It is now four weeks since I switched over to EMR. For the past week, I have felt very comfortable using the Tablet routinely for everything; the EMR is now becoming an integrated part of my practice. What works for me is carrying the computer around in Tablet mode, and opening it as a laptop in the exam room. I like typing better than writing, and I don't see why I should store my bad handwriting in the computer. I type during part of the patient encounter as I am listening to my patients. Some of my clinical notes are starting to get completed during or right after the encounter, and I plan to get more of them done that way.
One of my colleagues said that his notes became much better once he switched to EMR: the usual scribbled information looked very scanty when typed, so notes became much more complete. Templates can also put a lot of information in the record very quickly.
What happens during the encounter is that I start typing in the clinical notes section. If there is a problem that needs a template (for example, a cold), then I load and fill the template. Other issues continue being written in the clinical notes section. It splits up the subjective/objective part into several sections, but seems to work.
I've made a template for my abdominal examination (Abdomen soft, bowel sounds normal, no hepato/splenomegaly, no masses, no tenderness). If there is something abnormal, I just uncheck the check box and write comments. Templates are really good for automating things that you do over and over again, and for documenting groups of normal findings.
The ability to look at sequential results for electronic labs is interesting. I had a patient with a mild anemia, who had another blood count done two weeks later. I clicked on the check box beside her hemoglobin, then clicked on the tab for "tabular results", and showed her that her hemoglobin was 107 two weeks ago, and 112 two days ago. This is much better than leafing through paper lab results. The software also does graphs; you click on the "graph" button. This is very useful for on-going conditions, such as A1C's for diabetics, or INRs.
I had a look at the scanner that I bought. It can scan documents into Adobe Acrobat pdf format. It also can do "duplex" scanning, which means that it takes a picture of the front and the back of a page at the same time. You can put 50 pages in the automatic document feeder, and it scans 25 pages a minute (or 50 pages if you do front and back at the same time). I tried that for some of my clinical notes, and the pictures are really clear and sharp. This is very interesting, because it means that archiving charts of my transferred or deceased patients is not going to be all that difficult or take all that long. I will get the clinical notes scanned in duplex, and the lab forms/consult letters in simplex (one side of the paper only). We'll call the files something like Doe, Jane clinical notes, and Doe, Jane labs; I'll hire a student in the summer to do this. I'll put the files on CD ROM disks, and keep two copies, one locked at the office, and one locked offsite. You can search for things easily within pdf documents, so this is useful for data retrieval. If this works well, then I'll scan and archive paper charts of active patients, once I've fully transferred to EMR. Maybe I can then sell my filing cabinets on eBay. I wonder what I'll do with all that freed office space.
Michelle
Friday, April 28, 2006
Monday, April 24, 2006
Scanning and working with electronic faxes
We are still having difficulties with electronic faxes. The faxes come into a fax folder on the computer; they get transferred to the scanning software on the desktop. The filing clerk then has a look at them on the scanning console, files them electronically (both under the patient's name, and as a category--diagnostic imaging, consultation note etc), and uploads the report to the EMR.
At least that is what is supposed to happen. We're not quite sure where the faxes actually go; sometimes faxes stay in the fax folder, and sometimes they appear both in the fax folder and in the scanning console software. I found reports for several patients attached to a single patient this morning, so this was uploaded incorrectly. Clearly, the software is problematic and we're having trouble with this process.
Our IT lead has talked to the company, and they told us that a software fix is on the way. As well, I have to minimize the risk of misfiles from scans or faxes. If something is electronically misfiled, it is going to be very hard to trace.
What we decided to do is to print all faxes for now. I will look at them without chart pulls, to make sure that I've personally seen them, and will initial them. We have a "to scan" box, where I will then put the printed faxes. Once scanned, the print will be put into a "pending shred" box. I'll have a look at that box every few days, and if I'm satisfied that I've seen the report electronically and that it is OK, then I'll transfer to the "ready to shred" box. Then and only then will they be shredded.
We found that it is too difficult for my secretary to scan and upload while answering the phones and doing several other things; that is likely to lead to misfiling. What we decided is to leave scanning for the filing clerk, who will do nothing but take care of scans and electronic faxes when she first comes in in the afternoon. I can see that it will be difficult for the clerk to decide what is "DI", what is "cytopathology", etc, so she can allocate the scans properly. I will spend some time reviewing that with her, and explaining it. If that is done properly, it will be easier for me to find things in the electronic chart's sections, but this will not happen by itself. For scans, like for faxes, I told her to put everything that she has scanned into the "pending shred" box; it will only be shredded once I've reviewed it and transferred it to the shred box.
Sometimes patients have documents that need to be copied to the chart, with the original returned to the patient right away. I thought that this could be scanned, but the problem is the scan has to be filed, which is hard to do if my secretary is very busy. What she will do is just photocopy the document, and put the copy in the "to scan" box for later scanning. If, however, it is quiet(er), then my secretary will scan and file it on the spot.
This whole decision process happened this morning, during Monday morning madness (phones ringing incessantly, patients checking in and out). Sometimes you really do have to solve problems on the spot.
I expect the whole fax/scan issue to settle down eventually; however, I want back-up systems until I'm sure we've got the whole thing right. You have to figure out how to minimize the possibility of errors while all your office processes are changing--not that easy to do on a Monday morning.
Michelle
At least that is what is supposed to happen. We're not quite sure where the faxes actually go; sometimes faxes stay in the fax folder, and sometimes they appear both in the fax folder and in the scanning console software. I found reports for several patients attached to a single patient this morning, so this was uploaded incorrectly. Clearly, the software is problematic and we're having trouble with this process.
Our IT lead has talked to the company, and they told us that a software fix is on the way. As well, I have to minimize the risk of misfiles from scans or faxes. If something is electronically misfiled, it is going to be very hard to trace.
What we decided to do is to print all faxes for now. I will look at them without chart pulls, to make sure that I've personally seen them, and will initial them. We have a "to scan" box, where I will then put the printed faxes. Once scanned, the print will be put into a "pending shred" box. I'll have a look at that box every few days, and if I'm satisfied that I've seen the report electronically and that it is OK, then I'll transfer to the "ready to shred" box. Then and only then will they be shredded.
We found that it is too difficult for my secretary to scan and upload while answering the phones and doing several other things; that is likely to lead to misfiling. What we decided is to leave scanning for the filing clerk, who will do nothing but take care of scans and electronic faxes when she first comes in in the afternoon. I can see that it will be difficult for the clerk to decide what is "DI", what is "cytopathology", etc, so she can allocate the scans properly. I will spend some time reviewing that with her, and explaining it. If that is done properly, it will be easier for me to find things in the electronic chart's sections, but this will not happen by itself. For scans, like for faxes, I told her to put everything that she has scanned into the "pending shred" box; it will only be shredded once I've reviewed it and transferred it to the shred box.
Sometimes patients have documents that need to be copied to the chart, with the original returned to the patient right away. I thought that this could be scanned, but the problem is the scan has to be filed, which is hard to do if my secretary is very busy. What she will do is just photocopy the document, and put the copy in the "to scan" box for later scanning. If, however, it is quiet(er), then my secretary will scan and file it on the spot.
This whole decision process happened this morning, during Monday morning madness (phones ringing incessantly, patients checking in and out). Sometimes you really do have to solve problems on the spot.
I expect the whole fax/scan issue to settle down eventually; however, I want back-up systems until I'm sure we've got the whole thing right. You have to figure out how to minimize the possibility of errors while all your office processes are changing--not that easy to do on a Monday morning.
Michelle
Wednesday, April 19, 2006
Electronic lab results
My lab results came in electronically today. When I looked at my practice summary page this afternoon, there was a message saying that 147 labs were waiting for my review. The lab system sends the reports directly to the patient's chart. They also automatically flag abnormal results.
When I clicked the link to the lab results, all the results were there in two lists: abnormal (alphabetically by patient last name), and normal (same). The lab sent me all my results since March 23rd, which is why there were so many. To access each lab report, I clicked on the patient's name in the list, and the report came up, with abnormal tests highlighted. There is a section where you can make comments (I just put a "N" if the abnormality was irrelevant). You can print the whole report, or a subsection to give to the patient. You can also forward a note to your staff (for example, call the patient to let her know that the results were normal). When done, one click files the lab into the electronic chart.
Reviewing all these results and filing them electronically took me about 20 minutes (I'd already seen them before). My secretary would not have been happy if she had to pull 147 charts, put the results on the front, and then file the charts away again. I told my staff not to pull charts for lab results anymore, starting tomorrow. They will just give me the paper lab results unfiled; I want to make sure that there are no problems with the electronic results. If the two match, then the paper reports will be shredded. In a little while, I'll ask the lab not to send me paper reports anymore. The system checks for results every two hours; I'll have faster updates than through the current courier system.
I now have several patients who do not have any paper charts. Some are new patients; all new patients have electronic charts only. One new patient transferred from another practice with a bulky old paper chart; we scanned a couple of recent results and relevant consultations into the EMR. The rest went to the back room as a chart #2. Newborn babies do not have paper charts either: we scan the bit of paper we have, and the rest is electronic. The EMR generates percentiles for height, weight and head circumference automatically when I enter the numbers in, and the growth charts are also done automatically.
I'm getting more comfortable with doing some typing in the exam room. I'm a fairly good touch typist, so I can type while looking at and listening to patients.
I bought a docking station for the Tablet. I have a full keyboard and a mouse attached to the station; it also recharges the Tablet while it is docked. I leave it docked at lunch, and when I am finished seeing patients; I find that billing is much faster with the numeric keypad on a full keyboard.
My group is meeting on May 2nd. One of the things we will be discussing is remote access via VPN (see glossary); we don't have this yet, but it is supposed to happen sometimes in May.
Michelle
When I clicked the link to the lab results, all the results were there in two lists: abnormal (alphabetically by patient last name), and normal (same). The lab sent me all my results since March 23rd, which is why there were so many. To access each lab report, I clicked on the patient's name in the list, and the report came up, with abnormal tests highlighted. There is a section where you can make comments (I just put a "N" if the abnormality was irrelevant). You can print the whole report, or a subsection to give to the patient. You can also forward a note to your staff (for example, call the patient to let her know that the results were normal). When done, one click files the lab into the electronic chart.
Reviewing all these results and filing them electronically took me about 20 minutes (I'd already seen them before). My secretary would not have been happy if she had to pull 147 charts, put the results on the front, and then file the charts away again. I told my staff not to pull charts for lab results anymore, starting tomorrow. They will just give me the paper lab results unfiled; I want to make sure that there are no problems with the electronic results. If the two match, then the paper reports will be shredded. In a little while, I'll ask the lab not to send me paper reports anymore. The system checks for results every two hours; I'll have faster updates than through the current courier system.
I now have several patients who do not have any paper charts. Some are new patients; all new patients have electronic charts only. One new patient transferred from another practice with a bulky old paper chart; we scanned a couple of recent results and relevant consultations into the EMR. The rest went to the back room as a chart #2. Newborn babies do not have paper charts either: we scan the bit of paper we have, and the rest is electronic. The EMR generates percentiles for height, weight and head circumference automatically when I enter the numbers in, and the growth charts are also done automatically.
I'm getting more comfortable with doing some typing in the exam room. I'm a fairly good touch typist, so I can type while looking at and listening to patients.
I bought a docking station for the Tablet. I have a full keyboard and a mouse attached to the station; it also recharges the Tablet while it is docked. I leave it docked at lunch, and when I am finished seeing patients; I find that billing is much faster with the numeric keypad on a full keyboard.
My group is meeting on May 2nd. One of the things we will be discussing is remote access via VPN (see glossary); we don't have this yet, but it is supposed to happen sometimes in May.
Michelle
Sunday, April 16, 2006
Having a bad day
Last Wednesday was a bad day. I could not look at my scanned documents (a phone call to helpdesk), then I had trouble accessing the server and finally could not access it at all (another call to helpdesk). The Passover Seder was that night and I had to leave on time; I was also short of patience and very irritated. My lab is still not coming in, and I will be sending off another email to the lab company to remind them to start sending electronic reports. Some scanned images are printing as landscape instead of portrait, with nicely elongated letters. My Tablet crashed.
I also got a phone call from a patient asking why her glyburide was changed to bid. Her pharmacist noticed and called her. It is very easy to choose "bid" from the drop down list instead of "od". This was for one of the first prescriptions I wrote, on March 23rd. I apologized, and explained why this happened. It is challenging for me to transfer every single prescription to the EMR, and I am now very paranoid and very careful about re-reading what I print. As I was talking to her, I updated the glyburide order on the chart; at least I know that I cannot make that mistake when I refill her medications.
I have to remind myself to expect problems, especially at start-up. Every time I install a new program on my home PC I have glitches, and EMRs are so much more complex. This is where having support really helps; if you don't have this, days like last Wednesday can turn from bad heartburn to major disaster. Most of the time, when I call the helpdesk, they can help me; sometimes they take my computer over remotely and fix the problem. I also get screenshots emailed to me, so I know what to do the next time. Sometimes the person at the helpdesk can't help me right away, and then I get a "ticket", which is a number that they use to track my query. I get an email or a phone call sometime later. The "ticket" seems to be for annoying but not critical problems.
Problem solving is also much easier if you are part of a group. Our IT lead is not shy about making her views known (you go girl), and I've just received an emailed copy of her communication about the landscape printing problem; it is the same at her office. We all have similar hardware and software, so you can see pretty quickly what is a local problem in one office and what is a software glitch that needs to be fixed for the whole group.
I survived; Thursday was a better day, and then I was off for the long week-end.
Michelle
I also got a phone call from a patient asking why her glyburide was changed to bid. Her pharmacist noticed and called her. It is very easy to choose "bid" from the drop down list instead of "od". This was for one of the first prescriptions I wrote, on March 23rd. I apologized, and explained why this happened. It is challenging for me to transfer every single prescription to the EMR, and I am now very paranoid and very careful about re-reading what I print. As I was talking to her, I updated the glyburide order on the chart; at least I know that I cannot make that mistake when I refill her medications.
I have to remind myself to expect problems, especially at start-up. Every time I install a new program on my home PC I have glitches, and EMRs are so much more complex. This is where having support really helps; if you don't have this, days like last Wednesday can turn from bad heartburn to major disaster. Most of the time, when I call the helpdesk, they can help me; sometimes they take my computer over remotely and fix the problem. I also get screenshots emailed to me, so I know what to do the next time. Sometimes the person at the helpdesk can't help me right away, and then I get a "ticket", which is a number that they use to track my query. I get an email or a phone call sometime later. The "ticket" seems to be for annoying but not critical problems.
Problem solving is also much easier if you are part of a group. Our IT lead is not shy about making her views known (you go girl), and I've just received an emailed copy of her communication about the landscape printing problem; it is the same at her office. We all have similar hardware and software, so you can see pretty quickly what is a local problem in one office and what is a software glitch that needs to be fixed for the whole group.
I survived; Thursday was a better day, and then I was off for the long week-end.
Michelle
Tuesday, April 11, 2006
Unbound medicine
I've been wireless for two days now, and using the EMR with patients. I had a look at what my colleague, Dr. Brookstone, said about using the EMR in the examination room, and adopted the recommendations. The pamphlet that Dr. Brookstone's site links to is worth looking at.
I start the patient file in the EMR before I go in the room; that way I can say hello to my patient instead of fiddling with the computer. I keep the computer in Tablet mode , so that it looks like a clipboard, and it gets carried in that way together with the paper chart. Before EMR, I did not take very many notes during the encounter (other than numbers, such as blood pressure, because I was likely to forget those). After EMR, this has not changed. I figured out how to enter numbers quickly in the vital signs area using the tablet pen; this replicates writing the number in the chart. I've shown several patients their data on the EMR by picking the tablet up and holding it like a clipboard. My patient sits on the examining table, and we look at it together. This works. One of my patients had come in for an asthma exacerbation last week, and I entered her new peak flow yesterday, and showed the two readings to her as a graph; I think it helped her to see that. She's buying a peak flow meter.
I asked several patients what they thought of this, and had rather positive comments. When I did not ask, no patient commented on the computer being present. When I am not using the tablet in the exam room, it lies on my desk just like a chart would.
I sometimes convert it to laptop mode, when I need the keyboard. This is typically to enter medications; typing is faster than entering with the pen. I tell my patients that it will take a bit longer than usual for me to write the script, as I am learning to use the new system. I expect that doing refills will be faster with pen entry, since you just need to click on the drug's checkbox and hit the "refill" button. I also use the laptop mode to quickly look up handouts and print them.
We used the scanner for the first time yesterday, and got stuck. We had forgotten one of the steps. Another call to the helpdesk; nothing ever works perfectly the first time, and you have to expect glitches. Today, it was no problem. We talked about when to scan, and decided that my filing clerk would take care of this. It is hard for a medical secretary to scan and upload in the middle of phone calls and greeting patients. We made an inbox where all the documents to be scanned and shredded are placed, to be done when the clerk comes in. The faxes are all coming in electronically as well; my clerk will also manage this: some will be printed (for my partner), some deleted (junk faxes), and some uploaded to the patient file.
When my IT trainer was in on Friday, I gave him my home laptop to configure for my office system. I was worried about dropping and breaking the Tablet, and being stuck without a computer. I bought a laptop lock, and am leaving the laptop turned on, beside the vaccine fridge. Now my staff have an extra data entry area, and I can unhook the laptop and use it in case I drop the Tablet. I also have medical students in from time to time, and that is going to be their computer.
I started using the EMR without patients for a week and a half, because my wireless was not set up. By the time I took it in the exam room, I was familiar with basic navigation, and had less problems with finding my way around while trying to listen to patients. This was due to serendipity, but it is not a bad way to do it. You have to be comfortable with excusing yourself from the room to load the encounter and write prescriptions, for a week or two.
Michelle
I start the patient file in the EMR before I go in the room; that way I can say hello to my patient instead of fiddling with the computer. I keep the computer in Tablet mode , so that it looks like a clipboard, and it gets carried in that way together with the paper chart. Before EMR, I did not take very many notes during the encounter (other than numbers, such as blood pressure, because I was likely to forget those). After EMR, this has not changed. I figured out how to enter numbers quickly in the vital signs area using the tablet pen; this replicates writing the number in the chart. I've shown several patients their data on the EMR by picking the tablet up and holding it like a clipboard. My patient sits on the examining table, and we look at it together. This works. One of my patients had come in for an asthma exacerbation last week, and I entered her new peak flow yesterday, and showed the two readings to her as a graph; I think it helped her to see that. She's buying a peak flow meter.
I asked several patients what they thought of this, and had rather positive comments. When I did not ask, no patient commented on the computer being present. When I am not using the tablet in the exam room, it lies on my desk just like a chart would.
I sometimes convert it to laptop mode, when I need the keyboard. This is typically to enter medications; typing is faster than entering with the pen. I tell my patients that it will take a bit longer than usual for me to write the script, as I am learning to use the new system. I expect that doing refills will be faster with pen entry, since you just need to click on the drug's checkbox and hit the "refill" button. I also use the laptop mode to quickly look up handouts and print them.
We used the scanner for the first time yesterday, and got stuck. We had forgotten one of the steps. Another call to the helpdesk; nothing ever works perfectly the first time, and you have to expect glitches. Today, it was no problem. We talked about when to scan, and decided that my filing clerk would take care of this. It is hard for a medical secretary to scan and upload in the middle of phone calls and greeting patients. We made an inbox where all the documents to be scanned and shredded are placed, to be done when the clerk comes in. The faxes are all coming in electronically as well; my clerk will also manage this: some will be printed (for my partner), some deleted (junk faxes), and some uploaded to the patient file.
When my IT trainer was in on Friday, I gave him my home laptop to configure for my office system. I was worried about dropping and breaking the Tablet, and being stuck without a computer. I bought a laptop lock, and am leaving the laptop turned on, beside the vaccine fridge. Now my staff have an extra data entry area, and I can unhook the laptop and use it in case I drop the Tablet. I also have medical students in from time to time, and that is going to be their computer.
I started using the EMR without patients for a week and a half, because my wireless was not set up. By the time I took it in the exam room, I was familiar with basic navigation, and had less problems with finding my way around while trying to listen to patients. This was due to serendipity, but it is not a bad way to do it. You have to be comfortable with excusing yourself from the room to load the encounter and write prescriptions, for a week or two.
Michelle
Friday, April 07, 2006
Looking back at the first week
I've finished my first week after switching to EMR. Since coming back from March break vacation 3 weeks ago, I've logged more hours than usual at the office, probably 1 to 2 additional hours every evening. One reason for this was the post-vacation backlog, but the EMR implementation has been a major factor. I am trying to customize the software to work best for my practice, I have been charting in the EMR, and I am trying to enter at least 2 or 3 Cumulative Patient Profiles every day. There is always the temptation to play with the software, which I've given into way too often.
This Thursday, much to my surprise, I finished at my usual time. My charts were all written up, all my phone calls and letters were done, and I got away 1 hour after seeing my last patient. I can't imagine that this is going to continue, but it was good to see that it was possible.
I'm starting to learn little tricks like using the tab key to switch between fields, instead of the mouse (tabbing is much quicker if you are using a keyboard). I've started to make a template for the preventive health exam.
There is an area in the software that keeps track of pending consultation requests. When I write a consultation request, the software asks me to put in a date to check for the report. I put in "one day" for one of the requests (this was just for a derm consult for acne, but I wanted to see what it looked like). If it is overdue, it is highlighted in red, and is very obvious. Once the report comes in, you can click on the "received" button, and it goes off your list. Most of my requests are for 3 months from the date sent, but I wonder if I should make this longer; I don't usually know what the specialist's waiting list is like. This "pending report" list may be a problem for me to manage; sometimes patients don't go, and I'll have to be very rigorous about taking pending requests off when the report comes in. I already have 19 requests on the list.
I heard from my regular lab. It looks like my lab reports will start to come in electronically next week. I also received a note from the Ministry of Health: it looks like they're finally giving up on the old style lab requisitions, which have carbon copies (bad for privacy protection), and have to be tractor-fed into a dot-matrix printer. The new lab requisitions are printed sheets; EMR software applications should be able to print them straight from a patient's chart, so that the physician's information and the patient's demographic data is automatically entered into the requisition. That will avoid having to print labels for requisitions. As well, I'll be able to track which lab tests are overdue, since the software will be able to match incoming lab with ordered lab. I may have some trouble with that; patients often don't go for tests, and I have large volumes of results. Wading through pending lab data may not be possible.
Today, we had two people from Nightingale in the office, to do the last parts of hardware and training. They installed and configured the scanner, and did some additional training on how to use it. It scans much faster than my photocopier copies. The scanned copy is kept on the computer, and can be filed electronically at any time; if a patient needs their paper back, my secretary will be able to scan quickly, let the patient leave, and upload to the chart later. I can see that, in the future, printing copies of the chart for transfers, legal reports or insurance reports will be much less of a hassle. I think I will still be somewhat selective about scanning old charts, because the scan is just a picture: it is not searchable. This is good for storage only, which is not very useful if you want to find something in a very large file. We do EKGs and PFTs in my office, and those will be scanned into the file; there is a comment field in the EMR, and I will enter comments electronically rather that writing them on the report, so that I do not have to load the whole picture to look at what I wrote.
Electronic faxing was also configured. All faxes will now come into a computer, so we can upload them directly into a patient's chart without having to scan. We can delete junk faxes without having to print them; we can send outgoing faxes either from the computer or from my fax machine.
I now have 3 patient charts that are electronic only. These are relatively new patients to my practice; we scanned the 2 or 3 papers that I have for them, and I entered the Cumulative Patient Profile directly into the EMR. I put an alert into the patient demographic area saying that the record is EMR only, so that my secretaries don't waste their time looking for a paper chart.
The wireless router is now installed and ready to go. On Monday, I start taking my Tablet into the exam room.
Michelle
This Thursday, much to my surprise, I finished at my usual time. My charts were all written up, all my phone calls and letters were done, and I got away 1 hour after seeing my last patient. I can't imagine that this is going to continue, but it was good to see that it was possible.
I'm starting to learn little tricks like using the tab key to switch between fields, instead of the mouse (tabbing is much quicker if you are using a keyboard). I've started to make a template for the preventive health exam.
There is an area in the software that keeps track of pending consultation requests. When I write a consultation request, the software asks me to put in a date to check for the report. I put in "one day" for one of the requests (this was just for a derm consult for acne, but I wanted to see what it looked like). If it is overdue, it is highlighted in red, and is very obvious. Once the report comes in, you can click on the "received" button, and it goes off your list. Most of my requests are for 3 months from the date sent, but I wonder if I should make this longer; I don't usually know what the specialist's waiting list is like. This "pending report" list may be a problem for me to manage; sometimes patients don't go, and I'll have to be very rigorous about taking pending requests off when the report comes in. I already have 19 requests on the list.
I heard from my regular lab. It looks like my lab reports will start to come in electronically next week. I also received a note from the Ministry of Health: it looks like they're finally giving up on the old style lab requisitions, which have carbon copies (bad for privacy protection), and have to be tractor-fed into a dot-matrix printer. The new lab requisitions are printed sheets; EMR software applications should be able to print them straight from a patient's chart, so that the physician's information and the patient's demographic data is automatically entered into the requisition. That will avoid having to print labels for requisitions. As well, I'll be able to track which lab tests are overdue, since the software will be able to match incoming lab with ordered lab. I may have some trouble with that; patients often don't go for tests, and I have large volumes of results. Wading through pending lab data may not be possible.
Today, we had two people from Nightingale in the office, to do the last parts of hardware and training. They installed and configured the scanner, and did some additional training on how to use it. It scans much faster than my photocopier copies. The scanned copy is kept on the computer, and can be filed electronically at any time; if a patient needs their paper back, my secretary will be able to scan quickly, let the patient leave, and upload to the chart later. I can see that, in the future, printing copies of the chart for transfers, legal reports or insurance reports will be much less of a hassle. I think I will still be somewhat selective about scanning old charts, because the scan is just a picture: it is not searchable. This is good for storage only, which is not very useful if you want to find something in a very large file. We do EKGs and PFTs in my office, and those will be scanned into the file; there is a comment field in the EMR, and I will enter comments electronically rather that writing them on the report, so that I do not have to load the whole picture to look at what I wrote.
Electronic faxing was also configured. All faxes will now come into a computer, so we can upload them directly into a patient's chart without having to scan. We can delete junk faxes without having to print them; we can send outgoing faxes either from the computer or from my fax machine.
I now have 3 patient charts that are electronic only. These are relatively new patients to my practice; we scanned the 2 or 3 papers that I have for them, and I entered the Cumulative Patient Profile directly into the EMR. I put an alert into the patient demographic area saying that the record is EMR only, so that my secretaries don't waste their time looking for a paper chart.
The wireless router is now installed and ready to go. On Monday, I start taking my Tablet into the exam room.
Michelle
Monday, April 03, 2006
eDay
Today was the day that I officially switch to EMR. I am definitely getting faster at entering clinical encounters, to the point that I may have tipped over to being faster on the computer. My staff is now entering all heights and weights in the EMR; I have figured out how to have the "vitals" template (which includes height, weight, BP, Heart rate, Peak Flow) pre-loaded into each clinical encounter, so accessing it from that area is a single click. Phone calls are recorded in the computer. I have been notified by one of the labs that they will now be sending me results electronically; however, that is not the lab that I use the most often, so electronic lab reporting is not happening yet.
We are all trying to figure out how to decrease paper as much as possible. The chart for the second patient I saw today could not be located; that is one thing that won't be happening any more.
I have more letter templates, such as a transfer of information request. I have the referral letter process down pat. I have now written over 100 prescriptions, and my "favourite drugs" list is getting to be very useful. It is interesting that the EMR software numbers my prescriptions sequentially, so I know how many scripts I write each week. I can see that I'll be able to search easily for drugs. I get a prescription profile each January from IMS, which is a company that buys information on physicians' prescriptions from pharmacies and resells this to pharmaceutical companies and others. Those IMS summaries never looked very accurate to me, but now, I'll know.
My staff has "read only" access to clinical data in the chart; a patient had lost a prescription and my secretary was able to access that for the pharmacist from the electronic chart. We are getting used to finding out where things are in the EMR.
I can see that I will need to start building templates for XR facilities that I use most often, so I can print XR requests from the computer. I am sure that most places will not mind if I don't use their forms--it is probably more important that the information is clear, complete and legible. My information and the patient's information will automatically be generated on the diagnostic imaging requisition, along with the CPP if needed. I'll get rid of all those paper pads.
I've been trying to figure out how to get information from my tablet as efficiently as from my Palm. The EMR does not have good clinical calculators or decision support (the only one I found is Framingham for heart disease prediction). I'll still need to use outside software for that. The PDA is really good for quick decision help (for example, Medrules) and quick calculations (like MedMath). I found something that I think will work for me at the CMA website, InfoRetriever. It is at www.cma.ca, click on the "clinical resources" tab, then "InfoPoems clinical tools" on the tab on the left, then "InfoRetriever". It is very good for decision help (for example, the sore throat score), but not very useful for calculations, like creatinine clearance, because chemistries are in mg/dl (US values) not umol/l, which is what we use in Canada. I can use the decision help program to look up things, but will have to enter the result manually into the EMR. I wonder if that kind of thing can be integrated in the EMR, so I can load the rule straight into the patient record.
All in all, not a bad start.
Michelle
We are all trying to figure out how to decrease paper as much as possible. The chart for the second patient I saw today could not be located; that is one thing that won't be happening any more.
I have more letter templates, such as a transfer of information request. I have the referral letter process down pat. I have now written over 100 prescriptions, and my "favourite drugs" list is getting to be very useful. It is interesting that the EMR software numbers my prescriptions sequentially, so I know how many scripts I write each week. I can see that I'll be able to search easily for drugs. I get a prescription profile each January from IMS, which is a company that buys information on physicians' prescriptions from pharmacies and resells this to pharmaceutical companies and others. Those IMS summaries never looked very accurate to me, but now, I'll know.
My staff has "read only" access to clinical data in the chart; a patient had lost a prescription and my secretary was able to access that for the pharmacist from the electronic chart. We are getting used to finding out where things are in the EMR.
I can see that I will need to start building templates for XR facilities that I use most often, so I can print XR requests from the computer. I am sure that most places will not mind if I don't use their forms--it is probably more important that the information is clear, complete and legible. My information and the patient's information will automatically be generated on the diagnostic imaging requisition, along with the CPP if needed. I'll get rid of all those paper pads.
I've been trying to figure out how to get information from my tablet as efficiently as from my Palm. The EMR does not have good clinical calculators or decision support (the only one I found is Framingham for heart disease prediction). I'll still need to use outside software for that. The PDA is really good for quick decision help (for example, Medrules) and quick calculations (like MedMath). I found something that I think will work for me at the CMA website, InfoRetriever. It is at www.cma.ca, click on the "clinical resources" tab, then "InfoPoems clinical tools" on the tab on the left, then "InfoRetriever". It is very good for decision help (for example, the sore throat score), but not very useful for calculations, like creatinine clearance, because chemistries are in mg/dl (US values) not umol/l, which is what we use in Canada. I can use the decision help program to look up things, but will have to enter the result manually into the EMR. I wonder if that kind of thing can be integrated in the EMR, so I can load the rule straight into the patient record.
All in all, not a bad start.
Michelle
Sunday, April 02, 2006
How good will my data be?
I spent the past two days at a conference organized by my University's department of Family Medicine. There was certainly a lot of interest in EMRs; it will now be possible to contribute data for large studies. If (God forbid) we ever do get an influenza pandemic, it will be incredibly useful to be able to track things like patient temperatures directly from the charts in family medicine. I remember how helpless and out of touch I felt during the SARS crisis, and I hope better communication will help if there is a next time; SARS killed a family doctor.
The researchers will have to be very careful with protecting patient and physician confidentiality. I have done a bit of research in family medicine, and probably should think about how to use the EMR for that.
The EMRs are customizable, which is good because this lets you put in the data in a way that fits you best. On the other hand, everyone will enter data in somewhat different ways, so the charts will all look different. As well, there is some "free text", which is where you can enter things in any way you like. The free text is the easiest way to enter information, but will probably make it more difficult to search for things in the future. There will need to be some balance between "hard-set" entries, where you have to put in data in a certain way (so that you can do audits for things that interest you and to improve your practice), and ease of entry. A tricky proposition.
Maybe we should think at some point about making records more similar across many practices, so that we can share data more easily (for example, transferring a chart to another family physician, sending data to a specialist, to Diabetes education or to a hospital). I know that Canada Health Infoway is working on common standards (HL-7). It would be good if there was a common standard: if an EMR company goes under, the patient data is too valuable to allow it to be lost. A common standard may help to transfer the information into a different platform.
Perhaps, in the meantime, groups of physicians using the same software application can decide to record things in similar ways. I don't know how easy this would be (probably very hard), or how exactly it would be done. Maybe physicians who are interested could get some help with that.
Michelle
The researchers will have to be very careful with protecting patient and physician confidentiality. I have done a bit of research in family medicine, and probably should think about how to use the EMR for that.
The EMRs are customizable, which is good because this lets you put in the data in a way that fits you best. On the other hand, everyone will enter data in somewhat different ways, so the charts will all look different. As well, there is some "free text", which is where you can enter things in any way you like. The free text is the easiest way to enter information, but will probably make it more difficult to search for things in the future. There will need to be some balance between "hard-set" entries, where you have to put in data in a certain way (so that you can do audits for things that interest you and to improve your practice), and ease of entry. A tricky proposition.
Maybe we should think at some point about making records more similar across many practices, so that we can share data more easily (for example, transferring a chart to another family physician, sending data to a specialist, to Diabetes education or to a hospital). I know that Canada Health Infoway is working on common standards (HL-7). It would be good if there was a common standard: if an EMR company goes under, the patient data is too valuable to allow it to be lost. A common standard may help to transfer the information into a different platform.
Perhaps, in the meantime, groups of physicians using the same software application can decide to record things in similar ways. I don't know how easy this would be (probably very hard), or how exactly it would be done. Maybe physicians who are interested could get some help with that.
Michelle
Wednesday, March 29, 2006
Getting faster
We had our second (and final) training session this morning. We learned how to generate different kinds of letters, and to build our own templates.
I've already been doing letters in the EMR; I've done several referral letters, and now I'm comfortable doing this. I've set up templates for administrative forms that I commonly have to do, such as notes for massage therapy or orthotics. The form is printed at the front, where my patient picks it up and pays for it. This works very well.
My prescriptions are getting much faster; my "favourite drugs" list is getting built up, so prescribing is becoming easier. I have not used my prescription pad since Monday afternoon. I've only gotten one phone call from a very puzzled pharmacist, asking me what "30 doses" of Tylenol #3 were. I have to excuse myself for now, and go out of the room to write prescriptions, so I'm looking forward to having the computer in the exam room with me.
My wireless network is still not up and running, and I have been told that it will be installed next Friday. I don't want to write any more notes in the paper chart; I am jotting a couple of things on paper while in the room, and then write the encounter on the computer afterwards. Putting the clinical encounter in the EMR is now taking me about the same amount of time as writing it on paper, and the notes are much more complete and legible; I am using templates for repetitive things like Upper Respiratory Infections. Today, all my clinical notes were written in the EMR.
I have been putting 2 or 3 Cumulative Patient Profiles per day in the EMR. This is still a time-consuming process, because it has to be very thourough and accurate. Maybe I'll pick one day to do a bunch to speed things up. Once I've transferred a CPP, I write "EMR" on the paper copy, so I know it is done.
My staff will be entering height and weight in the electronic chart; BMIs are automatically generated once you do that, and I will be able to make graphs in the future. I was thinking of buying one of those electronic ear thermometers, so that my staff can check and enter temperatures before I see the patient. Maybe I should buy an electronic blood pressure cuff, so that can be done and entered ahead of time as well; or perhaps I shouldn't--it might be good to leave some work for me!
I should probably do a template for chart forms that I use very often, such as the Preventive Health tables. I can see that I fill out most of the tables at the initial full check-up, and then only go over parts of it at the following preventive exams. I seem to be asking about dental care (flossing), mood, diet and exercise (amongst other things) every year, but I don't need to ask about seat-belts repeatedly. I'll make one big template for the first check up, and then a smaller one for on-going preventive maintenance.
My scanner hasn't been installed yet. Once that is done, we'll start scanning (and shredding, if I see that it works well). I've notified the labs, so I should start getting electronic lab results in about two weeks.
It's a start.
Michelle
I've already been doing letters in the EMR; I've done several referral letters, and now I'm comfortable doing this. I've set up templates for administrative forms that I commonly have to do, such as notes for massage therapy or orthotics. The form is printed at the front, where my patient picks it up and pays for it. This works very well.
My prescriptions are getting much faster; my "favourite drugs" list is getting built up, so prescribing is becoming easier. I have not used my prescription pad since Monday afternoon. I've only gotten one phone call from a very puzzled pharmacist, asking me what "30 doses" of Tylenol #3 were. I have to excuse myself for now, and go out of the room to write prescriptions, so I'm looking forward to having the computer in the exam room with me.
My wireless network is still not up and running, and I have been told that it will be installed next Friday. I don't want to write any more notes in the paper chart; I am jotting a couple of things on paper while in the room, and then write the encounter on the computer afterwards. Putting the clinical encounter in the EMR is now taking me about the same amount of time as writing it on paper, and the notes are much more complete and legible; I am using templates for repetitive things like Upper Respiratory Infections. Today, all my clinical notes were written in the EMR.
I have been putting 2 or 3 Cumulative Patient Profiles per day in the EMR. This is still a time-consuming process, because it has to be very thourough and accurate. Maybe I'll pick one day to do a bunch to speed things up. Once I've transferred a CPP, I write "EMR" on the paper copy, so I know it is done.
My staff will be entering height and weight in the electronic chart; BMIs are automatically generated once you do that, and I will be able to make graphs in the future. I was thinking of buying one of those electronic ear thermometers, so that my staff can check and enter temperatures before I see the patient. Maybe I should buy an electronic blood pressure cuff, so that can be done and entered ahead of time as well; or perhaps I shouldn't--it might be good to leave some work for me!
I should probably do a template for chart forms that I use very often, such as the Preventive Health tables. I can see that I fill out most of the tables at the initial full check-up, and then only go over parts of it at the following preventive exams. I seem to be asking about dental care (flossing), mood, diet and exercise (amongst other things) every year, but I don't need to ask about seat-belts repeatedly. I'll make one big template for the first check up, and then a smaller one for on-going preventive maintenance.
My scanner hasn't been installed yet. Once that is done, we'll start scanning (and shredding, if I see that it works well). I've notified the labs, so I should start getting electronic lab results in about two weeks.
It's a start.
Michelle
Friday, March 24, 2006
First EMR steps
We had our first EMR class on Tuesday. I have to admit that it looked overwhelming at first; there seems to be so much to learn. We learned about the basic set up of the electronic patient chart, how to generate electronic lab and XR requests (and make sure that they are tracked), and how to document a basic patient encounter. I'm sure I forgot 3/4 of it; it's a good thing we have notes and handouts to take home.
After I got back to the office, I thought that I might as well start trying a couple of things. My Tablet is still sitting in my consultation room, wired to the network. I excused myself during a patient encounter, went to my consultation room, and generated a prescription from the EMR. It took about 5 minutes, and it was probably good that my patient did not seem me fumbling around. I had to read it carefully after I printed it; a local pharmacist told me that he had been seeing several odd-looking prescription instructions from physicians who have recently switched to EMRs. It looked reasonable, so I signed it and gave it to my patient. The good thing was that the drugs on the prescription were now stored in my list of "favourite drugs", so prescribing will be faster next time. As well, I did not copy the medications in the paper chart, as this would be duplicate entry. The meds were automatically entered in the Patient's electronic cumulative patient profile. The pharmacist won't have to call me about an illegible prescription anymore.
By Thursday night, I'd written 39 electronic prescriptions; I'm getting better at it. However, I've turned off the automatic drug interaction software. I couldn't figure out how to accept and print a prescription if there are interactions that don't matter; since we have the EMR2 seminar next Wednesday, I will ask then. I can see how some potentially useful (but irritating at the beginning) parts of the EMR can be bypassed; workarounds must be very common. I should probably take a refresher course in a few months.
I've also started documenting patient encounters in the EMR. I often write charts at the end of the day, so I thought I'd try a couple then. I type faster than I write. That actually wasn't too bad. I found a couple of useful templates (pre-made forms), and used those for patients presenting with a cold, for a couple of well-baby visits, and for complete check-ups. On Thursday evening, I wrote about 1/4 of the charts electronically. By the time I start using the EMR in the exam room with patients, on April 3rd, I'll still be slow, but not a total neophyte.
I tried entering my first Cumulative Patient Profile (CPP), which took me about 20 minutes of my lunch hour. I should have started with a simpler CPP, not a patient with complex medical conditions. I am very picky about my CPPs, want a lot of detail in them, want to do it right, and I'd like to make sure I can search them in the future. I'm going to start slowly with CPPs, and maybe do one to three daily. Some data, such as medications, will be entered directly from the clinical encounter.
The software offers a lot of customization for the CPP: you can set up categories and sub-categories for many things. For example, for "smoking", I set up a "never" category, a "social smoker" category in addition to the pre-set category of number of cigarettes/day and age quit. It is more time for me now, but will pay off in the future once this is all set. It reminds me of my electronic financial program, Quicken; I also had to find out how to do everything at first, and now I can't imagine doing my home or office bookkeeping without it. I bought my first copy of Quicken in 1993.
I typed my first consultation letter in the EMR. I signed it on the Tablet's screen, which was kind of interesting.
My front staff is calling the helpdesk less often. I've called a couple of times; once, the nice man at helpdesk took over my computer remotely; it was very strange to see the mouse moving about via an unseen hand.
My wireless router was delivered this week. I expect it will be installed sometimes next week; maybe I'll try unhooking the Tablet and bringing it into the exam room once that is done.
Michelle
After I got back to the office, I thought that I might as well start trying a couple of things. My Tablet is still sitting in my consultation room, wired to the network. I excused myself during a patient encounter, went to my consultation room, and generated a prescription from the EMR. It took about 5 minutes, and it was probably good that my patient did not seem me fumbling around. I had to read it carefully after I printed it; a local pharmacist told me that he had been seeing several odd-looking prescription instructions from physicians who have recently switched to EMRs. It looked reasonable, so I signed it and gave it to my patient. The good thing was that the drugs on the prescription were now stored in my list of "favourite drugs", so prescribing will be faster next time. As well, I did not copy the medications in the paper chart, as this would be duplicate entry. The meds were automatically entered in the Patient's electronic cumulative patient profile. The pharmacist won't have to call me about an illegible prescription anymore.
By Thursday night, I'd written 39 electronic prescriptions; I'm getting better at it. However, I've turned off the automatic drug interaction software. I couldn't figure out how to accept and print a prescription if there are interactions that don't matter; since we have the EMR2 seminar next Wednesday, I will ask then. I can see how some potentially useful (but irritating at the beginning) parts of the EMR can be bypassed; workarounds must be very common. I should probably take a refresher course in a few months.
I've also started documenting patient encounters in the EMR. I often write charts at the end of the day, so I thought I'd try a couple then. I type faster than I write. That actually wasn't too bad. I found a couple of useful templates (pre-made forms), and used those for patients presenting with a cold, for a couple of well-baby visits, and for complete check-ups. On Thursday evening, I wrote about 1/4 of the charts electronically. By the time I start using the EMR in the exam room with patients, on April 3rd, I'll still be slow, but not a total neophyte.
I tried entering my first Cumulative Patient Profile (CPP), which took me about 20 minutes of my lunch hour. I should have started with a simpler CPP, not a patient with complex medical conditions. I am very picky about my CPPs, want a lot of detail in them, want to do it right, and I'd like to make sure I can search them in the future. I'm going to start slowly with CPPs, and maybe do one to three daily. Some data, such as medications, will be entered directly from the clinical encounter.
The software offers a lot of customization for the CPP: you can set up categories and sub-categories for many things. For example, for "smoking", I set up a "never" category, a "social smoker" category in addition to the pre-set category of number of cigarettes/day and age quit. It is more time for me now, but will pay off in the future once this is all set. It reminds me of my electronic financial program, Quicken; I also had to find out how to do everything at first, and now I can't imagine doing my home or office bookkeeping without it. I bought my first copy of Quicken in 1993.
I typed my first consultation letter in the EMR. I signed it on the Tablet's screen, which was kind of interesting.
My front staff is calling the helpdesk less often. I've called a couple of times; once, the nice man at helpdesk took over my computer remotely; it was very strange to see the mouse moving about via an unseen hand.
My wireless router was delivered this week. I expect it will be installed sometimes next week; maybe I'll try unhooking the Tablet and bringing it into the exam room once that is done.
Michelle
Monday, March 20, 2006
Staff turn-over
I came back from March Break holidays to find out that one of my staff is leaving, as of next week. This is not due to EMR implementation (although this can be an issue); she has found another job, for which she is eminently qualified, and is very upset about having to leave now. As well, one of my other secretaries will be away most of April for family and personal reasons. I was planning to switch to entering patient data on the EMR as of April 3rd.
I have 3 part-time medical secretaries and 1 student in the evening, for two family physicians. This will leave us very short-staffed in April. We had an office meeting today to decide what to do. The staff member who will be staying in April offered to work full time for that month; as well, I have an extra person familiar with the office who can fill in on a casual basis in the afternoons. What we will do is have the casual worker come in daily in the afternoon to do filing/faxing and office work, leaving my secretary time to do the phones and booking.
In May, we'll all look at scheduling, and decide if we need to hire an extra person, or see if the rearranged schedule with a filing clerk in the afternoons works.
I now have to decide if I still want to start EMR on April 3rd. After thinking about it, I see no reason not to; I can certainly start to enter patient data in the EMR instead of the paper chart. We had already blocked off some appointments in April so as to give me time to enter data; slower scheduling then will be better for my secretary as well. I will likely wait a month before introducing EMR functions that require changes at the front, such as scanning documents into the chart. I am going to the EMR training sessions tomorrow morning and next Wednesday, and may as well start to apply what I will learn.
I have emailed Nightingale to find out about training if we hire an extra person. I would like new hires to get training, but this will have to be modified, as the new person will not have to learn about all the customization features; the program will already be customized to fit our practice. I am not sure if we should do this in-house; the answer will likely become more clear to me as we start using the EMR.
I don't think having an EMR will limit the opportunity to hire staff. The ability to deal with several requests at once, people skills, a solid dose of common sense, and some computer ability will continue to be key requirements. The rest can be dealt with through training.
Let's see how things go. I'm looking forward to tomorrow's training session.
Michelle
I have 3 part-time medical secretaries and 1 student in the evening, for two family physicians. This will leave us very short-staffed in April. We had an office meeting today to decide what to do. The staff member who will be staying in April offered to work full time for that month; as well, I have an extra person familiar with the office who can fill in on a casual basis in the afternoons. What we will do is have the casual worker come in daily in the afternoon to do filing/faxing and office work, leaving my secretary time to do the phones and booking.
In May, we'll all look at scheduling, and decide if we need to hire an extra person, or see if the rearranged schedule with a filing clerk in the afternoons works.
I now have to decide if I still want to start EMR on April 3rd. After thinking about it, I see no reason not to; I can certainly start to enter patient data in the EMR instead of the paper chart. We had already blocked off some appointments in April so as to give me time to enter data; slower scheduling then will be better for my secretary as well. I will likely wait a month before introducing EMR functions that require changes at the front, such as scanning documents into the chart. I am going to the EMR training sessions tomorrow morning and next Wednesday, and may as well start to apply what I will learn.
I have emailed Nightingale to find out about training if we hire an extra person. I would like new hires to get training, but this will have to be modified, as the new person will not have to learn about all the customization features; the program will already be customized to fit our practice. I am not sure if we should do this in-house; the answer will likely become more clear to me as we start using the EMR.
I don't think having an EMR will limit the opportunity to hire staff. The ability to deal with several requests at once, people skills, a solid dose of common sense, and some computer ability will continue to be key requirements. The rest can be dealt with through training.
Let's see how things go. I'm looking forward to tomorrow's training session.
Michelle
Wednesday, March 08, 2006
Week 1
Here we are, one week after switching to the new system for billing and scheduling. We've been calling the helpdesk often, whenever we're not sure of something. The scheduling part is working well. We're starting to figure out the ins and outs of the phonebook in the software application; my staff is switching from rolodex to computer. I've started putting in patient recalls, like abnormal pap smears.
I took my Tablet home over the weekend, to try it out. It works well as an electronic book because it is comfortable to hold and read while lying on a couch. I was at a meeting, took it out, and found a cluster of people around me; the tablet definitely has a high coolness factor. I showed it to a couple of patients, and told them that I would be using it in the exam room next month. I am starting to think that a wireless network and PC Tablet is definitely the way to go for EMR. I've bought a wireless mouse, and will probably buy a numeric keypad (I find entering numbers for billing much slower without the keypad).
On Friday, I received remote access to the hospital's database from home or office. I can now see XR reports, lab data, medications and consultation notes for inpatients and patients in Emergency. I'm not sure how I will put that into the EMR, perhaps cut and paste. There needs to be integration between the two systems, perhaps as an "import data" function.
Since Monday, I've looked a the CDC website twice to see if one of my patients needed malaria prophylaxis; I've printed two asthma management plans for patients from the FPME website; and I've printed contact information on the Alzheimer's society for a patient from the Toronto 211 site. I'm starting to develop a list of favourite websites at the office. The Tablet still sits in my consultation room, wired to my network and printer, so I go there to look up and print things. I can see that once I'm wireless and unbound, I'll be doing a lot more of this; that will come after I start using the EMR, April 3rd.
All in all, no major start-up glitches, and we're still sane. I'll be taking a week off for March break, and come back for the EMR training sessions afterwards.
Michelle
I took my Tablet home over the weekend, to try it out. It works well as an electronic book because it is comfortable to hold and read while lying on a couch. I was at a meeting, took it out, and found a cluster of people around me; the tablet definitely has a high coolness factor. I showed it to a couple of patients, and told them that I would be using it in the exam room next month. I am starting to think that a wireless network and PC Tablet is definitely the way to go for EMR. I've bought a wireless mouse, and will probably buy a numeric keypad (I find entering numbers for billing much slower without the keypad).
On Friday, I received remote access to the hospital's database from home or office. I can now see XR reports, lab data, medications and consultation notes for inpatients and patients in Emergency. I'm not sure how I will put that into the EMR, perhaps cut and paste. There needs to be integration between the two systems, perhaps as an "import data" function.
Since Monday, I've looked a the CDC website twice to see if one of my patients needed malaria prophylaxis; I've printed two asthma management plans for patients from the FPME website; and I've printed contact information on the Alzheimer's society for a patient from the Toronto 211 site. I'm starting to develop a list of favourite websites at the office. The Tablet still sits in my consultation room, wired to my network and printer, so I go there to look up and print things. I can see that once I'm wireless and unbound, I'll be doing a lot more of this; that will come after I start using the EMR, April 3rd.
All in all, no major start-up glitches, and we're still sane. I'll be taking a week off for March break, and come back for the EMR training sessions afterwards.
Michelle
Thursday, March 02, 2006
Going live
We've fully switched. The 2 label printers and the card swipe are now installed. We're printing little labels to put on test tubes, and big labels for lab requisitions. We're all getting used to billing and scheduling in the new system. Checking people in today was slower than usual, so it was good to book lightly.
We tried clinical messaging (sending short emails back and forth between different people in the practice), which was kind of fun. I think that this is something that I will use more often in the future, as I stop using the paper charts. My secretary told me that I could probably start retiring simple paper charts fairly early on: once I enter the CPP, we can scan a couple of lab reports (eg, last pap), and then retire the chart by putting it in the back closet. We'll have to mark the chart as retired by putting a stripe on it; I'll put a note in the electronic chart that the paper chart is retired, and does not need to be pulled.
I used the tablet today, but only as a laptop. We don't have the wireless router installed yet, so I'm leaving the tablet on my desk, and accessing the internet through the wired network. I don't like the little red button mouse that sits in the middle of the keyboard, so I'm going to buy a wireless mouse for the tablet. Maybe I'll leave a wireless mouse in each exam room.
I've synced my PDA's calendar and address book to the internet so that I can access them from the tablet PC. I'm not sure how much I'll continue to use the Palm once I start carrying the tablet around; probably a lot less.
I noticed that there is a bar code on the vaccine boxes. Perhaps I could get one of those bar code readers like they have in the grocery stores, so that the vaccine lot number and expiry date can be entered automatically in the patient's chart. I run a flu shot clinic in the fall; last October, I vaccinated about 100 people in a couple of hours. Being able to scan the vaccine in would save a lot of repetitive data entry.
Michelle
We tried clinical messaging (sending short emails back and forth between different people in the practice), which was kind of fun. I think that this is something that I will use more often in the future, as I stop using the paper charts. My secretary told me that I could probably start retiring simple paper charts fairly early on: once I enter the CPP, we can scan a couple of lab reports (eg, last pap), and then retire the chart by putting it in the back closet. We'll have to mark the chart as retired by putting a stripe on it; I'll put a note in the electronic chart that the paper chart is retired, and does not need to be pulled.
I used the tablet today, but only as a laptop. We don't have the wireless router installed yet, so I'm leaving the tablet on my desk, and accessing the internet through the wired network. I don't like the little red button mouse that sits in the middle of the keyboard, so I'm going to buy a wireless mouse for the tablet. Maybe I'll leave a wireless mouse in each exam room.
I've synced my PDA's calendar and address book to the internet so that I can access them from the tablet PC. I'm not sure how much I'll continue to use the Palm once I start carrying the tablet around; probably a lot less.
I noticed that there is a bar code on the vaccine boxes. Perhaps I could get one of those bar code readers like they have in the grocery stores, so that the vaccine lot number and expiry date can be entered automatically in the patient's chart. I run a flu shot clinic in the fall; last October, I vaccinated about 100 people in a couple of hours. Being able to scan the vaccine in would save a lot of repetitive data entry.
Michelle
Wednesday, March 01, 2006
Switching to the new system for billing and scheduling
We are switching tomorrow. Actually, we've already switched. The computers got installed and configured yesterday, which took most of the day. The installer worked while patients were being greeted, checked in, and seen--somehow it was OK. Once this was done, we started re-entering patient appointments in the new scheduler software.
It is interesting being connected to the Internet. I actually did send an email link to the DASH diet while my patient was getting dressed; I was able to look up malaria prophylaxis on the CDC website for a patient going to the Philippines pretty quickly. I also got an email query from a patient, and I cut and pasted that into the "phone record" area in the EMR; that seems somewhat better than laboriously recording a phone conversation in my usual chicken scratch.
The tablet PC came today; I'll start using it everyday so I can get a good feel for it. It is about 3 lbs, which isn't too bad, since I'll be carrying it around all day.
My dedicated staff members stayed very late yesterday and today to make sure the schedule was completely transferred. We also started billing from the new system today; the government may get some odd bills. A card swipe arrived today, along with a label printer. Our project manager came by to make sure everything was OK. We get a trainer at the office for the morning, but I think we are comfortable with the basics.
We'll spend this month getting to know the administrative functions of the software. After March break, I go back for two sessions of EMR training.
Michelle
It is interesting being connected to the Internet. I actually did send an email link to the DASH diet while my patient was getting dressed; I was able to look up malaria prophylaxis on the CDC website for a patient going to the Philippines pretty quickly. I also got an email query from a patient, and I cut and pasted that into the "phone record" area in the EMR; that seems somewhat better than laboriously recording a phone conversation in my usual chicken scratch.
The tablet PC came today; I'll start using it everyday so I can get a good feel for it. It is about 3 lbs, which isn't too bad, since I'll be carrying it around all day.
My dedicated staff members stayed very late yesterday and today to make sure the schedule was completely transferred. We also started billing from the new system today; the government may get some odd bills. A card swipe arrived today, along with a label printer. Our project manager came by to make sure everything was OK. We get a trainer at the office for the morning, but I think we are comfortable with the basics.
We'll spend this month getting to know the administrative functions of the software. After March break, I go back for two sessions of EMR training.
Michelle
Monday, February 27, 2006
Birth pains and other glitches
My office switches over to the new system for billing/scheduling on Thursday. My colleagues in the FHN have been switching one practice at a time, since last Wednesday. We've encountered some problems.
There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.
I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.
The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.
I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.
I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.
I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.
Michelle
There seems to be a problem with shipping, as hardware is being delivered to the wrong practices. Our project manager has been kept busy trying to get the right machines to the right places. This seems to be OK now.
I've sent all my demographic data to myNightingale last Wednesday night; no new data will be transferred to the new system. We are printing labels for patients whose information has changed, so we can enter this manually after Thursday. I do not have any computers set up yet to access the server, but they will come and set one up tomorrow morning. My staff will re-enter all the schedule information one evening before we go live, so that we do not have to schedule out of two systems. Everyone is planning to come in a half hour early on Thursday. I've distributed all the security fobs.
The IT lead for the other FHN (which started on the new system a month ago) sent an email to let us know that SSHA is causing difficulties with remote access to the server via VPN. Apparently, there is quite a bureaucracy to deal with there, and things move very slowly. There is no VPN access yet, and we do not know when this will happen.
I run an elders clinic once a week at a Toronto Housing for Seniors, close to my office. I've asked them for permission to connect to their cable modem to access my server at the hospital. I've run into problems with their bureaucracy as well; it has taken a month so far, and I still don't have permission. I may have to stop going if they refuse access, which I am not very happy about. There are drawbacks to starting an EMR.
I turned on one of the computers; the Internet connection is good, and I am typing this from my office. I can also access my web-based email from the office. I don't quite know if that is a good or bad thing.
I just received my copy of CMAJ. The last page has Dr. Ursus' column on EMRs. It looks like he's having a lot of trouble just receiving his lab results. I'll have to see what happens to my practice.
Michelle
Monday, February 20, 2006
Skinny labels
We had two more training sessions last week. The first one dealt with billing, both to the provincial government and for private bills. The second session dealt with scanning documents and managing security. There is a high level of security with the RSA security fobs (see Glossary) , and we have different passwords for everything (logging in at the office, logging in from home via VPN, logging in to manage security fobs, logging in to server to submit claims to the government). These passwords are proliferating like yeast spores.
Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.
We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.
Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.
We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.
Michelle
Scanning documents seems to be a complicated undertaking. You have to scan, import to the program, file with the patient chart, review and sign off. It is a shame that most of health care is still electronically disconnected; so far, only labs will send results directly to a patient's chart. I hope that more pieces will connect in the next few years; perhaps facilities that do not connect will find patient volumes dropping, as physicians will choose those that have made the effort to share data. Secure physician email will soon be widely available via OntarioMD; perhaps my specialist colleagues can email me reports through this portal. I can certainly use that to transmit referrals.
We also went over printing options. I am buying two Dymo label printers; one will be dedicated to printing skinny labels for test tubes or swabs. My staff won't have to laboriously write the patient's name on the tubes anymore. I wonder if we could add UPC codes to the printed labels; that would certainly help to track them. It is amazing to me that I can enter a code in Google and see where my Fed-ex package is, but I can't track vital patient tests at all. A UPC code would also help the lab process tests more efficiently; perhaps I could send the lab requision electronically to a central lab repository, such as OLIS, instead of using the paper forms.
Some computers came on Friday. We unpacked the PCs and the monitors, and put them where we want them. The screens look very sharp. The tablet PC should arrive this week, and the company is sending someone to set up and test the whole system. One of my two old computers died last week (hard drive failure), so I am back to writing letters by hand until we get the new system.
We have staggered go-live dates for my group (only one office per day). The first office starts this Wednesday. I have less than two weeks to go.
Michelle
Wednesday, February 15, 2006
Communicating on-line
I've started to communicate with everyone at my office via email. I've also changed my email software to web-based mail, so I can access mail from both home and office.
My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.
The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.
We have now put up signs letting patients know about the change, and asking for their patience.
My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.
Michelle
My staff has trouble covering one of the office days in April, due to other commitments. We thought what we could do is have one person log on remotely to the EMR, pick up phone messages from home, and book patients into the scheduler via VPN if needed. I would use the clinical messaging in the software to notify them if something needed urgent action. We could not even have contemplated this without EMR.
The server at the hospital is now fully configured. Our project manager and our trainer are sending emails periodically to update us. I have started receiving hardware at the office: 22 boxes of antivirus CDs(seems a little excessive) came yesterday, and 5 printers came today. We unpacked the printers, and tried to figure out where they should be placed.
We have now put up signs letting patients know about the change, and asking for their patience.
My group is also communicating fairly frequently via email; some people are happy with the training so far, some less so. There are the inevitable software glitches. Tomorrow I go back for the second training session.
Michelle
Sunday, February 12, 2006
Evidence-based programming
I've been playing around with the training software at home; I think this will work.
I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).
It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.
I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.
As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.
I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.
I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.
Michelle
I've been thinking about what works in EMR programs. There seems to be a lot of research done in computer-aided clinical decision making. Some programs don't work, for example, a large study showing that the EMR did not help with angina or asthma, found here (for the trial), and here (for an explanation of why it didn't work--basically it was intrusive, did not fit into the flow of work, and the so physicians didn't like it and didn't use it).
It seems to me that the EMR has to present the right evidence at the right time, in a way that is not too intrusive. This is challenging: patients present with multiple problems, and you don't want too much information popping up when you don't need it, or it is going to consistently be bypassed.
I think what will work is to start slowly, by giving us things we are interested in first. In Ontario, we have incentives to provide mammograms, paps, flu shots and children's vaccinations, and soon we will start on Fecal Occult Blood. The EMR will help us to maintain lists of patients that are eligible for these interventions. There is evidence that automatic prompts improve the provision of cancer screening and vaccinations (see Garg et al). The EMR can probably automatically generate a prompt if a patient overdue for a preventive service comes in.
As well, I will start doing electronic audits for these preventive services, this fall. I will assign this to one of my staff members, and we will generate recall letters for patients who are overdue (because recall letters work). I have been talking about this with a colleague from Nova Scotia, who will be using the same software, and who has been thinking along the same lines. We can start using some of the provincial databases that have secure access (for example, Cytobase for pap smears) to make sure our registers are up to date.
I think that for any EMR to work, it has to be used, and used consistently. It has to fit well into the workflow. Prompts and clinical decision support will likely prove their value, but they must be carefully integrated into the system. A good first step is preventive services, because I have incentives to do them, I can maintain registers, there is already evidence of successful implementation in the literature, and I can modify work processes in my office (assigning a staff member to do audits, generating recall letters, having alerts to remind patients) relatively easily.
I have been notified by my hospital that I can now have on-line access to their electronic system, which will help me with patients seen in Emergency, and for those recently discharged from the hospital. Interestingly, there was a recent research article in CMAJ showing that giving family physicians on-line access to Emerg patient data made no difference. I wonder if the reason for that was that they picked very busy physicians (over 4,000 patients in each practice), and also picked people who were not very familiar with computers. The family physicians may not have used the software, and so it did not work; if systems are not well integrated into daily practice, they don't work. You have to think about effectiveness; maybe we should call this evidence-based programming.
Michelle
Wednesday, February 08, 2006
Starting to train
We had our first training session today, for four hours. They train 8 people at a time; we all had a computer in front of us, the trainer shows us things via a projector and then we practice. We had a mix of physicians and staff members. There was a very wide range of comfort with computers, from one "super-user" who had already been using the software in another office, to someone who had never used a mouse or email (and was not too thrilled about all this nonsense).
We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.
The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.
We go back in one week for more training. The computers should come in in the next 10 days.
Michelle
We learned to enter patient demographic data, and to use the scheduler. There are a lot more fields and screens than I am used to at the office, which is confusing at the beginning. I can access the training software over the internet, and I showed my husband what it looked like just now. I'm going to practice some more on my own over the next few days.
The server at the hospital is ready to go. All my colleagues' offices but one have been networked. I received a call today to confirm final data cut: this is when I give the trainer a copy of my practice's current demographic data, for transfer to the new system. This will be one week before our "go live" date; we will have to manually keep track of any changes (health card numbers, address changes etc) during that week. I will still keep my old computer for a while, as we will need to manually reenter the schedule, and will also have to reconcile bills that were submitted before the changeover.
We go back in one week for more training. The computers should come in in the next 10 days.
Michelle
Sunday, February 05, 2006
Doing things differently
The EMR will allow me to do things differently. How differently will depend on what me and my staff decide to change; it won't happen by itself.
One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:
"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:
I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."
I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.
One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:
Michelle
One of the things I've been thinking about doing is giving patients a printed summary at the end of their preventive health visit. I know that patients cannot remember everything they hear in the exam room. For example:
"Exercise improves health. I recommend you walk at least 4 times a week, for a minimum of half an hour. Please write down
When you will start:
What time of the day:
Which days of the week:
I recommend you lose about 10% of your weight (xx lbs). Eat smaller portions, more fruits and vegetables, less fried foods and less salt. If you have hypertension, the DASH diet works; it can be found at http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
Quitting smoking will improve your heath. Please use the information booklet I gave you. The smokers' helpline number is 1-877-513-5333."
I could make a template like that, with checkboxes that I tick off on the tablet. Once I've done a couple in my practice, I probably will get very fast at it, and the printer is right there in the room. I'm already printing information for patients, for example, ASA for heart disease.
One of the things that can be automated in the office is the vaccine fridge temperature logs. Dr. Jim Kavanagh, who is a family physician in Cambridge, Ontario, and a VP at Practice Solutions Software has found a way to do this in his office. Dr. Kavanagh says:
"I use a Hoboware temperature recording device in my vaccineYou can get the Hoboware here. You need the logger, software and cable. Although there is a cost, it will make your staff's life easier because they no longer have to record fridge temperatures twice a day. This is something I will definitely do.
fridge. It is connected by a USB port to a nearby computer.
It records temperatures every 30 minutes continually, and
these readings can be downloaded to the computer when desired.
I use one of those cheap temperature displays for looking at,
but nobody needs to write down temperatures.
You can't continually display the temperature over USB because
it sucks the battery too quickly, so we left the cheap
thermometer attached, but nobody needs to write down temperatures
anymore.
I have been doing this for 18 months and it works well. Public
Health here is quite pleased.
You don't need to download the temperatures every day. Once
weekly seems adequate. Glancing at the external temperature when
opening the fridge is good enough for every day."
Michelle
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