Fridge police

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that the fridge temperature is properly monitored, and within range (2 to 8 degrees), that none of the vaccines are out of date, and that vaccines are properly stored (not in the fridge door).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

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

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

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

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

Michelle

Progress

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

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

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

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

I think we have progress!

Michelle

The big office

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

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

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

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

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

Michelle

EMR Enterprise: To Boldly Go.

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

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

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

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

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

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

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

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

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

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

Michelle

Managing change in my group

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

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

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


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

Michelle

Dealing with structural and mechanical failures

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

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

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

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

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

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

Here is the letter:

Dear ....

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

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

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

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

EMR in the waiting room

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

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

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

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

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

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


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

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

Michelle

Having an IT administrator

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

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

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

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

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

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

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

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

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

Michelle

The patient Dashboard: improving communication

I was talking with a colleague who uses a wired EMR. He walks into the exam room, and then quickly logs on. He then sees if there are any alerts or messages for that patient. He told me that this is different from the paper-based system, because the chart was on the door, and he looked at it before going into the room.

I don't do that. I can see when a patient is shown to a room (and which room), because my staff indicates this on the scheduler. I load the chart on my Tablet before I go in, and see the Summary (which I increasingly think of as the chart dashboard). Summary has today's visit and reason, all upcoming booked appointments (so I know if the patient already has an appointment for a full check up in the future), any upcoming recalls (example, colonoscopy due in 8 months), Follow ups that I set during a previous visit (example, 1st script for HCTZ, check potassium), overdue preventive services, and staff messages that have not been archived. I like to see this before I go in. If I need to, I take a quick look at the CPP, I open the encounter and then I go in and greet the patient.

This allows to say hello to my patient instead of to the computer. I can remind my patient to make an appointment for a follow-up abnormal pap if I can see that this has not been booked yet. I remind him or her about overdue preventive tests first, so this is done. We then address the presenting concerns together.

I know that this is not very patient-centered, but it does allow me to remember to do things that are in my patient's best interest more consistently. I think it is possible to do this with a wired system, but you do have to look at the chart before you go in. It may work better with wireless: just open the chart, look, and take it in the room.

I was talking about this to the Team pharmacist: we have to figure out ways to communicate effectively within the Chart-in-common. I referred the first patient to her via emessaging in the EMR; she will see him at the hospital, where she has her office. If she needs to have me see the patient as a follow-up, she will set this in her Encounter. She will assign a Follow-up to me, with a short explanatory note (example: LDL high, Lipitor was increased from 20 to 40). When I load Summary, I'll see it before I go in; I can load her past Encounter if I need to review it ahead of time. She has been practicing with the Dummy patient chart, and I have been looking at that remotely. I think we're ready to go.

We've set the Standing orders according to the toolkit for Medical directives. We are going to start with Diabetes. Here is an example of a Standing order:

In order to optimize care for diabetic patients, the Team has agreed to the following standing orders. These orders conform with the Guideline recommendations from the Canadian Diabetes Association. The CDA has also recommended Team Based care for Diabetics. Goal-based optimization of therapy has been found to improve achievement of diabetic targets (Level I evidence, Gaede et al).

The Team will use a common Electronic Medical Record, with all encounters, medication changes, laboratory requests and results to be entered in the chart. Each Team member will have access as appropriate to their professional roles; all accesses to the chart will be electronically logged.

Standing orders, optimization of dyslipidemia management

The goal for most diabetics is LDL 2.0. The pharmacist will look at the last lipid profile. If the LDL is above goal, AND lipids were done a year ago or less, AND the patient has no contra-indications to increased dosage (SGOT or SGPT is less than twice normal; patient is not complaining of statin-related myalgias), then:

If the patient is on a Statin, the pharmacist is authorized to increase the dose of the statin to a maximum of:

• Rosuvastatin (Crestor): 40 mg PO od
• Atorvastatin (Lipitor): 80 mg PO od
• Simvastatin (Zocor): 80 mg PO od
• Lovastatin (Mevacor): 80 mg PO od
• Pravastatin (Pravachol): 80 mg PO od
• Fluvastatin (Lescol): 80 mg PO od

The pharmacist is authorized to request cholesterol/SGOT retesting, using the physician’s lab requisition (with CK testing at pharmacist discretion, if there is concern about myopathy) for follow up of the changed dosage. The patient will be asked to retest blood a month after medication change, with result forwarded to the patient’s family physician.

The pharmacist is authorized to request lipid profile (total cholesterol, LDL, HDL, triglycerides, total cholesterol: HDL) testing (using the physician’s lab requisition) if this has not been done in the last 12 months, and the patient is not booked to see their family physician for an annual review in the next 3 months.

---

If we're going to do Team-based care, we have to have clear, common goals, based on solid evidence. We also have to have really good communication within the team. I think the EMR will help us do that. I wish we could have patient access to the chart; after all, they are at the very center of the Team.

Michelle

Video of EMR in my practice

Improving quality of care

I spent Friday afternoon with a colleague at the EMR company’s headquarter. We were invited to discuss future directions for the Reporting functions of the EMR. By Reporting, I mean the ability to look at data for an entire practice, or even a group of practices.

There are many things you can produce a report for. It is much better to look for data entered in fields (consistent entry), rather than free text. We can already generate clinical reports for diagnoses, immunizations, medications and family history. We talked about adding lab results, vitals (temperatures, blood pressures, BMIs), as well as social history items such as smoking, alcohol use, marital status, allergies, etc. We also discussed automated reporting, that is, reports generated automatically on a periodic basis (every month, every 3 months).

To me, the ability to look at this data is vital to quality improvement; you can’t improve what you can’t measure. Quality in health care is measured by many things; one of the things that I want to look at is our processes. For example, the large Veteran’s Administration reengineering project in the US used EMRs, chart audits, and disease management programs to improve their quality. They improved many processes, such as preventive services (mammograms, flu shots etc), monitoring for chronic diseases (lab tests for diabetes), meeting evidence-based goals for chronic diseases (140/90 for hypertension etc).

It is not difficult to find evidence-based processes in primary care; I think we will pick select processes and start working on them. The first processes will be those with incentives. Then, processes with strong evidence of reductions in the risk of illness or death; good examples are found in the UK’s list of incentives, and deal with chronic illnesses such as diabetes. As well, we can pick preventive services that do not have incentives, but which are recommended by the US or Canadian Task Forces.

Once we decide which processes we want to improve, we then have to decide what to do about them, and how to do it. There are several ways to improve things, such as point of care alerts, proactive patients notification based on whole practice audits, and Chronic Disease Management programs.

We already have pre-programmed point of care alerts for services that have incentives, as well as self-programmed alerts for overdue services (tetanus shot more than 10 years ago). My Summary page is loaded as a default when the patient comes in; if there is a service overdue, that is the first thing I see. My patients must be getting tired of getting a Fecal Occult Blood kit (bowel cancer screen) handed to them: if you are 50 to 75, you will get the FOB kit, rather than an antibiotic, when you come in for your cold.

Patient notification by mail is already happening in my practice; we send letters if someone is overdue for one of the services with incentives. I can do more of this; I would like to use email in the future.

Chronic Disease Management programs are interesting. That is where someone is responsible for overseeing quality for a whole program (example, diabetes). This is not something I can do at a single practice level.

We are now becoming a Family Health Team. That means we will be hiring Allied Health Professionals, such as Pharmacists, Nurse Practitioners, and Social Workers, to work with us. I think the CDM program will be managed by Allied Health; we can designate one person as responsible for on-going audits, monitoring, targeted recalls, and perhaps even setting up group education and patient self-care programs, for one or several conditions, depending on the number of patients and the complexity of the program.

Because the EMR contains an integrated chart-in-common, what one team member enters in the chart is available to the other members of the primary care team who have the appropriate permissions.

The FHT has not been set up yet. However, as I mentioned previously, we already have a clinical pharmacist as part of our Academic Unit. The first electronic audit of diabetes care has already been done in my practice, by my resident. The Pharmacist has remote access to the chart-in-common, with defined permissions. I am now working with her to define standing orders: for example, if blood pressure is above 130/80, the pharmacist is authorized to increase current hypertensive medications up to a maximum of (here we put the list of possible meds and maximum doses). We have identified patients with at least two out of three parameters that are out of range (BP, LDL cholesterol, A1C). She will recall them for lifestyle counseling and medication optimization, with the changes recorded directly in the chart-in-common, whether she sees them at the hospital or in my office. If needed, she will send me an electronic message inside the EMR. Team-based care is currently recommended by the Canadian Diabetes Association’s Clinical Practice Guidelines, and it is now becoming a reality.

I view this as a pilot for CDM programs for the FHT. We will have a chance to work out the bugs on a small scale. The EMR company will program the ability to Report across several practices, so we can see how we are doing as a group, and track progress.

Once this is set up, I would like to start tracking patient outcomes as well; for example, what is the rate of heart attacks (code 410) in patients with diabetes (code 250)? That will tell us whether the changes we have made are truly making a difference to our patients’ health, but it will come after the changes in process.

We will have a problem in my FHT: there are several FHN groups that have joined, and although the majority uses the same application as my FHN does, one of the small FHNs already uses a different EMR application, and cannot change (it is very difficult to change EMRs). We will have to program the audit and tracking to work on the second platform as well. It will be difficult for the CDM lead to learn to work with two different programs. We may need to have separate CDM planning and personnel for the small group. This is not ideal; each FHT should consider using a single EMR application if at all possible.

To my mind, the ability to track quality improvement projects and protocols across several practices is one of the things that lie beyond EMR implementation. Implementation is not quite Blood, Sweat and Tears (there is no blood), but it is tough. Once it is done, though, then the bonus parts come into play; the Veteran's Administration program has shown what can be done: they have gone from poor quality to outperforming the rest of the US. We can do the same.

Michelle

Housecall

I've been asked how I do housecalls with EMR. I did a housecall on Wednesday.

I review the chart before going. I print the CPP (which has the patient's date of birth, health card number, address and phone number on top). I take that to the housecall; it helps to have the address, I don't have to copy it from the chart.

During the housecall, I may make a brief note on paper; when I get back to the office, I document the visit in the EMR. For simple prescriptions, I give the patient a written script (entered in the EMR later); for more complicated prescriptions, I ask for the pharmacy number; I print from the EMR to fax it in later. I have an ethernet cable in my laptop bag, in case there is internet access where I am going.

On Wednesday's housecall, I had to call an ambulance. It was good to be able to give the ambulance attendants a printed CPP with all the information on it. It would be better if the CPP was securely available on-line when needed, but this can't be done yet.


I found out from a colleague that I can stop the paper lab reports; this does not have to be done as a group. It was was surprisingly easy to do--just two emails and a faxed letter.

I continue to be amazed at the satisfaction that I am getting from the paper Bgone process, and others are telling me the same thing. My consultation room is uncluttered, and my exam rooms are much neater. When drug reps come in, I no longer accept pads of patient handouts; I will take a single page if it looks interesting, and will scan it in later if it is really useful. The reps now manage the sample cupboard, they put the drugs in the cupboard (and never on the counter). A rep came in on Tuesday carrying two cases of enormously over-packaged samples; this was promptly rejected. My practice team is much more conscious of office space usage, and I think I feel more Green.


I've put patient instructions on my saved favourite DI reqs, so that these are always printed along with the req. As well, our Total Joint Assessment Centre has specific requirements for knee and hip XRs; I've saved those as a favourite DI req, so I know that the appropriate XR will automatically be done in the future. I've emailed samples of electronically generated Diabetes Education Centre reqs and MRI reqs to both centres, and have asked if I can use those instead of the scanned standard reqs. If I generate those electronically, they are part of the chart, all the demographics are automatically entered, there is no bad handwriting, and the referral can be tracked. They will have a look and let me know; there is a good relationship between the hospital and family physicians, so things like this often happen.

Very good

Michelle

Drug recall

We had a drug recall this week, for Zelnorm , a drug used for constipation in irritable bowel syndrome. Zelnorm was linked to an increased risk of heart attacks and strokes.

When I received the fax from the manufacturer, I ran a search for all patients on this drug. I also know how to put in alerts, and generate a mail-out. This wasn't difficult to do, as I've done it several times for preventive services. I sent out a "how to" email to my FHN colleagues, and also posted it on my on-line discussion group.

Zelnorm is not a drug used for many patients in family practice. It was good that the first drug recall with the EMR was small and manageable. I can see that the process works; it will work for a large recall, such as Vioxx, but the number of letters will be considerable. We should be be figuring out the role of the big pharmaceutical companies, they really should bear the costs of this targeted notification if one of their products is at fault. It may be time for our political organizations to get involved, ahead of time; this is certainly not the last time there will be a drug recall.

I found out that my application is part of the hospital's network, since the server is inside the hospital. This is interesting; I tried accessing my office from one the PCs in the doctor's lounge, which works. I think this is potentially very useful for members of my group who do OB, in-patient care or palliative care; they can access the EMR from any computer in the hospital.

On another note, I had an interesting discussion with a colleague on what exactly is meant by the EMR "dashboard", which is really a question about how information is presented. I think as a dashboard as an overall view of the information (like a car's dash). There are different ways of presenting that (and not one size will fit all).

I figure that there is a trade-off between a simple dashboard, which will be easy to learn, and a complex dash, which is more useful later on, but is harder to learn. Good programming will present the dash in a way that will shorten the learning curve, while preserving some complexity. A car is an example of a fairly intuitive dash, with some complexity; the fact that it is so prevalent in our society has made good engineering ubiquitous. You have a very short learning curve when buying or renting a new car, because of the similarities in dashboard construction. When you need more complexity, example, commercial airplane, the amount of training increases. Once you have used the dashboard for a while, the amount of unconscious processing increases dramatically; I can take in a lot when I look at the front page in my EMR, but this didn't happen at the beginning.

The Dashboard for individual patients, rather than practice level, would follow similar guidelines (simplicity vs learning curve; choosing the most important info to present, not too much, not too little; navigation issues). It is an interesting interface between the computer and human psychology; a Steve Jobs should get involved in EMRs--his elegance and flair for design would help.

Michelle

One year into implementation: different levels of EMR adoption

April 3rd will mark a year since EMR start-up. I can no longer even imagine practicing with paper-based records.

My FHN group met last week; we took stock of how we are doing. Two of the nine of us are now using the EMR full-time. Two are not using it at all, and really never started, other than for billing/scheduling. The reasons for that include front staff not agreeing to use EMR; not being able to type; not really being ready to change and so not putting in the needed time and effort. We are not making our colleagues feel guilty about this; they will decide to change (or not) at their own pace.

Eight of the nine of us are now receiving lab reports electronically; one never notified the labs and therefore never started. We are still receiving duplicated paper copies of the labs; this is just shredded at my office, I don't even look at it anymore. We have to notify the labs as a group when we are ready to stop the paper reports, and so it looks like this won't happen for a while.

Of the seven EMR users, all are entering CPPs--most of those are now done. Five of us are documenting at least some encounters in the EMR, and four are prescribing electronically. I am the only one who has scanned and shredded all my paper charts; one of my colleagues is scanning a couple of relevant reports in, and then taking the paper chart off-site.

What we decided at the meeting was to have the two consistent users available as a resource to our five colleagues who are still transitioning. We offered to help either at our offices, or at their office, for individual booster sessions. One of my FHN colleagues already came to my office for a couple of hours. I think this will help, but the offer may not continue to be taken up unless I push for it; we just tend to get too busy with day to day practice.

It is interesting that we are comfortable with different stages and speeds of adoption. This is fairly easy in my group, since we practice in different locations; failure to adopt EMR in one office has a minimal effect on the other offices. Even one complete non-adoption in a two physician office (as with my own practice partner) does not have to stop EMR implementation. This must be different when several physicians practice in a single location; there will be more push to implement, and more peer-to-peer support, so perhaps more successes at a year, but also more problems if some physicians are not ready to implement.

Someone in my group said that EMRs are like onions, they have layers. We need to explore these layers at our own pace, with help for the inevitable tears. We're slowly getting there.

Michelle

Doing a preventive health exam with EMR

Doing an "annual check-up" has changed with the EMR. I have programmed a template, using the preventive health tables, to make the whole thing easier. The template includes a check-box stating that I have reviewed and updated the CPP, the age/gender appropriate Preventive Table, a review of systems, and a physical examination. This makes recording the exam fast and thorough.

When a patient comes in for their complete check up, my secretary measures their height, weight, blood pressure (using the automated BP machine) and waist circumference. She records this in the EMR, and the patient is then shown to one of the exam rooms, and undresses. My secretary puts the room number in the EMR scheduler, which flags the chart and tells me that they are ready to be seen.

Before going in, I load the chart Summary (which shows me if there are any alerts or preventive services due), and then I come in the room. This gives me a chance to remind them of overdue services first. I then load the CPP, and put the Tablet on the exam table beside the patient; the screen is turned so that they can see it. I point things out as we review them together, and make any needed changes. When this is finished, I print the CPP for the patient. The majority of my patients now have a copy of their CPP, and I expect all patients to eventually have this.

Once we are finished with the CPP, I load the encounter. The BMI is automatically calculated, along with a note stating its range (underweight, ideal, overweight, obese); I show this to the patient. Since we started using the automated BP machine last summer, my patients know what their BP is, because my staff tell them. I then load the preventive health template, and put the Tablet aside to do the exam. I will sometimes glance at the template to make sure that I have done everything.

Once this is finished, I print medications, and then give my patient a verbal summary about their health. To emphasize preventive measures, I print a handout with common recommendations; I modified the handout from the Practice-based Small group's module on prevention. I circle things that I would like them to concentrate on, and then give the handout to the patient. A copy of this handout is reproduced below; I keep it in the handout section of the EMR, it is personalized with the patient's information on top, and the patient's record keeps track of the fact that it was printed. I have already remotely put a copy in the EMR of one of my FHN colleagues.

Then, I come out of the room to let my patient get dressed, and load the lab (usually one of my pre-programmed lab reqs, with additional tests as needed), and I send the req to the front printer. The patient comes to the front, and my lab technologist takes them for bloodwork, ECG, etc. If necessary, I also send a pop-up message to my secretary to book a follow up appointment.

This is very efficient and complete. There was a recent research paper which stated that family physicians would have to spend about 7 hours each working day just to get through all the recommended preventive interventions for their patients. With EMR, this is not true. My preventive health exams are booked for a half hour, and it is rare for them to take longer. The preventive health exam is very structured, and exams are very similar; the EMR can be used to guide the visit. It is worthwhile to think about the process of a visit, and to ensure that EMR tools are used to make the visit as effective and efficient for the patient as possible. Having the patient see their own information and share in building their chart, using a templated checklist at the point of care, giving written, relevant feedback, having your staff help you, and having point of care reminders are all easier to do with EMR than on paper. I have described the process in some detail to outline the changes that have happened in my practice, and to show the improvement in care that can result from the use of EMR tools.


Here is the patient Handout:

Thank you for coming in for your Preventive Health Exam; your health is important. Here are some things that you can do to stay well:

General Safety

• Wear a seat belt when you ride in a car or other motor vehicle

• Wear a helmet when you ride on a bicycle, motorcycle, or all-terrain-vehicle (ATV)

• Have a smoke detector on each floor of your home

• Regularly test each smoke detector

• Do not use alcohol or drugs when you are involved in activities such as driving, boating, cycling, or swimming

Please protect your hearing against excessive noise

If you are over 64 years old:

• Make sure that you do not have hazards (such as loose carpets, exposed extension cords, and stairs with no handrails) in your home that could cause you or someone else to fall or be injured

Dental Hygiene

• Brush your teeth with a fluoride toothpaste daily

• Floss your teeth daily

• See a dentist at least every year

Physical Activity & Exercise

Your daily physical activity should add up to at least 30 to 60 minutes (Include each 5- to

10-minute interval of activity or exercise.)

Pre-Conception Care

If you are planning to be, or could get pregnant, take a folic acid supplement

Potential Risk Behaviours

If you are a smoker:

• Would you like to quit?

• Have you ever tried to quit before?

• Are you interested in medication to help you quit?

• Are you interested in a smoking cessation program to help you quit?

• Do you have a “quit date” in mind?

I am always ready to help you quit; please use the tools (booklet, helpline, medication) available from my office

If you are sexually active, please:

• Take precautions to prevent an unplanned pregnancy

• Always use a condom to protect yourself from sexually transmitted infections (STIs)

• Avoid high-risk sexual behaviour

Diet

Please eat the right number of calories (enough to maintain a healthy body weight) every day?

Limit your intake of fat and cholesterol

Emphasize grains (such as cereals,whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet

Take enough calcium and vitamin D for a healthy body and bones

Vacation

I was away on vacation this week. This is now the third time that I've been away on holidays since starting the EMR. It was also the first time that the week before vacation was manageable; I think the efficiency is really starting to kick in.

I've noticed that the majority of lab results come in by Saturday; I had 12 labs to look at on Saturday, and only a few results came in afterwards. It is good to keep that in mind if planning to log in while away: the bulk of the work is in the first few days. As for previous vacations, I let everyone know if I will be accessing the EMR. What seems to work best is intermittent access: I don't want to be forced to look at results daily while on vacation, but I don't mind having a look every few days. That means that my partner has a quick look at the incoming data, and only takes care of urgent problems (like abnormal INRs).

Here is what I ask my partner to do while I'm away:

• Cc me on lab reqs so they go in EMR
• For incoming lab results:
• If they are normal, put them in the “to shred” box
• If they are slightly abnormal, put them in the “to shred” box
• If they need action, please write on them and then ask staff to put them on my desk after the action is taken
• For incoming letters/faxes, pls put them in the “to scan” box once you’ve seen them
• CPPs will be printed for you as needed
  
• If you need to see scanned old chart, there is a link on your desktop, double click on the file
• If you need to see a report on the EMR, go to Patient module, reports, then DI/lab etc.

• Our family medicine resident can see some of my patients while I’m away

Looking at labs/DI/consult notes is much more efficient if you know the patient and the context. Long consult notes can be left unfiled after a quick look, for more extensive review post vacation. Doing this lightens the load for your partners, and may make going away less difficult.

I am still receiving lab results on paper as well as electronically. Once my group decides we're ready to stop the paper, we have to notify the labs; this must be done as a group. For the past several months, I have not been looking at my paper labs, and they go straight into shredding. I'm not sure what I'll do during vacation once the paper labs stop, since my partner won't have those to look at.

I wonder if this would work for some maternity leaves. I know it has sometimes been difficult to get locums for maternity. It may be possible for one locum to look after several practices via remote access; the physician can decide to come in half a day a week after a couple of months, while doing much of the work remotely during baby's nap (if they nap).

My schedule for Monday does not look horrible; I think the week before and after vacation is much easier to manage this way.

Michelle

Looking at my data

It has now been almost a full year since I started using the EMR. I am starting to get some good cumulative data for individual patients. I am also learning to search for conditions in my whole practice, by using clinical reports.

This ability to search is essentially not available in paper records, and is a major benefit of EMR. Here is what I can search for:

-diagnostic conditions
-immunizations
-family history
-medications

I can also search by gender, and by age ranges. These searches can be combined by using boolean terms (and, or, not). The Report feature is fairly user-friendly, once you've worked with it a couple of times. The search query terms can be saved and reused, and I've used my saved searches to see how I am doing over time.

The Report feature is still limited, since I cannot search for lab results (example, give me all patients with cardiovascular disease AND LDL >2.0), or vital signs (all diabetics with BP>130/80). As well, I get a list of patients, but not the number of patients; I got around that by importing the file into excel and manipulating the data.

This brings up an interesting problem: we can save data to local machines (as I just did). The Hospital for Sick Children was recently severely criticised for losing some personal health data: a researcher took a laptop with patient data home, and the laptop was stolen from his car. Security for the EMR is very tight, especially for remotely hosted applications; however, this does not apply to data downloaded to my Tablet. I put passwords on Excel files, but I don't know if that is enough; I'm not sure what we should do for what is going to be an increasingly common issue. There will need to be a balance between data encryption to protect privacy, and the need to access files. Perhaps we should look at a large purchase of data encryption software for all physicians, rather than leave individuals to fund and buy this individually. I'm pretty sure Sickkids does not make each research buy the software themselves.

In a recent editorial in the New England Journal of Medicine (Performance Measurement in Search of a Path, Dr Hayward, March 1 2007), the author noted that "Perhaps our greatest barrier to developing a worthwhile performance-measurement system is our unwillingness to invest in it." He notes that the Department of Veteran's Affairs, a world leader in quality, does detailed reviews of electronic medical records. I think it is now possible to do this with current EMRs; we need to invest in data reporting, and target priority conditions. What you don't measure, you can't improve.

These are recent reports I've run:

	Report Name	Date Last Modified	Modified By
	Age 67 and over	Jan 25, 2007	Michelle Greiver
	Antidepressant prescriptions	Jan 16, 2007	Michelle Greiver
	ASA cad	Jan 16, 2007	Michelle Greiver
	asthma	Jan 23, 2007	Michelle Greiver
	Bipolar	Jan 30, 2007	Michelle Greiver
	depression, age 21 and over	Mar 9, 2007	Michelle Greiver
	Diabetes	Feb 17, 2007	Michelle Greiver
	diabetic on statin	Mar 6, 2007	Michelle Greiver
	family history of breast cancer	Mar 2, 2007	Michelle Greiver
	flu shots	Mar 6, 2007	Michelle Greiver
	Hypertension age 20 and over	Mar 9, 2007	Michelle Greiver
	kids shots age 15	Mar 6, 2007	Michelle Greiver
	Meningitis Immunization, teens	Jan 5, 2007	Michelle Greiver
	Patients age 12 and over	Jan 8, 2007	Michelle Greiver
	Patients with CAD	Mar 9, 2007	Michelle Greiver
	Schizophrenia	Nov 30, 2006	Michelle Greiver
	Women age 21 to 72	Mar 9, 2007	Michelle Greiver

Michelle

The Enterprise module: functioning as a group

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

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

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

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

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

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

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

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

Michelle

Paperless!

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

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

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

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

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

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

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

Michelle

Working with your EMR company

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

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

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

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

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

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

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

Michelle