CanadianEMR: EMR Comparisons, Ratings, Directory Services and Expert Discussions

Re-Designing Your Medical Office

It is now a couple of years since you have implemented your EMR. Your needs have evolved as you've become more proficient using the technology in your practice. In addition, your lease is up for renewal and you have important decisions to make. Do you renew your lease or move to a new practice location? Either may involve a refresh of the physical space with or without the financial support of your landlord. There are pros and cons either way, however staying in the same location and simply using the space more effectively reduces the needs for many of the administrative issues you may face. A major concern is disruption. How quickly can your office be refreshed? Is this turnkey or does the process continue piecemeal for days or weeks?

I had an opportunity recently to discuss these questions with a specialist in the office redesign market, Ruth Jankelowitz from the Janks Design Group.

AB: Ruth, as a design specialist, how do you respond to concerns about disruption to practice operations?

RJ: If you have a medical office that is tired or run down or are taking over an existing practice, scheduling and and tight timelines are critical. What we have done is develop a Five Day Makeover (FDM) that is best suited for renovations of existing offices/clinics. This renovation program incorporates weekend days resulting in only a 2 business day loss on the part of the clinic.

How does it work?

• If planned well in advance, we recommend scheduling “On Call” duty for those days or maybe even a weekend away with the family;
• We design and prepare all plans well ahead of implementation. We select all finishes, lighting, colours and ensure all ordering takes place well in advance to ensure every item is ready once we begin. In addition, detailed millwork plans are 100 % complete before raising a hammer;
• Once everything is ready, the transformation begins...
• A highly experienced construction team arrives on a late Thursday afternoon and removes all files and items to be stored/reused. The next step is to rip and strip (flooring, walls, furniture & lighting);
• Friday - clean up, repair, paint and install lighting;
• Saturday - second coat of paint plus install new flooring;
• Sunday - install millwork and hook up plumbing;
• Monday morning - finishing installation, touch ups and reworking of all Tel/Data;
• Monday afternoon - bring back files and items from storage.
• Tuesday morning - back at work... completely rejuvenated!

AB: Any suggestions when designing a new medical office?

RJ: It is important that your design/implementation contractor understands your philosophy, demographics, tastes, target patient base and your budget. Our approach is to develop a conceptual design that best suits your needs and present it to you in 3D model so that you can virtually walk through the space and approve, before spending a penny on construction.

Once a conceptual design is in place, we prepare detailed permit & construction plans, handle permit process, issue detailed millwork and finishes plans for construction and assist through the entire construction process. Occasionally we also conduct tender processes and provide full project management services to some clients. Many of our clients, who are busy providing care to patients, want the project to be completely 'Turn Key' without any hassle or stress, so we manage the constraction as a project project.

AB: How can you be contacted if someone is interested in assistance or a quotation?

RJ: Visit our website or contact us via email for more information.

AB: Thanks Ruth - I have included some of your medical office design images below.

Optimizing the EMR — Medication Management

One of the most useful functions of an EMR is the ability to manage medications more effectively. Currently, all EMRs in Canada can generate a prescription and record that prescription in the patient’s cumulative profile. Depending on the sophistication of the EMR software and, whether automatic drug interaction checking is integrated within the EMR, these clinical decision support tools can place more control in the hands of the prescriber — but only if they are correctly configured.

Consider a best practice for medication management via the following use case scenario. This takes place in a completely interoperable healthcare system where data is securely shared between multiple systems and providers:

Mrs. Smith, a 65-year-old patient with diabetes and atrial fibrillation, attends her family doctor for a check-up and renewal of her medications. She is taking oral Metformin and Glyburide for her Type II diabetes, Warfarin for her atrial fibrillation, as well as a beta blocker for her hypertension. After completing her check-up, Dr. Brown renews her medication using the EMR. Within Mrs. Smith’s summary record, Dr. Brown is able to click on a button and in one step enter an authentication code in order to access Mrs. Smith’s provincial drug information record. He notices that her cardiologist in the last few days has added a new anti-hypertensive drug, Enalapril, to her treatment regime. He confirms the new drug and is able to add Enalapril to Mrs. Smith’s medication list in the EMR by importing it directly from the provincial drug information system. During the prescribing process, because a new medication has been added to her treatment regime, the EMR conducts checks for drug-drug, drug-disease, drug-allergy, and drug-dose interactions. Dr. Brown has configured the EMR to display only severe interaction warnings, although a list of moderate and minor interactions are listed for review if felt clinically appropriate. Interaction warnings are quickly checked and noted by Dr. Brown via a single screen and he is able to acknowledge this medication combination so that the alerts are not presented at the next renewal unless a new medication is added, a new allergy alert is present, or a dosage has been changed. The EMR also calculates exactly how many pills Mrs. Smith should have left from her prior prescriptions (including the newly added Enalapril). He is able to select medications for renewal and enters three months for duration of renewal. The correct medication amounts are calculated and he confirms the pharmacy to which Mrs. Smith would like the prescription to be sent. (She has two pharmacies on her file as her son sometimes picks up her medication.) Dr. Brown is given the option of faxing the prescription directly through the EMR if the pharmacy is not yet able to receive E-Prescriptions; however, the pharmacy is fully E-Prescribing enabled and the prescription is submitted electronically. He immediately receives a notification that the prescription has been received and advises Mrs. Smith to pick up her medications. Dr. Brown is also provided with drug cost information at the time of prescribing and is alerted to the fact that generic drugs will be dispensed that will save Mrs. Smith 70% of the cost of brand-name products.

Although this appears to be a complicated process, it is fast and efficient. Screens only present relevant information, the user interface is optimized for rapid and safe prescribing, and the supportive data provided through the EMR’s drug interaction software, provincial drug information system, and drug cost information provides Dr. Brown with a comprehensive view of his patient’s medication profile and current status.

Much of what has been described in the above scenario will be available in Canadian EMRs (depending on the status of various provincial drug information systems) in the future. In the U.S., which has a sophisticated E-Prescribing network predominantly managed through Surescripts, much of this functionality is already being used. The system is not perfect and requires optimization, but all of the elements are in place. Similarly, both Sweden and Denmark have sophisticated E-Prescribing capability.

Medication management is going to be the next big area of focus across Canada for provincial programs. Because safe management of medications is complex and involves multiple parties, it will require significant effort and the involvement of pharmacists as much as physicians. The benefits are significant; it will just take time to get it right.

Do you have any experiences managing medications that you would like to share? Click on the “Comments” link below.

Integrating Computers for Maximum Patient Benefit

When upgrading an existing medical practice, small examination rooms can be difficult to reconfigure without losing seating space for patients, or critical counter space if the room is too small to accommodate a desk. So, what are your options when integrating computers into an existing medical office? Each clinic may differ to some degree and, rather than providing specific examples, here are some suggestions to consider:

• Do you need a local network to run your EMR? If you install an EMR system that has a server locally in your office, you may need to install a network to connect to workstations in the examination rooms, scanning areas, front office, hallways, etc. If your office is located in an old building, this may incur significant cost as it may not be simple to run the wires through the ceiling and walls. Check with your landlord and consider this when you are selecting your EMR and intended hardware.
• With the growing prevalence of high-speed wireless access points and networks, it may be much more cost-effective to run a wireless network for your examination room computers. However, make sure that you choose the fastest wireless network router and that you have an office survey completed to check the wireless signal strength throughout critical care areas. There is nothing more frustrating than having a great EMR and computers that continuously drop the network signal necessitating restarting the router or the computer. Also make sure that your wireless security settings are correctly configured.
• Make sure not to place the computer between you and your patient. The computer can act as a barrier and it can be disconcerting for patients to be looking at the back of a computer monitor wondering what it is that you are writing.
• Consider an L-shaped desk configuration enabling your patient to view the screen during the encounter. It is much more effective as a mechanism to engage patients in their own care; plus they will often identify errors or outdated information during the encounter allowing you to make the necessary corrections immediately.
• If you use a tablet to access your EMR, make sure that you have somewhere to “dock” the tablet while examining your patient so that the device is not left lying on a countertop or at the foot of the bed. This will protect your investment with the added benefit of charging the device during the encounter so that your battery is able to last for a full clinic shift.
• Some clinicians may opt for a second monitor screen specifically for the patient to view during the encounter that can be wall mounted for patient convenience. This is a reasonable option if the layout of the examination room requires a contortionist to share the computer screen while documenting clinical notes.

For examples of medical office configurations, click here.

Do You Need a Fax Server for Your Practice?

It was not that long ago that fax machines were the hot new technology for business and medical practice. Instead of mail and hand delivery, documents could be moved around securely by fax. With the adoption of EMRs, the deluge of faxed diagnostic results, referral requests, and consultation reports may have slowed slightly; however, we still live and work in a predominantly paper world. Without a mechanism to easily digitize these paper documents, a staff member needs to scan previously mailed or faxed reports, save them in a folder, and attach them into an individual patient's electronic charts. A software application called a Fax Server is designed to take over (to a large degree) the functions of your standalone fax machine. For a more detailed description of fax servers, click here (Source: Wikipedia).

Fax servers can send and receive documents, although you may not want to completely retire your traditional fax machine. Because the fax server functions as an application through a desktop computer (unless you have a very efficient scanner), sending multi-page documents such as referral requests through your fax server may be disruptive to staff. Keeping the traditional fax machine for some outgoing documents is a good strategy. If you are able to generate referrals through your EMR, these can often be sent directly using the fax server to a destination fax.

Another form of fax server is "Fax over IP" or Internet fax. Using one of these services, you can easily receive faxes via the Internet that are then delivered to you as documents attached to an email. Although not as easily usable as a fax server that runs directly off your laptop or desktop computer, these services provide great convenience, particularly if you are mobile and like to have access to your faxes from multiple locations. A popular service is MyFax.com, although there are many others. Prices are reasonable and usually volume based, and it is also a cost-effective way to obtain a toll-free fax number.

Document management is a critical part of the day-to-day work in a medical practice. As a result, you should have a detailed conversation about fax server software with a potential EMR vendor as part of the selection process. Different vendors may have different approaches, and it is important to understand the implications to your staff's workflow if the fax server is directly integrated with the EMR vs. a standalone service on the desktop computer. There are a number of steps in order to electronically receive and attach a document in an EMR. One step that deserves additional discussion with your EMR vendor is how the documents are named when they are received using the fax server. The fax server software may automatically generate a unique ID for each document received. It is then up to your staff to open the document, identify the patient name and contents, and then rename the document prior to attaching in the patient's chart. Your vendor may have a creative approach to managing this mundane and time consuming task.

If you are currently using an EMR and do not have a fax server, or if you are considering an EMR, the fax server is a simple, cost-effective tool that makes document management easier and more efficient.

Technology for Doctors | Digitizing the physician office: Usable software

Michael Martineau has written extensively about information technology and electronic medical records and is a regular contributor to CanadianEMR. In the following commentary in 'Technology for Doctors', he states:

"Around the turn of the century (that phrase still sounds odd to me, I keep thinking 1900, not 2000) I worked for a major Canadian systems integration company. One of the groups with whom I worked quite closely was the company’s usability team. I witnessed firsthand the power of incorporating usability into the software design process and the extent to which end-users willingly embraced the system produced using this approach.

While researching material for my book on digitizing the physician office, I have heard numerous complaints over the past few months about the usability (or, more specifically, the lack thereof) of many EMR systems currently on the market. Hence, I was intrigued to read a summary of a recent Technology for Doctors article (“How I learned to stop worrying and love my EMR,”) on FierceEMR. Although the Technology for Doctors article did not mention usability explicitly, the U.S. summary concluded: “So perhaps the lesson here isn’t that the U.S. health system is a mess – which it is – but that EMRs must be user-friendly and work the way doctors work.”

What is usability? According to a background paper produced by the Healthcare Information and Management Systems Society’s (HIMSS) EHR Usability Task Force, usability is “the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment”.

Technology for Doctors - Usable Software

Michael is eager to speak with physicians and medical office staff who have or are about to implement an electronic medical record system. Please contact him at michael.martineau@avenant.ca if you are able to provide feedback and to arrange an interview for a book that he is writing on digitizing a medical office.

Optimal Medical Office Design - Tips from an Expert

Listen the latest audio podcast on CanadianEMR. Tom Nater, a medical office design specialist with over 20 years experience in office design offers advice and tips for physicians who are either building a new office or re-designing an existing medical office. He covers issues such as the ideal size for an examination room and estimates that depending on size, an office can save up to 25% of floor space in an EMR based practice.

Listen on your desktop 

If you have any comments or thoughts regarding this podcast, click on the Comments link.

Sophisticated 10-12 Physician Practice Established in Ontario

The following has been submitted by a colleague in Ontario and describes the layout and configuration of a new practice that has been established to bring a number of smaller groups of physicians together in a shared care setting.

"The practice is designed to be a very open space with shared work "pods" where the physicians and nurses spend most of their day. The pods have 8 workstations that are used by physicians, nurses, our usher who moves patients around and residents when they are there. There is never more than 4 docs for the 12 rooms on one pod and we have 2 identical pods on each side of the building. Our offices are shared between 2 physicians since we end out spending very little time there. The physicians never have less than 3 examination rooms to work with at any time, so this makes for good throughput of patients - very efficient and quick. Our wait time is under 10 minutes for patients as a result of this (in fact we are usually ahead of schedule during the day) We have 90 workstations and about 60 printers so no one waits for a workstation or walks to get what they printed.

 

There are 24 identical examination rooms (12 per pod), 2 large treatment/emergency rooms, 2 nursing areas that can allow 3 nurses to work at once per pod We have about 10 offices for allied health professional and are starting to hire. We have just brought on a PHD in kinesiology as a health educator for our patients and as well to start our cardiovascular risk management program and do our research. We have our own ambulatory BP monitors and will be getting Holter monitors exclusively for our patients. EKG, PFT, and ambulatory BP are all integrated into our EMR.

We have a total of 14,850 square feet and occupy 55% of the whole building. Overall we are happy and have been able to let in 500 new patients since we moved (December 20, 2007) without adding any physicians or any additional hours of work. We are actually allowing people to call in every 6 weeks or so to get a spot on a first call basis and close the lines at 250. Once these patients are signed up and appointments are given we assess our capacity to take on new patients.

On a good day we see just under 400 patients and at most we have had about a dozen patients at any one time in the waiting room with 8 docs and 5 nurses working. Although I suspected that space was a big limiting factor in the whole improvement process, I never realized exactly how important it was. We are using the same EMR in the same way as we did for the last 2 years and in the past we often had one hour wait times in the waiting room and could not even dream of taking on new patients.

My final conclusion is that EMR's alone are not enough to make a difference and as much effort and investment needs to be made into the space to make real differences!"

This is an example of an efficient practice redesign. The evidence can be seen in the new practice layout and the ability to open capacity and reduce wait times while increasing physician satisfaction.

To add your thoughts or comments, please click on the 'Comments' link

Standardization in a Multi-Physician Clinic - Office Layout

Working together in groups has never been more attractive than right now for physicians. The ability to share costs and overhead, cover one-another for on-call and pay-for-performance programs for Chronic Disease Management (such as the Complex Care program in British Columbia) make the multi-physician clinic a very cost-effective way to practice. Adding an EMR into this environment provides additional capability to do pro-active recall, prescribe electronically and automate repetitive functions.

The following series of images was submitted by a colleague who has recently established a group practice.

What I particularly like about this set up is the very effective use of wall mounted monitors in order to maximize examination room and desk space for clinical use. Using space effectively (and cost-effectively) is one of the key challenges when designing a medical practice, particularly if you have a limited room size.

With the shift in patterns of practice from solo to group and with physicians making a significant investment in the infrastructure (EMRs, telephone systems, office equipment etc.) there are many more physicians who are re-thinking their work environment. I have always been struck by the difference between dental offices and medical offices in terms of the investment in furnishings and equipment that make a practice environment comfortable for staff and patients.

With practices such as this being developed, physicians are making a quantum leap forwards. Welcome to the medical office of the future.

If you would like to add comments or thoughts, click on the 'Comments' link below.

How Important is Line-of-Sight when Setting up Computers in the Exam Room?

The images in this posting were provided by a colleague who describes the importance of sight lines in relation to the setup of computers in the examination room.

He states: "I believe the sight lines to the patient and to the computer EMR are such that I don't believe interferes with the patient physician dialogue or interaction. I just have the computer table at 90 degrees to the wall as in the 2 exam rooms in the pictures. I hope it is helpful to anyone setting up. As an aside, I have put the BP machine in the corner which makes it easy to see without turning away from the patient (it is behind the white light stand)" (Click on any image to enlarge)

Have you had any experience with evaluating sight lines in your exam rooms? Should this be part of the usability analysis of configuring exam rooms?

To share your thoughts or experiences, please click on the 'Comments' link

Exam Room Configuration - Example 12

This is the power exam room table in the left corner of the room. The picture is taken from the door. Notice the placement of the Integrated Diagnostic System. Traditionally this was placed on the wall behind the bed. The short Health Professionals complained that they could not reach it over the new larger tables, therefore it was moved to the head. Minor problem with this placement is that you have to turn your head to read the dial when taking the BP.

This picture is to the left basically behind the door. Not optimal location, but this rooms are smaller than normal. The focus is on the modular furniture that is adjustable (height), has a tack board, slots and shelves in the overhead bin, cables can be run down the back for the computer equipment (no holes to drill) and the patient is just off to the left of the physician when seated. A task light could be added under the overhead, but we didn't feel that was necessary.

This picture is taken from the desk location. It would be in front of the door when you enter. This is all modular furniture. In this configuration, the doors are keyed. Notice in the first picture that there are no taps on the sink.

The foot pedals have replaced the taps (second picture) for infection control. The staff think this is great. No hands! We did not go with the electronic faucets because there is a requirement to have hot, cold, or warm water. The modular cabinets come with the cut-out for the pedals. This furniture is manufactured by Herman Miller.

The exam rooms in these pictures are less than the 10x10 foot that would be standard in Canada. Our new rooms that will be in our expansion will be the standard which will allow the configuration to be improved (not happy with the patient behind the door).

If you would like to comment on any of these exam room configurations, please click on the 'Comments' link