April | 2020 | OntarioMD Blog

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.

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