to implement new things.

One of the physicians emailed me with an idea: we could have meetings at the hospital to learn how to better use the EMR. We could use a projector tied to a laptop; one physician would act as a facilitator. Each physician would bring their own laptop and would log on to their own EMR application to try things out.

I think this may work; in fact, I was at a conference for my University Department on Friday. At lunch, a colleague who is using another EMR told me that her group of 22 physicians does exactly that: they hold monthly “EMR learning” meetings, and use exactly the same process. It has helped them a lot. EMR companies do not really offer much broad-based ongoing training, and we really need that.

At the departmental meeting, a physician who had come to visit my office with his whole office team a few months ago came by to say hello. He told me that things were running much more smoothly for him and that he was much happier. It was the processes we outlined that made the difference, although he was the one responsible for implementing them. He was now paperless, and ready to send all his paper charts to the basement.

I think that this type of individualized physician to physician dialogue on EMR is helpful. There is no one better able to say what works and what doesn’t than a physician in his or her own practice. Having a peer who has solved many of the same problems do an EMR housecall is valuable because it adds an extra pair of informed eyes and ears. I don’t expect that everything I suggest will be done; I think each practice is best placed to choose what they would like to implement, when and how. I was asked to do a follow-up housecall in a few months; the problem for me will be managing my time. I just don’t know if there are enough of us around to do this on a wide scale; however, I can see that even a couple of hours will help: each housecall took 1.5 hours.

My practice partner has now chosen May 5^th as his EMR start date. Two students are coming by next Thursday morning: they will start entering his CPPs for him. I will give them a bit of training and supervision for the first few entries. My office staff is now booking him very lightly for the month of May; it is important to do that, because he will be much slower at the beginning.

Michelle

Giving back

I will be giving a seminar at our national family medicine convention (Family Medicine Forum) in Toronto, this November. I put a submission together with my colleague, Dr Stephen McLaren, on "Electronic Medical Records: the first year of computerization". We have invited a Practice Management Consultant from OntarioMD as an additional resource. It should be fun and interesting; we'll really concentrate on the practical aspects of implementation.

I have now just finished my last class of my MSc; I am writing my thesis, much of which is about the transition to EMR. The last course was Thursday mornings, from 9 am to 12 noon; what I have done is left that time slot open for a couple of months. I think I will use the time to put what I have learned --through day to day implementation as well as from my courses-- into practice and give something back to my community: I will go visit some of my colleagues at their office. We have this new Peer to Peer program from Health Infoway, it says that we can offer support on-site; perhaps some of this can fit the PtoP program. I'll see if I can fill my dance card.


My practice partner works at the hospital today. I configured access to the EMR in the doctor's room, on the floor where he works; he told my secretary yesterday that he will be looking at his lab results remotely. He no longer has to call her for results on Fridays. He is now comfortable using our e-messaging system, and is also assigning tasks electronically; he told me that all his INRs are now managed via electronic flow sheets. I printed and gave him my list of medication favourites; he ticked off drugs that he uses often. I entered those in for him, which will give him a head start on prescribing. We practiced entering medications in the CPP, and did a prescription together.

He is approaching the transition with an open mind, and trying things out. He knows that the EMR is not perfect (not even close), but he is also aware of the significant advantages it has over paper records. I think that this is a very sound and very realistic attitude to take. He does have more support than most of my colleagues who are adopting EMRs; I hope that over time, what I am describing will be the norm rather than the exception.


We continue to have issues with medications. For example, a new study showed that one of the cholesterol medications we use (Ezetrol, or ezetimibe) may not be effective: it lowers cholesterol, but may not prevent heart disease. The study may or may not apply to my patients: a search of my EMR today shows me that two patients are taking the drug. I have asked our FHT clinical pharmacist to review the information, and to log in and see if it applies to my patients. She will also prepare a summary for me. I will review that, and draft a letter. Her summary will also be forwarded to my FHN colleagues; thanks to our experience with preventive services, we are familiar with the process of mailing information to patients as a FHN, and not just individually. We will then decide whether such a mailing is needed. We can accomplish far more as a group than individually.

Michelle

Uncertainty principle

We will be coming to the end of our EMR contract in early 2009. Most contracts in Ontario are signed for three years, because that is how long the subsidy lasts.

Now we have to decide what to do next. Our main options are to stay Local (server at the hospital), or to go ASP (server hosted at the big SSHA box). It is a difficult decision.

We were one of the first large local installations, with 18 physicians at multiple sites, all managed from a single server at the hospital; we own the server. This freed us from having to deal with lab downloads, backup issues, upgrade installation, and all the other server management problems. On the other hand, our server went down recently, and it was not clear who needed to reboot it (the hospital's IT department? The EMR company?) This led to a delay in rebooting the machine, and a loss of service; remote hosting is not without its problems. We are now growing, with additional physicians joining our FHN, as well as all the new Allied Health Professionals. While our server is still adequate to meet our needs, we don't know how long that will last.

Going to ASP (Application Service Provider) would mean moving our data to a fully managed server; the company owns the server, and we just rent space on it. There would be many more physicians also using the same server, so all upgrades happen at once to everyone, and problems are dealt with (or not dealt with) for many of us. We do not know if we can move our data safely to this new server. As well, it may be better for our FHT if all of us were in one large application, so we can share templates and information; I do not know if that is possible.

Because the problem is complicated, we have formed a committee to look into it. Committees are sometimes good: they spread the work (and the blame if needed) around. We'll be looking at the pros and cons of each alternative; just like when choosing EMR software, there are no perfect solutions.


After two years, I think my group has done pretty well. There are now 10 of us in my FHN (and my partner is about to start). We are now at 50% paperless, 40% partial (both paper and EMR), and 10% never started. It is very difficult to come by figures for the "average" implementation; it seems to me that partial implementation is the norm. The National Physician survey shows more family physicians on both paper and EMR (19.4%) than physicians who are paperless (12.3%). It seems to me that about 25% fail to implement, 50% have partial implementation, and 25% are paperless; that is the sense that I am getting from what I have read.

One thing that worries me is what happens when funding stops. For those who never implemented, this is not an issue, they will simply drop the EMR and only pay for billing/scheduling. The physicians who are paperless will not go back to paper. It is those in the middle, who are progressing more slowly, who are at risk; if there is no funding, I think some will abandon the EMR. It seems to me that this may still be a majority of physicians once funding stops.

More uncertainty for us; I thought we were finished with that once we bought the software, but it was just the beginning.

Michelle

First fruits of the FHT

In my Family Health Team, we are starting to talk about quality of care, and using EMRs to effectively improve care. We have two EMR systems, and perhaps we should switch to one; there is no consensus on this subject as of yet. It is quite apparent now to several of us that the systems are not fundamentally different, and that it is how we use them that makes the difference.

Here are some axioms of EMR implementation that we have developed:

Axiom 1: EMR implementation is far more dependent on us (our Communities of Care) than on the EMR software.

Axiom 2: Improving our care depends on changing our processes to take advantage of the EMR.

Axiom 3: We can accomplish far more as a group than individually.

We have been talking about how to improve our chronic disease management as a group. We are looking at using more flowsheets, reminders, and audits within our practices. All these are certainly possible with EMR systems, but often they are not used; for example, in the Annals of Family Medicine, Closson found that "The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality."

I also think it would be good for us to decide on what kind of diabetic program we would like; for example, we can have a Nurse practitioner do electronic audits, and follow up with patients who have not shown for their appointments, or who are not at goal for their blood pressures or blood sugars. We can develop and use good processes; we can work as a group. I am seeing inklings of this in recent emails.

It is interesting for me to reflect on my group's experience with managing our preventive services. We decided that we were going to use the EMR in a common way for those services across practices (click on the "done" button to indicate that the service was provided). We have one of my staff members as a Project Manager; she is responsible for following up with rostering, and regular mailings to patients. We agreed on the initial processes for entering the information (hire students for data entry over the summer). It took discussion, collaboration, consensus, and on-going work for it to happen. The result is a well-organized program, with tracking and consistent reminders being sent to our patients; in other words, better quality of care. The EMR enabled this, but it was the "human factor" (us) that made it happen, see Axioms 1, 2 and 3. I have talked with colleagues using the same software application, as well as other software applications, and this has often not happened in other practices.

The EMR is a major change; in my Knowledge Translation course, a student put this quote up: "change does not necessarily lead to improvement, but improvement is impossible without change."

We have also started talking about how to code our encounters consistently, to enable future searching for conditions across practices. If we can develop a system that we can agree on, we may then be able to build up a very good picture of what our community's health is like. There is a lot of brain power in this FHT.


My Knowledge Translation course is almost finished; it has been interesting, because so many of the concepts reflect what has happened in my own practice and in my FHN. Much of what we learn and decide to do and change is dependent on what things are like in our own practice, and on discussions with our peers and others (context, facilitation). I would like to start visiting some of my local colleagues at their offices, and see if we can try to figure out together how to do things better with the EMR; a sort of "practical Knowledge Translation" put into action. I'll have to figure out a way to do that.

Michelle

Wag the dog: of forms and cookies

I am not the only one who thinks these proprietary forms are simply bad care. Here is what a colleague in my on-line EMR support group said:

"I hate the multiple forms we have to use and I have dutifully filled out the exact forms they wanted to make the clerks' lives easier. I now take the stand that if I can increase the completeness of my record and as long as all the clinical info is there I will use the form of my choice and it is up them to convince me otherwise.

However when I talk to them I am very nice and it is amazing what a bribe of cookies can do :) "

I think that perhaps we should form an alliance, and collectively refuse to send or receive proprietary forms. After all, the EMR based forms are typed, are legible, and contain all the needed information. Bring on the cookies!

I am now generating my pap reqs from the EMR; we attach the paper based req on the front, with no information other than the label. The proprietary req says "see attached"; the real information is on the EMR req. I wonder what would happen if we forget the patient label. My public health reqs are now generated from the EMR, which stores the appropriate code; a paper req is clipped to the front, with "see attached".


My practice partner has now decided that he would like a Tablet, so we've ordered one for him. We've also ordered 3 network printers, one for his consult room and one for each of his exam rooms. The total hardware cost to equip a new physician is about $3,500, far less than what it costs to start.

He likes the electronic labs; this is one of the best parts of the EMR. Our community-based labs really have it right; the reports are unbelievably fast and efficient. I probably shouldn't complain so much about pap reqs; I think I'll send my lab a box of cookies, they deserve it. My partner started using the flow sheet for his INRs on the first day; our secretary showed me a message from him to call the patient about the result. He now knows how to use the e-messages and task lists. Paper-based INR sheets are gone as of now.

He seems intrigued by templates; I showed him how to use a Rourke well baby template, and how the EMR remembers the lot number and expiry dates for immunizations. I also showed him how an assessment in the encounter can be simultaneously placed in the CPP, the "write it once, have it go three places" principle of EMR. I will be away for March break next week, and I am hoping he will find some time to play with this. He does some in-patient care at the hospital; there is access to the EMR in the doctors' lounge, and I told him that it would be pretty easy to have it on the floor where he works. He can log on to see his office lab results, and won't have to call our secretary anymore.


I am starting to find more ways to look at my data. For example, there is a place in the EMR that tracks my referrals. In the past 30 days, I've made 8 referrals to social work, 5 referrals to dietitians and 2 to our clinical pharmacist. The total is 15 referrals within the Family Health Team. These represent new things for our health care system, as they would not have existed prior to the FHT. Remote access to our EMR for our FHT Allied Health Professionals has just been enabled, so those referrals will soon start to be generated and recorded within the common e-Chart.

As far as specialist referrals, the most common is Derm, with 6 referrals. Total number of referrals (specialists, programs and allied health): 60 in the past 30 days. 15 / 60, or 25% are within the FHT. This 25% represents the beginning of an integrated system.

Michelle

Helping my practice partner start the transition

My partner has been away in the past week. I had a look at his computer, and made sure that he has access to all the scanned documents on the front computer. These now include all the requisitions for programs at our hospital, and all the documents that I had previously scanned.

As well, I configured things for him within the EMR software. He has access to all the handouts, to outside links for patient education, to pre-made DI requisitions, and to ready-made consult requests. Many of those things (such as our phone book) can be shared, but some cannot. It took me about an hour to organize this, and I consider it time well spent; this work will ease his transition. We sent an email to notify the labs this morning, and the first electronic results already came in this afternoon. Things move much more quickly now than they did when I started. As of today, my partner has hybrid charts; he will need to decide how quickly he moves to fully electronic--that is where the biggest gains are.

I think I will put in some medications favourites for him; I have a list of drugs that I commonly use, and I will ask him to pick some. Maybe I will sit with him periodically at lunch, and we'll have a look at things together.

I sent him an e-message while he was away, and made a dummy chart for him to practice on. The flow sheets are programmed and are ready for him to use; I have a pretty good selection of useful templates as well. I have profiles and billing short cuts that are ready to use.

Setting all this up made me think about how much I now know about EMR, and how much work I did. When you first start, most of this is just not in the application; it can't be, since practices differ, and different physicians use different diagnostic facilities, have different referral patterns etc. I had to put in things at the beginning without really knowing how the software works. In retrospect, it was actually easier for me to start by myself, and to have a hybrid practice for a while. The new physician who joined me helped me to work out the bugs of having several physicians in the office on EMR instead of just one. She now requires no assistance from me, and is using many of the advanced features of the EMR, after only three months. I think things actually worked out well.

My secretary has started scanning in the paper charts for my partner's deceased patients. These are going into the networked hard drive at the front, same as mine. We have made new folders for his patients. He had a look at several charts from his computer, and I think he was happy with the excellent quality of the scans. We showed him how to use the "pages" tab on the left side of the pdf file (this produces thumbnail pictures) to quickly find what he is looking for. We have started shredding the paper charts that have been scanned in.

He now has a lot of work to do; all his CPPs will need to be entered in. I think he is considering hiring a student to do part of this work, which is not a bad idea. I will talk to him about coding his ongoing medical conditions in the paper CPP; he can enter the ICD code besides each condition, and that will help the student with accuracy. He will need to review each CPP that was entered.

There is still some uncertainty about when we move to the big office; I think this will most likely be in late Fall. It will be tight for him to complete the transition before the move; I have not allocated any space for paper chart storage. Starting now is not too early.

Michelle

EMR for the non-believer

My practice partner will be implementing the EMR. This is not because he strongly believes that it will make a difference. He is doing it because EMR comes as part of a package: we have decided to continue practicing together; he is joining my FHN; he will be joining the FHT; he wants to move with us to the big office. EMR comes as part and parcel of all of those, and the benefits to him of going in this direction outweigh the risks of staying put. This is called "relative advantage", and I think this calculation is increasingly tilting in favour of Electronic Records.

I do not think that doing this type of calculation makes you a "bad" physician, or an "IT laggard". I think it is a realistic assessment for many of my colleagues, given the initial difficulties with implementing EMR. I also think that it is up to our health care system to help us; EMR subsidies are important. Other possible rewards are giving incentives for quality of care (such as the preventive care incentives in Ontario) that are easier to track and measure through EMR. I would like to see more of this; these incentives will drive the programming of EMR systems towards making sure that we can measure and improve what we do. This programming is still in its infancy.

Another very important aspect is making sure that we are connected: reduce the amount of scanning due to non-EMR data, help to ensure that other parts of the system accept EMR generated forms. This is not something that can come from physicians, it must come from the top (leadership). If a private Diagnostic Imaging facility can send me reports directly into my EMR, I am more likely to refer there. I wonder at which point competition will come into play; I would prefer to remain within the public system, but will use private facilities if their care is better because they are connected.

What I am trying to say is that there is a very important role for government, and for policy-makers. There is a role for incentives that favour adoption at the same time as quality of care; we also need policies that promote effective and efficient information transfer, instead of the current status-quo of outdated forms and processes.

I just went to a conference on the management of mental health issues, which I attend annually. At the conference, several of my colleagues told me that they were about to adopt an EMR, or were in the early transition; this is a change from a year ago. A physician who started using an EMR two months ago told me that his staff are unhappy, and that it is hard for him because everything is taking so much longer. He had a realistic assessment of this, however, and told me that he knew the early slogging was tough, and that things would get better; he wasn't giving up. EMR even came up in one of the small group meetings (these are run by a psychiatrist and a GP psychotherapist); a family physician said that prescribing some of the complex psychiatric drugs was now better because of the automatic interaction and allergy checking. I do not think that the GP psychotherapists are adopting these systems; these physicians restrict their practice to talk therapy, and I cannot see EMRs as having a relative advantage for them. There will likely be corners of the medical system with late or non-adoption; however, these will run the risk of being disconnected from an increasingly inter-connected system.

Michelle

On-line Support group

I have an on-line support group for my EMR. We have about 70 members; some are more active, some less. There is also an area where you can post useful files, such as an excel gestational calculator template, or examples of EMR processes. The support group is monitored by the company, and sometimes we have replies or comments from them. When someone posts an entry, I get a copy by email; there are anywhere between ten and 50 entries or so per month, so it is not overwhelming.

Occasionally, a new user posts a question, and the replies have been very helpful and generous. I have noticed recently that comments are switching towards data extraction: my colleagues are asking for more Reports (procedures, labs, social history); we are talking about how to enter data in the EMR so that we can get good quality information on our practices. It seems to me that we are now starting to head into "phase II", which is the interesting part of EMR implementation: there is enough data in that we are now thinking about getting data out.

In my own group, I have noticed more clinical queries (or Reports); we can share queries as a group, so you see who programs and runs queries. Some of my colleagues re-use my queries for their own patients (and I am happy to see this happening); there are also new queries being done. I think our coding is becoming better in the second year of implementation; we are now used to entering the ICD diagnostic code routinely for every encounter, and this is no longer an issue. The payback is being able to search for diagnoses consistently. What this means is better data quality in the charts.


My new partner was asking me how to do a referral for audiology; I set this up for her, and showed her how to generate the request as part of the encounter. She told me that most lab/DI/allied health requisitions at her previous office were still done on paper pads. This is rare here; we use EMR reqs whenever possible, or scanned reqs if we have to. I do not think physicians are wedded to paper forms; I see my new partner using EMR forms, because these have been set up in the system. The work for EMR is all upfront: do it once to set it up, re-use it forever. For paper forms, there is no set-up; the work is all back-loaded and on-going: store and find the forms, stamp them with your name, write the patient's name on the form, or send to the front to label. I prefer EMR.

My new partner is not familiar with our local specialists, so I asked her how she was referring. She uses our EMR phone book. We have two phone books: one local (just for my practice), and one shared with all my FHN colleagues at any of our seven locations; I don't use the local one. In our shared phone book, information on the specialist's referral preferences (fax then patient phones, etc) is entered in Notes, and is shared with everyone; there is also a field where you indicate specialty. My new partner told me that she just searches for the specialty, and sees who we refer to. This is a good way to use aggregate information collected by the group; it made me realize that we now have a fairly extensive phone book. The information is used in referral letters as well as on the electronic lab reqs (the address of the specialist we are cc-ing to automatically appears on the req). I have access to a provincial database of physicians in the EMR, but our local phone book is better, because it is more up to date and has extra information.

My current practice partner has now decided that he is going go EMR. I have started showing him some of the really cool things in the system, as he starts to prepare for his transition. He will need to decide whether he prefers desktop or wireless, so I have asked him to try using the resident's Tablet so he can get an idea of both set-ups. We will need to figure out how to make the transition as easy for him as possible; I have printed a list of my medication favourites, and have asked him to pick out some of his commonest prescriptions. I will enter those for him, so he can see how it is done, and can start prescribing. We'll get lab and DI favourites set up for him. I expect that it will be harder for him than it was for our younger colleague; I have a fair idea now of what the likely start-up issues are, and having EMR processes already in place will help.

As for me, my encounters now start with a look at my reminders, the vitals are pre-entered by my wonderful staff, and the on-going meds are already all pending in the encounter, just waiting for a click and signature. I have access to the vast resources of the Internet at a click. One of my patients needed a referral to an addiction centre near him; I googled DART. We were both looking at the site on my Tablet, and decided together which centre he would be referred to. I think that the EMR helps me to be a better physician, and I like that.

Michelle

Snow storm

The weather is just awful today, so I am working at home. My labs all came in at 9:30 am. An INR is slightly abnormal, so I've just sent a note for my secretary to call the patient and adjust his coumadin dose. She can log in remotely from home if she cannot make it to the office.

My husband is working in our home office as well. He is accessing his office via VPN, as I am. His large database is in Cleveland, but the results for queries are near instantaneous. I guess many large companies are functioning via remote access (the common database is somewhere else), but they have made sure that the pipeline is big enough. We still have a long way to go with SSHA; I heard that there were outages last week in several locations on Ontario, making it impossible for practices to access medical records. I think this would be unacceptable in a business environment (my husband's multinational company could not function); I really don't see why this is acceptable in a medical environment, with people's health at stake. We have been promised good access at the new clinic; we'll have to see if SSHA does come through.

A blood sugar just came in as elevated for another patient, confirming a new diagnosis of diabetes. I've just called the patient to let her know. This lady has other serious health issues, as well as limited English and literacy; I had recently asked our FHT RN Case Manager to see her. The RN Case Manager does not have access to the EMR yet; the referrals are done by fax. I've just notified the Nurse of the lab results by email, without using the patient's name: "recently referred pt -initials- has new dx DM II". Once the RN has access, I will e-message her within the EMR, which is much better. I will probably need to send her an email to let her know that she has a message in the EMR.

It is taking a while to establish all the EMR connections within our team. Each FHN requires its own log-in, and there are two different EMRs to learn. All together, it is complex. I would like it done yesterday, as the benefits are so glaringly obvious, but I know I have to have some patience. We have a bit of IT support for the FHT, but it is limited at present; I am worried about what will happen when all of us move into the big office--will we have enough support to run all these machines and software? I can run my office as our FHN has its own IT person, but I don't know what will happen to the rest of the group. We probably should really start thinking about coordinated IT support.

My resident is now talking about joining me after graduation; I know of several young physicians who have joined EMR/FHN practices recently. I think the current primary care environment is much more attractive for new physicians.

My new partner is functioning well in the EMR environment. After a month and a half, we have worked out most of the initial bugs, and she now has remote access.

She is getting a fair number of old charts from her previous practice: we scan those to the networked external hard drive (I have made a folder for her) after she has seen them. Some of her old charts arrived on CD; we simply drag the file to the external hard drive; the patient can have the CD back immediately if they wish, as the process takes next to no time.

She is getting some lab/DI reports for patients who are not registered in her new practice at my office; we don't know if these patients will transfer here. Rather than starting a new chart, we scan those to a folder; if the patient does come in, we start an electronic record, and the files are then uploaded to the EMR.

She told me that scanning was very slow in her previous office; up to 3 months. It made it very difficult at times to know where results were (on loose paper waiting to scan? in a paper chart? attached to the electronic file?) leading to a lot of wasted time. The reason for the slowness was that scanning was only done in the evening, and the clerk did not have enough time to do everything. This does not work; in my office, scanning takes 1 day, or at the most two. It is really worthwhile investing in a good, fast scanner, and making sure that you have enough personnel to do it properly.

My practice partner is actually talking about converting to EMR! He can't type (using 2 fingers), which will present a problem. I think what would work for him is dictation:

Subjective/Objective
Favorite Notes:

The Subjective/Objective part can be dictated (dragon dictate, other). The Vitals are now often entered ahead of time by my staff. If not, these don't take long to put in.

The medications should be typed in. However, once his list of favourite meds is done, it will only take a few keystrokes to enter, as the rest is auto-filled:

Drug Name
amoxicillin 500 mg Refill: 0 Direction: Take 1 Tab(s) PO TID for 10 Day(s);

The Assessment requires typing the 3 ICD-9 digits (if you know them), or a couple of keystrokes to get the drop down list:

Assessments

---

ICD - Description	Status	Comments	CPP
- AcuteAsymptomaticChronicControlledExacerbationNot controlledPossibleRecurrentResolvedResolvingRule OutstableWorsening 401 - ESSENTIAL, BENIGN HYPERTENSION

401 - DISEASES OF THE CIRCULATORY SYSTEM/ESSENTIAL, BENIGN HYPERTENSION

The Plan notes can be dictated as well:

Plan Notes

Favorite Notes:

Enter a title for the above Plan Note, then click the 'Add' button and the Plan Note will be added to the list of favorites.

Title:

His CPPs are very organized and legible, we can hire someone to type these in for him. This combination of some typing and some dictating will likely work.

He may not be able to get to the office today. If my secretary can get in, he can call her for results, but otherwise it will be difficult for him to access anything. In Canada, we have snow storms; the EMR certainly makes it easier for us to cope with our weather.

Michelle

Planning my new office

Thinking about my new office presents challenges. I may have to change some of my technology (phone, fax), and rethink some of my practice processes (again).

For example, should I consider VOIP (internet-based phone)? What about Internet faxing? A fax line costs $50 per month; Internet fax costs about $10 per month, there is no need for a fax machine, and it is always on (without the need to leave the computer attached to my fax on). Long distance is free. My secretaries are already faxing directly from the computer more and more often. We can use the scanner to fax things that are paper-based. On the other hand, I don't know if Internet fax is secure, and I have not seen how it works. I really don't know anything about VOIP.

We will have many physicians and allied health workers in the new office; there will be 5 practices, each with 3 to 6 physicians. Our Allied Health Professionals will have their central offices there. The FHT administrative offices will be there as well. All of us will be on the same EMR system, and the plan is that physicians will be able to access it remotely for booking. EMR training for our AHPs has just taken place. We will need significant Internet bandwidth to take care of all this, and probably someone on-site to manage the IT. It is exciting, but also more than a little scary to me; it feels just like before we embarked on the EMR project, with many more questions than answers.



My group is now starting to think about what to do when our EMR contract expires, in 2009. We can choose to remain on the hospital-based server, or go to ASP. Our provincial subsidy ends after three years, so we no longer have to comply with the provincial stipulations (use SSHA's internet lines, use a Certified EMR etc). Many of my colleagues in Ontario are going to be in the same boat.

The benefits of staying with our current server are that it is a known quantity. However, it will need to be upgraded (we are taking on new physicians, and the amount of data going in is increasing).

The benefits of going with the SSHA ASP is that provincial healthcare data is going there, so there is a better chance of linking with the rest of the system. Hospitals and Home Care are sending data there. However, much of this is still theory, not fact. The drawbacks are that we have to continue to deal with SSHA; this has not been a physician-friendly (or even customer-friendly) organization in the past.

The benefits of going with the company's ASP (which is not Certified, we could not do this under the terms of our current contract) is that we can access over regular internet (faster than SSHA). This is much simpler and easier.

I am leaning towards the SSHA ASP. I know the problems with SSHA; however, I do think this type of structure gives the best chance of having the data follow the patients. As well, we need to have our data professionally managed and backed up; I was speaking with someone who had been at at physician's office, and saw a sign asking people for patience, as they had lost two months of data. I worry about the small servers in solo or small family practices; not all of us are good at backing up our data. Data loss happens, not everyone is careful; while there are risks in large data centres, I think the cumulative risks in many small, unsupervised practices are likely greater.

I was looking at CanadianEMR, and saw that the results of the 2007 National Physician Survey are now available. It looks like 19% of family physicians are now using a combination of paper and EMR records; that may well represent people currently transitioning to EMR. 12% of us are using EMR only; that must be those who have completed the transition. The total for EMR (full or partial) is 31% of family physicians; for all physicians under age 35, it is 45%. These are much higher rates of adoption than previously reported, and the numbers may mean that we are now in the "early majority" phase of EMR adoption.

Michelle

the New Normal

On Friday afternoon I had a meeting at the hospital. After the meeting, I went to the doctor’s lounge to get a coffee and to log on to my EMR from one of the Lounge computers.

I had several things to review. I had told one of my patients to stop her blood pressure medication a month ago (she had several BP readings in the 110-120 range). I asked her to drop by in a month to get a reading done by my secretary on the Automated BP machine. My secretary had started the Encounter, and entered her blood pressure, which was now above goal. The fact that the patient had come in was visible on the Dashboard as I logged in; I viewed her BP, and reviewed her Hypertension flow sheet to remind myself of what I had done. I re-started her medication and signed the prescription electronically, then sent a message to my secretary to call and let my patient know, and to fax the signed script to the pharmacy.

Lab tests had come in. One of my diabetics had an elevated A1C (blood sugar level). This patient had come in the previous week; my EMR has reminders to check diabetic parameters every 3 months, and he had not been in for 6 months; Summary immediately showed me that a diabetic visit had been missed. I explained why it was important to manage his diabetes, and that I wanted to work with him on preventing complications. His blood pressure was above goal (I increased his BP meds), and his weight had increased. He told me that from now on he will be making his next appointment prior to leaving the office (decreasing the risk of missed visits), and I sent a pop-up to the front for him to return and get wt/BP rechecked in a month. I also asked him to get fasting blood for cholesterol and sugar done in the next few days.

When I saw his A1C on Friday, I called him, and asked him to start on a new medication. I explained the side effects. Summary showed me that he did make an appointment in a month, and I told him that I would review the medication again with him at that time. I asked him to give me his pharmacy number, prescribed and signed the new medication on the Encounter (which also automatically placed it in the CPP), made a comment on the flow sheet, and sent a message to my secretary to phone the prescription in.

A holter monitor had also come in for another patient with palpitations. This showed Atrial Fibrillation (irregular heart beat). Fibrillation is a risk factor for stroke; we use coumadin (a blood thinner) for stroke prevention. I phoned my patient and asked her to make an appointment for Monday; a discussion of fibrillation and coumadin management is something that requires an office visit. When she comes in, I will use the MedCalc 3000 atrial fib stroke risk calculation, import this into the EMR, and give her a handout. The handout will be logged into the visit.

While this was going on, I was simply sitting at one of the Lounge workstations, a specialist colleague was dictating a routine hospital encounter beside me, and others were discussing their weekend plans. It was not until a few hours later that I thought about how extraordinary my New Normal really is.

This is how I practice now: remote access from anywhere; ability to manage problems over the phone or at the office, depending on what is most appropriate; immediate recording of phone encounters into the chart; alerts and flow sheets to enable improved chronic disease management; enhanced communication with my practice team; ability to delegate tasks; implementation of evidence-based tools into encounters; and more. What I see in my practice is not just more efficient care, but better, timelier care as well.

I think this should be Normal for everyone in the Health Care system. It cannot be individual physicians’ sole responsibility to pay for and implement EMRs, as is the case for too many of my colleagues; patients and our System benefit even more than physicians. It truly is time for our Governments to look at rational Health Care IT funding.


I have been thinking about what else I can do. We will be having our national Family Medicine conference in Toronto this Fall (FMF 2008). I spoke with a colleague I respect about doing a workshop together, on EMR implementation issues. He uses a different EMR, works in a larger group office, and has been very successful in resolving challenges with computerization. We also invited one of our experienced Practice Management Consultants at OntarioMD as an additional resource. I think having a mixture of experienced users from different settings, along with a consultant, is likely to result in an interesting and productive workshop. The submissions are peer-reviewed (and there is always lots of competition), so I do not know if this will be accepted. If it is, I will post the date when available.

I now write occasional blog entries for OntarioMD, in the EMR advisor section. They recently asked me if I would be interested in answering EMR questions from colleagues, a sort of “Dear Abby” approach; I thought I’d try, so they put a link to do this on top of my entries. I don’t promise I’ll answer everything, but I’ll do my best, and will ask experts when I don’t know.

Michelle

My Team: multidisciplinary care

The New Year will mean more Team-based care for me. A part of it will be the move to the Big Office, but much of it will stem from the on-going development of our Family Health Team: we are now deciding what programs to launch, and how to go about this.

The reason for FHTs is to increase access (more patients rostered, improved access for current patients), to create Teams so that care can be better coordinated, and to increase activities directed at health promotion and disease prevention.

We now have nurses, a RN case coordinator (for tough problems that need system navigation), dietitians, social workers and a clinical pharmacist. We are planning on hiring a clinical psychologist as well. The Social Workers were an immediate hit, and are now so busy that there is a bit of waiting time to see them. We do not have Nurse Practitioners, because there are very few of them, and they’ve all been hired by the other FHTs.

We have a board of directors (mostly family physicians), and an executive director, as well as admin support staff. We have identified several areas that we would like to focus on. Our Allied Health Professionals are getting a full week of in-service training in early January, followed by EMR training the following week.

I’ve been asked to talk about Medical Directives during the in-service training; this is something that we can now start thinking about as a group. Medical Directives allow AHP’s to do delegated act, for patients who fit criteria. For example, I would like to have a directive that will allow my nurse to do a quick strep (or throat swab) for patients who have a positive sore throat score, without asking me for permission first (nurses are not allowed to order diagnostic tests independently). Things like that are easier to do if you use EMR templates; I’ve seen my nurse use the sore throat template correctly several times (it is visible on the EMR Encounter as soon as entered), before I go in to review the history with her; she knows when to do a quick strep, and she has no difficulty in interpreting it correctly. We’ll have to start thinking about what makes sense, and is likely to improve access and quality of care.

There has been some thinking about how to use the EMR; we may go to a centralized booking system for the Allied Health Professionals, accessible remotely. I don’t know how well that will work; I have a feeling several offices will prefer calling rather than logging on to book. We have two EMR systems in our FHT (I heard that in Hamilton they have six!), and some AHPs will work mainly in one system, while others will be assigned to the other. This will be easier for AHPs working inside family practices; I’m not sure how it will work for those assigned to programs.

I have not been actively involved with our FHT board or planning committee, but I am the beneficiary of their work. One physician in particular has been instrumental in bringing this project to fruition, after years of hard work (and lots and lots of meetings for him). It is always like that: there have to be people with vision and dedication to make projects like this happen, and sometimes they are not recognized or rewarded. This is true for some of our EMR pioneers. It is gratifying to see that our provincial government has decided to re-invest in primary care; I think this will pay large dividends.

There will be significant changes related to Team-based care in 2008 for me and my FHT colleagues. I expect that, by the end of the year, my practice will have dramatically changed from what it was as of my first entry in December 2005. Although the upcoming changes may not always be directly related to EMR, IT will be a large component of the final transformation. I am planning to post regular updates on this last part of the journey here.

Michelle

Year 2: looking back, looking forward

A year ago, I had just finished entering the last of my CPPs into the EMR. It has now been a year since I have been fully electronic.

This is a log of a routine diabetic visit; I have erased the date and the patient's name:

	10:41 AM				View Summary
	10:43 AM				Add Encounter
	10:43 AM				Add Clinical Notes Templates
	10:44 AM				Edit Clinical Notes
	10:44 AM				Edit Clinical Notes Templates
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:45 AM				Add Medications
	10:46 AM				Add Lab Requisition
	10:47 AM				Add Immunization
	10:48 AM				Sign off Encounter

I view Summary as my entry screen, by default; this lets me see if there are any outstanding issues for a patient. In this case, she was overdue for her flu shot, which was the first thing I did (the two minutes between Summary and start Encounter). The active medications are auto-loaded into my Encounters, and they are batch printed (that's why they are all stamped on as being at the same time, this is the time they are printed). I sent the patient for an A1C (lab req), and recorded her flu shot. Log lets you get a quick snapshot of how your encounter goes; it doesn't include everything (I also looked at the diabetic flowsheet and the CPP), but it is pretty good.

I keep looking for ways to improve efficiency; the EMR software application is so large and complex that there is still lots to find and use. One of my colleagues was telling me that he feels he uses only about 5% of the functionality; I probably use more, but there is still lots to discover.

My new partner has been using EMR from day 1. I can see that there are some things that are still challenging, such as learning to prescribe more complex drugs (example, gardasil, at 0, 2 months, and 6 months, to be given in physician's office), or doing referral letters. The basic encounter was pretty easy for her to learn. Periodically, we sit down for a few minutes and I show her things. She did not go for EMR training, as it did not seem necessary; she is learning it as she uses it. I will buy a new Windows XP PC for her, because I just can't make Vista connect to my XP network properly. There were a couple of start-up problems: for example, we had to figure out how to make sure that encounters that are started for her by my front staff (they put the vitals in) are sent electronically to her and not to me. Her off-site access does not work; it seems to be a problem with her router blocking the VPN, and that needs to be solved.

She decided that she preferred desktops (wired) as opposed to wireless. Because I have network "drops" in every room, it was very easy to accomodate her. She has her own exam room (the room where paper charts used to be stored), and this now has the desktop with a local printer attached. The printer is the same brand as what I use in the rest of the office, so that we don't have to manage cartridges from different companies. We share an exam room, and she just leaves the laptop in there on the days that she is using it.

Overall, adding a new physician in my office was a lot of paperwork and some extra EMR work (configuring the machines, learning to work with two EMR physicians instead of one), but this is much less than initial EMR start-up, and is manageable. It has not been as difficult as I thought it would be, although there are still things that we need to fix. It helps a lot that my new partner is so easy to talk to, we can solve problems. I expect that, once she gets going, she will be teaching me things.

My son moved out of residence this year, and moved in with two other university students. They have a brief "house meeting" every two weeks, do discuss outstanding issues. He keeps minutes. This is working very well for them; it sounds like a good idea, and I think I will try that with my new partner.

I have been talking to several colleagues about joining me, as I will have a three physician office in the big FHT office; I do not yet have a third partner yet.

While there has been progress, there is still a lot that remains undone. What bothers me the most is the lack of action on the "electronic island"; we are still not connected to the hospital or to outside agencies beyond the labs, there has been no decrease in the incoming data that needs to be scanned, and there has been no progress on decreasing the number of proprietary (non-electronic) outgoing forms. There seems to be lots of talk, but there is no change in my practice.

As an example, we are now being forced to send out proprietary public health forms for Chlamydia urine PCR; up to a month ago, the Ontario lab req was accepted. If you make it more difficult for me to screen for chlamydia, I am less likely to screen (a decrease in quality of care).

There is nothing that a front line clinician like me can do to improve this. Because the health care system is still so fragmented, it is difficult to know who to talk to about these issues, and each problem has to be solved in isolation. We certainly have lots of organizations dedicated to decreasing fragmentation (the LHINs, Canada Health Infoway etc), but I cannot say that their work has percolated down to my practice. Maybe next year.

On the other hand, EMRs are spreading. I have now started the study that I will be writing up as part of my Master's thesis (effect of EMRs on preventive services). We are recruiting colleagues in family practice in my area, and have recently sent out letters of invitation. 26 physicians out of 130 have already replied; of those 15 have or are planning to implement an EMR, and 11 are not planning EMR.

In my own Family Health Team (composed of 6 Family Health Networks), all 40 physicians have or will have EMR by next year. Our Allied Health Professionals are getting EMR training the second week of January. I expect to have more EMR integration at the FHT level next year: by that, I mean that our social workers and dietitians will enter data directly into the EMR. My practice nurse and our clinical pharmacist already do this.

We are getting ready to start renovations on the big FHT office. My own office at the new location will be just over 2,000 sq feet; plans to move in later in 2008 are on track. There was a good article on office planning in a recent issue of Future Practice, by Dr Kendall Noel; just like him, I really like the fact that my patients can see the computer screen--it allows them to participate more in their own care. Almost all of my physicals are now done collaboratively with my patients: I point at what I am looking at on the screen (and I often ask patients age 50 and over if they need their reading glasses--because I'm starting to need those more routinely). It is important that you don't have your back turned to your patient while entering data. It is simpler to do this with wireless because the computer is portable, but the new flat screens make this a lot easier to do with desktops: they take up much less space, and it is easier to place them where they make the most sense.

For the next year, I look forward to planning the big move; this will make my practice fully electronic, as all physicians will be on EMR. I look forward to working as part of a Family Health Team. Now that I have lots of data in, I want to learn to use the capabilities of the EMR to systematically improve care: that will mean doing audits to figure out what patients need, deciding what to do, and using the Team to put our plan into action.

I would like to thank readers of this blog for your company through this journey, and wish everyone a good and peaceful 2008.

Michelle

Divorce, EMR style

At a recent OntarioMD meeting, several of my colleagues who are early adopters talked about being on their second EMR system. I've also heard from colleagues who are not happy with their system, and my new partner is now on her third EMR system because of changing to new practices.

I think going electronic is a bit like a marriage; you use the darn EMR all the time, sometimes it works and sometimes it drives you crazy. If it drives you crazy enough, then you get a divorce, which is difficult and expensive, but is sometimes necessary. No guarantees on whether the next partner will be any better.

There is no way that the electronic data from my partner's previous practice can get transferred to the new EMR. Her previous office manager is printing the charts of patients who are following her; she has to then re-enter the CPP. We are scanning the old charts that are arriving into the office's external hard drive. This is the current state of affairs.

In Ontario, all approved EMR applications will now have to be portable; in other words, you will be able to transfer data to a new EMR vendor if you switch. This document has what must be portable on page 40 and on. It is a bit difficult for me to understand, but it looks as if most of the CPP, lab and clinical notes are in there. I can't imagine that is will be easy or seamless, since EMRs store things in all kinds of different ways, and in all kinds of different databases. I'd like to see this in action; I think the most important piece will be the CPP.

In my EMR, I now see a Data Export and Data Import piece, so they are getting ready for this.

Having some data that is similar across EMRs is a good idea; perhaps one of the unintended (or maybe intended?) consequences of this initiative is that there will be a common CPP that can be transferred back and forth to hospitals, home care, and specialists when needed.

It is interesting that I have not heard of instances where the divorce was back to paper; the difficulty is with the initial transition to EMR. There is no reversion back to paper, but there is failure to launch EMR.


My Family Health Team is getting ready for the big move; about half of the physicians in the Team will move their practice to the same premises as our Allied Health Professionals. This looks like it will definitely be happening in 2008; I will be moving, along with my new partner and a third physician. Our AHPs will be getting EMR training early in the new year. It will be interesting to see how things get integrated. I've been asked to talk to the FHT Allied Health about medical directives in the new year, so now I have to think about what I would like them to do.

Three of the practices that are moving are now on EMR, and two will be transitioning after the move. On the Master Plan, there is space allocated for high density filing for the non-EMR practices only; I cannot see much wasted chart areas in the EMR practices. I will not be moving any paper charts to the new office; others in my FHN who are moving are now disposing of their paper as well. One physician has moved files to her home, another to a storage company, RSRS (and she is quite happy with the service). I think we are starting to witness the beginning of the end of paper records.

Michelle

Being irritated

We just got a new version of my EMR software. The colours are all different, the layout is somewhat different, my label machine didn't work and I get error messages with some of my bills. We got the new Ontario lab reqs, and I had to reprogram my saved lab favourites. I don't really like new software versions, it seems they never work quite right at the beginning and it takes a while before everything settles down again. Even giants like Microsoft can't quite get it right (Vista is very buggy).

I fixed the label machine; the billing error message is annoying but the bill goes through. I'm getting used to the new layout, and there have been some improvements, such as making the DI and lab areas of the charts easier to access without leaving the encounter. There have been some changes in the prescriptions that I haven't quite figured out yet; on the other hand, one of my FHN colleagues found that the EMR can now print a "non-prescription prescription" when drugs are stopped. That's useful, because I give this note to the patient so they know what has been stopped, and they can pass it on to their pharmacist.

I figure that if I'm irritated, I might as well be an oyster and see if I can make something out of it. I figured out a much faster way to get my lab and DI reqs into the record, which I hadn't seen before. I also followed up on my colleague's comment on the previous post, and now auto-load a pap requisition into the record, so that the pap can be tracked; while I was at it, I emailed the general manager of my lab company to ask him if it would be possible to send him my computer-generated req instead of the proprietary pap form. I sent him an example of a requisition, which is reproduced below. Maybe they'll agree this time.


Some of our lab processes are unnecessarily complicated; for example, a first prenatal exam involves generating a req for prenatal blood work, a second lab req with "IPS, part 1"(Integrated prenatal screening), along with a special Genetics form for the IPS; an Ultrasound req for Nuchal translucency; and a special public health lab form for HIV and other public health labs. That's five forms, plus the handout on IPS that I give patients.

I generated EMR form favourites for the two labs and the US, and they're now clicked into the encounter and batch printed. The special IPS form and the public health form (with my own information pre-entered, and all the public health blood tests pre-checked) are now together as a single file; Adobe Pro lets you put several pdf files together. I also include a letter of explanation that says: "book your ultrasound between 11 and 14 weeks; take the special IPS form, along with the lab requisition that says "IPS I" and the ultrasound requisition to the ultrasound place. The technologist will keep the ultrasound requisition, and write the results in the special IPS form. Take that form and the IPS I lab requisition to the lab on the same day; they will take your blood and keep both forms."

The single file with this letter, the IPS form and the Public Health lab form is then printed. That's one print for the EMR forms, and one print for the rest (instead of 6 load and prints--or having to look for a bunch of forms). Also, I'm much less likely to forget one of the forms, which I've done in the past.


This is my EMR pap req:


Cytopathology Requisition

Dr. Michelle Greiver 212, 5460 Yonge Street North York, ON M2N 6K7

Email: mgreiver@rogers.com http://drgreiver.com Phone: (416) 222-3011 Fax: (416) 221-3097

COPY TO:

---

Lab company

Phone: Fax:

---

Patient: Dummy2, Patient 123 any street Toronto, ON M1M 2M2

Date of Birth: Oct 1, 1947 Phone: (416) 222-2222

---

Date Created:	Dec 7, 2007
Priority: Routine

Tests requested:
Date of LMP:	December 2 2007
	Endocervical

Comments:

PAP SMEAR, LIQUID BASED, using broom. LMP 2 weeks ago. Cervix appears normal Physician OHIP number:

Adding a new physician

A colleague will be joining me in my practice on December 3rd. She has joined my Family Health Network (lots of paperwork), is coming on staff at my hospital (paperwork), will be using my EMR (paperwork) and will be receiving the OntarioMD subsidy (paperwork). I wonder if we could combine all this paper into one giant Sequoia. We also notified the labs so she can start receiving electronic labs from the outset.

I have been thinking about how to make it easier for her to start the EMR. It took a little while to register her properly on the system. I already set up her preferences for her, so that the system works from the beginning; these large systems are highly customizable, but the downside of that is that you have to set things up. When you first start, you don't know much about the options available, and it may not be intuitive. I have a good idea of how things run efficiently, so I put that in and she can always change it later. I've set up things in the EMR like lab favourites (1st prenatal etc) for quick lab ordering, quickfill for DI ordering, physiotherapy reqs, basic form letters, referrals etc. It takes a while to start a new physician, it is more complex than adding staff, a resident, or Allied Health; it is important to try to do it properly.

My secretaries know quite a bit about this, so they will help as well, and my nurse can assist.

She bought new machines, but the Vista system does not seem to see the Window XP machines on my network, so her computers can't access all my scanned documents. I will need to call my IT guy to have a look. In the meantime, I will lend her one of my machines so that things work from the beginning. There is a learning curve for the EMR, and it helps if everything is already set up and if you have some help and advice from the outset. I think one of the things that make the initial transition so hard is that you have to deal with everything at once: the hardware never works properly at first, and the software is terra incognita.

She has been using another software application in the practice she is leaving, and does not like it all that much. I'm not sure what the issues were, probably some combination of process problems and computer issues. I'd like to see if I can do a bit better, but I'm sure there will be glitches. I'm hoping to have everything running smoothly within 6 months, which I think is reasonable, and is certainly shorter than the 18 months that has been quoted for a transition from a full paper-based practice. It will be easier for the next generation of physicians.


I've just had a quick look at my overdue lab reqs: there are nine reports that were done but results were never received, from June to mid-November. We will have to call the lab and request copies. I cannot track paps that have not been received, because the lab will not accept electronically generated reqs (mine will only take their own proprietary form). I scanned the pap req in, and print it as needed, but that makes it non traceable. I have had a patient come back and ask for her pap result, which was missing. We called the lab and had them fax it; I can also look results up on line, but that doesn't help me if I don't know that the report is missing. Whether by fax or online, results do not flow into the EMR: we have to scan in.

I wonder why results go missing, and what can be done about it. We sometimes had paper lab reports delivered to us that belong to a different doctor, which explains missing labs on paper. It is more difficult for me to understand why electronic labs go missing; perhaps a technician miscodes the physician's name when the lab form is received. It is time for bar codes, which my system can do. There should be some way of having labs track missing results systematically, especially for the electronic labs.

Michelle

the structure of the chart

I have now used electronic charts for more than a year and a half. The way I look at the chart has changed substantially, because the chart is now much better organized and it is much easier to find data.

However, I look at my "plain" clinical encounter notes less often. In the past, much of the data was located there; for example, I'd have to search to find previous blood pressures or weights. Now, I click a link or look at my flowsheets.

There has been debate about "the patient's story" in the chart; in the past, that mostly meant ongoing longitudinal data in the encounter notes (legible or not). Now, the story tends to be all over the chart; the data is more easily accessible, but it is also more scattered. Some of it is only accessible in electronic form.

Much of my chronic disease management is captured in my flowsheets; the encounter is a poor format for following chronic diseases. For lab follow-up, I am less likely to write "hemoglobin was 88, now it is 97", because that is clickable in the electronic lab. I do put in assessments in encounters, although this is more likely for in-person encounters (for billing) than for phone conversations. I put in reasoning for treatment or investigations, so I can see what I was thinking. However, I will often not put in "DXA ordered"; the DXA (bone density XR) order is a link within the encounter. If I print the chart, the link will show a DI was ordered, but you will need to access the electronic version to see what it was for. Similarly, my lab requests show up in the encounter as a link, and not as discrete blood tests.

The data is generally richer and more extensive (because much of it flows in automatically), but some of it is standardized because of templates, such as a low back examination or a visit for a cold. My annual check ups also are standardized. This probably reflects an attempt to provide good care for everyone, but it does make the record less individual. I am probably conscious of the fact that there will be patient access at some point in the future (and I fully support this), which may make me a bit more cautious about what I write.

I think we may need to start thinking about "the patient's story" in a less linear manner. I am not saying that the clinical encounter document is not important, but it does seem to me that it is assuming less importance; I look at it less. I'm not sure if that's a good or bad thing.

Michelle

Peer to peer

I have often received requests to visit my practice; I think that there are still so few computerized offices in my area that people want some idea of how the EMR works in a real life setting. I also get requests from physicians who have recently started an EMR, so that they can see how things flow in my office and get ideas for their own practice. I have had visits from people in academia who are interested in the EMR transition.

I recently went to visit Alan Brookstone in BC, and got a chance to tour the recently opened PROOF office. This is a regular medical office, set up for EMR, so that physicians can test hardware and applications in a real setting that mirrors their own practices (waiting room, exam rooms etc). There is demand for this; having something organized and easily available will make it much more accessible.

I don't know if we can get something similar in my area; it will take someone to organize it. In the meantime, I have started passing requests to visit my practice on to OntarioMD. We have the new InfoWay Peer to Peer Network, and it says that one of the things we are supposed to do are "individual demonstrations of Electronic Health Records technology". To me, that means "come see my office". At OntarioMD, we have Practice Management Consultants (PMCs), who help with the process of choosing the EMR and receiving funding. I passed the last request on to my local PMC, and she arranged to meet with the physician's group to discuss things such as the subsidy and what their needs are. Once they are ready, she will then arrange for them to come to my office. I think that this is a much more efficient way to do things, and it also provides my colleagues with much more than a simple visit could.

I wish I could make an organized inventory of work flows that I use. I did not find such a thing, and had to invent many things as I went. I am sure many of my work flows are similar to other physicians'. I was watching my colleague, Dr Stephen McLaren, speak about this subject. The video will take a bit of time to download, but it is well worth the wait. This type of practical, day to day work flow advice is invaluable; maybe we should have some type of document on work flow (paper, or CD or internet based and searchable), with "how to" sections. There are enough power users now that we could have screen shots of different EMR systems so that the document is reasonably vendor neutral; I think it is important to have screen shots so that you can see how it is actually done.

All EMR systems have their strengths and weaknesses. I have been talking to users of other systems, and I am starting to see what those are. It is helpful for us to talk across platforms, because we will then go back to our own vendors and work with them to improve our products. In terms of choosing a system today, my advice is the same as Dr McLaren's: there are enough larger, established products now on the market; do not pick a small vendor--you will be a pioneer, there are no established peer networks for support, and your vendor is more likely to fail.

I am not saying that the cavalry is here to save your implementation; I am saying that there is much more available now than a year and a half ago, when I started. For those of my colleagues at the tipping point of deciding to computerize, your peers who have done it can tell you that the time is now.

Michelle