Monday, December 8, 2008

OSCAR User Interview: Dr. John Yap

Dr. John Yap, Royal City Family Practice, New Westminster, BC

My practice is in New Westminster, B.C. Originally, I worked with 2 other GP's in a medical building, but 11 years ago we relocated to a nearby mall, and picked up another GP along the way. We had a foursome going until about 5 years ago, when one of our partners decided to return to his native Ireland.

How long have you been using OSCAR?

I joined my current practice in 1990, taking over an existing practice that was 30+ years old. One of the reasons the departing GP was retiring, I found out, was that he did not want go through the headache of upgrading his charting. Charts were literally bursting at the seams! It took me over a year to separate all the family members out of a single chart! I could see the pattern repeating with me. As the charts were getting unmanageable, the amount of paper work that required filing became increasingly greater. I started using OSCAR for charting and scheduling in early October 2008.

Did you have prior EMR experience before OSCAR?

About 5 years ago, there was a proposal from the government and BCMA to get GP's doing more chronic disease management. Diabetes was the target disease. The program required an EMR of some sort, and Nightingale was the vendor chosen. The costs of the software were to be covered by the pilot project, but the ongoing costs seemed a bit high at the time. The hardware also seemed unaffordable. Remember, this was 5 years ago, and technology was way more expensive and less powerful than now.

As my charts got bigger, I would summarize them in a Word document, and put the old data into an inactive Volume 2. This was very time consuming, but necessary as some charts wouldn't even fit in the chart slot on the door! I made it a habit of doing these summaries whenever new patients had their charts sent to me.

Can you tell us a bit about your office and how it is set up?

I was fortunate to be able to visit several offices over the past year to see how they were set up. I saw three OSCAR sites and one non-OSCAR site. The latter was a health authority pilot project, which received funding to be a beta test site. The GP using this EMR was not satisfied with the product, but there was no turning back. I'm not sure what the situation is today. The OSCAR sites ranged from a complete "do it yourself" office, retrofitted and added to over the years, to a "planned from the bottom up to accommodate OSCAR" office. The latter office was the most high-tech office I had ever seen. It was "overbuilt" with future expansion in mind. It was a very slick operation, indeed. I was aiming for something in the middle.

My office, being in a mall, has some constraints, mainly becuase it is one long hallway. Each GP has 2 examining rooms, and a separate personal office. With one less partner, we were able to convert the extra office into to a server room!

To get started quickly, and to reduce some costs (hopefully!), I decided to go wireless. I wanted workstations in each exam room, and felt that a laptop in the office would give me portability, and a back-up if any of the workstations crashed. I have always used PC's, but decided this was a good time to switch to Mac's. My partner decided to keep to PC's.

My exam rooms have a Mac Mini, with wireless mouse and wireless keyboard on the counter. The 19" monitor is wall-mounted, and swivels to allow for private or collaborative viewing. I have a USB-connected printer in each room. We also have a networked printer for the office at the MOA station. The neatest part of my set up is the absence of a visible CPU. The computer is in the cupboard, locked away. The only wires seen are from the monitor, which lead into the locked cupboard. It's a very clean look! I had to do all the drilling, cutting, wiring, and lock installation myself. It took a couple of weekends to finish. If I had to do it again, I'd pay someone else to do it!

The MOA's have their own workstations, and are connected to a networked printer. One is using an Acer PC (Costco-bought), and the other has an iMac. We have a Fujitsu S510 desktop scanner connected to the Acer for now. We would like to have some sort of PC-based faxing system.

Now that you have been using the system for a while, would you go back to paper?

It's been about 6 weeks since I started typing my notes and printing my forms, letters, and prescriptions. I no longer have to duplicate my work by copying prescription and lab requisition details back into the chart. I can foresee how searching for information in the chart will be a snap in the future. Many patients comment that I'm finally going "paperless", but really, it is more accurate to state I'm going "less paper". I will never go back to paper!

What is your favourite feature?

I really like the prescription module. Sure, it's time consuming to input the data initially, but re-prescribing is a breeze. I even look forward to doing it! Plus, I was getting hand cramps from note taking, and my handwriting is atrocious! I haven't had hand dystonia in over 6 weeks! My initial plan was to start OSCAR with voice dictation, but I can type reasonably well, and Mac's don't really have great voice recognition software...yet. I'll stick with typing for now. My MOA loves the scheduler. The tickler system is great. No more missing Post-it notes!

How are you pushing yourself through the first few months transition, when learning the software was taking a lot of your time and effort?

Learning the software hasn't been that difficult. Sure, I've written in the wrong chart a few times, but that happened with paper charts too! I had a resident working with me a few weeks ago. We played with a test patient's chart on his first day, and he was up and running in 15 minutes. He loved the program. My MOA picked up on the scheduler easily too. It is way more reliable than the paper schedule...except when the wireless connection goes down, like it did last week!

How are you getting the initial patient data into the system?

I had my support person migrate my patient demographics from Osler, my billing program. This was not as easy or "clean" as I thought it would be. In our practice, we all used different programs. When we migrated our data over, we sometimes had 2 or 3 entries for the same patient. This would not happen if one were to manually input each patient, but it can if you load the demographics in with a migration process. That should be a warning for others who consider EMR's of any sort. I must have spent 100+ hours, outside of work, to identify these duplicates (triplicates, etc.) for deletion!

As each active patient comes in, I'm adding a bit more to the patient summary. We started getting labs imported electronically almost from day one. I plan on back-filling as many of the labs as possible, probably one year's worth, to get a good database going. We have not done a lot of scanning yet. We need another workstation, and probably another clerk to do this. It could be a good summer project for one our kids!

In retrospect, what would you have done differently during your transition to OSCAR?

Most offices are probably retrofitting their site to accommodate an EMR, rather than rebuilding. Ideally, a consultant could assess the needs of the GP/GP's and their budget, then advise what hardware and renovations would be needed, get the appropriate subcontractors in to do the work, order hardware, do the connections, migrate the data, etc. The doctor could simply show up for work on Monday, and everything would be working. If it could only be that pain free!

Despite losing a lot of sleep over it, I did learn a lot about computers, networks, wireless routers and the OSCAR program. Plus, I really know my way around Home Depot and RONA now!

Do you have any advice that you can give the new user as they prepare to make the move to an EMR?

For me, it was not a matter of if I would get an EMR, but when. The existing proprietary software seemed too expensive, especially 5 years ago when I was first introduced to the concept. However, after looking at OSCAR, and comparing it with other products, there is no reason not to get an EMR, even if retirement is looming in the next 5 years. If I was about to retire in a year or so, maybe I'd leave it to my successor. However, these days, it's probably not possible to get someone to take over your practice. Times have changed. I'd much rather look after several DVD's of data, than a basement full of charts!

We had one further challenge in our office. We have 3 GP's, and one is a bit of a techno-phobe who doesn't type well. He has yet to take the EMR plunge. He knows about voice dictation, and at one time he did have his notes typed and physically pasted into the paper charts. Nowadays, he always has piles of charts on his desk to complete, and I usually have a clean desk by the end of the day. I'll be reminding him of this frequently! So it is possible to proceed with an EMR, even if everyone isn't on board.

My original plan was to start OSCAR up during the early summer rather than in October, which is one of the busier times of year for me. However, having survived the busy flu shot season, I can honestly say it can be done at any time. And you don't have to do it all overnight. It took me 20 years to accumulate all this paper, it took me a year to separate out family charts into individual charts, and it'll probably take me 6 months or so to get the essential data into everyone's chart. After that, it only gets easier, not harder! Can't say that about paper!

Do you feel that the move to electronic records has improved your patient care?

Absolutely. Patient reminders are more reliable. Prescriptions are super easy to track. I'm actually documenting more thoroughly because I don't have hand cramps any more! The only time I use my pen is to sign my prescriptions. The patients are impressed with the technology. Plus, I have a screen saver showing beautiful landscape pictures while they wait for my entrance to the exam rooms.

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