Screening tool addressing poverty in patient populations

Submitted by Jerry Zeidenberg 

This article references a session that was presented at the EMR: Every Step Conference. Make sure to register for the EMR: Every Step Conference Ottawa at https://www.ontariomd.ca/about-us/events/emr-every-step-conference/emr-every-step-conference-ottawa-2019 for engaging content on OntarioMD digital health products and services.

It’s well known that poverty is a major determinant of health, and that one’s social and economic environments play a large role in whether a person becomes physically or mentally ill. However, little has been done in a practical way to identify and assist at-risk members of society at the primary care level.  

Now, however, a project has been launched to turn things around. Initially, a two-month pilot project was conducted in 2018 that gave primary care providers a computerized tool to identify patients who are at risk of living in poverty, and who could use the support of community resources.  

The project was conducted at primary care clinics in four Ontario cities – London, Sudbury, Cambridge and Toronto – under the leadership of the Toronto-based Centre for Effective practice (CEP), a not-for-profit organization which started at the University of Toronto’s Department of Family and Community Medicine to create and disseminate evidence-based improvements in primary care. 

“My office screened 700 patients for poverty, and 100 were identified,” said Dr. Mario Elia, a London-based family physician and one of the pilot site leads.  

Overall, 4,517 patients were screened at the four sites, and 12 percent were found to be at risk of poverty.  

Of these, 30 percent were provided with customized resources and referrals to community supports at the same visit.  

Dr. Elia and Claire Stapon, a manager at the CEP, spoke about the poverty screening project at a session for physicians at OntarioMD’s EMR Every Step Conference, held in Toronto in September.  

Stapon said that 20 percent of Ontario families live in poverty – about 1.57 million persons. At the same time, she noted that 50 percent of a population’s health is determined by social and economic environment, according to recent studies. 

Indeed, all of the following have been strongly correlated with a person’s environment: diabetes, asthma, arthritis, cancer, COPD and mental illness. 

“Often, doctors don’t have the resources, and we struggle with how to help patients living in poverty,” said Dr. Elia.  

The computerized intervention devised through the Centre for Effective Practice has been identified as a step in the right direction.  

The tool was developed in partnership with CognisantMD, which produces Ocean software, a system that helps automate information gathering as patients arrive at a clinic. Also involved is 211Ontario, a free helpline and online database of Ontario’s community and social services.  

The Centre for Effective Practice has been producing other tools used in clinics; the one created for this project has been optimized to screen for patients struggling financially.  

In the pilot, staff and clinicians at the four clinics were first given education about the topic and training on use of the tool. Dr. Elia said it wasn’t difficult to implement at his clinic, as the office had already been using Ocean questionnaires to gather patient information.  

All patients over the age of 18 were given tablet computers, on which the form to screen for poverty would pop-up. Questions included such examples as, “Do you ever have difficulty making ends meet at the end of the month?” and “Have you filed your taxes?”  

Not only does the tool effectively identify at-risk populations, importantly, it also provides physicians with sets of local supports and resources for patients.  

Low income patients who haven’t filed their taxes – because they fear they might have to pay – are often entitled to tax refunds. The tool shows doctors how to connect their patients with the right resources in order to file their returns and receive these refunds.  

Other social supports are also available, making it much easier for physicians and their staff to help patients in need.  

The Ocean tool integrates with EMRs and can automatically create reminders on follow-up visits to inquire about different issues.  

After the pilot project ended, each of the sites had the option to stop using the tool. However, they all wanted to continue using it, Stapon said.  

Now the Centre for Effective Practice wants to spread the resources to other primary care practices in Ontario. They have created a modified version of the tool for TELUS PS suite physician systems, to start. Eventually they’d like to make the tool available for all EMRs in Canada. Those who are interested in more information can visit http://cep.health/poverty.  

OLIS Wizards My EMR

Contributed by Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader

Recently, I accepted a 70 year old man into my family practice. He presented to our first encounter with nothing but his spouse to aid his recall. I had prior hints of his complex history but it soon became evident that neither of the pair had the memory or detail that would have been nice for this intake interview.

One of the tools I have come to cherish in such encounters is OLIS. Subtly integrated within my EMR, in a matter of a couple of clicks I am in the position to query the database for the patient in front of me. On verbal consent from this septuagenarian, I launched digital minions to fetch the last ten years of his labs. Moments later another click of a button allows me to download the retrieved treasure trove into my EMR. Less than a minute later I am pointing to a graph generated by my EMR of his hemoglobin and asking him, “ What happened to you at this dramatic dip in February 2016.?” Visibly impressed, he recalls, “Oh that is when I had my stroke and was given clot busters”. In just minutes, I was able to get a better picture of trends and perspectives that improved my ability to care for this patient without having to send him for duplicate lab tests.

Later, my questions about his diabetes were met with firm denial, yet his previous family doctor had already ordered a Hb A1c in 2015 which was reported at 6.7%. A picture of denial was emerging. The graph of his LDL cholesterol shows the classic swings of someone at one time started on a statin who later stops it only to be started again. In this case, the statin had evidently been stopped approximately a year before his stroke but promptly restarted in February 2017 fitting perfect with my lab graph. My patient and his wife look at me like I have psychic powers. I smile and thank my EMR and OLIS for the good start we were off to.

Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader

Tapering opioids for chronic non-cancer pain patients using an EMR tool and academic detailing

Submitted by Dr. Kevin Samson

The 2017 Canadian Guidelines for Opioids for Chronic Non-Cancer Pain emphasized the importance of safely minimizing the dose of opioids that patients are being prescribed. The guidelines made it important for me as a primary care provider to reassess my population of patients on opioids and ensure that I was doing my best to implement the new recommendations accordingly. This presented a formidable challenge and led to the realization that it would be very useful to have an EMR tool to support this process.

In response, the East Wellington Family Health Team (FHT), the Guelph FHT, the eHealth Centre of Excellence (eCE), and TELUS Health partnered to create an Opioid EMR Toolbar (Figure 1) using content informed by the Guidelines and work done by the Centre for Effective Practice (CEP).

Figure 1. Opiod EMR Toolbar

The toolbar provided a practical and effective way to implement the new guidelines into my practice through the following capabilities:

The figure below illustrates the steps I took in using the toolbar to implement the new guidelines.

Figure 2. Steps used to systematically manage my population of patients on opioids.

During this process, I also found it very helpful to participate in Academic Detailing sessions provided by the CEP. These are one on one sessions in which an expert from the CEP met me at my office and reviewed key topics including:

  • Non-pharmacological and non-opioid options for the management of patients living with chronic non-cancer pain
  • Managing opioid therapy for patients living with chronic non-cancer pain
  • Managing care for patients living with opioid use disorder

Results

The toolbar gave me the information that I needed, when I needed it, provided individualized patient decision support, and saved me a lot of time on documentation. I was able to spend more time with my patients. They felt engaged and well informed.

Within nine months of the adoption of the toolbar I was able to safely taper the dose of opioids for a significant number of my patients and there was a statistically significant reduction in the overall MEQs I prescribed over this time period (p<0.05).

I really hope that others will find similar success in helping their patients manage their pain safely and effectively. The Guidelines have paved the way for us, and the Opioid Toolbar has proven to be an effective vehicle to help get us there.

Resources available

  • The Opioid Toolbar is now available to all users of Telus Practice Solutions EMR. The simplified version of the toolbar used for this quality improvement initiative is available through theeHealthCentre of Excellence for PS EMR (Oscar under development). eHealth coaching sessions are also available through the eCE (with Mainpro+ credits) for primary care providers across the Waterloo-Wellington Local Health Integration Network.
  • The Academic Detailing sessions are free-of-charge and free of commercial interest. Physicians can earn Mainpro+ credits for each AD session. More information and the process of signing up for a session is available on the Centre of Effective Practice website.

References:

Busse, J.W. (2017). The 2017 Canadian guideline for opioids for chronic non-cancer pain. Hamilton, ON: McMaster University.

Need help supporting your patients in managing their pain? Visit the Ontario Pain Management Resources for a coordinated program of tools from partner organizations across the province. 

How OntarioMD Measures Our Success

Since 2004, OntarioMD has supported more than 16,000 Ontario primary care clinicians with the adoption and efficient use of electronic medical records (EMRs) and other digital health technology. From having the lowest rate of adoption among Canadian provinces just eight years ago, the EMR usage rate for Ontario physicians is now one of the highest among all provinces. OntarioMD’s strong industry knowledge, relationships and understanding of the health care goals of both clinician practices and the province are keys to our success.

We assist clinicians directly with their digital health needs by certifying EMRs, connecting clinician practices to provincial digital health services, developing solutions to connect these services to EMRs, and help practices adapt their workflows through hands-on change management support from OntarioMD Peer Leaders and our EMR Practice Enhancement Program, as well as at various OntarioMD events.

The digital health space is evolving rapidly as health care needs change, and potential solutions are regularly introduced. However, not all digital health services are effective solutions for clinician needs or for health care system challenges. With this in mind, we constantly test and measure the success of our innovations and support programs with end users. We also collaborate with system partners on assessment and evaluation activities, with the end goal of continuing to build an integrated, effective, patient-centred system aided by technology. The following are just a few examples of how we measure success.

Health Report Manager (HRM)

Health Report Manager (HRM) enables clinicians using an OntarioMD-certified EMR to securely receive patient reports electronically from participating sending facilities including hospitals and specialty clinics. Clinicians connected to HRM automatically get text-based medical reports such as discharge summaries and transcribed diagnostic imaging reports sent to patients’ charts within the EMR. More than 9,000 physicians receive reports through HRM from over 160 hospital sites and more than 200 specialty clinics locations – and the numbers of connected clinicians and sending facilities goes up each month.

In 2017, we asked Deloitte to conduct a survey-based benefits evaluation of HRM that was supplemented by an OntarioMD-led study where practice advisors studied workflow variations and conducted timing assessments. Findings from Deloitte and OntarioMD found that HRM saves an average of 33 minutes per clinician per day by not having to manually handle paper reports. HRM also reduces hospital expenses on printing and postage, as well as labour related to reports that would otherwise need to be faxed to clinicians. The Deloitte report estimated that HRM avoids an average of $15 million a year in costs to the Ontario health care system.

EMR Practice Enhancement Program (EPEP)

EPEP was launched in 2016 to help clinicians and their staff unlock the full potential of their EMR and realize benefits for their practice and patients. Using a hands-on, evidence-based approach, the EPEP team has helped over 500 clinicians and their staff improve EMR data quality and practice workflows and tap into their EMR to proactively monitor and treat patients.

EPEP works with evidence-based tools developed by OntarioMD: the EMR Maturity Model (EMM) and EMR Progress Assessment tool (EPA). These tools assess maturity on a six-point scale (0-5) across three functional areas: Practice Management, Information Management, and Diagnosis and Treatment Support. During EPEP engagements, advisors conduct baseline assessments of a clinician’s EMR maturity and EMR data quality in several priority measures, such as smoking status, cancer screening adherence, and immunizations. They then reassess at regular intervals during and after an EPEP engagement. Our results of these assessments have revealed that data quality measures show improvement after six months. More importantly, most improvements are sustained or even further improved upon at 12 months.

EMR Quality Dashboard

OntarioMD has recognized the need for busy clinicians to quickly and easily visualize their entire patient roster based on their EMR-based patient data. Working with TELUS Health, OSCAR EMR and various industry partners, we developed an EMR Quality Dashboard. The proof of concept initiative is currently in phase 2 with approximately 500 participating clinicians. The Dashboard:

  • provides clinicians with real-time access to EMR data in a user-friendly visual manner, using widely-recognized primary care indicators from Health Quality Ontario, the Canadian Institute for Health Information and the Association of Family Health Teams of Ontario;
  • provides the ability to drill down to patient-level data for each indicator, enabling clinicians to take immediate proactive steps to improve patient care;
  • helps clinicians standardize their data entry to improve the quality of patient data in their EMR;
  • allows clinicians to trend and compare their indicator metrics with other physicians using the Dashboard;
  • would scale provincially to all Ontario physicians using an OntarioMD-certified EMR, and
  • is easily expanded as practice needs and clinical indicators evolve.

Phase 1 of the proof of concept involved approximately 100 physicians. We conducted a benefits evaluation at the end of that phase, which found that over 75% of participating physicians recognized the Dashboard’s value in identifying target patients and generating actionable patient lists. In addition, 80% said the change management support they received from OntarioMD while using the Dashboard was effective in addressing their questions and concerns and optimizing their use of the technology. Following the end of phase 2 in December 2018, we will conduct a more in-depth analysis of participating clinicians to further demonstrate the clinical impact of Dashboard on participating practices.

In each of these cases, our focus on measuring the success of our initiatives has helped us refine and expand our offerings, and integrate them with OntarioMD’s robust change management and support services. Find out more about HRM, EPEP, Dashboard and our other programs and services at www.ontariomd.ca or by contacting us at support@ontariomd.com.

One Visit. Multiple Services. Efficient Use of Clinicians’ Time.

Physician practices can choose multiple digital health services to help them care for their patients effectively and efficiently. They’ve seen the ads, they’ve talked to colleagues who already use them, but simply don’t know who to contact or what’s involved to get the process started. OntarioMD has a solution that respects clinicians’ valuable time. In one visit, OntarioMD can describe the benefits of each digital health service, get the onboarding process started and help get you trained on using each service. We call this approach the Digital Health Services Bundle. Much like bundling your cable, Internet and phone services, there’s a current bundle of digital health services available to clinicians that give you access to provincial digital health services that contain information about your patients. This streamlined approach is convenient for clinicians and saves time. Instead of multiple organizations knocking on your door, OntarioMD, because of our experience over the last decade in working with physician practices, is their chosen partner to roll out their digital health services across Ontario. OntarioMD is currently rolling out a bundle of services to clinicians on behalf of eHealth Ontario, Toronto Central LHN, the Northern and Eastern LHINs, University Health Network and the Ontario Telemedicine Network.   

The current bundled services include:  

In order to access provincial digital health services, clinicians require a ONE ID provided by eHealth Ontario. Think of it as your proof of identity, like a passport, to log into digital health services. With ONE ID, clinicians do not need to remember multiple user IDs and passwords. It provides one secure single sign-on to access multiple services like the ConnectingOntario ClinicalViewer.  

ONE Mail, also from eHealth Ontario, is a secure e-mail service specifically created for health care organizations and professionals. You can send encrypted patient information to 390,000 users in Ontario across 800 organizations. Set-up is easy and there’s 24/7 dedicated support and no need for an on-site mail server.  

The ConnectingOntario ClinicalViewer allows you to access and view a patient’s real-time information through secure, web-based portal. You can view your patients’ digital health records that include hospital visits, laboratory results, dispensed medicationss, diagnostic imaging reports and more.  

eConsult, managed by the Ontario eConsult Program, is a tool that provides timely access to specialist advice and often eliminates the need to send patients for an in-person specialist visit. Through a private and secure web portal, you can send a specialist a clinical question about your patient and receive advice quickly and securely. This saves you and your patient time and provides quicker access to care and treatment for your patients.  

To use any digital health services, you need privacy and security training to fulfill your legal obligations and protect your patient data from privacy breaches. OntarioMD has made it easy, and free, for you to get this kind of training. We offer the OntarioMD Privacy and Security Training Module at OntarioMD.ca. You can do the training whenever you have time, from wherever you can access the Internet. Family physicians also earn two Mainpro+ credits for their time. If you’d like some help to complete it, just ask our staff during the Digital Health Services Bundle visit and they can help you. Once you’ve completed the online training module, you can print a certificate of attestation to prove that you are familiar with the best practices to protect personal health information.  

With so many digital health services now available to Ontario clinicians, you may be confused about what’s out there and how the services can help your practice. One email or phone call to OntarioMD will help you make sense of it all and connect you to the tools that are best for your patients and your practice.  

Dr. Therese Hodgson, a family physician in the Ottawa area, has found the bundled approach to digital health services valuable and says of some of the services, “The ConnectingOntario Clinical Viewer provides me access to critical information for my patient in an easy and reliable way. This prevents delays in obtaining the information I need to best care for my patients. The OntarioMD Privacy and Security Training Module is a great resource and has helped me educate my staff in our duties as Health Information Custodians to protect personal health information”. 

Get connected to digital health services efficiently, in one visit. Contact OntarioMD at support@ontariomd.com to talk to one of our staff in your area.

EMR Quality Dashboard: Data Quality and Analytics

In this fourth entry in our video series on the EMR Quality Dashboard, OntarioMD CMO Dr. Darren Larsen discusses the importance of good data quality and how analytics can help patient care through population health management.

How EPEP Helps You Reach Your Practice Goals

OntarioMD’s EMR Practice Enhancement Program (EPEP) helps you realize even more value for your patients and your practice by tapping into more of the benefits of your EMR. EPEP staff will work with you and your staff to achieve your unique practice goals, at a time that’s convenient for you. We will analyze your EMR workflow and data quality, and identify quick wins that achieve tangible results or save your valuable time. EPEP emphasizes hands-on support as you move beyond basic data capture to use your EMR for enhanced patient care and improved practice efficiency. 

Watch the latest EPEP Success Story to find out how EPEP helped one practice focus on population health through better prevention and screening management. For more information on EPEP, visit https://www.ontariomd.ca/products-and-services/emr-practice-enhancement-program

Digital health helped me breathe again!

suryablogpic

Contributed by Surya Qarin, OntarioMD Practice Management Assistant 

Anyone that has known me long enough knows I have spent much of my life in and out of hospitals – and that’s not because the doctors are cute. As a matter of fact, Etobicoke General’s nurses and I are on a first name basis now, and they know exactly which vein works best when drawing blood, and which ones “hide.”

As a child, I was hospitalized every other week for severe asthma. It seemed to subside after I turned 12… at least I thought it did. I didn’t even think asthma was a real issue for adults. I’d always been told people outgrow it. But this is not the case: According to the Centers for Disease Control and Prevention, 9.7% of women aged 18 or older have asthma and are more likely to die of asthma than men. Adults are also four times more likely to die of asthma than children. Asthma Canada stats show that up to 250,000 Canadians are living with severe asthma.

Asthma returned to my life a few years ago, as a moderate condition. I had become more active, believing it would help with my other health issues (which it did). As long as I took my puffers before and after working out, I would not have any issues with breathing.

Then flu season hit, and I got sick a few times between December 2016 and February 2017. Those who know me understand my strong belief that I am super woman and do not like to complain about being sick or having “a little cold.” Unfortunately, this was not just a small cold: it had turned from a cold, to bronchitis, to full blown pneumonia by April 2017. Even then, I still refused to see a doctor. One day, on my drive home from work, I felt a sharp chest pain, and something didn’t seem right. I was not just having a little difficulty while breathing as I had been the last few months. I actually could not breathe.

Gasping for air, I pulled over, sent a quick text to my sister and drove to Humber River Hospital. There, I realized how difficult it would be for me to get my medical records: My family doctor was not affiliated with the hospital, nor was Etobicoke General. They were, however, able to pull my past drug history from my pharmacy and go based off that information. I was stabilized and discharged.

A few days later, my breathing difficulties returned. I went into Etobicoke General, and they were able to pull my history right away and admit me to hospital within the hour. Turns out my lungs had started shutting down due to the pneumonia and asthma, and as it was high-humidity and high-allergy season, being outside did not help me. During my stay in the hospital, my family doctor received hospital reports via Health Report Manager (HRM) and he was kept updated on my condition, as were my respirologist and cardiologist.

After a few weeks of recovery, I thought all was well. However, I caught a “cold” again in October, and this time things deteriorated fast! I ended up in hospital yet again. My respirologist was made aware of my condition in real time via the hospital’s EMR and was able to work with the other respirologist on duty and doctors working on my case to provide the best course of treatment given my history. My current spirometry test results were easily available for the clinicians, and the instant connectivity between those on my medical team helped improve my care and recovery process.

Once again, my family doctor’s ability to receive hospital reports to his EMR through HRM enabled him to follow-up accordingly, ensure I had the contacts I needed for my health, schedule regular testing, and most importantly, help ensure that I didn’t end up in the hospital again. I’m happy to say that I have not been hospitalized overnight since November of 2017.

As a member of the team at OntarioMD, I help clinicians across the province understand the value that EMRs and digital health tools such as HRM can bring to their practice and the quality of patient care they’re able to provide. But being a patient in the health care system has really demonstrated the importance of these tools to me first-hand. If you’re a clinician who has questions about optimizing your EMR use, or you want to connect to HRM or the wide range of other digital health tools in Ontario, contact OntarioMD at support@ontariomd.com.

 

 

I hate paperwork!

Submitted by Dr. John Crosby 

I am a family physician in Cambridge with 1,400 patients serving 2 nursing homes in an 18-physician family health team with 30,000 patients in total. I have spent 26 years as a physician, with 20 years’ experience as an emergency physician.

A recent survey in the Medical Post listed paperwork as the biggest stressor for physicians. Luckily for me, paperwork is a thing of the past as we have eliminated paper coming from hospitals and specialty clinics and gone digital using Health Report Manager (HRM). It was easy to implement, and both my office manager and I have found that it saves us time to focus on delivering better patient care.

HRM is simple to implement as OntarioMD does all the work in helping to get your practice set up. OntarioMD came into my practice to sign subscription and user agreements and TELUS helped with the set-up of the system. Report types such as imaging, emergency, specialist and other hospital reports automatically downloaded into our EMR system. This eliminated the need to store paper reports. If I were to get an MRI report showing a brain tumour, I can quickly call the patient in and refer them to a specialist.

I can also access lab results through my EMR via the Ontario Laboratories Information System (OLIS). I simply login into my computer and click on lab reports to view any abnormal patient results. If a patient’s potassium level comes back low, I can simply tell my office manager to tell they will need to change their diet or take certain medications.
One of the newer digital health tools I’ve connected to is eConsult. I can send a message and documentation to a specialist anywhere in Ontario without having to send my patient for an in-person visit. This means faster advice, usually within a couple of days, I can use for my patient who doesn’t have to wait months to benefit from a specialist’s advice.
These tasks are all done without paper. Prior to using an EMR, HRM, OLIS and eConsult, receiving, sending and viewing patient health information was tedious and time consuming. In the past, all my reports were mailed or faxed. We would have to physically travel to the hospital and pick up the paper reports daily. Then the paper report was scanned, the patient’s file had to be opened and the report dragged there. Then my office manager would mark it as seen by me.
With HRM, I see a patient’s report as soon as it downloads. With a couple of clicks, the information is posted into the patient’s chart. I no longer need to go to the hospital and wait for mail and faxes. Now I can receive specialist reports the same day of the patient’s visit all thanks to HRM. HRM also sends me eNotifications so I know when my patients were in the hospital and know that I can expect hospital reports to follow.
My practice is more efficient all thanks to my EMR and other digital health tools like HRM. They have benefitted my practice by:

  • Enabling me to find patient information quickly
  • Allowing me to spot trends and abnormalities
  • Providing faster patient follow-ups
  • Accessing specialist advice and getting responses sooner
  • Enabling more time spent on patient care
  • Creating workflow efficiencies
  • Less time spent on administrative and operational tasks

Physicians and other clinicians need digital health tools to practice medicine today. They really need the services of OntarioMD to advise them on how to go digital. You can start with one digital service and OntarioMD will help you integrate it into your workflow. Or, you can start with multiple digital health tools. OntarioMD can connect you to all of them and help you understand how to use them effectively to care for patients and to manage your practice. If you hate paperwork like I do, contact OntarioMD to get HRM, eNotifications, OLIS, eConsult or any other available provincial digital health tools (e.g., ONE® ID, ONE Mail, ConnectingOntario Clinical Viewer and more). Call 1-866-744-8668 or e-mail support@ontariomd.com.