Are we using EMRs to their fullest potential?

Written by Dr. Darren Larsen, Chief Medical Officer, OntarioMD

So we use our EMRs every day for every aspect of care. We bought them, we trained on them, we became moderately proficient, but then what? As experienced EMR users and skilled clinicians, how far did we go beyond that? Are we using EMRs to their fullest potential? Do we understand all the opportunities to do more with the data we produce? Do we see beyond record keeping? Have we automated workflows wherever possible to make our lives easier?

At OntarioMD, it is our business to know and help you find out as well. Seven years ago, a maturity model for measuring EMR use was created. The EMR Maturity Model (EMM) was tested and compared to other similar models such as the HIMSS EMRAM tool. It was put in the hands of EMR expert users. It was re-written and expanded to be relevant to daily community practice. It was also converted to a self-administered online tool, now known as the EMR Progress Assessment (EPA). The EPA was Ontario born, but now is used by other provinces as well to measure effective use of their same EMR systems.

Despite the clinical validity of the tool after years of use and its practical nature, the model itself had never been scientifically tested. We thought it should be subject to the same academic standards as other measurements. So, we asked such questions as: what does the tool actually measure? How well does it measure it?

We engaged in a systematic process of validating the EMM via statistical tests of validity and reliability on the data collected by the EPA tool. This study was recently published in the International Journal of Medical Informatics. Here’s what we learned:

  1. We measure one major thing well – EMR maturity! This means that, when you take the EMR Progress Assessment, you can be confident that your results are a sign of whether or not there is more of your EMR you could use. It can point you to areas you might want to expand or improve on. It can prompt thoughts about quality and efficiency.
  2. Measures are consistent across the list on how we measure maturity.  They line up so that a level 3 is the same level 3 over time and across clinicians.
  3. Maturity is not an indicator of performance. Using an EMR for good proficiency in care gets us to the maturity level of just over level 2. We can be great clinicians, but never move higher than that level.  Beyond level 2 is more about how the practice’s EMR is used within the larger health system. It involves system integration. It revolves around data. A fully integrated system and standardized, high quality data are super helpful when you’re trying to do the most with your practice in designing care for populations.

If you are a clinician who wants to know more about your EMR use, as well as wants to carry your practice further into automation, integration and use of data, then an EPA is a great place to start. You can take the complete survey in about 20 minutes. You will not only learn where you are in terms of EMR proficiency, but also be able to compare your level according to the EMM with where you want to be. And then you can drive out a plan of attack. And there is help. OntarioMD can move your practice ahead exactly the way you want it to be moved.

When Virtual Reality Becomes Reality

Written by Ashok Bhattacharya M.D., FRCP(C)

March 23 2020, 1:00pm

I was sitting across from my patient watching the words escape from her mouth as she inspired to make them. Then she exhaled…no mask, no gloves, no gowns. I was more than 6 feet from her face. I was listening, I really was, but there was something in the back of my mind. What if she has COVID? I was ‘wiping down,’ and had a few bottles of Purell salvaged from the box the Ministry of Health sent during the 2003 SARS crisis. I felt like a lonely soldier, low on ammunition, nervously defending a post as the enemy closes in. I couldn’t see or hear this foe—I could feel it. I should stay…but should I run? Dedicated doctors often suffer from presenteeism. I stayed.

The Practice

I have been practicing psychotherapy since 1986. I graduated in 1989 from the University of Toronto in the specialty of Psychiatry. The 1980’s marked the end of the dominance of psychoanalytic theory and the explosive beginnings of the biological revolution spearheaded by Prozac. For the first time, patients were asking to be placed on an anti-depressant: an SSRI. The arm-twisting efforts to encourage compliance with the tricyclic antidepressants were antiquated.  The vicissitudes of the mind had become the chemicals of the brain.

Setting up my practice was easy; I just opened the doors to my moonlighting practice a little wider. In two weeks, I was full and had more referrals than I could cope with. I started out doing 60-hour weeks. I know, this is a recipe for burnout. Since 2014, I have been presenting at conferences on the topic of burnout. By the time COVID-19 hit, my regular caseload was 45 hours a week. I see a lot of couples [Oakville has a high divorce rate], victims of PTSD, and depressed/anxious clients raging in age from 20-80 years old.  Being a psychiatrist is the only career I seriously considered. It’s the only reason I went to medical school. I love my job. I know that sounds cliché, but it never ceases to amaze me how you can aid a person by assisting them to alter their narrative. Yes, I am a psychotherapist at heart.

March 26 2020, 6:00pm

My patient emailed me, “I have a high fever and a cough.” She’d been tested. “I won’t know the result for a week.” My denial crumbled like a wall of salt being hit by a tidal wave. I realized my post was already surrounded, I had run out of ammunition, and the invisible enemy was here. “Scotty, beam me up!” There was no Scotty; there was virtual care. That was the last time I saw a patient in my office. I was scared, and I felt like a fool. I had put myself in this place. I’m the doctor! How could I put my patients and myself at risk? I felt shame. (Her test was negative. I’d dodged a bullet.).

Virtual Platforms

I applied to OTN to use the site to conduct eVisits with my patients. On March 23 2020, I downloaded Doxy.me, one of the virtual care tools curated by OntarioMD on OntarioMD.News. Luckily, my tech-savvy daughter was visiting, so she could help her old dad with the inevitable stupefying moments of learning a new computer technology. Incidentally, she lives in Italy and was stuck in Ontario during Italy’s worst times with COVID. She has since managed to return to Italy safely.

The Learning Curve

I was one of those ignorant die-hard believers in face-to-face therapy. Previously, if someone told me they had a ‘virtual session,’ I dismissed it as an irrelevant experience that couldn’t possibly replace a three dimensional ‘in the room’ session. I was utterly and completely wrong. The virtual experience became easy once the technology became familiar.

Advantages of Virtual Care

  • Patients can see me in the comfortable surroundings of their home. They are more relaxed, they haven’t had to commute, they don’t need to find a parking spot, and are ready for the session immediately.
  • Patients seem more motivated; like me, they have to work a little harder to make an impression on a little screen. It captivates them. They are also less intimidated by the ‘doctor’s office’ vibe. Their waiting room is their own familiar surroundings. They don’t have to spend their time reading out of date magazines in a waiting room full of sniffles.
  • Since TV, we have become used to learning from a screen. It’s a great teaching tool, and I have developed many props that make explaining things much faster. It’s as if you are the presenter and PowerPoint slide in one.
  • Sessions are much easier to close especially for the ‘sticky patient’ who has trouble with the session ending.
  • In a normal office visit, you see the patient and they see you. In a virtual session, you can see yourself, how you come across, and your facial expressions. Finally, you can see what your patient is seeing. Initially, it was a bit of a shocker. But like a golfer learning how to improve their swing, it’s very helpful to see yourself wind up and follow through from a third person perspective. In psychiatric training, you may watch a video of you interviewing, but with virtual care, you see yourself in real time. It has definitely improved my technique.
  • Face masks are a new reality for enclosed spaces. With virtual care I can see my patient’s face, and they can see mine. I can’t imagine someone crying vigorously while wearing a mask.
  • If direct physical procedures are not required, virtual care is the pinnacle of physically distanced medical care during a pandemic caused by an infectious agent.
  • Thankfully, it doesn’t come up often, but physician safety—especially when you’re alone in an office with a volatile, or dangerous patient—is much less of a worry with virtual care.

Disadvantages of Virtual Care

  • With some patients, especially those who live in close quarters, privacy has been a problem. They may take the call in their car, garage, bathroom, or behind a tree in their backyard. My office is very private and those clients prefer that environment.
  • Virtual platforms require solid Internet connections. Drops and disconnections do occur. I simply advise my patients at the beginning of the session that if we get cut off, we may have to use the telephone to continue the session. Luckily, this rarely happens.
  • Virtual care cannot replace direct patient contact for many necessary medical procedures at least with the present technology.

A Success Story with Virtual Care

My patients who suffer from Post Traumatic Stress Disorder (PTSD) are all doing better. Initially, I didn’t know why. I think the physical separation and the virtual distanced format make them more comfortable, less triggered, more grounded, and able to focus on the psychological effects of their trauma. We can get to those psychological issues faster and achieve a deeper quality in the work. Therapeutic progress seems to be occurring twice as fast as office-based care. Interestingly, the men appear to be benefitting more from the virtual experience than the women. I think men are more comfortable sharing their feelings when they are not facing someone, especially another man. In office sessions, men don’t cry as much as women in therapy session. They do now in virtual care! Those patients have all asked me to see if we can continue with virtual care after the pandemic is over. I hope we can.

After an intense session with a patient with severe PTSD, I may worry about them getting home safely especially if they were very dissociated. That worry is gone. With virtual care I can quickly and easily check in with them and improve continuity of care. That ‘bridge’ between sessions is allowing the therapy to have a steadier flow. Patients are calmer and I feel more confident as a therapist.

Future Plans with Virtual Care

I am hoping that virtual care will be a substantial part of my psychiatric practice going forward. No more ‘snow days’, no more ‘empty hours,’ and a huge saving in time for patients with the elimination of transportation issues. As technology improves, I think this could surpass the ‘office visit’ as the gold standard for psychotherapeutic care.

It’s likely that there will be events in the future that will require us all to physically distance ourselves again. With a foundation of well-established virtual care, we will be ready to act immediately, and not be that lonely soldier standing guard in a battle that can’t be won. Virtual care is safe, easy, and the right thing to do.  

About the Author

Dr. Bhattacharya graduated from Memorial University Medical School in 1984. He completed his specialty training in Psychiatry at the University of Toronto. Since 1989, he has been in private practice as a psychotherapist for individuals and couples. He has been married for 33 years, has three adult children, bikes and runs, and writes, records, and performs musically.

He is the author of two books:

CAKE   A Guide to Reciprocal Empathy for Couples 2006

Deep Fried Nerves   A Study of Burnout in Doctors 2016

Virtual Care is Here to Stay – by Dr. Darren Larsen, Chief Medical Officer, OntarioMD

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The last four months have seen the rapid rise of the use of virtual care tools in practice.  This has been a remarkable change. Doctors went from about 7% use of virtual care to 89% of primary care physicians using a virtual care tool, and 80% of all visits happening virtually. Due to the rapid spread of the coronavirus pandemic, doctors and nurses went straight into problem-solving mode (which I am very proud of, I must say!) and changed the way we provide care almost overnight. Having said that, there are major gaps in care that we must get to very soon or the downstream effect will be a challenge.  Virtual care is here to stay. The horse is out of the barn and cannot really be corralled again, but some order needs to be applied to the current disarray.  Where do we need to direct our attention next? 

1) Provision of virtual care in some of our most challenging care environments:  long-term care and congregate housing like group homes for disabled adults, shelters, hospices, jails, etc., are perfect examples.  Some of these places have started to apply virtual care.  Many have not.  There needs to be a consistent approach to making sure location and living conditions are taken into account and prioritized. 

2) Many medical problems require examination and the laying of hands to diagnose or treat.  Paramount at this point in time is cancer screening, preventative health visits, palliative care, lung disease, neurological disorders.  How will we do better with virtual to get these programs up and running again?  We will have ago to rethink our processes.  Physical exams are still possible virtually, but they take on an entirely different form.  This will require retraining and knowledge transfer. 

3) We must focus on areas where inequity of care prevailed before COVID-19; remote communities with poor internet access, indigenous communities, homeless communities, refugees and recent immigrants are all at a disadvantage when it comes to high tech solutions like video visits.  The reasons are obvious.  They must be faced head on and planned for.  The approaches needed here will be different. 

4) Some high-risk areas are left behind: seniors care, the mental health system, and home care come to mind.  We must pay attention to these as they are ripe for care redesign and virtual care may actually be very impactful. 

5) Integration of products into the point of care is important. This largely does not happen now.  For this, we require APIs from EMRs and hospital information systems, rules allowing open data flow and a reduction of the competitive nature of the virtual care and data business.  We need a more unified approach focused on creative co-design and outcomes. 

6) Standards for virtual care tools are important now, and certification to these standards must follow to ensure safety. “Caveat emptor” thinking applied at the start of the pandemic crisis, but we are past that now. Security and privacy can and must be guaranteed.   

7) Attention to the blending of virtual and in-person care is needed.  We can never be permanently ”all virtual” or even “80% virtual”.  In a recent CMA survey, 60% of patients stated that they still want an in-person visit as the first option for their new problem  This is because we are human, and trust between humans evolves by looking into each other’s eyes, interpreting body language, and even holding a hand in tough times. This is important as the physician-patient relationship is special, and trust matters. 

OntarioMD is helping to lead the pace of change for clinicians in adopting virtual care.  We want to be there for you.  You are living the change and crafting your practice for excellence in real time.  We need your ideas about where your energy in making your technology life better is best spent.  I encourage you to bring them to us.  We are developing a plan for the future that responds to your practice needs.  Help us design it.  Reach out to me with ideas at darren.larsen@OntarioMD.com. 

Virtual Care Tips and Tricks

Contributors include OntarioMD Practice Advisor Tania Hunt with recommendations from OntarioMD Physician Peer Leaders from our Virtual Care Webinar Series

This is part two of our blog series on virtual care for clinicians. Check out part one on Virtual Care: Preparing your staff and notifying your patients here.

In part one, we discussed setting up your practice for a virtual care environment, preparing your staff and notifying patients. With your practice set to go, and everyone prepared, let’s review some of the different virtual care options you may wish to consider for your practice.

Telephone visits are the easiest virtual care platform for most practices and will be part of your virtual care toolkit. All patients have access to a phone and do not need any instructions on how to use it. Phone visits are quick to set up, and do not use internet bandwidth. Remember to always use a private number when calling patients that will not be visible on the phone’s call display. To maintain privacy on the patient’s end when you call, ask them if they are able to speak to you privately without being overheard.

It is important that your staff tell the patient that when you call at the agreed-upon time, their phone will display ‘unknown caller’ so the patient knows to answer the call. When speaking to a patient, always confirm the patient identity.

If the patient needs lab work/DI, determine if it is really necessary or if it can be delayed to limit the patient’s exposure during COVID-19. If you and the patient both feel it is absolutely necessary, have the patient follow up with a lab to schedule an appointment.

When it comes to other virtual platforms, if it is difficult for you, it will be difficult for the patient and you will become tech support for them so pick a platform that you and your team understand and can operate smoothly. Purchase necessary equipment such as back-up headsets with built in speakers and a desktop camera. If possible, work with two laptops, one with the EMR and the other with the video visit tool (OTN, etc.). If multiple screens are not an option, leverage your smart phone for the virtual visit and keep your computer for the EMR. Remember, for both phone and video visits, you will need the patient’s consent before you begin the visit. See part one of this blog series for how to obtain consent.

When you start the video visit, it is always reassuring for the patient  to have a quick scan of the room you are in so they see no one else is in the room while you communicate with them and their privacy is preserved. Ensure the patient’s privacy and security on their end as well. Ask questions like “Are you in a quiet room?” “Can you hear me properly?” “Is anyone else hearing this call?” “Do you feel safe having this discussion?” Look into the camera, not the screen, when asking questions. If a video visit does not work, revert to the telephone.

How can video visits be most helpful? They are especially valuable for patients with mental health issues. Connecting with them in their own home can be a more positive experience and put the patient at ease. Video visits are also helpful for patients with rashes, burns, cellulitis, etc. Use an app with imaging capabilities to capture an image of the patient’s issue for tracking and uploading to the patient chart for comparisons during future visits.

Video visits are a great way to learn more about patients by seeing their home, and meeting pets and family members. This will put patients at ease before you start the visit. Remember to always hang up the phone or disconnect the camera after a virtual visit. Turn the camera off when not using it or use a webcam blocker to avoid any unwanted visibility of your surroundings.

Be on time for your virtual appointments. The patient is not in the waiting room so they will not know if you have forgotten them or if you are behind. Be considerate of language barriers, and if you can, leverage a medical translation service during visits. This can be achieved by 3-way tele-conferencing, 3-way video conferencing, or having the patient on video and the translator on speaker phone. Regardless of the approach, consent should be obtained from the patient to use a translator and documented in the chart.

Some other tips for using virtual care in your practice:

  • For specialist referrals, consider using eConsult instead of sending a referral by fax. You can get a response from the specialist in about two days and sometimes within hours. eConsults also helps avoid unnecessary visits (in-person or virtual) for patients.
  • If your EMR allows for ‘stamps’, use them to prevent typing the same messaging repeatedly.
  • Doing group visits? Google Hangouts for psychotherapy or used with diabetes patients works well and is free. You can conduct a video call with up to 10 people. A virtual environment can work well when patients who do not like talking or leaving their homes see other patients with similar issues.

Virtual visits are not appropriate for all patients. You will want to see some patients in person during COVID-19. You and your staff should be in full PPE when you are in the office. Our clinician Peer Leaders recommend that you try to set up your schedule so that vulnerable patient populations (prenatal, well-baby, geriatric, immune-compromised) come in only during protected time slots so that the risk of exposure to potential COVID-19 patients is limited. For more information on virtual care and tools to consider and other useful resources, visit OntarioMD.News, . For questions about a specific tool on this site, please contact the vendor directly. If you have any general questions about using virtual care tools, please contact support@ontariomd.com

Virtual Care: Preparing your staff and notifying your patients

Contributors include OntarioMD Practice Advisor Tania Hunt with recommendations from OntarioMD Physician Peer Leaders from our Virtual Care Webinar Series

With the onset of the COVID-19 , clinicians have quickly adapted to physical distancing with their patients and using virtual care to avoid unnecessary trips to the office. You may decide to make this change in how you practice medicine an ongoing option for your patients beyond the current global pandemic.  The change to a practice that offers virtual care options can be done easily and efficiently by selecting a virtual care platform that’s right for you and your patients. There are many virtual care tools on the market and the choices may seem overwhelming. OntarioMD has facilitated your review of virtual care tools available to Ontario clinicians by bringing them all together in one convenient spot, OntarioMD.News. This site contains lists virtual care tools for video visits, direct-to-patient interactions, virtual clinics, EMR-integrated tools, and more. The tools have been curated, but not endorsed by OntarioMD. Please contact the vendors directly for product-specific questions.

You may wish to delegate the task of finding a virtual care platform to one of your staff who will also be using the tools and you can also ask your family and friends for recommendations. Involving staff is an opportunity to keep them feeling needed and invested in any new tools for your practice. A critical success factor for virtual care is being able to network with colleagues on similar platforms for support and advice so you may wish  to select tools that colleagues in your social network, study groups, etc., are using.

The transition to offering virtual options might be challenging for some staff. You can leverage Zoom or similar platforms to train staff on the benefits of the virtual tools. You may also want to consider an Interactive Voice Response (IVR)system to route phone calls for staff working from home.

Before you adopt a virtual care tool, a good idea is to keep your schedule flexible when you start using it and until you and your staff get used to the tool. This will help to ease stress, give you and your staff space and plenty of time to learn from using virtual care tools. You can see what works well and how your patients like the tool.

One of the most frequent requests from patients is for online appointment booking. Online booking is a great way to introduce your practice and your patients to virtual care tools. Check out the options for an online booking platform. Online appointment booking will cut down on phone calls asking for appointments. This frees up your staff to do other things. You should allow for some same day appointments, and leave only options video or phone options for the patient to choose from. Work with a nurse or your admin to triage who you need to see vs. who you can treat over the phone or eVisit.

So you’ve prepared yourself and your staff to use virtual care tools. Now it’s time to notify your patients that your practice has gone mostly virtual. Your staff can implement the IVR and voicemail system so patients are informed that your clinic has gone virtual when they call. If your staff are booking appointments over the phone, ensure they ask the patient what virtual platform they would like to use (phone or video). If they are booking an appointment from your website, change your website to only show the video visit or phone visit options. Let patients decide which technology they are most comfortable with. Once an appointment is booked, have staff confirm the patient phone number and email so you have the most up-to-date information. It’s also a good idea at this point to obtain the patient’s consent in advance of the virtual encounter. This can be done by admin staff.

A consent statement that your admin can read to patients over the phone was prepared by OMA and OntarioMD Legal teams and vetted by the CMPA.  It should be posted on your website and in your office for your patients to read. You can also obtain consent by email. In both cases, record consent for each patient in your EMR. Instructions for how to obtain consent to initiate a virtual care encounter and the consent statement are available on OntarioMD.News.

If you use Facebook, a newsletter or another method to communicate with your patients, try and get the word out on how patients can reach you and provide links to resources if they have traveled outside of Canada or think they may have developed COVID-19 symptoms.

Search your EMR for patient email addresses and send a mass communication to notify patients of clinic updates, COVID-19 updates and that they can email you. This “keeping the door open” approach has proven to be popular with patients.

All the best as you move forward with your virtual practice.

This is part one of a two-part blog. Part two will focus on virtual care tips and tricks.

Dear Doctor, your computer can help you with time management

Author – Dr. John Wyatt Crosby, OntarioMD Physician Peer Leader

John Crosby

As an OntarioMD Peer Leader, I act as an efficiency expert for family doctors. OntarioMD Peer Leaders are a network of over 60 physicians, nurses and clinic managers across the province who are expert users of OntarioMD-certified EMRs and are available to help physician practices realize more clinical value from their EMRs. Peer Leaders usually get a referral by word of mouth from other doctors or OntarioMD practice advisors talk to the doctor’s staff and tell them an OntarioMD Peer Leader can help for free. The Peer Leader will help the doctor to become more comfortable with the computer and EMR software.

I help prepare for my visit to the doctor by sending the doctor my free eBook on time management (email me for your free copy at drjohncrosby@rogers.com). I ask them and their staff to read it. They can also hear it on audio book hands free while driving. It is on YouTube and you can listen to it using Bluetooth. I then book a two hour meeting with the doctor in his/her office without interruptions. No phones or patients.

I ask the doctor what his/her goals are. Some want to improve patient care, cut paperwork and learn how to utilize their computers better.

Some want to work less and earn more.
Some want to cut stress and avoid burnout.
Some want to avoid malpractice and college complaints.
Some want to improve billing.
Most want all of the above.

I get them to describe a typical week. When do they get up? When do they go to work? I look at their patient appointments in the computer. How many per hour? How many coffee breaks? How much time off for lunch? When do they get home? What do they do at night, on weekends and holidays? Do they take work home? Do they do office work on their laptops in the off hours?

I then walk them through their computer. Many doctors don’t realize how much time the computer can save them and how it can improve patient care. I click on everything to show all the tools. For example, with capitated practices paid a set amount every month like Family Health Organizations (FHOs) and Family Health Teams (FHTs), I find almost all have not rostered all their patients leaving tens of thousands of dollars unclaimed yearly. They usually tell me their staff is too busy, and being doctors (like me), they are too cheap to pay a high school student $14 per hour to do this on a weekend. They often work through breaks and lunch and get home exhausted at 7:00 pm risking their marriages and relationships with their kids and friends.

I show them how to use the computer to write consult letters, graph weights and heights and use stamps or templates to type faster and more thoroughly. I often get push back on this as ‘cookbook medicine’. I tell them that the best chefs use a cookbook. Also, the Rourke Baby scale is a stamp as are the Ontario Prenatal Forms.

I show them how to use ‘Find notes containing only’ to find MRIs and CT scans.
I show them the absentee note feature.
I show them how to click on the left side of the chart to have a green bar come up that they can attach to consult letters.
I show them how to double click on an existing medication to reorder it.
I show them how to double click on a lab value to get a trend which can be printed off and given to the patient or specialist.
I show them how to cut and paste for repeat visits for the same problem.
I show them how to load and use the handout function.

After 2 hours, their heads are exploding so I send them a brief email a week later with a summary of my recommendations. I then set up a phone chat weekly for 1/2 hour at 8:00 am or noon to go over each recommendation.

I find that the use of stamps is the biggest time saver for doctors. It also improves quality because it encourages the doctor to be more thorough and not forget anything.

Here is a recent example (some items changed to ensure privacy):

The OntarioMD Practice Advisor for Waterloo Region, Sunny Hayer, emailed me with a request from a doctor with 10 years of practice who was buried in paper. Sunny and I set up a 2 hour meeting on a Wednesday morning at 9:30 am. Sunny met with the clinic staff and I met with the doctor. I asked her what her problems were, and she pointed at her desk which was buried in paper. Also, her computer was chock full of lab results and imaging.

I got her to describe a typical week in her life. She got up weekdays at 6 am and took her two young kids to school at nine and she started at 9:30 am in her office. She took no breaks and at 1:00 pm she grabbed a sandwich and ate it in 10 minutes, then went back to seeing patients. She worked until 7:00 pm then had a reheated supper alone (the kids were fed by the nanny at 5:00 pm). Her husband got home at 6:00 pm. She then did computer work from 8:30 to 10:30 pm, collapsed into bed and got back up again the next day at 6:00 am like in the movie Groundhog Day. She did this 5 days a week. The weekends were all about getting caught up on cleaning and laundry. She was exhausted and rarely had time to enjoy herself, her husband or kids. She was using her office computer like an expensive typewriter.

My solution:

I told her to read my eBook (reminder to email me for a free copy) on time management. She didn’t have time, so she listened to it in her car while driving to work. It comes in eight 10 minute chunks.

When she got to her office, she loaded in stamps for the top 10 most common problems seen in her general practice. This helped her stay on time with her patients. She had a 10 minute break at 11:00 am to go for a walk around the block. Lunch was blocked out in her computer appointment screen at 12:30 pm for one hour with the phones on answering service to give her staff a break too. The last appointment in the morning was booked at 12:00 noon.

The last patient was booked for 4:30 pm and she was home at 5:00 pm to have dinner with the kids. Her husband arranged to be home by 5:00 pm too. Computer and paperwork were done from 12:30 to 1:30 pm daily in her office. She got caught up on her backlog of paper and computer work by coming into the office one time at noon on a Sunday and working with no distractions until 6:00 pm. Her smart phone calendar and office patient appointment list has an appointment booked with herself from 12:30 to 1:30 pm weekdays for paper and computer work. Her off hours are free. No work texts, calls or emails. She hired a home cleaning service and now she has time for her husband, their kids and herself. She has a night out alone with her friends every Thursday night. She hired a high school student to roster 500 patients which earned her $50,000 more per year by paying out $14 per hour x 40 hours or $560 – not a bad return on investment.

Computers can help doctors improve patient care and office efficiency. You don’t have to do it alone. Contact OntarioMD (support@ontariomd.com) and ask for help from a Peer Leader.

Integration and Enterprise Primary Care: A Point of View

 

Paul

Author – Paul Sulkers, Healthcare Consultant

The COVID crisis is placing huge demands on the Ontario health system, with a heavy reliance on acute care, perhaps our last line of defense. COVID has also brought in to focus the need for strong primary care and population health management, as we seek better ways to assess and manage COVID patients, many with other health or social challenges. To achieve population health, we need a health system that is integrated from a consumer perspective, understanding their needs and tailoring strategies to improve the health status of the entire population.

We understand that population health management must be enabled by primary care and consumer engagement, and we understand the policies needed for integration[↓1][↓3]. However, we have launched an OHT strategy that integrates around hospitals, fragmenting primary care into regions, and challenging consumers affiliated with multiple OHTs [↓4]. Our OHT approach also lacks the ability to scale investments, such as Toronto’s SCOPE, [↓5] or Sunnybrook’s “One-Team” [↓6] which could be classified as the ‘right idea’ in the ‘wrong place’, trapped within OHTs. Under the pressures of COVID, there is a natural tendency to fall back on OHTs as the ‘right path’, reinforcing acute-centric culture [↓18] rather than building capacity with primary care and consumer engagement to manage population at the front lines.

We can learn from others. Leading jurisdictions have invested in primary capacity, scaled across entire populations, and are now reaping the benefits of a seismic shift in the way that health is managed, funded and measured [↓7][↓13]. Spain established a population health strategy for Catalonia, segmenting their population into 320 risk categories [↓10]. Denmark reduced the number of acute hospitals from 98 to 36, shifting funds from acute to primary care [↓11]. The NHS uses community outreach and partnerships with the post office, re-defining health as a “team sport” to better manage the elderly closer to home [↓13]. In the US, Kaiser Permanente has created an integrated care delivery model that emphasizes preventive care and management of chronic disease [↓12]. Geisinger utilized centralized clinical leadership across enterprise-scale primary care, reducing costs per patient by 11% over five years, and reducing avoidable readmission rates by over 35% [↓8][↓9].

In all cases, enterprise-scale primary care was key, recognizing primary care’s critical role to be consumer-facing and leader of population health management. Enterprise-scale means moving from individual practices to integrated primary care governance, including standard care models, shared resources including virus surveillance capacity, paediatrics and palliative care, and partnerships with home care to manage care closer to home. Enterprise data enables central physician leadership to develop new funding models, addressing cohorts with similar risks, co- morbidities, and social determinants. Consumers view an enterprise or integrated system, including their care plan, educational content, health reminders, appointments and referrals.

A critical enabler of their enterprise primary care was a shared EMR, with the ability to scale care models and process, enable jurisdiction-wide view of population data, and a single digital view for consumers regardless of their residence [↓14]. Clearly, Ontario is not going to move to a single EMR any time soon! However, we can learn from other industries who have used digital process automation to integrate the ‘front’ end of the enterprise across a variety of disparate IT systems. Digital process automation will allow the fragmented Ontario health IT landscape to ‘appear’ integrated, shifting from variable and open loop process (using fax, phone and pagers) to digital processes that are patient-centred, closed loop, and measured, evidenced by Toronto’s ConsultLoop [↓14] [↓15].

Digital process automation across our primary care practices will enable enterprise status, including the ability to scale innovation across the entire population. Supported by outcome measures and innovative funding models, primary care will leverage shared resources and partnerships with home care and community services to better manage complex patients closer to home. Enterprise primary care will engage consumers via ‘extended reach’, moving knowledge to the patient, and reducing patient administration costs via the ‘healthcare manager’ in each household [↓14]. Social distancing has exacerbated the importance of communication and extended reach, not only with providers, but also among families, split apart by COVID.

Enterprise primary care will also achieve increased productivity by leveraging healthcare AI, including virtual care, predictive early warning, digital assistants, as well as digitally supported case managers [↓16] [↓17]. Increased productivity will free-up clinical resources to focus on in-person care, critical to manage patients drifting towards high cost cohorts.

However, digital is not the core competency of our health system. We must leverage the Canadian private sector to invest in enterprise primary care, pulling Ontario in to the 21st century. Private sector has the know-how gained from other industries successfully addressing similar integration challenges. Importantly, Ontario’s health digital expenditures must become an investment to build a new digital health & health AI economy in Ontario [↓14].

Together with private sector, we must start with enterprise primary care to integrate the ‘front-end’, ensuring consumers see a seamless view of Ontario healthcare, regardless of any OHT-defined relationship. COVID-19 presents a watershed moment to either continue acute-centric models or invest in enterprise primary care, at scale – rapidly!

References

1. World Economic Forum; Value in Healthcare Project

2. Peggy Leatt, George H Pink, Michael Guierre, Towards a Canadian Model of Integrated Healthcare, March 2000

3. Dr Robert Bell, August 2019

4. A Healthy Ontario

5. UHN’s SCOPE

6. Sunnybrook Case Study

7. Primary Care Patient Centred Collaborative

8. D Maeng et al. “Can Telemonitoring Reduce Hospitalization and Cost of Care? Geisinger’s Experience in Managing Patients with Heart Failure”. Journal of Population Health May 2014

9. Geisinger Case Study

10. Catalonia Spain

11. Denmark: Australian Financial Review

12. Kaiser Permanente Integrated Care Models

13. Jersey Post – Call and Check Program

14. Sulkers, P. “Integrating Ontario Healthcare: A POV”

15. ConsultLoop Case Study

16. Case Management: Mobiheatlh News, David Muoio, January 4, 2018

17. Productivity of Case Management: AHIP blog, Darcy Lewis, January 25, 2018

18. COVID-19 Assessment Centre