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.  

Support + Training = EMR Knowledge for Busy Ontario Clinicians

More than 16,000 clinicians use OntarioMD products and services, and over the years our staff both in the field and at our head office have built strong relationships and had thousands of conversations with primary care providers. So, we’re intimately aware of how busy most primary health care practices are. And we know that most of you want to maximize the benefits of the EMR to enhance patient care and make your practice more efficient. If only you had the time and money to devote to learning how to make the technology work for your practice! 

You’re likely already using several digital health services like our award-winning Health Report Manager (HRM), or want to start using them. Did you know that OntarioMD also has staff all over the province available to help you better understand and use digital health services? Our staff and Peer Leaders are clinicians, practice managers and EMR experts who understand how you work, understand your challenges, and understand the demands on your time. They can help you achieve your unique practice goals. They will come to your practice, or Skype with you, to work with you one-on-one, give you training tips, show you useful features and tools, analyze your EMR data, all to help you better use your EMR to manage your patients’ health. They can help you learn in as little as one visit or work with you over several sessions, depending on your practice objectives.  

You can also get EMR and digital health support surrounded by a small group of your peers through OntarioMD’s unique On the Road with OntarioMD regional learning seminars.  

On the Road with OntarioMD are free Continuing Medical Education (CME)-accredited interactive evening seminars near you for you and your staff to learn how to get more immediate clinical value from your EMR. Whether you’re a seasoned, active user of all your EMR’s features, or you want to learn how to use it for more than just data entry, these seminars will teach you new skills in a stress-free environment. 

On the Road with OntarioMD seminars begin with a presentation on Partnered Efforts for Safer Opioid Prescribing conducted by an OntarioMD Physician Peer Leader or our Chief Medical Officer, Dr. Darren Larsen. You’ll then meet with other Peer Leaders in small breakout groups with other clinicians who use the same EMR as you do. Peer Leaders listen to your challenges and provide their own EMR best practices that you can take back to your own practice and use immediately. The small size of On the Road with OntarioMD seminars give you the opportunity to share and compare your digital health experiences with other clinicians. 

All that, plus dinner is included! 

On the Road with OntarioMD has visited 14 Ontario cities and more seminars are scheduled.  

Register now for our upcoming seminars – or keep an eye on OntarioMD.ca for an On the Road with OntarioMD near you soon! 

Wednesday, November 28, 2018
Delta Hotels by Marriott Toronto East
2035 Kennedy Road
Scarborough, ON
M1T 3G2

Tuesday, December 4, 2018
Hampton Inn & Suites by Hilton Barrie 
74 Bryne Drive
Barrie, ON
L4N 9Y4

 

Physicians Own the Value of the Data Within Their EMRs

Submitted by OntarioMD Dr. Adam Stewart 

This blog post was originally published on April 22, 2018, on Dr. Adam Stewart’s website at www.stewartmedicine.com.    

Information and data have value in every industry. The value of data in health care is only beginning to bloom. Who owns it, though?

Patients undoubtedly have rights with respect to their medical records. It goes unrecognized by most, however, that physicians own the value of data with their electronic charts.

Patients have rights to the content of the data within their medical records. The charts contain their personal information. This is unquestionable. However, the value of data comes from its structure and the organization, which is fully dependent on the physician who generates and maintains the medical record.

The organization of a patient’s chart may vary from being a barely legible handwritten paper chart to the other end of the spectrum of being a complex Electronic Medical Record (EMR) with the advanced data structure. Across the spectrum, the exact same patient information (content), can have widely different functionality and analyzability (value). This quality differential is entirely dependent on the physician and there can be extreme differences when comparing the charts, and thus data quality, of one physician to another.

Governments covet the value of the aggregate, even anonymized, data within EMRs for planning and policy purposes. Pharmaceutical companies share a similar craving for the data for marketing and development purposes. Innumerable interest groups and organizations equally desire data that relates to their agendas. (The legalities and ethics of sharing or selling data are beyond the scope of this article. Rather, the intent of this article is to identify and raise awareness of the value of EMR data that physicians possess).

As per College of Physicians and Surgeons of Ontario (CPSO), “patients have a right of access to their personal health information that is in the custody or under the control of” a physician.1  Patients can request copies of their charts. Even if the original chart was in EMR format, though, what the patient is entitled to and receives is either a printed paper copy of the records, or an electronic PDF document saved on a CD or memory stick, for example. In these formats, the data has relatively nil to minimal value because it is not structured in a way that is easily navigated and analyzed.

Physicians, and staff hired by physicians are the ones who input the notes and structure the data within their charts. Many physicians further build and customize tools within their EMRs to aid in the documentation. Physicians are the ones who pay for the EMR software, training, and vendor support. Physicians are the ones who are responsible for funding all of the computer hardware, technical support, and the physical space in which to house the infrastructure. Accordingly, in every sense, physicians own their EMRs.

One might try to argue that part of the payment to physicians from Ontario Health Insurance Plan (OHIP) for their services includes the generation and maintenance of the medical record.2  However, OHIP simply mandates and includes payment for physicians to “keep and maintain appropriate medical records”.3  It specifies nothing with respect to a standard of quality. The CPSO has more specific requirements.1  However, even a legible and complete paper chart meets those standards of care. Anything above and beyond the minimum baseline of those requirements has value, and that value is derived from, and therefore owned by, the physician who generates and maintains that chart.

There is obvious variability with respect to the quality of data within physicians’ EMRs. The difference from one extreme to another highlights the differences in the value of EMR data. Physicians own that value.

Patients have rights to the content of their individual data. Physicians own the organization, structure, functionality, and analyzability of the data. Physicians own their EMRs. It follows that physicians own the value of the aggregate data within their EMRs. These are careful and important distinctions.

References:

  1. http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Records
  2. https://www.ontario.ca/page/what-ohip-covers
  3. http://www.health.gov.on.ca/en/pro/programs/ohip/sob/optometry/sob_optometrist_services_20090401.pdf

EMRs and Empathetic Patient Care

Contributed by OntarioMD Peer Leader Dr. Yves Raymond

Recently, Newfoundland physician Dr. Thomas Hall contributed an opinion piece to CanadianHealthcareNetwork.ca, the online home of The Medical Post. Hall’s article – which can be read here (if you’ve registered for a Canadian Healthcare Network account) – argued that while EMRs are useful for connecting health care databases and analyzing patient data, using them during patient encounters risks the doctor being seen as distracted and lacking empathy.

I commented on the website that I find it interesting that we’re quick to blame technology when, in fact, it is how the user chooses to use the technology that is the real issue. In my comment, I also took the liberty to rewrite Dr. Hall’s article substituting paper charts for EMRs as evidence that his arguments could still be made if the medium were paper rather than EMRs. My version is below. Leave a comment below this post to let us know your take on this important issue.

***

Paper charting no doubt helps remember what you did, but what do they do to the more subjective nonverbal parts of our patient encounters in office?

Over the last number of months, I have been talking with both psychiatry colleagues in Newfoundland and with staff at the British Columbia Psychiatry Association about their thoughts on paper charting in a family physician’s office. Generally, they felt, and I agree, that paper charts in a physician’s private office as a place to write notes after an undistracted face-to-face patient encounter is potentially helpful. However, in my informal conversations with these physicians, they all expressed serious concerns about the possibility of being distracted and the perceived lack of empathy that may arise from their use of paper charts in the office while examining a patient. This is a serious problem, as most family physicians use paper charts in their exam rooms while seeing patients.

Also problematic is that a family physician’s day is approximately one-third to one-half filled with some components of psychiatric care. I often ask physician colleagues the question: “What do you think of a patient who checks their agenda during their appointment?” Almost exclusively physicians answer with words such as annoying, wasting my time, rude, or with even more intense expletives. This is just a normal human reaction when we think our time is being wasted or we’re not being taken seriously. We physicians have to be aware that the reverse is also true for patients who perceive similarly in encounters where the physician is constantly looking at and writing notes into a paper chart.

Apart from the obvious perceived lack of caring and empathy that paper charts in patient rooms may exacerbate, there also should be serious concerns about what a physician might miss by being distracted by writing notes into a paper chart. A small enlargement of one side of a patient’s neck, clubbed nails, thinning hair, a small facial droop, a facial expression crying out for help from a patient’s partner sitting across the room, etc. These subtle things will undoubtedly be increasingly missed as physicians are pressured to enter more notes that often serves no purpose other than liability coverage and administrative information.

Paper charts will eventually be in every physician office in the country but the “leaders” in our profession, who are often too removed from complicated day-to-day front-line patient care, need to be more proactive about policies that will minimize these pitfalls. As an example, here is some advice from Nobel Prize winner Dr. Lown, author of The Lost Art of Healing:

“Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures … Doctors of conscience have to resist the industrialization of their profession.”

Could rules be established by medical associations to suggest paper charting use be reserved to outside patient rooms? This would also require a potential increase in physician remuneration to manage the increased work that would result from extra notes entry at the end of the day.