Power outage

We had another power outage last week, this time for over an hour. It is hard to keep working when the power is out; however, my back-up systems worked.

My routers are plugged into an Uninterruptible Power Supply (UPS) box; if the power goes out, the UPS battery takes over. The two front computers are also on UPS. The Tablets are battery powered. The UPS battery only gives you a half hour of power; we have to shut down the front computers after a short while. However, the routers use so little power that they can function for quite a while, so access to our remote server was not interrupted.

The fact that we still had computers working gave my secretary access to the scheduler; she was able to call several patients to let them know that the power was off, and some appointments were rescheduled. Our phone system was down (the phones are dependant on electricity), so we used cel phones.

We were still able to see patients, to some degree. Only two of the five exam rooms have windows, so me and my practice partner were down to one room each. Although all the Tablets worked, none of the printers did, so I could not print lab reqs, prescriptions or handouts. I have frequently emailed handouts to patients, so I just switched to email for this. I left some prescriptions in the chart (issued, but not printed), and asked the patients to call in their pharmacy numbers later; I sent this as a “to do” to my secretary. I had a pharmacy fax number on file, so I emailed that prescription via Internet fax; fax via the phone line didn’t work (our fax machine and fax box are electricity-dependant), but I could use my Internet fax, which did work. For the lab reqs, we used blank forms and my lab tech had to copy the patient information by hand.

It is not fun to work without power, but it can be done in an EMR office; as in a paper based office, you are limited to where there is available light, and many things (especially peripherals like printers and labelers) don’t work. You need to have the critical components (routers, your server if you are on a local system, at least 1 front computer) plugged into UPS devices; for offices using desktops only, it may be worthwhile considering having a laptop in the office to take over from desktops. You will also need 1 wireless router, and make sure that it is plugged into a UPS. I can see that offices in remote areas (or even not so remote, like my cottage, which has chronic power outages) also need to have a generator as back-up.

We had a group EMR learning session in the evening, later that day. My FHN lead had arranged for a room and projector at our hospital. Because the server is at the hospital, I can plug my Tablet into a network jack and have access to the EMR from anywhere within the institution.

Space and equipment to set up a Booster learning session may be a problem. Some groups have access to their own boardroom, with computers. Some, such as my group, don’t have access to this (we are a collective of small, independent offices). The Boardroom approach is best, I think, because everyone can log in to their EMR during the session and follow along. However, the simple setup with just a room and projector, worked well; I think most groups may be able to get that from the local hospital. You have to make sure that you can log-in to the EMR. Failing that, see if you can get a demo CD ROM of the application from your vendor; you can set the demo version up on the laptop attached to the projector.

I had done individual visits to each of my FHN colleagues in May, so I was familiar with the questions that they had. Several problems had been solved while I was on-site. A group training session is a bit less useful (all of us are at different stages of implementation), but is more efficient; individual visits are hard to arrange. I am very familiar with small group educational sessions, because I have been a facilitator for my own Practice Based Small Group for over 10 years; I think this is a fairly effective way to learn things. There is no question that we need on-going training, and that this is not well provided through the EMR companies, if done at all; the lack of on-going education is something I’ve heard from colleagues using several different EMR systems. We do get the initial training at start-up, but afterwards, education is very haphazard.

We spent about an hour and a half at our small group booster session, going over several things. If you would like to see the basic layout of the session, it is below; some of it is specific to the EMR we use, some is likely generalizable to most EMRs.

Booster session July 8, 2008

Prescribing

• Basics: using quick fill in encounters: start typing the name of a favourite drug, and the rest auto-fills. If there are several dosages (example, amoxil), pick your dose from the drop down list (amox susp 125 tid x 10 d; amox 500 tid x 10 d)
• Expiry date: that is what makes it stay on or go off your CPP
• Short for short term drugs
• Longer (eg, 1 yr or more) for long term drugs

• Discontinuing or modifying drugs in the encounter: double click on the Medications tab, then pick Update or Discontinue.

• How to check drug interactions before you prescribe: click on the checkbox for the drugs you want, and then click the “interactions” button on top.

• Hx button: check on what happened to your drugs; you get a quick history of what you did (changed dose; stopped drug because of adverse rxn; drug no longer needed etc)

• CPP, Archived to see previous drugs, or double click on Medications in Encounter

Lab bundles and diabetes

• Using bundled labs: all the recommended annual lab tests are saved in the “diabetes” lab, which everyone now has. Double click on the requisitions tab, click on the checkbox for the “diabetes” lab, then Sign and Print. If you want to add more tests, click on the blue link for the lab test, Open, and then add extra tests. Save, Sign and Print
• If you have a lab that you would like to re-use (example, annual check-up, female), click on the “save as favourite” checkbox.

Practice functions

• Dashboard, My practice: click on the MyPractice tab to see how many of your patients are overdue for preventive services
• Dashboard, My Settings: use that to change your overall preferences
• Adding tracked diagnoses to Dashboard: Use MySettings, MyPractice to pick what you would like to track (example, how many diabetic visits you have per month, and per year); this is updated daily, overnight
• Checking your overdue preventive services list: go from MyPractice, click on the blue link for your service and it will bring you directly to your list of overdue patients

Coding

• Code long term conditions through Assessments in Encounters or in your CPP. **Do not use free text for Assessments in CPP, these cannot be used reliably for registers or for tracking**
• Do not code if you are not sure (example, better to code 786—respiratory problem not yet diagnosed-- than 493 for asthma, if you are not sure the patient has asthma); when you go to Reports to pick out your conditions, you only want to see patients who actually have asthma.

Lost in Transition: why residents use EMR and the rest of us don't

A large US survey of EMR adoption was published today in the New England Journal of Medicine. It found that "fully functional EMRs" exist in only 4% of practices.

Welcome to medicine in the 21st century: information starvation in the midst of data plenty.

It is still too hard to implement an EMR, and full implementation continues to be the exception instead of the norm. In the NEJM article, younger physicians were more likely to adopt (same as for the Canadian National Physician Survey); perhaps it will be the next generation of physicians who will practice in an electronic office, and not us.

We have two residents who started today in my practice: one starting with my new partner, and another one starting with me and my "old" partner, who is away this week. The new residents will be with us for two years; most of the time, they are in the practice for a half day a week.

Here is what it took to get the residents set-up: a computer for them, a registration in the EMR with permissions set at the Resident level, a log-on ID and a security FOB. I bought a Tablet for residents two years ago, as my department recognized that this was needed for teaching practices, and funded an extra computer for learners. I know how to set up all the basic log-in, so it did not take long, but it still needs to be done by someone (either a physician or a clinic manager). There is extra work for EMR set-up, which does not exist for paper-based practices.

My new resident came at lunch time, and my clinic manager oriented him to the practice; she gave him his security FOB. We logged him on to the resident Tablet, and he set up his PIN. I set his basic chart preferences to make sure that they were the same as mine; I don't know if I have the "ideal" preferences set-up, but it seems to work for me, and I'll be showing him how to use the software.

My resident followed me for the rest of the afternoon. I showed him how to load encounters and CPPs. He took his Tablet in, so that there were two computers in the exam room. He saw how I was using my Tablet, which helped give him a sense of how the EMR works and can be used in a patient encounter. He could also load screens on his Tablet during the encounter, since he had the same electronic chart open as me, but on his own machine.

He saw me touch type while talking to patients, write prescriptions, do a consultation letter while in the exam room, look data up in various areas of the chart (CPP, DI, labs, flowsheets), order labs and Diagnostic Imaging electronically, respond to pop-up alerts and other care reminders, and use e-messaging and Office Actions sent to staff. While he was there, an electronic message came in from our clinical pharmacist via remote access from another site; she had reviewed a problematic case for me and sent some suggestions in the patient's chart. She had also emailed me a relevant article via regular email.

My resident had never been in an office using EMR. He will only use EMR while working with me; there is no choice, since there are no paper charts. I spent at least as much time teaching him the EMR as discussing clinical matters. I don't think that's bad for the first day, since his care will depend on his familiarity with the chart.

On the other hand, he has access to all my saved favourite drugs, all my batched labs, all the CPPs are in the EMR, and drugs automatically go into the encounter. There is also a lot of knowledge in the office about what to do when computer problems happen.

I simply cannot imagine that he will be willing to revert to paper after two years here. Many of our residency teachers affiliated with my hospital have now switched, or are in the process of switching to EMR. We have 8 academic Family Health Teams in Toronto, and these are the teachers of family medicine. Although not all have implemented, three now have (including our FHT); all units have either bought or are considering buying EMRs. I don't know if EMRs are more common in practices that teach, but this is worth exploring. I think many teachers are modeling EMR use for our new physicians.

We get new residents every two years. While one resident will be exposed to the initial pain of transition, the next one will see the EMR at a later stage.

I think many residents will use EMR during their training, and will then start working in practices that have computerized. The rest of us will have far more difficulties.


My practice partner is away this week. He decided to spend the week at home, and use some of his time to catch up with his work. I sent him aan EMR message about whether he wanted me to look at his results during his week off, and he emailed me back (in the EMR, via remote) that he would take care of them. He is now used to looking at the EMR via remote access, and can see all his labs and scanned reports. A student started entering his CPPs as of yesterday. Remote may well be one of the most useful features of the EMR for him.

Michelle

Research and Quality Improvement

I have been interested in research for several years, and have a couple of projects under my belt (Using a PDA for the diagnosis of angina; Cognitive Behavioural Therapy in primary care; effect of incentives on preventive services). I think EMRs have enormous value for research that is relevant to family medicine and useful for patient care; beyond that, the data in EMRs can certainly contribute information to run our health care system more effectively and efficiently.

The issue will be how to collect data from our practices; you want to fully protect the privacy of both patients and physicians, yet ensure that you still collect enough useful data for analysis.

I am a co-investigator in two studies that have recently received funding:

1. Canadian Primary Care Sentinel Surveillance Network (CPCSSN), and
2. Development of an Electronic Medical Record primary care research database, at ICES

These represent two different way of collecting EMR data for research. The CPCSSN sites will collect data on some chronic conditions locally from many different EMR systems in Canada; the data will not contain patient identification. All this data will then be amalgamated at the national site.

The benefit is that you can collect data from several different EMR systems (as we have a tower of Babel of EMR systems in family medicine). The drawback is that you depend on local investigators to try to collect data from their EMRs, and that you are pretty limited in terms of what you collect. You have to say what you collect at the beginning; if you forgot or just couldn't get something important, you don't have it in your database.

For the ICES study, we will explore anonymization software; this will allow, in the future, collection of the entire EMR database while protecting privacy. All names and identifiers are scrambled; after this is done, no one has access to the scrambled data, except for an ICES analyst. Researchers only have access to data after it is analyzed (once they obtain permission), and only for larger groups of patients, never for a single record. In other words, what you get is things like x% of patients in this geographic area have diabetes, y% were prescribed a cholesterol drug, and z% have a cholesterol level that is at goal.

The benefit is that you have a fairly complete description of care; if the database is mirrored (sent automatically to a second server), data collection is on-going and is pretty much live. The drawback is that the anonymizers will have to be programmed for each EMR software, since they all work differently. You will only get data from a select group of physicians, and there will have to be some extrapolation and assumptions if you say that the data represents an entire population.

Because the practices in my group are run remotely out of a single server, we can collect data without having to personally go to each office and access the server. In fact, the amount of bothering physicians, staff or patients is pretty much zero. Ideally, that is the way it should be--we're busy enough during the transition without imposing more work related to research. We will have posters informing patients, and giving them the option of opting out.

I do not know which way is best, and I think these two projects will test both approaches. We will start small, and go slowly and carefully; it may well be that we need a variety of approaches for data collection.

It is very interesting to me that some of the ground work that makes this possible started out of our group Quality improvement initiatives. We wanted to use our common EMR to improve our preventive services, and our diabetes care. Out of that came the realization that data could be collected remotely, and we also learned how to do it.

Research is difficult and time consuming. You also have to go through a Research Ethics Board, and there are lots of forms to fill out. I am not saying this is a bad thing, although sometimes it is very bureaucratic and it doesn't always make sense. Quality Improvement does not require all this overhead; in fact it works better when you have a goal, try small things, see if they work, then fix problems and keep going. This is called a Plan-Do-Study-Act cycle (PDSA); much of what I learned about collecting data in my group's EMR was through that process. For Research, you have to plan thoroughly, apply for your grant, hope it gets accepted, then implement and hope it works. This is not a great way to start something with as many unknowns as EMR data collection. We probably need to re-think the interface between Research and QI.

As for me, I think I probably have something to contribute to this nascent EMR research enterprise. I have now finished the coursework for my Masters, and am writing my thesis (on the Effect of EMRs on preventive services in a Pay-for-Performance environment). I have asked my University department for a second day of research, and will take Wednesdays for this, as of September. I'll practice three days a week, and devote two days (and some evenings and weekends) to research. I have asked for permission to join ICES; we'll see how things go.

Michelle

FHN staff meeting

Our FHN administrator organized a meeting for staff at all of our FHN practices, earlier today. She asked me to attend, which I was happy to do.

Every practice was represented (7 offices), most with more than one staff member. It was very gratifying to see that both my colleagues and their staff considered this to be important enough for time off to attend.

The first problem we had is that my office is too small! We really need a boardroom, which we don't have. Much of the discussion involved the EMR, so everyone crowded around the three computers in the front office area.

Interestingly, one of the first questions was about what a FHN is. In Ontario, we have a regular alphabet soup of primary care reform (FHN, FHT, FHO, FHG, CCM). Don't ask. I explained that the main difference between independent Fee for Service practice and a Family Health Network is in the payment (largely capitated, or one set fee per patient per year) for FHN, and piecework for FFS. As well, in a FHN, patients roster, or identify a particular family physician as their physician.

We did not find much change in our practice when we became a FHN. I think capitation is supposed to decrease small visits for minor problems, and encourage visits for prevention and chronic disease management; I'm not really sure this works. One of the main reasons we joined was that the government said they would subsidize EMRs for physicians joining FHNs.

Our FHN administrator went over the rostering process, and why it is important to keep rosters up to date, using the monthly update list. The roster list in the EMR drives the preventive services; only rostered patients get recall letters (that is the way the government set it up). I think that it really helps if people know why they are doing things. Maintaining the list ensures that letters are sent to appropriate patients and not to those who don't need them (patient moved, switched physician etc). We went over the process for de-rostering patients, both with the paper form from the ministry, as well as tracking in the EMR.

We showed the list of preventive reminder letters, and showed everyone how to easily access it in the EMR. Our administrator showed how phone calls are tracked, and reminded everyone that patients are now getting called if they have already received two letters and have not answered yet.

Staff member were very enthusiastic about participating in the FHN preventive services program. We discussed the fact that reminders do make a difference in cancer prevention, and they know they are taking part in a good program.

We discussed efficient messaging in the office, as well as pop up messaging. We have a summer student that will go around and install the pop up software, as well as fix computer glitches as needed. Several offices were interested in having electronic faxing installed, so that they could import faxes straight to the EMR without having to print and scan.

Finally, our FHN administrator took everyone's email address. It is not sufficient to email physicians, some things need to go to their staff as well.

Overall, it was a very productive and interesting hour and a half (included lunch). I think there is a lot of value in involving practice staff, not just physicians.


My practice partner is progressing quickly. He now writes some prescriptions, and has done several consult requests in the EMR. He uses office messaging and "to do" notes consistently. He is starting to write electronic encounter notes more and more often. The Tablet goes in with him consistently. He is using INR and diabetic flowsheets. All incoming reports are getting scanned in, and no charts get pulled; his labs are electronic. My staff still pull his charts for him for patients coming to the office, and I expect this to continue for several months, until there is enough data in the EMR. His first preventive services mail-out went out last week.

It has been a month on EMR for him, so I think this is not bad. There is still a ton of extra work for him, mainly the CPPs. We occasionally go over things quickly after the office, and I'm there to troubleshoot minor problems. He does not have to call the Helpdesk, which is a big difference from when I started. It makes a big difference once the EMR is up and running; adding extra physicians is not quite as tough.

We are getting two new residents in the practice in July; it will be interesting to see how they pick up the EMR. I was lucky to have an exceptional resident for the past two years; she bore with us during the transition with good grace, and is pretty expert at the use of the EMR now.

Michelle

Generating new ideas

I am sometimes asked about how I think of new things. The EMR is a powerful driver for new processes, because if you do things the old (paper-based) way, it does not work very well.

Very few things are completely new and world-changing like Google; my new ideas are small re-combinations of older things. This ability to figure out things is very human; machines certainly can't do this, and most animals probably don't either--at least my cat does not appear to.

Usually, I start with something that bothers me. For example, printing something and then re-digitizing it so it can be faxed seems silly; how do I fax directly from my Tablet? I don't have a fax server, and installing one does not seem practical. I can email; perhaps there is a way to combine email and fax.

The next step is to google "internet fax", and many sites pop up. Wikipedia gives me a quick run-down of how it works, and it seems reasonable. I give it a try, and it works.

I now have to figure out how to collate documents: many of my faxes consist of several documents (a consult letter, labs, scanned diagnostic images). I have to put all these into a single file, so I can email it to fax; if I don't do that, I have to save all the files to desktop, then attach a whole bunch of documents to the email-fax. That is too labour-intensive, and won't work.

When I write a consult letter, I sign it on the Tablet, then I print it. I have Adobe Pro; I can print it to Adobe and it saves it exacly, including my signature. I look at the Help in Adobe, and it tells me that I can create a document from multiple files; that seems pretty easy to do. I open three files, and try it, and it saves it as a single document. That works, and it is fast.

On top of the document, there is an email icon. I click that, my email program loads and I enter the fax. It works and is faster than printing and putting the letter at the front with a sticky.

Now I have a bunch of fax numbers saved in my address book. Sending a fax is now the same as sending an email. I still put long, complex faxes at the front, but most of the smaller notes go straight out from my Tablet.

That is how I do new things; it consists of figuring out what the issues are, trying things in small incremental steps, and solving problems along the way. Being curious and persistent helps.

If you like trying new things, the EMR is a gold mine for this, because it is early in its life-cycle. Bonus for innovators. If you prefer to let someone else start new things, but are open to trying them out for yourself, there are now enough innovations that you can help yourself from the menu. The on-line helpgroups for your EMR are a good place to look; provincial organizations like our EMR Advisor in Ontario also have good suggestions.

As another example, I am trying out new templates to help me with the clinical management of various conditions. At our recent Practice Based Small Group educational meeting, the module suggested a 3 question screener for suspected dementia. It seemed like a good idea, and you can see the resulting template at the top. I put a drawing area in the template, and the patient can draw the clock directly in the Tablet. It is saved as part of the record. I put this template in our Enterprise section, so it is available to everyone in my FHN.

The ability to try new things is a real EMR asset; the speed of communication also allows for a potentially very rapid spread of new ideas. I kind of like that.

Michelle

Preventive services results for our group

We now have my FHN’s results for our preventive services:

Children’s vaccinations: 98%;
Pap smears: 74%
Mammograms: 75%
Influenza vaccinations: 71%

We mailed out 7,666 reminder letters in the past year. Our FHN admin is emailing individual and group results to each physician.

The results are OK. I think they are not as accurate as they could be, because it was hard for us to figure out how to keep our patient rosters up to date at the beginning, so some patients are on the list and shouldn’t be. We are now much better at it: most practices fax the monthly update to our FHN administrator, and she enters the changes in the EMR. As a result, our patient databases are becoming much cleaner. I received a note that the Ministry of Health will soon be sending us our patient Roster lists electronically, so that will help--if it does happen and if the EMR company programs an interface for it.

I expect that our preventive results will be better in the second year because we are better organized and we have worked out the initial problems. I think this was a good experience overall for my group; I am now getting requests from several colleagues to start a Fecal Occult Blood screening program.

We are about to do our next mailing; this is now routinely happening every three months. We are also organizing a system to phone patients who have already received two letters and have not responded yet.

The five new physicians joining our FHN will be part of this, once they implement the EMR; my two practice partners have started, and we will do their initial mail out this month. Having a project that you do as a group is a good idea: it will make you function as a group (groups don’t really happen unless you do things in common), and these projects can be used to help with EMR implementation, because they add value to the EMR.

The diabetes project is going faster than expected. Most of the flowsheets have now been put in; the work is all being done remotely, since we no longer have to go to each practice to get data from paper charts. We are now going to start putting in automated reminders for diabetes care.

I have now visited five practices in my FHT. There are different things happening at each practice, but I am starting to see a couple of things that are common. Several of my colleagues wanted the vitals and current medications to load automatically into the encounter. I showed them how this is set up in Preferences, and we changed it while I was there.

I installed several batched lab requisitions at some practices, as well as requisitions for Diagnostic Imaging. For other colleagues, I went over how to prescribe using the favourites list, and how to quickly enter ICD codes for assessments. I re-worked saved letters and handouts to make them a better fit, after asking what my colleague needed; several people will now be doing sick notes directly from the EMR.

At several of the practices, I also spoke to the front staff. I have a CD with my scanned requisitions and patient handouts, and I installed this on a networked folder on the front computer.

I can see that this type of individualized assistance is of value. I was able to fix some annoying problems fairly quickly, and I think everyone was happy with the experience. I spent 1.5 to 2 hours at each practice, and the visits were pre-booked: the physicians cancelled appointments to make sure that we could sit together. I don’t expect that everything we discussed will be done, but I know that some things will, because we changed the Preferences and practiced together; if two or three common things work better, I think that’s pretty good.

It was interesting that while I was at their office, several colleagues told me that the computer made them feel “stupid”. You really have to wonder why this is happening to intelligent, very competent physicians. I think we have a lot of experience and knowledge about caring for patients, and we don’t have the same for computers. I reminded my colleagues that the amount of education and training we receive in Information Technology is several orders of magnitude less than what we receive in medicine; we are physicians and not IT specialists, after all. I don’t expect my lawyer to solve my computer problems. The stupidity lies on the side of the machines: if they worked perfectly, we wouldn’t have to deal with their frequent mood swings and reboots. My patients are used to hearing me vent at my stupid Tablet.

I went to another group on Tuesday evening, as part of the “official” Peer to Peer program. The issues were somewhat similar; their administrator was there, and we discussed work flow issues for different conditions, such as diabetes; I have now posted several entries on workflow at EMR Advisor. I showed how to make new templates using pieces of old templates. This took about two hours, which I think is about the right amount of time; more than that and everyone gets a headache.

Little pieces of integration are starting to happen on their own. I am receiving the occasional email about patients; I received a note from a specialty clinic asking if we would prefer to receive consultation letters via email. Even if the “System” makes it difficult, electronic communication is starting; perhaps we can use “going green” as an excuse to avoid paper and fax.

Michelle

First week on EMR

My practice partner has just completed his first week on EMR. The student pre-entered his CPPs for this week's patients.

My partner started doing some encounters. He is taking his Tablet into the examining room, and typing things in. He still has the paper charts with him, and I expect this will last for several months. He has prescribed a few medications, starting from the first day; this is more challenging for him, and he is still writing many scripts on paper. The medications that auto-load from the CPP into the encounter, as well as those that are in his list of favourites, are easier for him to do, so he has started with those. Prescribing using the drug database is much more challenging.

Interestingly, he noticed that the dosage of acetaminophen in Tylenol #3 was 300 mg, and he sent me an e-message about this. Dosage of regular tylenol is 325 mg of acetaminophen, and we both assumed this should be the same in T3. I had to look it up in the CPS (our drug bible), and in fact, it is 300 mg in the T3; a new pair of eyes is a powerful thing!

My partner is comfortable entering coded diagnoses in his encounters, and is now doing this fairly routinely. Family physicians generally know the ICD9 codes, because we use those in billing. Having the diagnostic codes will help once he goes on to the more complex aspects of the EMR, such as searching his whole practice for health conditions.

Our staff is scanning incoming documents for him. He still wants to have a look at the paper, so these are left in an area at the front for him. However, the secretaries are no longer pulling charts for scanned documents or electronic labs; this has immediately cut down on clutter at the front. If he wants to see a paper chart, he asks for it (verbally, or via e-message). Once he is done with the paper report, it is shredded.

Faxes come in to the front computer, and are uploaded to the EMR without printing; what we do is print the fax to pdf, save to the "Files to upload" folder, and then upload to the EMR. My partner has asked that the faxes be printed for him for now, so his faxes are both printed and uploaded at the same time.

He is spending more time at the office because of the EMR; we had discussed this, and he is prepared for the extra time investment. Our staff is trying to book him very lightly. He sometimes asks me for help if he is not sure what to do, and I am very happy to assist; our staff members are also very supportive.

We went over how to use a Tablet in the previous week. He is a bit tentative with the stylus, but is getting used to it. He has the same Tablet that I do (a convertible, with a keyboard), so I was able to show him how to use the Tablet effectively.

Overall, he says that the first week was OK. I think starting with basic things like putting in an encounter and assessment, and trying some prescriptions, works well. My partner is getting used to the way the CPP looks, and has entered some data in it.

What helps a lot in this case is the fact that the office is familiar with the EMR, so he is not starting from zero. There is a lot of on-site knowledge and support from both his practice partner and his staff; there is no need to call the helpdesk, which can take a lot of time. We are able to handle glitches and questions pretty quickly, so that if he has a problem, it gets solved. The questions he asks help him to figure out what the system does (and doesn't) do.

We have started to scan his old charts; I have ordered a second scanner, so we can do all the charts in the summer, and he is getting a student to do this job. He goes to a senior's clinic off-site, and he does not want to drag the paper charts with him any more. Those charts have been scanned in, and backed up to his Tablet. He will be logging in remotely while at the Senior's clinic.


I now have received the lists of diabetics back from my FHN colleagues, so we have a diabetes registry. There are 801 patients on this registry. I have a summer student now; he is currently entering the data for the preventive services for the new FHN physicians (rostering, checking off patients who have received the service). This is going much faster than last summer, because we are used to the system. Once he is done with that, he will be putting in electronic flowsheets and reminders for all diabetics on our common register. I have notified my FHN colleagues that this will start happening in the next few weeks.


I am currently trying out Internet faxing. Our system continues to be fax-dependent; even though secure email exists, no-one is using it. The way Internet fax works is that I upload the documents via email to a fax server, and it then transmits the information to fax at the other end. It is electronic (fast and easy to use) from my end, and paper-based fax (slow and non-secure) from their end. This may be one way to bypass the paper system. A problem is the cost: $14 per month includes 100 outgoing pages; I sent out 35 pages the first day. I then figured out how to avoid a cover page, which will reduce the number of pages I produce.

Something that happened once transmission was easier is that I am sending out more information. I had a lab result that I thought might possibly be useful to the geriatrician who co-manages a fragile patient with me; I emailed it to his fax. I would not have done this by plain outgoing fax, because you have to print it, put a sticky with the fax number on it and bring it to the front, then the secretary faxes it. I was off site at the Senior's clinic when I saw the result, and just emailed it. Make transmission of information easier to do, and it is more likely to happen; too much security can mean a loss of information, and there is little attention paid to the downside of security measures. Make a system too secure and too difficult to use, and the result is that nobody uses it; this is what has happened to our SSHA email system. Of course, fax is neither secure (everyone can see the pages that come out, sometimes you fax to the wrong number), nor fast or particularly easy to use--we're just used to it. It is time to consider abandoning our fax addiction.

Michelle

Taking care of our server

Our server is getting full. This is both a good and a bad thing. We thought we bought plenty of capacity when we first started; however, we are running out of space, after a little over two years.

This reflects the fact that the EMR transition is going fairly well; pretty much everyone is scanning everything in. We are increasingly giving up on paper-based processes. All labs are coming in electronically.

As well, we are now adding five more physicians to our group. Information Technology changes at such a rapid pace that what was considered pretty good two and a half years ago, when we bought our server, is now barely adequate. We now have to add extra capacity, and are working with our EMR company to do so.

When I switched to EMR, I ditched my old computer, which dated from 1996. EMR applications are far more demanding, and you use them constantly. It is a good idea to maintain and update both hardware and software. Some peripherals, like printers will last longer; the computers' hardware and software will likely need upgrading sooner. You also have to think about replacing parts.

For example, a label maker broke recently and we had to replace it. I just ordered a second scanner; I will have to buy a PC to go with it. I bought a new battery for my Tablet, after a year and a half. We broke three shredders when we first started (buy shredders with a replacement warranty).

However, the server is at the heart of your practice. It will need to be upgraded, and eventually replaced. Plan for this, and budget for it; a server that does not meet your needs is dangerous: it will slow you down, and it will eventually fail.

The IT committee for my group is functioning well, and we are meeting regularly; we also talk frequently by email. We have met with OntarioMD and with SSHA, as well as with the head of our hospital's IT department. We are still weighing the risks and benefits of a move to ASP; in Ontario, there are now three large EMR companies on ASP (1 previously approved, and two approvals are pending). We see the finite lifespan of a server happening in front of us, and what server maintenance for a mid-sized group of 23 physicians entails. Going to ASP means renting space on a very large, continuously updated server (not that this is without problems either); doing this would mean completely outsourcing server maintenance and upgrading.

In Ontario, government subsidies for EMRs end after three years. We will be at that mark in 2009. I can see that there are on-going costs; in Alberta, the government has decided to continue to subsidize and support EMRs. Perhaps this is something that Ontario should consider as well.

I have joined the IT committee of the Ontario College of Family Physicians. We are reviewing the key issues impeding the transition to EMR; failure of the system to connect continues to be right at the top of the list. I am increasingly reluctant to forward any proprietary forms. We have a new tri-hospital initiative to expedite colonoscopy after a positive fecal occult blood test; however, the first thing that the program did is send us copies of their proprietary referral form. We discussed this at my hospital's recent family medicine business meeting; programs have to realize that this approach is no longer acceptable. I had a patient with a positive Fecal Occult Blood last week; my first referral was generated in the EMR, with a note requesting a waiver from the form (Je Refuse).

I am now generating public health requisitions within the EMR; the req contains the same information as the proprietary form. I have staplers in every room, and I staple a blank proprietary form behind the real form with four staples so it is strongly attached. There is a Six Sigma Method for improving quality; I call this method the Four Staples Method for patient safety.

Michelle

Summer students

University students are now finishing their last exams. High school students will be out in two months.

Getting some help from students is very common during the transition to EMR; my partner hired two students for data entry. The students are entering the CPP, and my partner then reviews those for accuracy and completeness. Several other physicians in my group did this when we initially started the EMR.

It is not bad to start the EMR transition in the spring; the office is quieter then. As well, you have some idea of what the EMR looks like by the summer, as you hire your student help.

However, CPPs are not the only thing that bright students can help with. Data entry for the preventive services for my group, last summer, was done with student help. It worked, so we discussed a diabetes quality improvement project at our recent FHT meeting, with funds allocated for data entry. There was consensus that we should go ahead. This is the project:

1. Get a list of all diabetics for each practice
2. Verify the list
3. Put in an electronic flowsheet in each practice location
4. Put the flowsheet in every diabetic's e-chart
5. Put in reminders to look at the flowsheet, every 3 months

It looks simple, but it is actually fairly complicated. Not everyone is entering the ICD code for diabetes (250) in the CPP or in encounters. As well, this code is sometimes used for Impaired Fasting Glucose ("pre-diabetes"), or Gestational Diabetes (diabetes only during pregnancy). These patients don't have diabetes. What I will do is get the list of all patients with 250, together with "comments". We often enter a comment like "IFG" if the patient does not qualify for diabetes. If the Diabetes list is poorly populated (I expect about 10% of adults for each practice), I can extract the billing code specific for diabetes.

Once the list looks reasonable, it gets faxed to my colleague's office for review and approval. We proceed with putting in flowsheets only when the list has been approved.

The advantage of electronic flowsheets is that much of the data is automatically populated. Vitals and labs go in automatically; the vitals go in straight from the encounter, and the labs straight from the e-results. I don't have to re-enter this data twice.

However, like everything else, this is not perfect. The labs all use different databases, and patients don't always go to the same company's lab. What I did for my group was meld the databases: in our Enterprise module, there is a place where you can say "this test from lab A is the same as that test from lab B". For some reason, it works very well for two of the three electronic lab companies, and not all that well for the third. It doesn't work at all for paper-based lab results, like the hospital's. When it works, results from any lab just go into the flowsheet.

To get around this problem, I have a cell called "notes" in the flow sheet. I just type the non-electronic tests there. I also give patients a handout with their lab form, with locations and hours of the two preferred lab sites, along with the URLs for lab locations. We do most of my lab tests in my office. We really need to have a common nomenclature for lab tests, as well as a common way to store and transmit lab results electronically; I keep hearing this will happen (OLIS), but I see nothing happening yet at my end (maybe this year?).

There are blank areas in the flowsheet to record other things, such as foot exam and monofilament testing. I ordered some free monofilaments last month from LEAP, and distributed them at our recent FHN meeting.

The students will take the approved lists, and enter a flowsheet in each chart. They will also put in a reminder to look at the flowsheet and check diabetic parameters, every three months. Finally we have a code that we bill every year for managing diabetes and reviewing flowsheets. The students will do a billing list for every physician, and if this works, we will bill this yearly as a group.

I don't yet know what problems I will encounter with this summer student project; I learned a lot from last summer's project, and I think I'll be able to figure out ways to fix things as they happen. Because we all access a common database remotely, all this will be done from my office, with no disruption to any practice; there are some very significant advantages to remote access.

What I hope to achieve is:
-a registry of all diabetics for my whole FHN
-use of flowsheets for every diabetic

My resident is almost finished her two years in my practice, and will be graduating as a full-fledged family physician soon. We will miss her. We get a new resident in July; one of the things that residents have to do is a practice audit; my resident did one for me on my diabetics two years ago. Audits are now a lot faster with EMR; I think I will ask the new resident to audit my practice, and if it is really quick, we'll ask some of my FHN colleagues for permission to remotely audit their practice. We can probably get some very good baseline and on-going data that way. I think I may get to find out if this little diabetes quality improvement project works.

My FHN is growing, and we now have 14 physicians. All three hybrid practices (EMR/paper) in my group are now going to be EMR only, as all practice partners have joined the FHN. We will go from a 12,000 patient base to about 16,000 patients. I expect that we care for about 1200 to 1400 diabetics (there are 89 diabetics in my practice). I think we can use EMR tools to make a real difference in their care, and I plan to have our summer students put in some building blocks to enable this over the next few months.

Michelle

EMR housecall

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Michelle

Giving back

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

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


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

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


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

Michelle

Uncertainty principle

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

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

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

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

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


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

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

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

Michelle

First fruits of the FHT

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

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

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

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

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

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

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

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

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

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


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

Michelle

Wag the dog: of forms and cookies

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

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

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

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

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


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

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

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


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

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

Michelle

Helping my practice partner start the transition

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

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

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

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

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

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

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

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

Michelle

EMR for the non-believer

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

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

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

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

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

Michelle

On-line Support group

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

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

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


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

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

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

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

Michelle

Snow storm

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

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

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

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

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

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

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

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

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

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

Subjective/Objective
Favorite Notes:

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

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

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

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

Assessments

---

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

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

The Plan notes can be dictated as well:

Plan Notes

Favorite Notes:

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

Title:

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

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

Michelle