TECHNOLOGY:
Already There...Implemented Health IT The Ideal
Micropractice Concept
Readers of The Digital Office met Kevin Fergusson, MD, in the first issue in
January 2006, when this column profiled his practice, VitalTrust ® Physicians.
Now, Dr. Fergusson, of
As Dr. Fergusson can attest, with few resources, some physicians are quitting
salaried jobs with benefits to jump into the frightening uncertainty of
independent practice. The Ideal Micropractice was designed to help physicians
do what they are trained to do: practice medicine and feel like they are making
a real difference in a way consistent with their personal values and ethics.
More than 100 primary care physicians across the
HowsYourHealth in Exam Room.
I'm from
IMP1. I've done something similar to this with a few of my patients. I have an
old laptop I keep out in my 'waiting area' - a bench next to a curio cabinet -
in my MA's room (front desk/lab/vitals area).
Because I only have 1 exam room/my office, most people are not waiting for me,
so they wouldn't be able to do it in the exam room. It has been utilized when a
spouse/family member is waiting while I'm with the pt, or if someone doesn't
have internet access. I had an 80 yo woman who had never touched a computer do
it - talk about starting from the beginning (this is a mouse, here's how you
use it, here's how you click on a box, etc). She was not speedy, but got it
done, and called her daughter while she was doing it
because she was so excited/proud about using a computer. I've offered people to
use it after their appt on numerous occasions, but they are usually ready to be
on their way (most of my appts are an hour long). If
people are waiting for you in the exam room, that could be a way to help fill
in the time, but not ideal - the survey is only recommended every 1-2 years,
and you will probably be seeing them more often than that. If it works out for
you, it might help to focus on this with just a certain type appt - like CPE,
eg. While you are reviewing their preventative recommendations/results, they
could be doing the HYH survey.
1. HYH was tested in touch screen kiosks (in several languages) in many
clinical settings during the late 1990s. Walter Reed used HYH in the office as
a requirement for care. ARMY info was fed directly into their EMR.
My summary is that unless you are the ARMY, no matter how we did it, we found
that office staff were often disrupted by having to worry about HYH in addition
to other duties. Time varies for completion by some patients. Some patients
want help. Etc.
2. My recommendation. Best to do what Gordon did. Ask as many as you can and
continue to nag those who don't complete initially. Tell them it IS important
for you and them to be on the same page. Tell them to get family to help if
they feel inadequate. Best to time a week or two before a planned office visit.
(You should have received infor this last week and this coming week we will set
up your HYH/Docsite.
3. We do offer a touch screen tablet version of HowsYourCare for hospitalized
patients and we will soon adapt HYH and the version for the very frail to this
method as well. IT IS VERY NICE. But tabglest pcs makes the most sense for
relatively small volumes of patients (unless you are the ARMY).
4. This summer we plan to finalize our ever gestating personal health record
output of HYH for patients. This will enable practices to give patients lab and
other info (if they wish) and patients to give IMP or consultatnt doctors infor
about what matters to them.
Re: [IMPcohort2] Start Up Practice/ "self-made"
EMRs
I totally agree that a self-made EMR is inexpensive and you
can set it up any way you want. It has a range of creative options -
making your own templates, macros, etc.... and no monthly fees, hidden fees, or
techies that you need to reach in the middle of the night.
I created one on my apple laptop using textedit (very
primitive) files, yet I can do everything I want to do.
Pamela Wible, MD
Re: EMR. I would encourage anyone starting out to not
overlook the "do it yourself" EMR approach. We are using an
"electronic filing cabinet" as well and have adopted pretty much the
same naming conventions that you describe. The use of yyyymmdd_file name
leads to cleaner organization. Our first level of folders is simply each
letter of the alphabet. The second level is Last_First_MMDDYYYY.
The third level is an assortment of whatever applies to the patient but usually
includes folders titled "Office" "Labs",
"Studies", "ECG" etc. Then the individual files as
named above in these folders. We can burn this whole "tree" to
a single DVD-RW disk for offsite backup. For documenting visits, we
started with Amazing Charts and have been pleased with it for easy
documentation of visits, but chose to use Outlook for our schedule and
EZClaim/Quickbooks for our billing/collections. Finally, we wrote an
Access database to track review of lab results and documentation of action
taken as well as tracking of pharmaceutical samples and a reminder
system. This is a "home-spun" database, and was a fair amount
of learning and work to put together but it serves our needs very well. I
guess the take home point is that there is a lot of "off the shelf"
software out there that can be made to do what we need it to do without having
to spend lots on one product that does it all. These home-spun EMR's may
not be as slick, but they accomplish most of what technology can offer and
allow the "low-overhead" approach to work financially and also
hopefully deliver the same quality outcomes that we are all looking for.
My current dilema is whether to switch the file format that
we use for storing all of our documents in the "tree" from TIFF and
MDI to PDFs. TIFF seems to be the standard format for a scanned document,
but I have found that it is more memory intensive, and that when I email these
to patients, many cannot open them to view. PDF has the advantages of
anyone being able to read the file using adobe acrobat reader ("the de
facto standard electronic document") and uses less memory, but requires
purchasing some licenses of Acrobat which are several hundered dollars a
piece. Has anyone had experience/thought surrounding this choice?
Greg
ACCESS:
Here is a
link to terrific open access materials:
http://www.ihi.org/IHI/Topics/OfficePractices/Access/
The goals of an open access scheduling approach are:
Eliminate the need to sort demand by urgency
Have enough capacity each day that you can offer appointments "today"
CROSS-CUTTING
I just wanted to share the joy of co-creating a practice WITH
the community. I held forums and solicited input from the community and then
designed my practice around their needs rather than holding them hostage to my
beautiful vision of a community practice.
Check out my website for details at www.idealmedicalpractice.org
I can not put into words how fulfilling it is to practice this way. Even if
your practice is up and running you can lead public forums and gain appreciative
patients, fill your practice, and get all sorts of help from the community who
would LOVE to nurture a co-created medical practice. Pamela Wible