Monday, October 5, 2009

Spoonful of Sugar

I got a big dose of my own medicine last week. And it was bitter.

We've been waiting for our new electronic medical record (EMR) system for several years. We implemented our old EMR over 4 years ago, and I posted previously about some of the benefits. Unfortunately, the EMR program was "orphaned" about 2 years ago when the software company was bought by another company. It changed hands again, this time acquired by one of the companies applying for approval by the Saskatchewan Medical Association (SMA).

While software vendor approval has been drawn-out, it's an important process that helps ensure that vendors will be committed to and capable of providing service in the long-term, as well as expanding the capability of their EMR software to include connectivity with laboratories and between physician offices. We are fortunate that the company that owns our old EMR has received SMA approval, as they have all the necessary codes and knowledge to transfer records between the two systems. As far as we can tell, the transfer of patient information went smoothly. But that was the easy part...

After several days of hands-on training, our new EMR went live last Monday. You may have heard the metaphor of "trying to change a tire while driving your car down the highway." That's what using the new EMR felt like. We had adjusted our office bookings so that we were seeing 2 patients per hour rather than 4 per hour. We had each spent several hours with the software vendor trainer who led us through a hands-on demonstration. I had even poked around in a dummy version of the program. But, it was still quite stressful to make the switch.

We had always known that the workflow in our old EMR was somewhat inefficient, but we had learned how to do all those inefficient steps rapidly. Getting the same information out of the new EMR was frustrating. The screens and buttons were unfamiliar. The layout and flow of data was different. By the end of the first day, I just wanted to go back to the old system.

The second day was worse. On Tuesday afternoons, I rely on having remote access to our office EMR while I'm doing procedures at the hospital. I check each patient's chart just before their visit. If I see that person for regular checkups, then I will likely remember the important details of their medical history. However, if I'm seeing them for the first time, I need to review the letter and test results their family doctor has sent me. Usually, it would take a minute or two to check their chart. Last week, it was taking me up to 5 minutes each. Data transfer across the wireless network was slow. Unwelcome windows kept opening and cluttering my computer screen. I knew that the old system would have been much easier.

By Friday afternoon, I was starting to see some blue sky. The layout of the program was getting more familiar. I was learning some of the keyboard shortcuts that work more efficiently than dragging a mouse around the screen. Plus, I learned some features that weren't available in the old system. This weekend, I was able to get some work done from home that would not have been possible to complete with the old system.

I'm pretty gung-ho when it comes to change initiatives - or at least I flatter myself that I am. I think that's why I was getting so frustrated with the new system. I was excited to make the switch, but I had over-romanticized the idea of getting a new system that would be easy to use and make my life easier. When it turned out that it wasn't as simple as I had anticipated, I wasn't mentally prepared. I've either led, or been deeply involved with, most of the quality improvement changes in our office, so have had a thorough understanding of the mechanics of the change. This time, one of my partners and office managers were the change leaders. They've done a great job and have been teaching the rest of us how to use the software. But, it's been very annoying to struggle with something that is so integral to my daily work. It must be doubly frustrating for anyone who may be both distant from the project planning and implementation, and also uncomfortable with technology.

I was surprised at how upset I was about having to learn the new EMR. I thought I was immune to the stress of change!

There are several aspects to the EMR switch that have been helpful and important.

First, our old EMR is turned off. As soon as patient records were switched over to the new system, we could no longer use the old system. It would have been tempting for me, last Tuesday, to flip back to the old EMR - just to get through my clinic. I would have justified it by saying, "I'll do it this one time." Without that option, I was forced to work through the problem and become familiar with the new system.

Next, we've been sharing our discoveries and failures. Having everyone struggling with the same problems means that we also benefit from each other's experience. Last week, there were a lot of huddles around computer screens as someone would demonstrate how to fill out a form or use a shortcut to get to certain information. As we start to use some of the more advanced features of this EMR, such as using templates to simplify data entry, our community of users will be a great mutual support.

Finally, there have been some quick wins. I can immediately see some processes that will be more efficient with the new EMR. For example, our workflow to send out consultation letters to referring physicians will be much improved. Formerly, staff would transcribe letters, print them out and then give each physician their stack of letters. Docs would review the letters for corrections, sign them and return them to staff who would fax them to the referring physician. If I wanted to make a correction, I would write it on the letter and return it to staff who would edit it and return it to me for signing.

If I wanted a letter to go out without delay, I would indicate that it was to be sent "Dictated but not read." Staff would fax it without me having read it. That was handy if I was going to be away from the office for holidays, and didn't want to delay letters going out. However, mistakes do sneak into letters, and a misplaced "not" or "don't", or a missing decimal point, can drastically change a sentence's meaning. I prefer to proofread consultation letters.

Also, if I wanted to review letters while I had a few minutes between surgeries at the hospital, I would have to carry the stack of paper with me.

With the new system, letters remain in electronic format. Staff transcribe the letters and send them to an inbox where I review them. If there are any changes needed, I can make them myself, which saves one or two days of turnaround time over the old system. Once I'm satisfied with the letter, I can fax it directly to the referring physician. It's a simple process that gets the consult letter to the referring physician more quickly, and means that our staff don't have to handle the paper copy a second time, feed it into the fax machine, and dispose of the obsolete paper. We still have some paper copies to be sent out, for example if we're sending a letter to a patient. But virtually all doctors' offices have fax machines, so we'll also be saving huge amounts of paper and reducing garbage by moving to this electronic format.

This was the big win I discovered this weekend. From home, I was able to review all the letters that staff had transcribed this week. I don't have to lug reams of paper to the hospital anymore. Plus, I'll be able to keep up on my paperwork while I'm away from the office, as long as I have internet access. That means I'll be sending fewer letters out "dictated but not read."

That was a nice spoonful of sugar for what started off as some pretty bitter medicine.

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