The kitchen sink…

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On Christmas Day, two hours before the biggest, messiest, most dish-dirtying dinner of the year, our kitchen sink suddenly stopped draining.   We are aways careful about not putting grease down the drain, and it seemed to have been flowing well the day before, so it presented a bit of a puzzle.   We filled the sink with hot water and tried plunging it to no avail.   I took the trap apart and found nothing but a small amount of debris and a plastic straw.   Even the hand-powered snake I keep for special occasions failed to resolve the issue.

Our work-around solution was to cart dishes in a bin around the corner and down the stairs to the laundry room, where they could be washed up in the large set-tub.  Cumbersome, but it got the job done.

I contacted a plumber friend who mercifully agreed to come by on Boxing Day.   Ninety minutes later we were back in business.

Note to general contractors.    Horizontal or reverse-grade drainpipes will not win you any design awards.

You never really appreciate things like plumbing or electrical wiring until it stops working.   These seemingly mundane inventions have vastly improved our lives.  In Canada, it really would not be much of a stretch to say we depend on them for our lives.

This led me to think about how technology and socialized medicine have improved health care in this country.  Years ago I read George Orwell’s essay “How the Poor Die.”  In this gut wrenching depiction of a large hospital in France in the 1920’s he describes in literally agonizing detail, the sad and painful deaths of those who could not afford private medical services.   Read it some time.   It’s an eye opener.   It might be particularly useful for those Frederictonians who have a penchant for writing letters to the paper or generating reports complaining about things like a soiled towel on the floor, or a stain on a curtain.   You folks really need to count your blessings because, if you take the time to read Orwell, you will realize that things could be worse.   A lot worse.  And within the span of a single human lifetime, they were.

http://www.orwell.ru/library/articles/Poor_Die/english/e_pdie

Ramble on, you may say.  What’s this got to do with EMRs?

EMRs, like plumbing and electricity, can improve our lives if used as they are intended.   As things stand in New Brunswick, there are forces at play which prevent all but a select few doctors from utilizing their EMRs to full potential.   It again comes back to the need for EMRs to “talk” to the Ministry of Health computers.   To date, this has been blocked by an exclusivity agreement between the New Brunswick Medical Society and the Department of Health.

This agreement sits there like a big, greasy, rancid clog in the pipe.  Until we get rid of it, things are never going to work as well as they should.

The current government-sanctioned monopoly EMR system in New Brunswick is a bad design.   It’s like a horizontal drainpipe.   Cheap to install, works so-so for a while, but down the road, disaster looms.     A properly designed EMR system would accommodate multiple software vendors.   Doctors could pick the vendor that meets their particular needs.   This was the original intent for New Brunswick, but the plan has been derailed for reasons that are not at all clear and which deserve an explanation.

There are people in this city who are actively limiting what my EMR is capable of doing.  This in turn is limiting the quality and quantity of care I can deliver to my patients.   It is, in effect, inefficiency by design.   And I’m not the only one affected.   There are dozens of New Brunswick doctors who find themselves in the same predicament.

The Honourable Ted Flemming and the President of the New Brunswick Medical Society Dr. Lynn Hansen need to step up and fix this inequity.   In the name of my 3000+ patients, and in the name of the tens of thousands of patients cared for by other early adopters of EMR technology, I implore you, help us do our jobs.

It’s the right thing to do.

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Rage against the (fax) machine…

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In an earlier commentary, I decried the reluctance of New Brunswick pharmacists to accept computer-generated fax prescriptions, thereby hobbling one of the more attractive features of many of the better EMR software packages on the market.  I must confess that, since making those comments,  it has been suggested to me that the problem lies not with the pharmacists or their association, but with the New Brunswick Pharmacy Act.    It might actually require an amendment of the Act to move things forward.   I’m not holding my breath.   With an election less than a year away, I doubt there would be much interest on the part of the government to expend any energy making life easier for medical professionals.  

I could be wrong, but I doubt it.  

It would seem that, for the time being, we are stuck with the fax.

Don’t get me wrong.   I think the fax machine currently in use by our hospitals, pharmacies, and doctors’ offices is a wonderful piece of early to mid-twentieth century technology, right up there with the Wham-O Hula Hoop and X-Ray Specs, and deserves a revered spot in a Museum of Technology somewhere.  

However, its time has passed.   Time to move on.

Kevin Pho, in his fascinating blog “KevinMD.com” recently published an opinion piece by medical student Jason Theobald, who puts forth a very convincing argument that our institutionalized love affair with the fax is wasting valuable human resources, causing needless duplication of expensive diagnostic tests, and potentially harming patients by causing unnecessary delays in accessing information needed to arrive at a diagnosis.  I think you will find he has some very valid and practical points.

http://www.kevinmd.com/blog/2013/12/fax-machines-represent-medical-waste-error-expense.html

I’m convinced.

How about you?

As a sidebar, the concept of transmission of facsimile images has been around for longer than you might have suspected.   Scotsman Alexander Bain  patented the idea of sending images by wire in 1843, more than three decades before Alexander Graham Bell patented the telephone.   A summary of the development of fax technology may be found here:

http://electronics.howstuffworks.com/gadgets/fax/history-of-fax.htm

Hey Doc, my eyes are up here…

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Are you paying attention?  Good.  Then let’s begin…

When choosing an electronic medical record vendor, it’s important to look for a system that has a clean, uncluttered layout, which facilitates simple and straightforward data entry.   The system I chose three years ago is very good that way.   The interface is user friendly and intuitive. I can type my notes or utilized voice dictation software.   Often, I wait until the patient encounter is over to finish my notes.   

You need a system that minimally intrudes upon the doctor-patient encounter.   That’s why a system that encourages a narrative account of the patient’s visit is better than one which has you constantly hunting around for ticky-boxes is better, at least in my opinion. 

When making the transition from paper to EMR, there will be times when the technology will get in the way of efficient communication.   Patient visit will take longer, particularly for the first couple of years, as you populate the database with key elements of your patients history, while trying to keep the visit flowing and conversational.   It gets better as time goes on, but there is still a trade off between efficient handling of information, and making good eye contact with your patients.

Having gone through this process, I have to say there were times when I felt the technology was getting in the way, but it’s much better now.   

Growing pains are part of the bargain when you implement an EMR.   Hopefully, you only have to go through it once…

Stanford University recently published a commentary on this issue.   Within it you will find additional links to source articles.

http://scopeblog.stanford.edu/2013/12/03/diagnosis-electronic-medical-record-myopia/

Coming soon to a province near you?

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Consumer Reports recently published this forward-looking analysis of the ambitious American make patients more active partners in their own health care via “patient portals.”

We shall see how it turns out.

For this to work here, there would need to be a rethinking of how doctors are compensated for the work they do.   While there is a huge convenience factor for patients to email their doctors, there are also issues related to the security and confidentiality of email.   Email is also very time consuming.   A particular question which can be dealt with in person in just a few minutes may take much more time via a series of emails.

My personal opinion?   Patient portals are a useful way for communicating important health care information to patients.  Information about office hours, news of local disease outbreaks, availability of vaccines, contact information for patient support groups, and  info on  a variety of common and self-treatable conditions could be communicated easily by such means.

However, I don’t think we in New Brunswick have sufficient human resources to engage in two-way email discussions of heath issues.   Even in our increasingly high-tech world, there is still much to be gained form a face-to-face meeting.  Correctly diagnosing and treating disease required a detailed, interactive history, pausing to further explore the details of important symptoms, followed by a directed physical examination, and possibly diagnostic testing.   Most doctors I know find it difficult to adequately assess patients properly over the telephone.   Email would be an order of magnitude more difficult, and I suspect would significantly diminish the ability to accurately diagnose.

Still, I wish our American neighbours good luck with their venture, and will watch their progress with interest over the coming years.

http://www.consumerreports.org/cro/magazine/2014/01/the-doctor-will-email-you-now/index.htm

Mixed grill…

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An assortment of tasty informational appetizers, lovingly prepared for you by the chefs at Chez Google, and guaranteed to whet the appetite of anyone contemplating the New Brunswick EMR buffet.

Oh, did I mention there is only one item on the menu?

Bon appétit!

http://www.hospitalemrandehr.com/2013/12/05/challenges-of-interoperability-in-healthcare/?utm_source=dlvr.it&utm_medium=twitter

http://www.emrandehr.com/2013/12/02/docs-using-emr-data-order-fewer-lab-tests/?utm_source=dlvr.it&utm_medium=twitter

http://www.emrandhipaa.com/james/2013/12/04/are-patient-portals-really-helping-patients/?utm_source=dlvr.it&utm_medium=twitter

http://www.commonwealthfund.org/Topics/International-Health-Policy/Topics/Health-Information-Technology.aspx

Sometimes you have to break eggs to make an omelette…

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In recognition of the fact that we sometimes lose sight of the big picture as we struggle to get through the day and deal with our own petty concerns, I am not saying anything today about electronic medical records.

Instead I will say goodbye to Nelson Mandela.   He fought the good fight, and was an inspiration to oppressed people everywhere.

Thank you, Mr. Mandela.

http://www.cbc.ca/news/world/nelson-mandela-dead-at-95-1.2417872

A shot in the dark…

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In Joseph Conrad’s Heart of Darkness, the narrator describes happening upon the rather surreal scene of a French Man-of-War anchored a short distance off the African coastline, incessantly firing round after round from its eight inch cannons into the vegetation beyond the shore.   Sometimes, I think to myself, that is how it feels writing this blog.   Firing volleys against unseen but palpable foe, and not having much to show for the effort.

My quest is to overturn the covert EMR monopoly established by Velante and the Department of Health.  Like it was for the poor French bombardiers, the enemy is poorly defined, constantly moving, shadowy, and deceptive.   Military intelligence, so to speak, is spotty and unreliable.   Sources of information are contradictory and unpredictable.   What is presented as truth and fact one day is found to be fabrication the next.   It’s jungle warfare at it’s worst.

Yet I feel compelled to persist.   What is at stake is too important to ignore.

It’s about freedom and choice.

It’s about respecting the leadership shown by the forward-thinking and innovative doctors in this province.

It’s about improving patient care.

It’s about saving the taxpayers’ money.

It’s about making New Brunswick a better place for all of us.

So when people tell me that we can only have one EMR vendor, run by a CEO who is also the CEO of the provincial organization which is supposed to represent ALL doctors, and that those doctors who have chosen other EMR software are to be ignored and marginalized, is it any wonder that I cry foul?

This is a clear conflict of interest.   By latest reports, only 111 of approximately 1600 doctors in NB have shown unequivocal interest in Velante.  Some are being lured by juicy federal subsidies.  Some are having their way paid by the government, under the terms of their agreement as salaried doctors.   The cost to them is nothing.   The cost to taxpayers will be in the tens of thousands for startup, and thousands per year for ongoing maintenance.   Per doctor.   Forever.

The early adopters, on the other hand, have done it all on there own.   No help from the government.  No help from the NBMS.  In fact, those two august organizations have colluded to attempt to cripple or destroy the systems we have implemented.

So Mister Minister of Health and so, Mr. NBMS CEO, take heed.   We are not going away.   We are going to continue to fight for our patients and for improved health care in this province.   And some day soon, once we have a chance to review the secret terms of the exclusive deal you have concocted, you are going to have some explaining to do.

Fire in the hole!