Summertime data entry

I am now back from vacation. Our summer students did a lot of work while I was away.

In the previous post, I mentioned that we have missing data on smokers; we also found inconsistencies in terms of how the data was entered if the patient was a non-smoker. In this EMR program, a non-smoker is indicated through a check-box; most patients had this data entered correctly, but some had "non-smoker" entered as free text. Our summer student was able to identify all the free text "non-smokers", by looking for terms such as "ex-smoker", "x-smoker", "quit smoking", "non-smoker", "non smoker", and entered the correct information in the check box. We now have a more accurate list of non-smokers for my group.

As well, the summer student put in an alert in all the charts of all active patients age 15 and over who did not have any information about smoking in their Cumulative Patient Profile; while my partner was away this week, I saw one of his patients with an alert, and just added the information. We'll see if this approach works.

Our summer students verified our lists of preventive services, and double checked all patients. They also checked the lists of rostered patients sent by the Ministry of Health for my group, and updated the information in the EMR.

Our FHN administrator oversaw the work while I was away. I have a lot less supervision to do now. The main problem I have is that the students did the work so fast that it was completed ahead of schedule!


The move to the new office is now less than two weeks away. I am very happy that we are not moving our paper files, this considerably decreases the amount of stuff that needs to be moved. I have discarded some old textbooks that hid in my office; I no longer look at them as they are obsolete. We have gotten rid of the vast majority of paper handouts, and now print as needed. My partner continues to have paper in his office and exam rooms; he is currently away, and will need to sort what needs to come and what can be discarded when he returns. We have a common consult room, and there is very little storage space for paper--all opportunities to retain and use paper have been deliberately minimized in the new office. The first two group practices have already moved in on the 7th floor as of last week; I went to visit them, and they are happy so far. Our new offices are much brighter and better laid out, and are taking advantage of the fact that we are paperless.

I had a look at the FHT office, which is being built next door to mine; it will be interesting to work so closely with a large group of Allied Health Professionals. The fact that we are co-located will no doubt lead to multi-disciplinary medical education sessions; we need to start thinking about how to do this.

Speed of access at my current office continues to be an intermittent problem; I have been told that this will be fixed in the new office. We have had several service interruptions in the last two weeks as well, where I had to switch over to my backup internet line. I am not sure what the issue is, but it is always aggravating when things slow to a crawl, and this has been happening all too often recently. We lost service completely a few weeks ago; eHealth Ontario arranged to have a technician come over, and we found out that somebody had pulled out our internet line in the basement! The technician felt that this wasn't vandalism, but rather an error by somebody who didn't realize what this line was; he added a label on the line warning that it should not be removed. We need a stable, fast line; this is key to a well functioning EMR that runs remotely. This function is the core business of eHealth Ontario.


I continue to move towards more prepared, pro-active care. In the past several months, my practice team has decided to help patients prepare for their annual physicals. What that means is that we mail a letter to them asking them to do their blood tests before they come in. The first few letters were sent too late and patients did not have time to do the blood tests; we then decided to send a letter at least a month prior to the appointment. As things evolved, I added a reminder for my new location, added several lab locations, and then also added a space for the secretary to put in the date of the upcoming appointment. They usually phone the patient to remind them of the upcoming appointment, but we decided not to do this anymore, since a reminder letter is being sent. I then added a comment about self management (I got the idea from an article in Family Practice Management) , and then I added the preventive care questionnaire from a Practice Based Small Group module.

Now, once a week, I look at all the upcoming physicals 6 weeks from now, and then print the lab reqs for what I want. My secretary then prints the reminder letter, and mails it to all patients. The majority of patients have all their blood tests done by the time they come in; I ask what they think of this approach, and they feel that it is much better. We have a look at their lab together when they come in, and I print it for them. If there is a problem, my nurse calls, and asks them to do the follow up lab before they come in. I think this works very well, and illustrates the multiple cycles of Plan-Do-Study-Act we are using in my office to try to improve things.

Here is the letter

Dear

**We are moving to our new location, 240 Duncan Mill Road, suite 705, Toronto, M3B 3S6 on August 22nd 2009**

We are sending this letter to remind you about your upcoming physical; Please bring all your medications with you (including all over the counter medications and vitamins); please think about your self management goals and what you would like to accomplish at the visit.

APPOINTMENT DATE AND TIME:____________________________

Please have your lab tests done at least a week before you come for your complete physical; all the results will then be available for you at your appointment and can be reviewed with you.

Please make sure you fast for 12 hours before doing the tests. You can have water, and you can take your regular pills (except for medications that lower blood sugar).

You can also have this done at any CML or LifeLab locations. Please make sure you take the attached requisition when you go.

CML locations:
http://www.cmlhealthcare.com/

Address: 4430 Bathurst St. -
Cross St: Sheppard Ave. W. Phone: 416 - 636-2040
Hours: Monday to Thursday: 9:00am to 6:00pm Friday: 9:00am to 2:00pm

Address: 5927 Bathurst St.
Cross St: Drury; Phone: 416 225-1629
Hours: Mon to Thurs: 8:00am to 8:00pm Friday: 8:00am to 6:00pm Saturday: 8:00am to 1:30pm

Lifelabs locations:
http://www.lifelabs.com/Lifelabs_ON/locations/default.aspx

149-1333 Sheppard Avenue
Toronto M2J 1V1 Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m. - 5:00 p.m.
Fri. 8:00 a.m. - 4:00 p.m.
Sat. 8:00 a.m. - 12:00 p.m. Toll Free :1-877-849-3637

4800 Leslie Street, Toronto M2J 2K9; Phone : 416-675-3637
Hours of Operation: Mon. to Thu. 8:00 a.m.-5:00 p.m,
Fri. 8:00 a.m- 4:00 p.m.

217-4949 Bathurst Street, Toronto M2R 1Y1
Phone : 416-675-3637
Hours of Operation : Mon. Tue. Thu. 8:00 a.m. - 4:00 p.m.
Wed. Fri. 8:00 a.m. - 2:00 p.m.
Sat. 8:00 a.m. - 12.00 p.m. Toll Free :1-877-849-3637


Preventive Health Questionnaire for Adolescents & Adults

Please complete this questionnaire before you come for your check up.
We will be pleased to help, if you have any problems or questions.

Please circle the most appropriate answer for each question: Y = Yes; N = No; X = Not applicable or Don’t know

General Safety
Do you always:
• Wear a seat belt when you ride in a car or other motor vehicle? Y N X
• Wear a helmet when you ride on a bicycle,motorcycle, or all-terrain-vehicle (ATV)? Y N X
Do you:
• Have a smoke detector on each floor of your home? Y N X
• Regularly test each smoke detector? Y N X
Do you regularly protect your hearing against excessive noise? Y N X

If you are over 64 years old:
• Do you have hazards (such as loose carpets, exposed extension cords, and
stairs with no handrails) in your home that could cause you or someone else to fall or be injured? Y N X

Dental Hygiene
Do you (every day):
• Brush your teeth with a fluoride toothpaste? Y N X
• Floss your teeth? Y N X
• Have you seen a dentist in the past year? Y N X

Stress Management
During the past month:
• Have you often felt “down,” “blue,” depressed, or hopeless? Y N X
• Have you often had little interest or pleasure in doing things? Y N X

Physical Activity & Exercise
Does your daily physical activity add up to at least 30 to 60 minutes? (Include each 5- to 10-minute interval of activity or exercise.) Y N X

Pre-Conception Care
If you are planning to be, or could get pregnant, are you taking a folic acid
supplement? Y N X

Potential Risk Behaviours
Do you smoke? Y N X
If you are a smoker:
• Would you like to quit? Y N X
• Have you ever tried to quit before? Y N X
• Are you interested in medication to help you quit? Y N X
• Are you interested in a smoking cessation program to help you quit? Y N X
• Do you have a “quit date” in mind? Y N X

Do you ever:
• Try to cut down on drinking or drug use? Y N X
• Feel annoyed if someone mentions your drinking or drug use? Y N X
• Feel guilty about drinking or using drugs? Y N X
• Drink or use drugs as soon as you get up in the morning? Y N X
• Use alcohol or drugs when you are involved in activities such as driving,
boating, cycling, or swimming? Y N X

If you are sexually active, do you:
• Take precautions to prevent an unplanned pregnancy? Y N X
• Always use a condom to protect yourself from sexually transmitted infections (STIs)? Y N X
• Avoid high-risk sexual behaviour? Y N X

Diet
Are you eating the right number of calories (enough to maintain a healthy body weight) every day? Y N X
Do you limit your intake of fat and cholesterol? Y N X
Do you emphasize grains (such as cereals, whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet? Y N X
Do you take in enough calcium and vitamin D for a healthy body and bones?
Y N X


Thank you for taking care of yourself and helping to prepare for your visit.

Phase change

My moving date to the new office is August 22^nd 2009. We are getting very busy with the many details that go into the move.

Informing everyone is very challenging. As soon as the date was set, we sent a letter to all the patients in the three practices in this office. I also periodically update my website (http://drgreiver.com), and we have the date and new address on our answering machine’s message.

We have been informed by eHealth Ontario that the new Internet connection will be ready on time; there will be several family practices, as well as the Family Health Team’s main clinical location (home office for Allied Health Professionals, program managers) all operating from the 7^th floor at 240 Duncan Mill. About half of the physicians in the FHT are moving to the new office; all of us will be using the same EMR software, and all accessing the software remotely; there will be no server on the premises. My husband tells me that these days, many larger companies (including his) are distributed all over the place and no longer have a server with their corporate database on site; his is actually located in Cleveland. If you include all physicians moving in, Allied Health Professionals, support staff, medical students and Residents, we’ll have between 75 and 100 people accessing data remotely at the site. I hope we have a big enough connection for our size.

Our Family Health Team is actually fairly complex; it is composed of six smaller groups of family physicians (Family Health Networks or Family Health Organizations). Some of the groups had already chosen their EMR system before the formation of the FHT, which is why we ended up with two different systems. As well, some groups chose to transfer their software to the new provincial eHealth Ontario ASP server; my group had thought about it, but for reasons detailed earlier, decided to stay on our server at the hospital. Within our server, there are two groups, mine (with 14 physicians) and our sister Family Health Organization with 9 physicians. Even though we use the same server and the same database, we cannot share EMR data across our two groups.

17 colleagues in two different Family Health Organizations decided to go to the eHO ASP model, but as a single data base with shared data; they use the same EMR software as I do.

14 of my colleagues use another EMR software. Four are in one office as part of a FHO, with their server in the office. Ten physicians in a different FHO are dispersed and access a server located in one of the offices.

That makes 6 physician groups, two EMRs, 3 databases using one software application and two databases using a different software application. No wonder our Executive director is getting grey hairs! Even though we are now a mid-sized company as a FHT, our IT infrastructure does not make running programs in common very easy. In retrospect, I guess it may have been better to form Family Health Teams first, and then choose a common EMR and common database for all of us. However, primary care renewal initiatives happened at the same time as the EMR transformation, so things like this were bound to happen. We’re not the only FHT with this issue; a large FHT in Hamilton has 6 different EMRs. Maybe what will happen over time (perhaps a long period of time) is that we’ll eventually join our information in a single database (or maybe two databases, one for each EMR) so that we can actually run and track programs based on our actual data. I can’t imagine any mid-sized corporation not knowing how they are doing, and not having data for forecasting and planning purposes—and yet that is how we operate at the present time.

In any case, we are slowly starting to develop some Data Management skills in my group of 14; part of this is through participation in studies like CPCSSN, where we have a Data Manager to help us, part is through Quality Improvement collaboratives like QIIP. My practice has a Facilitator through QIIP, and she is helping us think about how to organize our data so it makes sense. There is no FHT Data Manager, which is a bit strange considering how much data we have.

For example, having some idea of what percentage of smokers are in our practices is useful if you want to think about planning a program for this. We have 9515 patients with data on smoking; of those, 1964 have been tagged as smokers (20%). I’m sure there are issues with inconsistent data entry, data errors, etc, but at least it is a start. We need to figure out how to identify patients who have no entry on smoking in their chart, and perhaps decide as a group to put a reminder or alert in the chart, so that the next clinician who sees that patient can ask them if they smoke or not.

As you can see, change in ongoing for me, for my practice Team, for my partners, and for our Allied Health Professionals. When I look at this ongoing diary, I guess one way to think about this is as a very slow motion train wreck. However, it does not feel like that to me at all; I prefer to think about it as a slow thaw towards a much more interesting state—ice to water. Phase change.

Reviewing and changing my scanning process

I have changed my scanning process. My EMR company had provided software called "ADM" (or Advanced Document Management) in the past, but I didn't use it. The reason for that was that the quality of the images (they were in jpeg) was poor.

There are two ways to scan data in my EMR:

1. Through the ADM program, which is separate from the EMR, and automates much of the process
   
2. Directly to the EMR, through an upload and attach process in the application

I used the second method; we scan documents as pdf files, save them to a folder on the PC's desktop, and then upload and attach to each patient's file. This is a very laborious process, but the images are very clear. I prefer to have a longer process at the front of the office and to end up with better quality images.

However, I heard from several colleagues that the new ADM program was significantly better; I went to see it, and it was better. Another physician in my group came to my office to have a look at our scanning process (she was using ADM). We had a look at her scans during lunch, and figured out that some of the quality problems were due to the fact that she was not using the right software to open the files. Her scanned files were saved in tiff format; we switched to MS document imaging--it looked better and we could use OCR (Optical Character Recognition) very easily. I had found out how to associate file extensions with different programs because of a home computer problem, so I was able to do the switch for her.

The ADM software does not work out of the box. My IT guy had to install it and to tweak some other files to get it to work properly. However, once that was done, it worked. He showed us how to use it; we started and had to make a couple of changes, but now it works well.

My scanning tech can now scan papers in batches: she puts a whole stack of papers in the scanner, and scans everything into a single file. The program automatically saves it to the right area without the need for naming the file. Once it is in, the ADM software shows her what has been scanned, and she uses it to attach different pages to different patients and different areas of the chart. The software then uploads the file to the right area of the EMR.

I then see it as a tiff file attached to a patient chart in my EMR inbox (separated into lab, DI, correspondence). I can click on the file's link to open it up. Once I see it, I run the OCR process (using the little "eye" icon in MS doc imaging), which is very fast, and then I can highlight what I want and copy and paste it into the "comments" section.

OCR in tiff seems to work better than in pdf--it is easier to highlight the section you want to copy. I find that I am copying more of the letter to the EMR.

This is still problematic. OCR is not perfect, and there are always errors. You have to proofread and correct the text, which takes time. I have a saved copy of the original, so what I do is look for bad errors (numbers being wrong etc), and leave minor problems alone--example: MRI OP BRAIN.

Anything which is OCR'd and copy/pasted is now saved as part of the EMR record (not a scan), and is searchable. If you are parsimonious with what you put in, you end up with a nice summary which is easy to look at (CT chest: granuloma RUL. Echo: Normal). If you put in lots of stuff, it becomes harder to wade through the information or you have to do a text search. If you put everything in via OCR, you don't have to individually load each scanned document when printing a referral or a transfer, but you can end up with a lot of misspelled garbage, and there is no formatting--it is hard to look at.

I'm kind of in between the two. I'll copy the relevant paragraph to the EMR (diagnosis, management suggestions), and leave the rest as a scanned document. When we transfer a chart because a patient is moving to a new family physician, my secretary copies the EMR chart to a CD, but not the scanned documents. I figure the EMR really contains the relevant summaries of everything that is needed. I don't know if I should start including only the EMR summaries instead of the scanned documents when sending referrals; I guess it depends on what the referral is for.

You can see what it took for me to change my process:

• Better software from the EMR company
  
• Seeing for myself that the quality of the images had improved
• Figuring out the file attachment problem (over lunch with a colleague)
• Having a good IT person who could both do the installation for me, and troubleshoot it afterwards
• Training on the new processes and revising how the secretary scans at the front and how the doctor looks at the scan
  

Of course, there were problems in the first couple of days: my scanning tech found the pictures on the screen too difficult to look at (until we figured out where the magnifying glass button was); there were errors in attaching scans (wrong area, wrong patient). My partner has MS Office 2007, and MS document imaging doesn't automatically install itself in that version--I had to go online to figure out how to make it load on his computer. You have to have patience with these new things. Our IT guy also figured out how to make faxes and scans automatically go into the same folder, so now the upload process is fully integrated. It doesn't matter whether the incoming is via fax or via scanner, it all looks the same.

I don't mean to imply that I like scans now; I still think that it is a waste of everyone's time to have to re-digitize documents that were originally produced in digital form. However, the hardware and software is getting better at handling this necessary evil.

Michelle

User group meeting

I went to the annual user group meeting last weekend. I believe that bringing together users is extremely valuable; we shared many tips and tricks on how to use the EMR more efficiently and effectively. We complained a lot, and laughed a lot too. I met several colleagues who were at various stages of implementation; more experienced users were extremely generous in terms of sharing what works for them.

The EMR company's executive team were there; at the end of the meeting, we discussed our "wish list". Some of the requests were:

• Templates that can be exported and shared with others (the #1 request)
• Increased scheduling flexibility for larger groups
• Improved data mining and reporting capabilities
• Better ways of entering and reporting chronic disease management data
• Ongoing training
  

The head programmer demonstrated the new data mining software they are working on; this looks like it fishes data straight out of the database, and should give "power users" a lot of control over what is reported. I can't see having everyone learn database management skills, but several of us are getting more and more interested in seeing what we can do with all the data we are accumulating. Perhaps what will develop in some groups is data expertise (this does not have to be a physician), so that quality improvement projects can be started for entire groups. It will be much easier to do this for groups of physicians rather than for solo physicians. I think the formation of groups in Ontario (Family Health Groups/Networks/Organizations/Teams) is likely to bring benefits in terms of data management capabilities.

The company talked about their plans for "reportable fields". There was a lot of interest around this. As far as I understand it, this is new fields that can be inserted into templates, and that automatically go into into flowsheets, and that can be searched for later.

Altogether, I think this was a valuable meeting to attend, and I plan to attend next year. The EMR is now so central to our practices that it is worth investing time and effort to build and maintain proficiency in it.

Our last two filing cabinets were sold and picked up, and I did a happy dance over the floor space where they used to be; there is now a lot of space at the front. Our moving date to the new office looks like it will be in August (likely August 22nd), and I am trying to get rid of as much paper as possible. We still have some paper handouts, and these are getting tossed out. I'll have a look around and make sure that we are as paper-lite as possible.

The move to the new office is much more complex due to the EMR. eHealth Ontario is overseeing the internet connection in the new office, and we have to make sure that there is overlap (we need to have two SOFAs--Small Office Firewall Appliances) during the transition so that we can continue to function. We are investigating VOIP phones as a group. I have to make sure all the wiring is planned properly and that there is redundancy for the future. I have a small IT closet in the office for all the routers. I started an Excel spreadsheet of all the things we have to do, and this is growing faster than public health swine flu notices.


I took part in the CPCSSN national meeting later in the week. CPCSSN is composed of 9 different sites in Canada, and all sites are reporting anonymous EMR data on five different chronic illnesses: diabetes, hypertension, depression, Chronic Obstructive Lung Disease and osteoarthritis. I am part of the Toronto group, Nortren. There are eight different EMRs involved, so this is a very complex project. It looks like this is feasible, and primary care can be used safely and effectively for chronic disease surveilance. This likely represents an important part of the future of Public Health.

Finally, it upsets me a great deal to read about the problems currently besetting eHealth Ontario. I agree with Dr Brookstone's post, this will be a major distractor for the organization. My group has had multiple difficulties with eHO and its predecessor (SSHA), mainly centered around service provision and communication; however, I completely agree with Allan that this is a large and complex undertaking. The current chair, Dr Hudson, and the previous CEO, Sarah Kramer, have extensive knowledge and experience in this sector; I hope the executive branch of eHO will be able to maintain focus on their priorities. This news release came from our Minister of Health, David Kaplan, today:

"The board reported to me that the current uncertainty surrounding eHealth Ontario threatens to delay initiatives that are crucial to our government's plan to modernize and improve our health care system.

I am acting immediately upon its request to revoke Sarah Kramer's appointment as eHealth Ontario President and Chief Executive Officer. Ron Sapsford, Deputy Minister of Health and Long Term Care, will serve as acting President and Chief Executive Officer of eHealth Ontario until an interim President and CEO can quickly be appointed.

This decision is an important step to restore public confidence in the agency and its mandate of modernizing our health care system."

Michelle

Quality improvement, year 3

Our quality of care for preventive services continues to improve. We have 9,985 eligible services. We provided 87.75% of these services, compared to 73.53% last year, an increase of over 14%. It was interesting, because quality of care went up for every service, for every physician. We also went from 9 physicians to 12. Part of the improvement was better, more consistent data entry by everyone, and part is an actual increase in services; I can't know which is which, but I have no doubt that there is an actual increase in services.

Pap smears went from 74% to 89%; mammograms from 74% to 88%, and influenza vaccinations for the elderly from 71% to 85%.

Our Fecal Occult Blood (FOB) screening program has now started. We were able to extract a list of patients with Colorectal cancer or Inflammatory Bowel Disease for every physician (through ICD codes); these lists were then faxed to each physician for verification. Our data entry person has now entered a code in all Cumulative Patient Profiles to exclude those patients from screening. Every practice knows about the code, so patients newly diagnosed can be excluded in the future.

My colleagues have been good about entering colonoscopies consistently and in the right area of the CPP; we generated lists of all patients with colonoscopies <5>

We will then cross check the remaining patients with the paper lists of FOBT (from lab billing data) that the Ministry of Health recently sent us; we mailed FOBT letters last year as a trial, and this worked, so once all the data entry is done and cross-checked, we'll go ahead with mailing patients overdue for this screen. Our FHN administrator will notify everyone ahead of time, so all practices have time to prepare (order extra FOB kits, make sure that everyone knows to put in a lab req when patients come in to pick up the kit etc); we also email a copy of the letter template to every physician for approval prior to mailing. This will enable us to monitor FOBT from now on and to add FOBT to our regular 3 monthly mailings. I expect this to be completed by July or August, with the first mailing going out then.

Here is the letter to patients:

Dear

Our records show that you are due for a Fecal Occult Blood (FOB) screening test. FOB screening has been found to decrease the risk of dying of cancer of the lower bowel, and should be done every two years.

Please come to the office to pick up your FOB kit. You do not need to make an appointment for this.
If you have had a colonoscopy in the previous 5 years, then you do not require this test. Please inform the office if a colonoscopy has been done.

FOB screening is an important part of keeping you healthy; more information on early detection of lower bowel cancer can be found at http://www.coloncancercheck.ca

As your Family Physician, I appreciate the opportunity to work with you to prevent illnesses and enhance your health.



We are now at 14 physicians in my FHN; we'll add our two new colleagues to the preventive program this summer, which will bring us to just over 15,000 rostered patients. We will also get data auditors to cross check the paper lists to make sure that patients who are rostered on the EMR are shown as rostered on the Ministry lists. We'll do a cross check for patients who already have two letters mailed, to make sure that they have not had an overlooked service. You have to maintain your database, and double check things. As well, during the summer, all patients with two reminder letters and still no response get an extra phone call, as we hire summer staff for this.

We are also getting data entry for our diabetes registry; this adds reminders to look at the flowsheets every 3 months. Several physicians in my group have been looking at overdue reminders, and have called to remind these patients to come in. I thought this was a good idea, so we had a look and found 6 diabetics who had not come in for over 6 months. My secretary called all of them, and four have booked appointments.

As a test, I had data entry done for all my diabetics for last date of retinopathy check (for eyes) and neuropathy (foot exams). I was able to generate a list of overdue retinopaties (>2 yrs)--17 patients--and these are now all getting a reminder letter; as well as overdue foot exams--14 patients--and these now all have an alert in the chart. My nurse saw a diabetic in for another reason, noticed the alert, did a foot exam and marked it as completed. The system now shows me the list with that exam completed, and the date it was done.

I think that our system is slowly maturing, and I have evidence that we are using EMR capabilities to improve quality. I think this is what you should be able to achieve by the third year of EMR.


The last two filing cabinets have now been emptied; all paper charts are gone from the front. I put the filing cabinets on Craigslist yesterday, and sold them today. Paper charts have no place in this clinical setting.

Michelle

Outbreak

We are now in a Category 5 outbreak, with several cases of Swine Flu (H1N1) reported in Ontario.

I went through SARS in 2003; my hospital was at the epicenter of the second wave of the outbreak; I had been on the floor where the first cases were detected. I was quarantined; my practice partner volunteered for the SARS unit of the hospital and he took care of our colleagues and co-workers who were ill. I remember this.

At that time we had no way of rapidly communicating information. Most of us were receiving everything by fax; Public Health and other government agencies had no email lists of physicians. Our hospital department could not reach us (they didn’t have our email addresses either); the physician’s lounge was closed, and we could not pick up reports or information. Our department chiefs went to work and rapidly built up email lists; giving your email is now a routine part of reappointment for hospitals and medical organizations, and the lists have been maintained.

Since I started using the EMR, I have left my email on at all times at the office. I am now receiving updates on the outbreak from Public Health several times a day. My hospital also sends out routine updates and reminders, as does my Family Health Team; so do medical organizations, such as the Ontario College of Family Physicians and the Ontario Medical Association. It is a bit overwhelming at times, as I get the same information from several different sources, but I am updated. Many of my colleagues use a Blackberry. I think the information “push” is now very good, and certainly light years of where we were in 2003.

However, it is still difficult for me to send back information to Public Health. They want us to report the information on cases of suspected swine flu by phone. This is going to be a problem if the numbers surge: they are going to be quickly overwhelmed, just like the last time. I think it would be better to upload via secure web, email, or fax as an alternative. Ideally, I’d like to send the information electronically straight from the EMR, but I know this is not possible because systems for this were never put in place.

I also think we should be able to automatically send some anonymized EMR data straight to public health; I would certainly volunteer to be a sentinel practice for this. Here is what I mean: I would like to automatically upload to Public Health temperature readings from my office (they are in a field in my database) with their associated EMR date and time stamps, linked to the patient’s postal code (only the first half, or Forward Sorting Area, FSA). It would not be difficult to aggregate temperatures and FSAs from several practices; Google does this kind of thing very well. Sort through it and pick out temperatures >38 degrees. You can quickly see the clusters of fever by geographic area. This would require special protection for privacy, but would potentially allow real time tracking of an outbreak in an emergency situation.

I’ve been thinking of the most efficient way to remember what I have to do and to record the data in the EMR; this is through an encounter template. What I did is program a template for my entire FHN (since we are on a common database), which contains all the information sent by Public Health—so we know what to do. As the information changes, I’ll just update the template. I put the phone and fax number of our local public health unit in our common FHN phone book; when I have a suspected case, I’ll load up the template, fill it, and save it to the record. I’ll then start a consult note to Public Health (which automatically contains all the required patient demographic information straight from the record, as well as my name, address, phone number and email), attach the encounter note to the letter, and electronically fax this to Public Health. Then I have a record of what I did, as well as of the fact that it was reported.

Perhaps Public Health could set up a secure email address for reporting, through eHealth Ontario’s ONEMail system. I have access to ONEMail (see previous post), and this would actually be a very good use of that system. Reports emailed within the ONEMail system are completely secure.

Here is the structure of the template; it is very simple. If you have an EMR, you are welcome to reproduce or modify this as you see fit.

• Swine flu (ILI, Influenza Like Illness) template

• Report all cases of Influenza-Like Illness (ILI) with a travel history to Mexico or contact with a case of swine flu in the last 7 days to the public health unit, phone xxx fax yyy
• 
  
• Travel to Mexico in past 7 days? (Y/N)
• 
  
• Contact of swine flu case in past 7 days? (Y/N)
• 
  
• Date of symptom onset:
• 
  
• Outpatient (Y/N)
• 
  
• Upper Respiratory Tract infection? (Y/N) OR
• 
  
• Lower respiratory tract infection? (Y/N)
• 
  
• 
  
• Other Major symptoms such as gastroenteritis?
• 
  
• Temperature:
  
• 
  
• For patients presenting with ILI (Acute onset of fever and new/worse cough or shortness of breath; additional symptoms may include sore throat, arthralgia, myalgia, headache or prostration. In children under 5, gastrointestinal symptoms may also be present.) and a history of travel to Mexico or contact with a confirmed case within 7 days of onset of symptoms, a nasopharyngeal swab can be sent to the Toronto or regional public health laboratory.

Michelle

The three year old EMR

I now have a three year old EMR. I am way past that terribly disruptive newborn period, have dealt with the Terrible Twos, and am starting to reap some nice benefits from a maturing system. The EMR is definitely more responsive and pleasant these days, although it can still throw the occasional tantrum.

I now have three years' worth of data in my system, and am increasingly interested in using this data to improve my quality of care. My practice team went to the Quality Improvement and Innovation Partnership (QIIP) a few weeks ago; there were 50 Family Health Teams represented. My team was able to generate some statistics from our system, but few others could do this. Almost all FHTs are using an EMR, but many are newly computerized; the ability to routinely generate practice-level information (how many diabetics do I have? How many of those are at goal for their cholesterol?) is still very rare—even for those with older systems. It was a little worrisome to see that all this information cannot be put to good use because it cannot be routinely aggregated within practices.

I think that there are a couple of reasons for this

1. EMR systems were initially designed for individual patient care, replicating our paper charts. They are not designed for practice-level audits (which are critical to improving quality)
2. We do not enter data consistently; in other words, we do not have good Data Discipline. If you enter “diabetes” as T2D, NIDDM, DM2 etc, you can’t consistently look for diabetes afterwards. You have to code your diagnoses.

We have to report on a whole series of measures for QIIP, for diabetes, colorectal cancer, and office efficiencies, and I can see that this will present a whole lot of problems for all of us. Perhaps it will make us demand more and better auditing capabilities from our EMR vendors. Perhaps it will make us think more about how we enter data in our EMRs.


I will be moving to a new FHT office designed specifically for the EMR. We have just signed the lease, which is very exciting; construction will start now and I expect to move this summer. We have printed announcements on cards which we are handing out to patients, and we are asking them to regularly check my website, http://drgreiver.com for updates.

We finished scanning my partner’s paper charts into the hard drive at the front, and they have been backed up to two sets of DVDs. He won’t allow my staff to shred the paper; I think many of us still need the old charts for security. I have not allotted any space in the new office for filing cabinets, so the charts will have to go to his basement or to storage when we move; then we’ll finally be paperless. I am selling the last two remaining filing cabinets on Craigslist soon.

The Allied Health Professionals (AHPs) in my office are now using the EMR routinely and consistently for all care. We decided to use eMessages in the EMR instead of faxing referrals; they check the EMR remotely on a very regular basis, and this avoids generating paper. We talked about where to enter data, and our Team’s Social Worker, Dietitian, and Clinical Pharmacist all decided to enter their reports in the Clinical Notes. They sign off when done, and send me a short eMessage linked to the patient’s chart. Both my practice partners agreed to try this system, and are much happier with it; I hear this approach is spreading to other practices in our FHT. If I have a question about a patient, I just send a message; this has greatly enhanced Team communication. For example, I routinely fire off a quick query to our Clinical Pharmacist when I have a question about the best approach for a patient’s medications; she links to and reviews the chart, and sends me back a note along with a link to appropriate on-line resources if needed.

The schedule for the AHPs was being managed centrally at the FHT’s office, using non EMR software. We all decided that it would be better if the schedule was within the EMR and in our office. I made a schedule called “Allied Health Professionals”, and when I need to refer somebody to our Dietitian, they just go to the front and book the appointment with my secretary. The Dietitian can see her own schedule both remotely and when she comes in the office, and she brings up the patient’s eChart directly from Scheduler.

AHPs in other FHT offices must be hearing about this, because I am now regularly being asked to set up them up in the EMR; everybody wants to use the EMR. I don’t mind doing this, because I can do it fast, and I think it is important to do it correctly. Our FHT’s AHPs get their initial training at the EMR company, and then some come by at lunch for a quick orientation and help with initial log in. I think the integration of all Team members will accelerate even more once we are co-located at the FHT office, and can do EMR “lunch and learn”.

My FHN colleagues are doing some very innovative things with their system. Quality Improvement initiatives and good data entry practices seem to be routinely on the agenda at our FHN meetings. For example, one of my colleagues systematically looks for patients who are overdue for their diabetic visits (using the EMR reminder system we set up last summer), and sends them a recall letter. Another physician decided to have her FHT RN recall the overdue patients and manage their visit. I think we are starting to mature as a group, along with our EMR. I updated our FHN diabetes registry (we now have 805 diabetics out of 15,000 patients), and the coding was much better than last year.

My office administrator recently received a letter from a specialist in MS Word, emailed to our office address drgreiveroffice@rogers.com . We talked about what to do with it, and decided to copy and paste the note into “comments” in the incoming correspondence part of the EMR; no printing, no scanning, no OCR, and no OCR-related errors. It is not quite as good as a direct electronic import into the chart like labs, but is so much better than fax; I would really like to use secure email, but the SSHA email system is very impractical so nobody uses it—you have to change your password every six weeks, you can’t have a general office email for people to send things to, it won’t forward a notification that there is something waiting for you. I don’t use it. It looks like it was designed by security experts, with no emphasis on the practical aspects of a communication system. The results are a continuing lack of electronic communication; you get the system you plan for.

Overall, I think things are coming along nicely. There certainly has been a noticeable decrease in EMR-related stress in the past few months; I think our system is now well domesticated, and we can start planning more and better things.

Michelle

The importance of communication

I had a difficult day last week. A patient came in with two reports: one (from a downtown hospital) showing a decreased bone density, and a second (from a different downtown hospital) showing some compressed and fractured vertebrae. This patient needs medication for osteoporosis. The issue for me was that neither of these reports were sent to me, and there was no treatment. The patient was seen at hospital #2 for a different reason; a physician gave her the report and told her "if I was your family physician, I would treat you". The patient handed me both reports. The report from hospital #1 had my name on it, but was never sent to me. The patient's comment was that the system seemed to be failing her. I agree.

Our current College of Physicians and Surgeons magazine talks about the importance of communication; the article discusses two plane crashes that happened because of poor communication between flight crew, cabin crew and flight control. When this happens to planes, there is an investigation, and they figure out what happens and how to prevent it in the future. The CPSO's comment is that "the more complex the system, the more sophisticated the communications"; health care is at least as complex as aviation, if not more.

A problem in health care is that we often don't learn from our mistakes, so we just repeat them. The example above will go unreported, unsolved, and unimproved. We have the technology and the ability to send reports electronically today (my labs come in this way), but I continue to receive most of my reports by fax or mail (or via patients). The reasons why this is happening are multiple:
-other priorities
-lack of money
-lack of time
-the tragedy of the commons (this is an issue that affects everyone, but is no-one's responsibility in particular)

The error above occurred due to multiple systemic factors; however, there is no agency responsible for investigating this or for recommending a better system of communication (send it to me electronically). Each individual hospital has their own individually maintained address book (with all the attendant problems that these duplicate entries entail), and there is no obligation to send reports back to the family physician if he or she didn't order the test. The ordering physician cannot reasonably forward all tests to the family physician. The list of rostered patients (which patients are registered with which family physician) exists at the Ministry of Health, but is in no way tied to any of the hospital's physician address books. The CPSO mandates that we give it an updated list of addresses and contact numbers, but this database is separate as well. We need to make sure that all this information is securely tied together (with all privacy safeguards).

Everyone in my practice team (physicians, nurse, front staff, administrator, social worker, dietitian, clinical pharmacist, residents) is now using the EMR; there is no paper record. We communicate via the record. If there is a problem, I get an electronic message, and it is tracked--and I want to hear about it. I recently had a difficult mental health issue, and my social worker sent me a message remotely, which prompted me to call the patient--the chronological story was recorded in the record.

A physician in my group was not receiving her pap results; I believe that a database error at the lab caused them to be sent to the wrong location, and the other office simply bounced them back to the lab. They were never forwarded. It takes 3 months for us to get our paps back, making it difficult to remember who had the test. Because this physician had decided to generate her pap reqs within the EMR, she was able to generate a list of all pending paps so these could be tracked. We know that the system sometimes fail us and fails our patients; being able to track things in the EMR has a lot of value; you would think that everyone recognizes this, but that is not the case--and sometimes the problem is one of communication.

One of my electronic reqs for Diagnostic Imaging was rejected, because it did not look like the standard paper req. My problem was that I became so upset by this that I was going to make the issue worse by not communicating; I decided to phone instead (after calming down a bit), and they were more than helpful in helping me to resolve this. The problem turned out to be that the person receiving the reqs at the front had not been notified, and found the fonts too small. I can understand this; I'm also a bit past high noon, and can't suture without drugstore glasses anymore. Communication is a two way street; it will take a lot of it to change this system.

This enormous process of change that we are undergoing is a social one. In this system, we function as independant units far too often, and we need to start talking to each other more. The EMR is of incredible value in enabling this type of communication; there is no one in my practice team who would go back to the old way. However, EMRs are still isolated within the whole system, and we continue to have far too few electronic links. Perhaps once we can talk more, we will talk more and better; as the CPSO puts it, "among health-care teams (and in any field), the best communications feature a clarity of roles, a unity of purpose, the ability to not just carry out orders but share ideas, and respect for each other's professionalism and views. That's what will allow any team to take flight."

Ministries and regulatory agencies need to recognize this need for communication, and to enable it. This can't be the responsability of individual teams alone.

Michelle

The spread of EMRs

We had our monthly departmental meeting recently; about 50 to 60 local family physicians regularly attend. These colleagues tend to be more involved in the department (teaching, committees etc) than those who don't attend. My hospital is community-based, but has a strong teaching mandate, especially in family medicine; several of us are involved in research activities.

Our Chief asked people who are or were about to start using an EMR to raise their hands. About 85% of those present did so. Granted, this does not represent all of the family physicians in this area, but it was impressive to see this. Perhaps we have a technology cluster in this area. Certainly, EMR is a frequently mentioned at our meetings. We recently had a brainstorming session for priorities for our department at our executive; members then voted on their top two priorities. The #1 priority was linking the hospital and the community EMR electronically: we all want to reduce scanning. This has not happened yet, but now there is vocal demand for it.

I belong to a Practice Based Small Group (PBSG); we meet monthly for ongoing medical education, since 1995. A year ago, I was the only one using an EMR. This year, out of 11 physicians, three are currently using EMR, three have purchased and are about to start, and two are in the process of buying an EMR. Only three of us do not have immediate plans to start. We use four different EMR systems, which is going to make sharing information and EMR processes a little challenging!

I think that, at least in some geographic areas, we are now past the early adopter stage, that is, an Early Majority of physicians are now purchasing these systems. Purchasing does not mean implementing; I think we will continue to see implementation failures, and the focus of support may need to change towards supporting those who have purchased, rather than encouraging purchases.

I write the occasional PBSG educational module; we have just finished work on the module on Depression. It incorporates some information relevant to physicians using EMRs. I think EMR-specific information will become increasingly added to other types of medical communication and educational materials, as more physicians adopt these systems.

I will be attending the Quality Improvement and Innovation Partnership (QIIP) introductory meeting this week. This is for members of Family Health Teams interested in systematically improving quality in their practices. Although having an EMR is not a requirement, I don't think that many QIIP Teams are still paper based; it is simply too difficult to audit practices without electronic means. Our FHN administrator, our RN, our FHT Clincal Pharmacist and Dietitian are on the Team. It is a good mix. The FHT Executive Director and Medical Director will also be coming. We have two EMRs in our FHT, so a team using the other EMR application will also be participating--and I think this is a very good thing. Unfortunately, some of us have become very proprietary about our EMR application (my EMR is better than yours), and we sometimes forget that we are all on the same Team. Having us participate as a Team in the same project will help us figure out what is similar about our EMRs, and how we can run programs in common across applications (at least to some degree). Or, perhaps we'll have some competition as to who can provide better quality--and that's not a bad thing to be competing about.

Michelle

Structure, process, outcome

An academic group I belong to has been having a pretty lively discussion on the initial difficulties with starting an EMR. There is consensus in this group (in which everyone is using different EMR systems) that, for the first little while, there is a lot of loss of efficiency. You are quite a bit slower on the computer than on paper. The gains don't come until later, and many people still find that recording a consultation in the EMR (while the patient is in the room) is slower than on paper.

Why is that? Paper is simple. You write things down. It doesn't matter how you write things down. Paper doesn't crash.

The benefit of the EMR is that you can have point of care reminders and you can mine your data for useful information at the practice level. This doesn't happen until (and unless) you enter information consistently, and in the right areas--in other words, you have a well-tempered chart. It is harder to do that than to just jot something down on a piece of paper, and the EMR can make it difficult to enter things in the right area. I went to a conference where the keynote speaker, a GP from England, showed a short clip of how he struggles to write a prescription--after more than a decade of using EMR.

The initial difficulties are magnified by the start-up problems inherent in this technology. Let me explain what I mean by that.

The EMR involves both software and hardware. The hardware means lots of different machines that all have to work properly together. The number of hardware permutations and combinations (servers, routers, firewalls, connectivity, networks, printers, scanners, labelers and all their assorted drivers and software applications) is very large. Failures due to issues involving hardware are very common since there are so many possible points of failure, and can be very difficult to diagnose. There is no dedicated funding for hardware maintenance, nor local expertise in most small medical offices. The EMR companies know more about their own software than about our hardware; they cannot possibly be aware of all the different hardware pieces present in many different offices (unlike corporate branch offices, each medical office is an independant operation, with an individual IT setup). Sometimes the EMR company can't help with hardware problems; we have machines from different vendors, and it can be very difficult to know who to call for help. We also lack the knowledge to plan for hardware failure and redundancy.

"Structure" failing means your printers won't print, your computer doesn't work, you can't connect to your server, your speed is slow. If you don't have a sound Structure, you can't even get to your Processes, and you certainly can't change your Outcomes. Structure is where many EMR projects fail to launch, and the root causes of this are systemic (see above). Paper has a very simple basic Structure (filing cabinets, file folders, pieces of paper), and can't fail at this stage. EMR can, and does.

"Process" is the way in which we do things. If you can't access your records because of a Structure failure, this is moot. If you have solved the Structure problems, then you have to tackle Process; not always easy or intuitive--takes time and thinking. Those that have not bought into the EMR, but are just there along for the ride because their group got one, are much less likely to invest in this. They may benefit from herd immunity, because the group is now functioning better, and the front staff is more efficient--but will be slower with their own patients and in most aspects of their practice.

"Outcomes" is where the big payback happens. This means that the quality of care actually changes: more of your diabetics now have their BP at goal. This requires the ability to not only enter data properly (good Structure and Processes), but also the ability to audit your data and then decide what processes to change, and then re-audit. This is present in potential form in the EMR, but cannot and will not happen unless and until we solve the earlier steps--and if this doesn't happen, you will continue to see studies showing that the EMR is not making much of a difference.


We had a FHN meeting recently; we regularly have EMR booster education sessions at our FHN meetings now. I demonstrated changes since the recent upgrade, such as improvements in our drug module and consultation letters; I also handed out notes. I think it is important to have on-going EMR education. Interestingly, the mood was quite a bit different than in some of our previous meetings: we had less complaining (but not zero), and more interest in what the EMR can do for us and our patients. One of my FHN colleagues talked about how he uses his diabetic reminders to recall people who haven't shown for their regular 3 month visit: he can see the list of overdue visits. This represents a change in Process that is likely to produce a change in Outcomes. It took us three years to get to this point.

Structure - Process - Outcome is a very common way to assess the quality of health care. I think it is equally applicable to EMR implemention.

Michelle

EMR transition for the second wave of physicians

My practice partner is continuing on his journey through the transition. It has now been nine months for him. He is definitely not a "techie", but has now adopted the EMR, and has adapted fairly well.

There is no longer any data going into his paper charts; they are now "volume 1" of the record. All his encounters are in the EMR. He started electronic prescribing about two months ago, and is now generating almost all of his scripts through the EMR. Complicated medications continue to be a challenge for him, but he has learned to deal with the commonest issues.

He was still writing referral notes on paper at the beginning, and those were then scanned in the EMR. As well, most of his faxed repeat medications requests were authorized on the paper from the pharmacy, then faxed in and scanned. My secretaries noticed a significant increase in the volume of scanning. He is now doing his referrals via the EMR; if the drugs have been entered in the CPP, he'll just click them on the EMR, and the pharmacy rx paper no longer gets scanned in. If the meds are not in the EMR yet, it is faster for him to write "Ok" on the paper, generating a scan.

He uses flow sheets, especially diabetes and INRs. He has had no difficulties using the eMessaging or To Do notes. He really likes the remote access, and logs on both from home and from the hospital when he is working on the ward.

He is using our preventive services point of care reminders; his rate of flu shots (88%) is better than mine (86%)! He is now part of our FHN's regular preventive mailing program for the past several cycles. Our FHN administrator will be mailing the next letters in early February.

His CPPs are not finished. His practice is older, and has more complex patients with big CPPs than mine. Putting in this data certainly is a massive job, and I think it will be better for him once this is done; it is one tough slog.

He knows how to access and manage his electronic lab data and scanned data. He is now regularly using electronically generated electronic lab reqs, and is using some of our bundled reqs as well. He is less comfortable with DI reqs, but uses them.

We sometimes go over tidbits of EMR information in the evening if neither of us is too tired. That is useful, because it involves things that he has questions about and is very practical and short. He periodically asks me to show him things during the office. My office administrator is very helpful, and will show him things when he is ready as well.

We are now scanning and shredding his paper charts; we have hired a temp to do this. All of the "inactive" charts are gone, and we are now starting on the Deceased. The charts in our back closet are gone. My partner's office currently looks like a bit of a disaster zone, as there are charts piled everywhere, but I expect this to start getting better now. We are planning to move to the new office this summer, and should be completely paper-free by then.

I think that the transition is more manageable for the second wave of physicians, that is, those transitioning once office EMR processes are already in place and working well. There is more in-house knowledge and support. There is still additional stress and time during the transition for the physician, as you have to learn the EMR and put in all the data, but it is less than for the first wave (and that is a good thing). Patience, willingness to learn and to help, as well as a sense of humour all help.

It is possible to have completed most of the transition, even for non "techy" physicians, by nine months. It does require some extra support. It would have been nice to have this for the first wave.


My EMR company has now started web-based training on a regular basis. I think this is very helpful. I attended the first session; what happens is that you have a trainer and several physicians phoning in via teleconferencing. Everyone logs in to the same website, and the trainer demonstrates various aspects of the EMR. This is a good way of doing training for IT, because you can see what is happening right in front of you. The session was 1 hour, which is a good length, I think. We will be having our first user conference in May, and I've been asked to do a seminar. I'm not sure what I am going to do yet, maybe "the efficient office visit".

We will be having an EMR booster session for my FHN in mid-February. I am now familiar with the features in the new version, so that I can demonstrate the most important elements. I think we are starting to do better with our ongoing training.

Michelle

What to do when your connectivity fails

We had a long, hard look at whether to change to the new ASP model run by eHealth Ontario--eHO--(previously called Smart Systems for Health Ontario, or SSHA), or to continue with our server, based at the hospital.

We decided to continue with our server for now.

There are several reasons for that decision. While I strongly believe that ASP is the way to go over the long term, I am reluctant to switch today. We now have good IT support for the server, through our own IT manager, and have bought additional hardware insurance. The server generally functions well and is closely monitored.

I cannot say the same for our connectivity, which is managed by eHO. We have had several outages in the past six weeks, and two outages this week. On Tuesday, we were off for the whole morning, as the eHO lines were down. Regular Internet was fine, so I was running on my backup line.

Trying to run a backup Internet line using the rules imposed by eHO is a daunting task. We have to use a SOFA (Small Office Firewall Appliance), through which the internet line connects to the office. I have a second, private, internet line coming to my office in case of failure. I had a private company install a failover router, so that the second line picks up when the first one fails. That itself failed the fist time SSHA's internet line went down. When SSHA was back up, the private modem interfered with the SSHA modem, so we could not re-connect properly.

What I had to then figure was how to force the two system to cooperate (a bit like what is happening between all the different players in the EMR field).

Basically, when we fail to connect to our server, we check Google. If that fails, then we know that it is the eHO lines (again). We go to the back closet, turn off the eHO modem and turn on the private internet modem. The private modem bypasses the SOFA, and is connected straight to the main router for my office.

What that means is that we have to connect via VPN (which is our bypass software). I have the VPN software installed on every computer at the office. We load the VPN, and then log on. VPN is not meant to be used in this way, so we sometimes get kicked off the EMR, but at least it works somewhat.

I have a list of instructions posted on the wall besides my router, just in case this happens when I am not there. I have shown my practice partners and my office administrator, so they know what to do. There is no help or manual to figure this out, and the way I have done it is by learning from my mistakes with each subsequent failure; I do not think that this is a good way of planning for problems.

When the eHO lines go back up, we reverse the process. We have to then wait for 5 minutes for the eHO internet lines to connect, so I either wait for a call from our IT guy letting us know that we are good to go, or we try at lunch. We can't do this in the middle of the office, as physicians are seeing patients, and staff are fielding calls and incoming patients at the front.

Today, three HydroOne transformers blew near my hospital, so all internet connections coming into the hospital are affected. We have no service at all, even through backup. We are now starting to wonder if we should have a backup line going to the server--if eHO allows this.

These issues have affected our decision on ASP. The ASP server is hosted at eHO's facility. Their service and communication (we still don't know what happened Tuesday) have been consistently less than stellar--and we are still off-line at the time I am writing this. It would be fair to say that we do not trust that organization with hosting a server managing our data; I think they will have to demonstrate improvements in reliability and communication before we reconsider.

We have to deal with eHO for the lines coming to our new office. I have just received forms for the Order Agreement, which I do not fully understand. I will need help filling those out; I am now frankly worried about whether that organization can supply the connectivity for the 80 to 100 people who will be accessing the EMR remotely in the new location. I guess we'll have to see what happens.

Michelle

Adding more machines

My partner's tablet just spent a month in the shop getting fixed, as there were several things wrong with it (bit of a lemon). It came back after major transplants, and is now working well.

However, we were short 1 machine for a while. He took the Resident's tablet while his was away.

I had bought a very small computer for travel recently (the Acer Aspire). This machine costs $400, and runs Windows XP. During the past month, my RN and the residents used it (they don't need reading glasses). The nurse told me she likes the little machine better than the Toshiba laptop that was also available, as the Acer is much more portable. I found it somewhat surprising that something so small (and inexpensive) was actually useful; the EMR actually runs well on it.

I did not add MS Office to the Acer, as I don't need it; I downloaded OpenOffice, which is free and runs my word processing well.

We only use a fraction of the computing power on most of our machines, and most of what we use is repetitive. Much of the slowness in computers is due to adding new software (especially software that loads at start up and takes up a lot of memory), and not maintaining the hard drive. Hard drives need to be defragmented from time to time.

I don't like Vista all that much; I'm used to XP, and my network runs well with it. I'm not enough of a "techy" to be able to figure out the Vista-XP network problems (and I'm not that interested in doing it). The problem is that new computers have Vista on them. I'm going to need some additional computers for my new office, and I've been thinking of buying some good off-lease Dells, which are sold by several reputable companies. They're about $350 to $450 each. I'll put OpenOffice on the new machines.

The Family Health Team's Allied Health Professionals working in my practice all use the EMR now. The clinical pharmacist has been using it the longest and is very proficient. The dietitian uses it routinely. Our new Social Worker just started entering electronic notes; I sent her a message in the EMR, and was pleasantly surprised to receive a note back within two hours--she was logging in remotely.

What we had decided to do was to have everyone record things in the clinical notes instead of in separate areas of the chart. You can view a summary of the clinical notes which indicates which provider signed off, so it is easy to find the dietitian's notes if I need to review them. However, if a note is scanned in I'll see it because I have to review and sign it off. If something is written and signed off in clinical notes, I can't tell that there is a new entry and may not see it. What we decided to do is have our Allied Health Professionals send me a message in the EMR that there is a clinical note to review. So far, this seems to work well.

I now send a message within the EMR to our pharmacist that there is a patient to see her. As well, she now has her own schedule in my practice, along with "pharmacist appointment" that with a special colour. My staff is starting to book patients directly into her schedule. I think an e-message or direct booking are far superior to faxing a referral. I'd like to try this with the other members of our team.

I need to make sure that there are enough machines for everyone when they come in. On Fridays, the social worker and dietitian are in. My partner is in, as well as her resident; they need the Toshiba laptop and the Resident Tablet. I have an older Dell laptop in the office, as well as that new little ACER. However, if one of the machines goes down, we're now short. I just bought an off-lease Tablet for $700 (same machine as what I am using). We now have far more people in my office than when I started the EMR almost three years ago, and most machines are in use most of the time. It shows you that you really have to think about expansion when you start an EMR, and the investment in hardware does not stop; you can't see patients unless you have access to the record, and you can't have access to the record unless you have a computer.

Our fax machine bit the dust. My secretary bought a new one, a Brother MFC 7220. It came with some interesting sofware that makes faxing from the computer much easier: print the document, choose PC Fax and you have a single pop up to enter your fax number (or you can load your address book and choose a recipient from there). I can also fax from any computer on my network--the PC Fax software thinks it is a printer, and can be installed as a network printer. My staff were impressed, and I think they are going to start faxing straight from their PC very routinely. This even works over the wireless, so maybe I'll install it on the Tablets and laptops. New peripherals seem to be getting much better.

I think that eventually I'll have to replace all of my computers all at once. I'll plan for a new network then, and who knows what the technology will look like. In the meantime, what I have seems to be working.


Our residents have completed diabetic audits for six of my FHN colleagues, so now seven of us have results. 77% of the patients had data on BP, A1C and LDL within the past year available. Of those, 54% were at target for BP (<130/80), 38% had LDL <2, and 57% had A1C <7%. It is not bad, but we should figure out what happened to the 23% of patients with missing data; LDL is problematic, and we need to figure out how to improve those results.

Michelle

Workflow is king: how to maximize a Peer to Peer visit

I did a Peer to Peer visit to some colleagues working in two large group practices, in another city. The visit really highlighted the value of reviewing and updating current workflows. The physicians and staff at this site did a very substantial amount of preparation, which greatly enhanced the value of the visit.

I can certainly give quick tips to my colleagues on how to use the EMR more productively. Much of this comes under the guise of “task analysis”, which relates to the speed and efficiency of data entry. For example, keeping hands on the keyboard (instead of switching back and forth to the mouse) and reducing the number of clicks and travel between clicks needed to achieve a task (especially a repetitive one) can make a large difference. For example, double clicking on the “Invoice” tab to bring up a bill is much faster than clicking “Invoice”, then “New Invoice” in a different part of the screen. I use the Tab button to go to the next cell, instead of the mouse, and I use the spacebar to fill in a checkbox, not the mouse. However, there is much more to workflow than individual data entry.

My colleagues had structured the visit over two days. The first part was a large group session, with the EMR being projected on a screen (using dummy data). They had prepared questions ahead of time, and asked me to demonstrate different areas of the chart. The benefit of having a clinician do this (instead of an EMR company representative) is that I have had the chance to think through all the various issues in actual practice and with patients, because I am familiar with both practice and EMR. As well, I am not financially tied to the company, so I have the freedom to show where the bugs are, and how to get around them.

There was a lot of interaction and many questions during that initial 1.5 hour session; I spent most of the session demonstrating the “quick tips” above. Once that was done, we went to see the scanning area, and the front area, and I spoke with a nurse and an administrator. This group had clearly decided that EMR implementation was done as a team, and wanted to make sure that I saw how different areas of the clinic functioned; this is the right approach to take. We went through what happens when a patient checks in at the waiting room, then gets their initial work up (done by a Practical Nurse), and then gets put in a room. What was really interesting was that the lead physician identified bottlenecks in flow as we were going through the clinic; the first step in solving a problem is to actually see what the problem is. At lunch, we went over the bottlenecks as a group, and brainstormed several possible changes.

For example, I saw the front secretary taking calls, checking patients in, and being handed a couple of papers by another staff member. There was a small queue of patients waiting to give her their health cards, and the phone was constantly ringing. The problems here are that incoming calls can’t always be answered and patients can’t get through on the phone; this leads to call backs and telephone tag (extra work, less patient satisfaction); as well, multitasking can make it challenging to do work well. One of the things we came up with was the concept of the “front and back”: the front secretary could direct traffic (greet patients and check them in), but not answer phones, and the back secretary could answer the incoming calls and do outgoing calls as needed. Any papers or tasks that do not have a direct impact on the front need to be given to the back secretary. We also talked about management of notes that are paid for privately; in my office, these are printed at the front (not in the physician’s office), and payment is received at the front. Payment, in other words, is directly linked to work produced (the form). What that will mean at that site is networking the front printer to all of the clinic’s PCs, and having agreement on a common workflow for the notes and payment from all clinic members. The front secretary can handle payments, unless the clinic prefers to direct patients to the back secretary for this.

For the second day, I went to the other site, and again observed different areas of the clinic. We then had several small group sessions with a projector, to go over particular problems that had been identified. For example, one of the administrators was having difficulty with large group scheduling. We sat around the table with her; there was a lot of discussion and input, ideas were flying back and forth, and we kept trying different scenarios on the projector. Within a half hour, the issue that had caused her a large amount of stress was substantially resolved. She still has the work of implementing the suggestions, but we could all see that the problem was solvable.

We then had an additional large group session. Several physicians had already tried some of the “quick tips”, and were happy with them. We discussed further improvements in charting, such as using coded entries for chronic conditions. I showed how to rapidly enter data in the CPP, as this had been a common query. This session gave everyone a chance to solidify the gains that they had made in the previous day, and to think about additional changes.

The last part of the day was a “debriefing” session with the key physicians, staff and the unit administrator. The administrator ably helped the group to decide which changes in process they were going to implement first and how, and which changes were going part of the next phase.

We have planned a return visit to my office in several months; I think a very worthwhile thing to do is for one or two of their key admin staff to spend time with our FHN administrator. We did this following another P2P meeting, and it worked well; you can’t change processes if you don’t involve all staff, and I wish the program allowed non-physician members as P2P consultants--in other words, a Team consultation.

What was done at this visit shows how to maximize the value of a consultation; the more you put in, the more you get out; have good processes in place for the consultation itself. The value to this group was largely due to the fact that they were well prepared, had clear questions and goals, and were ready to consider how to implement changes at the end. It also helps to have a cohesive group, were there is mutual respect and good communication between team members. I was very impressed with this group.

I am starting to wonder if one of the outcomes of this Peer to Peer program may well be the formation of a group of physicians familiar with both EMR and workflow analysis in primary care practices. This was not the intent of the program, but EMR implementation is so intimately tied with workflow re-design that an effective P2P physician must address both. There are already practice management consultants (through organizations such as MD Management), there are physician leadership training programs (PMI), and there are “EMR experts”; what I don’t know is whether there are “cross-overs” familiar with primary care practices—and those are the ones who may be the most useful as we transfer from paper to EMR. Perhaps Infoway should discuss this with the Practice Management people.

Michelle

After the upgrade

We are now a week and a half post-upgrade. My stomach acid level is starting to decrease.

As expected, we had some problems with the printers. In my office, my prescriptions wouldn't print from the application. I took screen shots and printed those, then hand signed them.

The problem was due to the Java program. It doesn't work properly with the new version. Java allows me to sign my prescriptions and consult letters on my Tablet. I found that when I disabled this feature, I could print; some pharmacists are going to be happy--I can't sign on the tablet any more.

In order to determine what the problem was, Helpdesk had to remote into my tablet to test things, which took about an hour. I have spare laptops, so I could keep working while this was going on. I told them that I could live without the signature for now; that can be fixed later.

We then had trouble connecting to the EMR on Friday. Everyone assumed it was because of the upgrade, but in fact it was SSHA (now called eHealth Ontario) that had a service breakdown; it took quite a while for our IT guy to determine what the issue was. Late on Friday afternoon, he reported that the issue at SSHA was "flapping vanes" (I have no idea what that is), and that they had resolved it.

By Monday, the system was working again.

I then started to have a look at what is new in the EMR. We have a pretty good method of generating lists of rostered patients meeting different criteria (not previously available). I could more easily generate a list of percentages of elderly patients who have had their flu shots this year; we are currently at 77.9% average for 12 physicians (2,965 eligible patients), with 50% of the physicians having given shots to over 80% of their eligible patients. Last year, we ended up with 71% of patients vaccinated.

We have until the end of January to complete our flu vaccinations, so I expect us to go over 80% as a group.

We mailed letters of invitation once the shots came in; we had our clinics set up, with the help of FHT nurses. In early December, our FHN admin sent a reminder letter to all patients who had not had a shot yet. I think our preventive group project is working well.

The new upgrade includes automatically generated and tracked lists of patients overdue for Fecal Occult Blood screening, similar to the four preventive services (flu, paps, mammos, Kids vaccines) we currently track and manage as a FHN. We previously had to program FOB screens individually. I think I will use the Summer Students to enter the initial data, and then we'll add this service to our current regular mailing, which is done every 3 months.

I will be having a look at the other goodies in the next few weeks, and then will plan an EMR booster for the group in the new year. I think EMR upgrades are all like that; expect some initial glitches, work to solve them, then go on to figure out what is new and how to implement it.


Our FHT clinical pharmacist is currently under-used. I think the problem is that she doesn't come to the different offices on a regular basis, so we don't always think of her. This is a new service in family medicine, so it will take a while to work in; talking to the pharmacist in person is pretty vital to integrating her into the practice.

We negotiated this with our FHT medical director. She agreed to have the clinical pharmacist spend a morning every second week in my practice. I am ready to let her prescribe for my patients, as she has the skills and knowledge to do so. We have worked on medical directives together, and I am ready to sign the document allowing her to prescibe. I will also have to change her EMR permissions with respect to prescription rights. One of the problems that I foresee is that community pharmacists may not be familiar with directives, and may not accept a prescription signed by a clinical pharmacist. What worked in another FHT is having the pharmacist call the prescriptions in after issuing them (but not printing them) in the EMR. We can do that as well, or the FHT pharmacist can assign the call to my front staff electronically. We'll have to practice this in January.

We have applied as a group to QIIP, the Quality Improvement and Innovation Partnership. I will be going with our FHN administrator, my RN, our dietitian, our clinical pharmacist, and perhaps our Social Worker as well. The plan is to use the Team to improve office efficiencies, care for diabetes, and colorectal screening. Although they say an EMR is not a requirement for this, I think it is pretty hard to really implement quality improvement without electronic tools--especially those that allow measurement of quality.

Michelle

Upgrading our EMR software

Our EMR software needs to be upgraded. The version we are currently on does not conform to the new OntarioMD requirements (Clinical Management Systems Version 2.0). We are getting the upgrade next Tuesday.

I view upgrades with both anticipation and trepidation. The anticipation is about the new features (improved medication management, vastly enhanced ability to search the record). The trepidation is about the unknown problems that we will face: will our printers and labelers still work? Are there bugs that we are not aware of?

These programs are now so complex that it is impossible to predict what changing things will do. As well, each province sets its own requirements for EMRs, and the software applications are programmed to meet these requirements. The requirements are usually tied to funding, and are thus more important than user requests; you get the system you plan for.

I understand that it is quite expensive for each EMR company to meet the requirements, on the order of $200,000 to $300,000 per province. This will make some of the smaller companies drop out of the market (not necessarily a bad thing in the long run). However, there does not seem to be a rigorous process for testing the new software, which means that physicians and other front line users are exposed to what is essentially an untried product. Even Microsoft can have missteps with new releases (see Vista).

Another issue is the interoperability factor. Some large physician groups have managed to negotiate a connection between their system and their hospital's system. However, these are currently one-off solutions, meaning that they cannot be replicated. The difficulty here is that the software upgrade needs to be tested in the environment it is currently in to guarantee continued interoperability. Two things can happen:

1. Testing does not happen, and interoperability (or parts of it) fails with the upgrade, or
2. Testing does happen, but only after a long delay; that group is now several versions behind their colleagues

I hear that these issues are common in the business world as well. Even large, enterprise-level databases (such as Oracle or SAP) cannot be completely tested; the results of new implementations can be dropped customer orders, difficulties connecting electronically to large external customers, materials being shipped in twice the quantity ordered due to software bugs, and difficulty with planning production due to missing/incorrect information. Testing can take so long that implementations are rushed in due to deadlines, with unknown consequences.
It takes time, money and work to fix the universal initial software problems, and these may be less available in small medical offices than in large corporations.

We received a 47 page document a few days ago on what is available in the new version of our EMR, as well as a 10 page document on medication enhancements. I am going through the documentation in preparation for the upgrade. However, I am concerned about my FHN colleagues; most of us are unprepared, and have had no training with the new version (and may not have the time to go over the documentation). I think what will happen is we'll get the upgrade, I'll give it a few weeks to see what the issues are, and then we'll schedule a booster learning session for my FHN. I think some formalized training may be useful: it is not necessary to train the whole group; having a web session for the "super-users" may be what's needed, as we can then spread the knowledge to our colleagues.

Michelle