Doctor shares EMR experience on blog

“I have wanted to computerize my records for a long time,” Dr. Michelle Greiver says.

By Saul Chernos

Dr. Michelle Greiver, a Toronto family physician, implemented an electronic medical record system earlier this year. Through a blog on the Internet, she went public with the project, tracking its progress and relating her experiences, blow-by-blow, for the world to see.

I have wanted to computerize my records for a long time. However, like most of my colleagues, I have been reluctant to do so … EMRs are good for patients and good for the system. The rewards for physicians are less obvious.
    – From an introduction to Dr. Greiver’s EMR (www.drgreiver.com)

In an interview a few weeks after the EMR was successfully installed at the midtown clinic she shares with another general practitioner, Greiver elaborates on the implementation and why she decided to share her experiences.

“EMRs are something a lot of doctors are going to want to do,” Greiver says. “It’s just the beginning, the upswing. I thought if I recorded what I did and how I did it, it might be useful.”

Greiver, a University of Toronto medical graduate who has practiced family medicine for more than two decades, is no stranger to information technology. She purchased her first home computer in 1993 and quickly learned how to make it do practical tasks such as accounting. Experimenting with early modems, she made her system crash, but she kept on trucking. A strong natural curiosity drew her to research projects – one looking at using Palm-based tools to manage patients with chest pain. She says she sees the implementation of an EMR, and the overall move to an electronic environment, as significantly advancing the level of care she will be able to provide.

“There are tons of things I can’t do on paper. To see whether all my diabetics have good blood sugars I’d have to pull tons of charts, look at each level, and then record the data. I’m so busy with my practice, I simply haven’t had time to do this kind of an audit. With EMR, I just push a few buttons and I can track an entire area to see how my practice is doing.”

The decision to choose EMR software is not easy. There are many vendors out there, different pricing levels, and different levels of support.
    – Dr. Greiver’s EMR, Tuesday January 3, 2006

Actually, the decision-making started long before January. Greiver says she wanted an EMR a decade ago but considered the cost prohibitive and the technology not quite up to snuff. “I didn’t think the machines were good enough to have my entire practice on computers, and I didn’t know anybody who was doing it. I didn’t want to be isolated.”

The recent SARS episode raised the stakes. “I was quarantined and would get many pages of faxes from Public Health. I wanted to receive information electronically, but I didn’t have broadband in my office back then.”

A watershed moment occurred when the provincial government announced subsidies for physicians who join a family health network and agree to implement an approved EMR system. “All of a sudden it was financially feasible,” Greiver says. “I wasn’t the only one wanting to do it. There were 18 of us (in two family health networks) and we had the advantage of bulk buying.”

Greiver joined her network in 2004 and its members’ subsidies were approved in February 2005. A month later, one of the participating physicians scouted the EMR software market and produced a short-list. Communicating back and forth with the rest of the group, the scout spoke with salespeople, watched demonstrations, talked with users and explored integration and operational issues. With contenders gradually voted off the island, a single prospect emerged. Greiver and several of her network colleagues met last fall with representatives from Nightingale, an EMR systems developer based in Markham Ontario that offered a package including myNightingale software, as well as hardware, wired and wireless connections, and a service contract.

Greiver chose a PC Tablet for herself, several workstations and a network printer for the front office, plus a series of smaller printers, a card swiper, two label printers and a scanner. With a provider in place and basic equipment agreed to, there would be internal issues to resolve.

My practice partner decided he wasn’t quite ready for EMR. However, he agreed to switch to the new system for billing and scheduling, as our current system was over 10 years old, and was DOS-based. We would therefore have a hybrid office, but with a single billing and scheduling system.
    – January 18, 2006

“My partner doesn’t like computers and didn’t want to join,” Greiver says. “Our (front-office) computer system had served us well, but we bought it in 1993. We agreed to buy one system for the administrative staff, and my partner will stay paper-based.”

The EMR system is able to absorb paper-based data for front-office functions such as billing and scheduling and, should Greiver’s partner decide to implement EMR later on, the going will be relatively smooth. “The software is modular. He’ll have to negotiate by himself, but he’ll have a system already in place, with trained staff. He’ll mainly be looking at extra software.”

With the view that EMR is here to stay, that it’s only a matter of time until it’s standard practice, Greiver signed the contract and joined her administrative staff and her colleagues for training at Nightingale headquarters.

There was a very wide range of comfort with computers, from one “super-user” who had already been using the software in another office, to someone who had never used a mouse or email (and was not too thrilled about all this nonsense).
    – February 8, 2006

Following several four-hour sessions, covering the basics and issues such as data transfer and file conversion, the front office was hooked up. “We needed to implement the up-front administrative side first because that’s where the existing computer systems were,” Greiver explains. “I was still on paper when my staff went live.”

Data transfer wasn’t always simple. “Things like patient names, addresses and OHIP numbers were easy to transfer electronically. But we had to take our old schedule and manually re-enter it into the new software.”

When the front office was up, Greiver and her fellow physicians were taught how to set up electronic patient charts, generate digital lab requests, document patient encounters. Inevitably, Greiver and her staff found themselves learning on the job.

By Thursday night, I’d written 39 electronic prescriptions; I’m getting better at it. However, I’ve turned off the automatic drug interaction software. I couldn’t figure out how to accept and print a prescription if there are interactions that don’t matter; since we have the EMR2 seminar next Wednesday, I will ask then.
    – March 24, 2006

With the planned April 3 launch date drawing near, earlier concerns about costs gave way to a realization that time was the major expense. “For a big implementation like this, you have to put in time at the beginning,” Greiver says. “Things don’t always work as planned, and I’ve been going home late. From everything I’ve read, it starts to get back to normal after six to 18 months, and soon you get extra time.”

I now have several patients who do not have any paper charts. Going forward, all new patients have electronic charts only.
    – April 19, 2006

Another concern was security. Greiver arranged to store her data off-site at two hospitals. Data can be accessed online but is protected by several safeguards. Electronic records, properly housed, are safer than paper files, Greiver says. “You could steal all the hardware from my office but not get any patient data.”

Greiver’s office launched its EMR April 3, as planned, and went fully wireless two weeks later. Despite minor glitches – scanners that didn’t read properly, occasional delays in connecting with the server, and software that didn’t always cooperate – Greiver says she is buoyed by the many things that are working. On April 19, her first electronic laboratory results landed directly in the patient’s chart, with abnormal results automatically flagged.

As far as her blog goes, Greiver says feedback has been tremendous. Doctors from coast to coast have e-mailed to express their opinions, relate experiences and ask questions. One physician reported finding a product that uses a sensor to monitor the temperature in his office refrigerator, where he stores vaccine. The sensor comes with software that enters temperatures into a spreadsheet. Greiver says her own office fridge happens to be next to a computer, so she has hooked hers up, too.

Maybe I can ... sell my filing cabinets on eBay. I wonder what I’ll do with all that freed office space.
    – April 28, 2006  •

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Cardio clinic stresses tech

Dr. James Swan has transformed Rouge Valley Cardiology into an almost totally digital operation.

By Issie Rabinovitch

In northeastern Scarborough, far from the bustle of downtown Toronto, a cardiology clinic has been doing pioneering work in software and image management for the past six years. The project that began in 2000 under the direction of senior cardiologist, Dr. James Swan, has transformed Rouge Valley Cardiology, a seven-partner clinic, into a digital operation that does things in a way that other cardiology clinics in Canada must surely admire.

By 2003 RVC had become the first to integrate the results of stress echo and ECG into a single interactive report on the screen (“Our claim to fame,” says Dr. Swan). The technology continues to advance. The continuing project makes for an interesting and instructive story, one that Dr. Swan is pleased to share.

Dr. Swan, from all appearances, appears to practice what cardiologists preach. He is trim and fit. An accomplished hockey player in his younger days, one who might have become a pro but for the talents that led him into medicine, he remains an avid runner to this day.

He’s very enthusiastic about the technology in daily use at RVC, which he helped to develop and implement. It’s been a big part of his work life for about six years, but it has also impacted the rest of his life, in a favourable way. More on this later.

In 2000, Dr. Swan and his partners decided to undertake the transformation of their clinic from analogue to digital echo and to develop a system that could display the stress echo images and stress ECG on a single interactive computer screen. There were also some secondary goals, such as using digital technology to standardize reports, reduce staff and to achieve immediate reporting, making reporting from a remote location as easy as reporting in the office, becoming essentially “paperless”, and achieving an easy-to-use system that improved patient care.

I hate to spoil a good story, but all objectives were met, some sooner and more easily than others. However, it didn’t look very good back in 2000. There wasn’t much available then for the small digital echo lab. The only ECG machine with digital output at the time was from Quinton. The big players, such as GE, HP, Toshiba, and Siemens were not interested in Swan’s ideas. Instead, he asked Prosolv and Quinton to join him.

At the start, the team consisted of Prosolv engineers to support data management and reporting, Quinton engineers for stress ECG integration, ATL (Philips) engineers for ultrasound data and images, internal IT coordinator, and cardiology project leader, all supported by partner cardiologists, echo techs and staff. Dr. Swan and RVC took no financial position in the project. In essence, RVC became a beta site for Prosolv and Quinton.

It wasn’t easy, but progress was steady. Some milestones include:

• 2001, getting echo machines to integrate with Prosolv for 2D echo.

• Mid 2003, adding the Quinton Q-Stress image files and data to the final reports.

• Mid-2003, becoming the first clinic anywhere to simultaneously display the combined stress ECG and stress echo images and their data on a single interactive computer screen.

• Early 2006, refining the automatic interpreter to meet ACC, ASE and CSE guidelines.

• Mid-2006, spell checking has been added to the program and integration of 3D echo is under way.

The technology currently at RVC includes: a server-based office network with two reporting stations and laptops with reporting software. The network connects to the Internet via a T1 line. There are three HDI 5000 and two Q STRESS ECG Machines. The RVC Echo Lab has Stress Echo, Stress Echo Doppler, Echo Doppler, Stress ECG with integrated Duke treadmill score, and Integrated Framingham risk score from Q Stress (soon to be available in the stress test reports).

RVC has successfully used this technology in over 7,500 stress echocardiograms. Studies can be read locally or remotely with all final reports generated through the central database.

RVC no longer uses ECG Paper, VCR tapes, CD ROMs, transcription or filing staff. The first year saw savings of $38,000 although that was offset by software and installation costs. Annual software maintenance costs of $15,000 kicked in after the first year but support staff numbers went down. According to Dr. Swan, the payback period was two years.

All database fields in the SQL database are searchable, permitting clinical research and outcome analysis. Individual studies can be copied to a CD and sent with a reader that any computer can view. This same program has been used successfully since 2001 for regular stress testing and echodoppler reporting in over 10,000 additional studies.

Reporting can be done from any computer with an internet connection, even a slow one. It is possible to generate the final report from anywhere in the world without secretarial help. Dr. Swan and the other cardiologists can travel, take vacations, or work from other locations and still keep current.

The remote reporting capability is part of Dr. Swan’s lifestyle. He is pleased to list the places he has used it: Toronto (office and home) and other Ontario locations, Chicago, New Orleans, Phoenix, Seattle, Grand Cayman, and Vienna.

However, even Dr. Swan admits that the single most important benefit of the technology is the speed with which the patient and the patient’s doctor get the result of a test. “The report is done and ready to send via e-mail before the patient is at the door,” say Dr. Swan. When I had a stress echo test done at a hospital a couple of years ago, it took 2 weeks for the results to reach my GP and a bit longer to reach me. I watched as Dr. Swan was able to complete his final report within 45 minutes of the patient leaving the treadmill. The technology saves money while enabling the cardiologists at RVC to see more patients in a day.

Dr. Swan reports that everyone in his clinic is pleased with the digital technology. It has become much easier to implement since RVC showed the way. Regardless, Digital Echo has been slow to catch on in Canada. I wondered why. Dr. Swan gave several possible explanations.

Cardiologists are skeptical, most think the cost of doing this is too high, there’s a reluctance to trust computers, and education on the benefits of going digital has been slow to catch on. Two reasons are specific to Ontario: There has been no increase in technical fees in 15 years (although some money was made available for going digital in the first quarter of 2006), and Ontario hospitals are not digital due to inadequate funding and poor IT infrastructure.

However, to end on a positive note, Dr. Swan says that current guidelines and industry advances are making cardiologists rethink their position. Perhaps a visit to Scarborough would hasten the process. •

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