Lakeside Medical Clinic

Dr. William Haver Lakeside Medical Clinic Busy, high-volume clinic streamlines care delivery with the EMR Saskatoon, Saskatchewan WWW.STUARTKASDORF.COM A family physician in Saskatoon, Dr. William Haver created Lakeside Medical Clinic in 1981 as a small two-physician practice. Since then, it has relocated and expanded into a much larger facility with 26 family physicians and about 30 other staff. With 108 chairs in the waiting room, this busy clinic has about 700 scheduled appointments per day and accommodates 150 190 walk-in patients. Reception staff answer about 600 telephone calls per day. Why an EMR? From its early stages and through three decades of steady growth, this clinic has incorporated computers and electronic medical records (EMRs). Not only has the EMR helped the clinic mange its high volume of visits and calls, but Dr. Haver also believes it has improved physician recruitment and retention. Specialty: Primary care Practice type: Large group Using an EMR for 25 years Location: Saskatoon, SK (pop. 209 400) 23

Experiences from the forefront of EMR use Making the move Dr. Haver began using an early version of an EMR in 1984. Eleven years later, the clinic expanded and moved locations and the physicians brought no paper charts with them, instead relying fully on the EMR. The new clinic was designed to facilitate patient flow and incorporate information technology. Workflow has changed gradually over time to respond to new EMR features. Through the years, Dr. Haver and the EMR vendor have worked together to ensure that the EMR system is flexible and responsive to the physicians needs. Each physician can customize the way information is presented on the screen. As Dr. Haver puts it, If you spent an hour with me and if you spent an hour with five other doctors here, you would find that each physician uses the software differently. Working with the EMR How it s used Each exam room is set up identically with a computer, printer and telephone. Five identical nursing pods serve different areas of the clinic. Each pod has a computer, as do each of the workstations at the reception desk. The EMR is used in almost all aspects of patient care and information management. Direct download of lab results increases efficiency and reduces labour costs. Referral letters and supporting documents are faxed to specialists directly from the EMR, prescriptions are sent directly to pharmacists, and x-ray images and reports can be viewed electronically. The EMR is also used to collect and extract anonymized data for use in research. EMR features In use: billing scheduling appointments intraoffice communication entering patient encounter notes generating and recording prescriptions generating referral letters ordering diagnostic tests downloading and direct import of lab results capturing and storing x-ray images generating and maintaining patient summaries generating patient reminders scanning and storing documents remote access electronic communication of patient information to other facilities clinical decision support tools data collection for research purposes* *Extraction of anonymized patient data. Four assistants work at the front desk area and use the EMR to check in patients, update contact information, create files for new walk-in patients and search for necessary information when answering telephone calls. The EMR s Next Available Appointment function helps them quickly and easily fit patients in as early as possible. Medical office assistants divide tasks among themselves and specialize in different areas. In this large clinic, approximately 60 staff hours a week are dedicated to scanning. An assistant sorts through the faxes that arrive electronically, deciding which to print and which to copy and paste into patient records. Files that require signatures, such as requests for authorization, are printed and given to the appropriate physician or staff person. The assistant ensures that the text copied and pasted electronically into patient files is readable and, for accountability, types his or her initials at the end of each note. By consulting the EMR, assistants stationed at the clinic s nursing pods learn which patients have checked in and are waiting to be shown to an exam room. When required, they take the patient s weight, height, blood sugar levels and urine samples, according to each physician s preference. They record this information in the EMR and run urine samples using the urinalysis machine on one of the nursing pod counters. They can use the EMR s intraoffice messaging function to communicate with other staff without having to walk across this large office space. Dr. Haver prefers to check the EMR in his office before entering the exam room, in preparation for the encounter. During the patient visit, he consults the EMR for information on recent lab results, prescriptions and previous encounter notes. Following the visit, he usually returns to his office briefly to do dictation, which will later be sent out for transcription. By doing this right after the visit, Dr. Haver feels that he can include nuances and details that result in a more comprehensive note and better care. After dictation, he can check the next patient s file and move on to the next exam room. Lakeside has a special agreement that allows its physicians to fax prescriptions to pharmacies without a signature: We made an arrangement with the Pharmacists Association of Saskatchewan, as well as the Saskatchewan Medical Association and the Saskatchewan College of Physicians and Surgeons. We had a signed agreement, years ago, that we would be able to fax these prescriptions, no signature required. We got past the signature issue by instituting a system where every prescription has a unique identifier. It s a computer-generated 10- or 12-digit 24

20 Canadian physician case studies number that is unique. It s alphanumeric and it can t be repeated. So any time a prescription is generated, even if I generate two prescriptions for you right now, they have different numbers. There s a check digit inside that number for verification purposes on all of our prescriptions. Our staff can verify that the prescription was done here, and when it was done. They are all date-, time- and userstamped, so there s an audit trail within the prescription. They decided that that was acceptable and allowed us to do it that way, which is what we ve been doing now for years. Works very well. Faxing prescriptions is really not new technology. That s pretty old stuff. Benefits At Lakeside Medical Clinic, the EMR has sped up the provision of care. Under certain circumstances, a patient can receive the results of a diagnostic imaging test in a matter of hours. The EMR also makes it easier to refer patients to specialists by providing comprehensive information in a functional format: If we send somebody for review by an orthopedic surgeon, just to send along the x-ray report is a piece of cake. But if you want to send somebody to an internist, you have to send along maybe x-ray reports, probably some lab work and maybe other imaging. Maybe other consultant s opinions, maybe some notes for the last year. Maybe some other outside information has come in from other sources. We can do that, because we ve put everything into the chart. So it s a very functional letter with a lot of data attached. The consultants really like that. Dr. Haver believes that the EMR helps him provide better care in other ways as well thanks to the: accessibility and security of reliable, legible information flagging of abnormal lab data, which are obtained quickly ability to display data in different ways to facilitate patient education automatic drug interaction alerts ease of generating patient lists in the case of a medication recall. Dr. Haver noted that his use of the EMR reassures patients that their data are being accurately captured and safely stored. He notes, I ve had some patients tell me cat- Clinic floor plan Note: All exam rooms in the clinic have a similar layout 25

Experiences from the forefront of EMR use egorically that they would not even come here if they thought this information wasn t secure. Showing patients graphs of their results makes them comfortable with the EMR and gives them evidence that the computer is protecting their data. Dr. Haver also believes it improves compliance with treatment plans. Some patients like to look at the screen; others do not care, he says. Patients seem impressed by the speed of the EMR and its ability to connect with pharmacies; one exclaimed, That s amazing! when Dr. Haver told him that his prescription was already waiting for him at the pharmacy. Another important impact of the EMR is its effect on the work environment. By increasing productivity, it has allowed physicians to make choices about how to spend the extra time. Some doctors have actually given themselves more time. I have two young docs who took off an extra half-day a week each. They did more work in less time, or they did the same amount of work in less time, and they just took the time off. One of them has taken up carpentry. Working conditions are also better for support staff. They do not have the stress of delivering messages and pulling charts, and the office is quieter. Information is easily accessible, and there is less concern about losing charts or pieces of paper. Dr. Haver says that it s just a better way to do things, especially considering the complexity of their responsibilities. The overhead savings realized by capabilities such as the direct download of lab results helps to make the business case for EMR use. It had the benefit of reducing labour costs because the old lab system required a huge amount of file pulling, attaching results, taking it to the physicians physicians marking it off as received, acknowledging the results, making a note in the chart perhaps, sending it back to the front, getting it refiled only to find out that that was a preliminary result. Then the final result comes in and you repeat the process. We have 115,000 patients on file. Can you imagine what that would be like? When we started doing it electronically with the lab system, there was a huge reduction in our staff time. Over time, allowing for normal attrition, we reduced that staff. Challenges The introduction of information technology and the Dr. Haver s description of Lakeside s planned patient portal The patient portal is more than just our website. They not only can see what s available for an appointment, there would be an algorithm to allow specific appointment availability to be displayed and a disclaimer saying that this might get cancelled. It also would allow them to see parts of their charts on a secure website. It would be only those parts of the chart that we felt were safe to put out there. And it would even allow them to put parts into their chart. Allow for patient input to their own health care, to leave a question for a physician or something like that these are all things that we think could be very useful for the patient. Enhance that doctor patient relationship; allow them to feel comfortable that they had access to the information, that we weren t seeing something that we weren t telling them about. Every patient thinks that we re not going to tell them that they re dying. That d be the first thing I m going to tell you, because that s the last thing I want to keep a secret. By allowing them to have that kind of access, they would feel even more comfortable that they re seeing the real bill of goods. PHOTOS.COM 26

20 Canadian physician case studies EMR at Lakeside Medical Clinic has been a process of organic growth, says Dr. Haver. It has been so organic that computer use is now second nature: It s virtually transparent to me. I m not really sure when I m using the computer and when I m not. If somebody asked me how much I d used the computer this morning, I d say, Well, I didn t. It s just the way I get information. I realize that I look at the computer a lot, but I don t think it s ever hindered me. It s certainly never slowed me down. I think it s actually sped me up. Moving forward Lakeside had hoped to introduce a patient portal this year, but encountered delays and now expect it will be available next year. The clinic takes advantage of new EMR features and connections with other facilities as they become available and hopes there will be greater interoperability and communication among care providers. Although the physicians are already able to send prescriptions to pharmacies electronically, Dr. Haver is eager for the introduction of Saskatchewan s Pharmacy Information Program. The Pharmacy Information Program in Saskatchewan will eventually allow for an electronic prescription to the pharmacy. I just do up the prescription here, hit Enter, and it just goes out into Never-Never Land the patient can go to any pharmacy, they ll swipe his health card, pull the prescription down, and he can have it filled anywhere. That s the way it should be. At Lakeside, ongoing EMR training helps staff share knowledge. Dr. Haver believes that no one should have unique knowledge about the EMR, so the clinic holds occasional lunchtime meetings in which new techniques, solutions to common problems or information from conferences can be brought to the entire team. To read more about how this clinic uses the EMR, the full case study report is available online at cma.ca/emrcasestudies. Key lessons and advice On the business case for the EMR: The business case gradually became obvious to us. We tried to do some analysis and we showed that each stage, as we developed it, was cost-effective in itself. We look at our total overhead now, running a very sophisticated [EMR] system. We have computers in every room, in the offices, in the examining rooms, in the reception we have computers in our staff room, for crying out loud. But every step along the way has been based on a business model that we believed in. On implementing an EMR in the absence of funding programs: Everything that you ve seen here we have done without a single incentive, without any reward, without any grants or bursaries. We were committed to it and we felt that there was an advantage in doing it. We ve actually proven that s the case, and we ve developed a business case for it as well. On the EMR s impact on physician retention: In the last 10 years we have shown phenomenal growth. I have talked to some of my colleagues who have had no growth and have been struggling to find docs. I m sure it s not just because I m a great guy. I m assuming that it has something to do with the clinic and the computers. 27