From rags to riches: Information and the electronic medical record

Just over 10 years ago, I was juggling family commitments and running a computer business and an average-sized medical practice. It was what I had expected from my training as a physician and what I thought physicians were meant to do. But I was tired and moving as fast as I could.

About the same time that I realized I wasn’t going to be able to keep up my fast pace, physicians were being encouraged to switch to electronic medical record (EMR) systems. An organization called PITO (the Physician Information Technology Office) was offering funds for computers and EMR software. Thanks in part to Typing 9 (taken on a mechanical typewriter!) I knew computers and was comfortable with a keyboard and mouse, so when a physician community of practice/EMR user group started in my small town, I decided to sign up.

The challenge of change
At the start of the EMR process, I attended software demonstrations and found that none of the systems could completely meet my needs. I wanted all my patient test results to simply show up in my computer. I wanted to be able to modify my display to see only what I needed when I was with a patient. I wanted to share information in a timely way with other health care providers. I wanted to be able to look back at chart information in a way that made sense and showed patterns and trends: whether blood counts were falling, what the last thyroid function test indicated, and if the patient was overdue for a mammogram. I wanted relevant information at my fingertips when I was planning for a patient visit and information that was easily accessible while I was seeing a patient. It didn’t happen exactly that way, at least not at the start.

Moving from paper to electronic records
The change to electronic record keeping was slow and incremental and I made mistakes, but I learned from them and always held onto my belief that information was key. When I began, I could have chosen to populate each patient EMR with data from that day’s visit and ignore the older records. Had I done this, I would have had little data to search through until each patient file was built up over time, and I would have needed to continue referring to old charts. I was too impatient for that approach. So, for each patient record I manually entered all important lab results, imaging reports, and consult summaries. I transferred the complete patient problem list from the paper chart and updated all medication and allergy information. With my wife’s approval, I spent evenings and weekends doing all the inputting work myself. I could have hired someone, but it would have cost me and I couldn’t have provided adequate instruction to the inputter because the system was new to me and I needed to figure things out as I went along. Meanwhile, new lab results were still arriving on paper and had to be entered manually by staff. I’m glad those days are done! In the end, everything was nice, neat, and organized. I could access information easily right in front of my patients: no more searching for an old chest X-ray report, no more wondering when the last PAP smear was done. But I still wasn’t going home any earlier.

Of course frustration and problems were both common during the introduction of the new office EMR system and conflicts did arise. Communication between the physicians and the office staff hadn’t always been great before, and introducing a new system led to some acrimony. Staff members were unhappy with an office manager they felt was bossy and hypercritical. The office manager thought staff members weren’t working up to their potential. The physicians believed small jobs that would improve the workflow and make their lives easier weren’t being done. Visits were disrupted when patients produced unexpected driver’s medical examination forms for completion. Outdated and disconnected phone numbers were attached to patient phone requests. Staff would be confused by each physician in the practice insisting that a particular task be done in a different way.

Without realizing that we were embarking on a quality improvement journey, we asked for outside help and received some coaching from PITO support personnel at a meeting of the physicians and staff. We defined roles, worked out job rotations, streamlined office management tasks, and started weekly team huddles. Huddle goals were simple and SMART: specific, measurable, attributable, realistic, and timed. We began documenting reasons for patient visits when appointments were made so that staff and patients could prepare properly and physicians had a fairly good idea of what to expect when they walked in to meet a patient. The EMR system documented evidence-based goals of care tailored to the individual patient and allowed staff to use these goals for proactive care planning. Staff would check care plans 1 to 2 weeks before a patient visit, note what tests were due, and arrange for patients to complete these so that the results were ready for the visit. These changes made everyone in the office happier.

Adding and using clinical content
Over time, we added more clinical content to the EMR system to facilitate decision support. For example, medication templates were named by clinical conditions so that a physician managing a case of atopic dermatitis could type “atopic” in the prescription and have it populated immediately with a list of topical steroids, creams, ointments, and lotions stratified by potency from weakest to strongest. For a case of actinic keratosis, typing “actinic” would give the physician access to proper treatment regimens and patient handouts. The system was saving us time! No more searching for things that we couldn’t quite remember!

In 2013 when PITO introduced the objective data dashboard, a tool to reward physicians who increased their meaningful use of EMRs, I realized that most of the required data elements weren’t clinically relevant. Physicians were being rewarded for doing one-time work. It was interesting, however, to see charts of elements being measured over time. This got me thinking of ways to search the EMRs for more clinically relevant elements. So, I started with a common scenario.

A patient arrived for an appointment to have sutures removed. He had cut himself on a sharp stick while gardening and gone to the emergency room to have the wound cleaned and sutured. During his visit with me he asked if I had a record of his last tetanus shot. At the hospital he had been asked about this. He thought it was at least 10 years ago, and so was given a tetanus shot. When I reviewed his chart and found no record of a previous tetanus shot he was surprised that I didn’t know this simple thing about his medical history. I documented his shot at the hospital and then wondered how many other patients in my practice didn’t know their tetanus vaccination status. It turned out this applied to most of them.

I used a report wizard (a tool that doesn’t require any programming knowledge) to search my office records for the information I wanted and found that only 3% of patients had a documented tetanus vaccination. My MOA and I notified public health, stocked up on tetanus vaccine, made a little template to record vaccinations, and a dashboard to show progress over time. In 2 years, 86% of my patients had current tetanus vaccinations.

Were the changes described here easy? No, not initially. But my patients were impressed when I started asking more questions about them and I was happy to be providing proactive evidence-based preventive care. Soon I saw that this proactive process could be taken one step further with the help of the EMR system.

Imagine any clinically important measure, something meaningful you do (e.g., infant immunizations) or an important patient health outcome (e.g., blood glucose control for a patient with diabetes). Imagine looking at your own measures and being able to compare them with the same measure of any other group that wants to share information with you—perhaps your own clinic colleagues, physicians from the clinic down the street, or other physicians in your community, region, or the whole province. Imagine this comparison helping you understand what’s working for other physicians and medical practices, and what’s not. Finally, imagine using EMR data to help understand the health needs of an entire community. For instance, how many patients in the area are frail and will require support in the coming years? Or how many patients are too economically challenged to afford medications? With a better understanding of future needs and issues, physicians can work with the local health authority and lobby or plan for services that will be needed, not just react to needs when they arise.

The Health Data Coalition
In BC a platform is now available to find answers to important clinical questions. The Health Data Coalition (HDC), a physician-led data-sharing initiative funded by the General Practice Services Committee, has built a tool that can look at information from one EMR system and combine it with information from other systems in groups of the user’s choosing (www.hdcbc.ca). The EMR-agnostic platform makes it possible to aggregate data across hundreds of clinics and providers while maintaining patient and physician confidentiality.

Using the HDC platform, a physician can ask a range of questions. For instance: How many diabetics are in my practice? What percentage of my COPD patients have had pneumonia vaccinations? The answer can then be sent to the physician or combined with answers from other practices to provide an aggregate answer. No individual patient information leaves the physician’s office, ever. No physician or practice names are shared, unless a user wants this. Nobody can use the practice data to monitor or judge a physician. Instead, physicians can use this information to see how they are doing in specific practice improvement areas, to collaborate with others, and to share best practices.

Engaging with collaborators
In today’s political and fiscal climate, physicians feel increasing pressure to improve the quality of services delivered to patients and to engage in measurable quality improvement processes beyond obtaining CME credit hours. By providing access to a robust source of medical data, the Health Data Coalition can play a large part in this. The initiative is the work of an enthusiastic and dedicated group of family physicians from across British Columbia, and is supported by their mutual passion to improve health care quality, to innovate, and to protect the privacy of both physicians and their patients. The physicians on the board of the HDC believe that the electronic medical record provides exciting opportunities to use clinical data to reflect on patient care. Unlike paper-based patient records, EMRs make it much faster and easier to search, summarize, graph, and share data.

The HDC is governed by physicians who respect the needs of other health care collaborators and patients but recognize that the initiative is for physicians, and its value will be measured by the level of engagement from individual practising physicians. Ultimately, the HDC hopes to achieve improvements in patient outcomes, physician experiences, and cost-effectiveness of health care delivery.

Improving health care
The HDC’s technical platform has been developed to help achieve the Institute for Healthcare Improvement triple aim by providing primary care data for:
•    Individual physicians curious about their practice profile.
•    Small groups doing peer-led learning on topics such as antibiotic stewardship and polypharmacy.
•    Division-level evaluation of local initiatives (something that can occur seamlessly in the background without surveys).
•    Practice Support Program evaluation of learning modules.
•    Ministry of Health system planning and population metrics.

The HDC’s relationships can create a culture of continuous improvement by:
•    Inspiring curiosity and professionalism among individual physicians.
•    Creating a positive and “just culture” among physician peers that is both voluntary and irresistible.
•    Building a collaborative culture between providers and health system planners by asking and answering questions together.

Health care is changing, and in order to keep up with the times and be accountable to our patients and our health care system, we have to change our culture as well. I believe that we can do this, one physician and one patient at a time, by:
•    Supporting motivational interviewing education to help physicians listen and communicate better.
•    Teaching standardized evidence-based self-management techniques such as action planning.
•    Finding the tools to look at data and reflect on our work so that we understand what is practical, meaningful, clinical, measurable, and valuable.
•    Trusting other qualified health care providers to help us care for our patients.
•    Learning to work and share with other health care providers.

With the help of the Health Data Coalition, I believe physicians will have more job satisfaction, go home on time, and be happier. We have enough bad pulling us down—it’s time to experience some good.

Competing interests
Dr Hobson is employed as medical director of the Health Data Coalition and receives financial compensation in the form of sessional payments.

This article has been peer reviewed.

Dr Bruce Hobson has been a family practitioner in Powell River, his home town, for 35 years. He serves as a peer mentor with the Doctors of BC Practice Support Program (PSP) and is working to convert PSP learning modules to electronic form and to integrate the tools and resources into electronic medical records. He is a member of the Vancouver Coastal Interdivisional Collaborative Services Committee. He also serves on the Doctors of BC Guidelines and Protocols Advisory Committee and the CPD Nucleus Committee, and is a clinical instructor in the Department of Family Medicine at the University of British Columbia. Additionally Dr Hobson is medical director of the Health Data Coalition.