I like MY OSCAR EMR Setup....but I'm getting sour about EMR's as I think about them

Wow.  June seems like just the other day.  I was all glowingly positive about getting an Alberta LAB module done for OSCAR.

Two people have approached me about it.....one stated that he has an Alberta Lab module built....but he has disappeared in puff of smoke (no, I was NOT smoking anything).....and the other guy said that he was close, but needed an extra $15k or so.  I pledged my $5k, but I have not heard any further discussion about the matter.

So what's up?

I've been thinking about this whole EMR thing and I have to say - I've become disenchanted about the whole EMR concept.

My disenchantment towards EMR's came as a surprise to me.....after I followed an esteemed 85 yo colleague around for a bit at his busy and thriving rural practice.

The practice was a model of efficiency that was "time warped" back to the 1950's.  It was clean, neat and extremely efficient.  This old fellow had an EMR in the office - but he had never seen it.  His office was very modern - even including the XM radio channel that softly played through the waiting room for the sakes of his patients.  He knew what XM radio was, but he just didn't really care to know much about it.  His office manager organized "all that stuff" for him.

I have not chased an Alberta LABS module for OSCAR as aggressively as I could because I don't see much real benefit to it anymore.  Alberta has a really good EHR now, that I can simply keep open in another browser window on my laptop.  I can very easily do a patient search on the EHR and get any labs that I want at any time.  Also included is all LAB/PATH/DI/CONSULTATIONs as well as DRUG Hx on Alberta's Netcare.  I can easily copy/paste anything into OSCAR.

The only thing that I am missing is the ability to analyze patient populations in order to conduct population health audits....ie. how many diabetics do I have that require optimization of their meds due to sub-optimal lab results.

At the end of the day - while it would be good for patients if I could have this functionality.....I would have to undertake that work at my own personal cost in terms of time and income.  There are no rewards or remunerations for Physician in Alberta to do population analysis and health optimization.  This is clearly stupid - but we have a health care administration in Alberta that is not known for its cleverness and efficiency (quite the contrary).

LONG STORY MADE SHORT:

At the end of the day, it seems that the "Real" purpose of an EMR is to download menial clerical activities to Physicians in order to waste their time and expertise.   In the old days of simply dictating a note and having a Nurse follow me around to make notes and chart discussions - we used to be a LOT more efficient.  The use of EMR's in the hospital and clinics by Physicians has probably contributed to at least a 50% deterioration in Physician efficiency.  


This elderly Physician that I followed around for a couple of days literally blew me away with how efficient he was. He rarely looked at a piece of paper and he was totally 150% focused and concentrated on his patients. He missed absolutely nothing.....from the slightly crooked crease in a Mom's ironed slacks (clued him into the carpal tunnel disease).....to the subtle lack of attention to "normal" makeup and hair styling in a young lady (trying to secretly battle a suicidal depression). He had time for everyone and carried himself through medical interview after interview with an unhurried regal dignity that I have promised myself to emulate as much as possible as I modify my practice to mirror in like over the next couple of years.

His staff followed him from room to room and they made notes, looked up labs and handed him information on a tablet - all in a seamless ballet of medical astuteness, efficiency and ultimately - caring.

Most "modern" Physicians that have never practiced "the old way" could not fathom the cost of having a full time nurse and transcriptionist follow them around all day long.  Now, such Professionals would cost us about $80,000 for the nurse and about $50,000 for the transcriptionist.  This translates to about $550 per day in increased overhead costs (a 400% increase from what the same services would cost only 25 years ago). Almost all EMR's are a bargain compared to this.....except that they totally ignore the value of a Physician's time.....which is about $4000.00 per day.  EMR's easily waste about 20% of that time and so they real cost of an EMR is about $800/day.  Probably better to hire a full time Nurse and Transcriptionist at only about $550.00/day!

Yes, you may argue with my figures...but you would have to argue proportionally if you want to challenge the above numbers.....you'd still lose the argument "for" EMR's.
Sorry to blather!  I've just been feeling frustrated in poor EMR design over the past couple of years.  You should see how I use OSCAR....I maximize the "awesome" in it and totally ignore the "time wasters" in it.  This approach has probably doubled my efficiency and income.

I am going to gradually transition to having more staff in the office to undertake more of the clerical tasks that OSCAR is trying to assign to me.  I will dictate notes into OSCAR via voice transcription, and I will write Rx's using OSCAR's prescription module.....but I think that will be it.  The rest of everything OSCAR can do will be delegated to other staff.  I have started to miss my patients behind the fog of the computer screen and I want to get back to them.

Wish me luck.

Great news for OSCAR in Alberta: A LAB MODULE IS POSSIBLE!

It looks like the tech wizards have invested some time and effort - and have decided that a Lab Module for OSCAR in Alberta is possible to do within a few short weeks!

The cost for development is about $100 per hour, and it is estimated that we need about $15k to get this done properly.

We probably have about 60% of the money we need, and I'm looking for a bunch of good young men, women or other that would not mind contributing a bit to the fund to get this off the ground.

We ARE going to get this off the ground!  It would just be nice to get it done sooner than later.

If you're willing an able - just send me an email to:

drjohnf@me.com


And I'll make the necessary connections.

Hope to hear from you!

John Fernandes.

5 Years of OSCAR use in Medical Practice

I started using OSCAR in 2009, and I've learned a lot since then.   Here are some of my observations about using OSCAR in Medical Practice: some are good and some are bad - but they're all honest.

THOUGHTS ON OSCAR AS AN EMR

PAPERLESS PRACTICE

A lot of Physicians seem to have the goal to "be paperless".

While this is possible - it should not be a mindless goal just for the sake of being totally paperless in some sort of non-existent ideal to be a super duper Physician that hugs a lot of trees.

The fact is that paper is still much more efficient than any sort of digital medium in many ways.  Most practices should strive for efficiency rather than unattainable goals. 

While you CAN scan the load of paper (we get about 20 lb PER DAY) into OSCAR, it HAS to be done by somebody that is pretty much devoted to it full time.  Doing this in OSCAR takes a significant amount of effort, typing, organizing and mouse clicks, and is not for the faint hearted.

Additionally, accessing the information later is TERRIBLE.  There are simply not enough descriptive fields in OSCAR to be able to adequately and efficiently/sufficiently describe each and every little piece of paper that you scan into a patient chart.   I have found that scanning the odd paper report into OSCAR is okay - but to scan everything would be a pretty much fruitless an unrewarding task until the method of doing this is essentially redesigned.

For now, we scan only the essentials into OSCAR and keep paper files on patients for consultant reports, etc.  This seems to be the real sweet spot for efficiency.  

Electronic Scheduling

While some practices seem to like doing this on a computer screen - my staff tends to have to multifunction and they HATE using OSCAR's scheduling program.  The program is basically too inflexible for real world use, and appointments seem to change with great rapidity.

We have found that the smoothest and fastest and most efficient way to schedule patients, is to do a traditional paper schedule - and then transfer that schedule into OSCAR the day before the actual day of service.

Our scheduling is done through an artfully applied combination of triage and "active scheduling" that makes use of time analysis and which considers patient needs.  For example, some patients only need a two minute visit to renew a prescription, whereas others typically take 20 minutes due to multiple complex issues.

OSCAR's scheduling program is not all that flexible and seems to require an inordinate number of mouse clicks in order to accomplish the simplest of tasks.  This is not a criticism, but rather our observation.  Lots of offices seem to like OSCAR's scheduling system, and I suspect that those offices tend to have full time office reception staff that do little other than schedule patients.

ELECTRONIC LABS

Lots of people that use OSCAR in BC use a third party to deliver lab information directly into OSCAR.  While there are good and bad things about it, it seems to be working for them overall.

In ALBERTA, Alberta Health, who has taken over Alberta Lab Services, has decided to no longer play nice with EMR's outside of their bizarre and arcane approval process that has been highly politicized and essentially ground to a halt as a result of bureaucratic inefficiency and paralysis.

I could go on for hours about Government inefficiency and how it adversely affects almost every level of Health Care, but most of you are probably already aware of that. 

NETCARE

Having said that - while I remain personally critical of the administration of Alberta's Health Care system, I have to grudgingly applaud Alberta's approach to dealing with Electronic Lab information.  In Alberta, we have a Provincial Electronic Health Record (EHR) called, "NETCARE".

Accessing Netcare is simple, and it can remain on your computer desktop in the background.  Through NETCARE, you can access any Lab, DI and a growing list of diagnostic tests that every Alberta patient has had in the past 3 years.  Soon, we will be able to access referrals to Specialists, Special Services and estimate "real world" wait times.

So while I personally find it tempting to criticize our Politicians and Health Ministers - they have actually built something to be greatly admired and which is unique in North America.  Every patient in Alberta will have an EHR chart that every Medical Professional will be able to access.

We frequently copy DI reports, etc. from NETCARE into OSCAR when needed - but, I cannot seem to find any instance where I would need to bring lab information from NETCARE into OSCAR.

While it is a bit of a bummer to have to log in simultaneously into the patient's EHR (NETCARE) and the patient's EMR (OSCAR) - I really think that this is the wave of the future.   In fact, I can see that one day, Physicians may have the option to use the EHR instead of an EMR if they want to.  I would personally never do this, as to do so would require an inordinate amount of unjustifiable trust in Government and its attendance to the exclusive responsibility of being the custodian of the patient's electronic medical records.

Suffice it to say - ELECTRONIC LABS into OSCAR are probably unnecessary.  It would be cool to be able to data mine for our practices and to make use of OSCAR's tools to figure out which of our diabetics, for example, has undesireably high Hba1s levels....but Alberta's EHR is shortly going to be able to make this happen anyways. 

There are some dangers to this.  "Pay for performance" is looming in Canada.  EHR's will allow Administrations like Alberta Health to pay a Physician less for "lack of performance".  For example, if you have a patient who is a 450 lb diabetic on a diet of twinkies and root beer - you will not be paid for the high sugar levels that are indicator of your poor "performance" as a Physician.

The obvious answer to this is that many Physicians will simply abandon patients that become financial liabilities.  Colleges will naturally "forbid" this, but that is rather like trying to herd extremely smart and irritated cats into doing what you want them to do.  They will ALWAYS outsmart you.

It will be interesting to see how this plays out.  For the time being, however, NETCARE is awesome, it's growing and it works very well symbiotically - though independently from OSCAR.

PRESCRIPTION WRITING WITH OSCAR

This is the cat's meow.  I have seen most of the EMR's available in Canada, and none of them even comes close to OSCAR's ability to write, review and renew prescriptions.  There are a lot of tools that work together symbiotically to make writing prescriptions in front of your patients quick, efficient and a real pleasure.  You can even sign the prescriptions with a "wet signature", which is required by the Colleges.  I now use a YOGA 2 pro in the office, and sign prescriptions right on the screen.    While I'm sure that there are some ongoing improvements made to the prescription module - it is probably one of the best in the world.

PATIENT NOTES

Recording patient encounter notes into OSCAR is very easy in the "toiletpaper roll".  This is just a roll of notes that start at the top and go down chronologically.  They are separated by date and are entirely searchable. 

I frequently dictate my notes into OSCAR using Mac's or Windows 8's speech recognition in the operating system.  Between dictation, typing directly and using Text Expander (Mac) or Breevy 3 (Windows 8) - my capture of very detailed patient encounter notes is extremely efficient. 

In addition to dictation, typing and text expansion; I often use templates in OSCAR.  For example, in the search field at the top of the toiletpaper roll, I simply type "CFM" and a template is displayed in the toiletpaper roll in the patient notes field, that displays my template for "Complete Medical - Male".   I just fill in various details from the medical encounter and I'm good.

I have the same approach for "Dysuria, Abdominal Pain, Back Pain, etc., etc.

OSCAR's patient notes capture is possibly the best of the best in EMR's.

E-Forms (Electronic Forms)

You can make forms easily in OSCAR for DI, lab services, etc.  I have made a ton of these forms for Calgary Labs, EFW Radiology, Radiology Consultants, etc.  You can pre-populate these forms with information from the patient charts, such as demographics information, medications, allergies, medical history, etc.

Making forms is easy using the "E-form generation tool".  There is a bit of a learning curve to using the tool, but it really isn't all that bad if you have enough alcohol.

CONSULTATIONS

Creating consultations in OSCAR is easy, but you have to go to the main screen to be able to enter a consultant into the database.   This is a HUGE PAIN, because sometimes you have to do a consultation for a patient - right in front of the patient.  There is no way to enter a new consultant into OSCAR's consultant database from the screen where you actually create a consult request letter.  OSCAR automatically does the patient demographics, appointment scheduling (with the consultant), meds/allergies/patient history.  Notes can be then faxed directly to the consultant's office directly from OSCAR. 

OSCAR Messenger

This is like an internal message system for you and your staff.  It is very useful to ask staff to check on this or that, or to accomplish various administrative tasks or patient checks, etc.  They can also send you surreptitious messages while you are with the patient, like (patient is depressed because they are getting divorced, but they didn't want to bring that up with you today), etc., etc.    The messaging system is an indispensable tool.

Billing Alberta Health

ClinicAid has written a billing module for OSCAR.  The company that developed the billing tool has done a crack job at it, to the point that it is probably the single best billing program available in Canada.  They are new on the block and are looking for new clients.  I am happy to recommend them.  Billing happens right on the OSCAR screen so that by the time you exit the patient room - you are done billing already for that patient visit.  I save each billing, which is reviewed by my office billing staff and then submitted at the end of each work day.

One thing that could really enhance ClinicAid, would be to add a private billing module to is so that you could easily keep track of private billings, which can amount to 25% of practice income these days.  Printing invoices for patients would also be an ideal thing.

The billing module has not been out for very long, but it is already hands down the best billing module in Canada.  I can't wait to see how it continues to evolve.

Measurements

This is NOT very good at all.  The intention is to be able to record blood pressure, height and weight.  It's cumbersome and takes an inordinate number of mouse clicks.  But if you bother with it, you can easily generate a graph of blood pressure or weight, etc.  Hopefully this will get redesigned in an OSCAR update, but for now not very many OSCAR users make use of this (I tend to bother with it, hence my chronic frustration with it).

 Preventions

This COULD be incredibly useful, but it isn't the way it is set up.  With this module, you can organize OSCAR to set reminders for PAP tests, Colonoscopy, PSA's, etc., etc.  You have to get your OSCAR service provider to customize this list for you a bit before it can really be used.  Once it is customized, I imagine that it will lend to increased quality of care in your practice.

FINAL THOUGHTS

OSCAR has several other features that are a little more arcane, but which could be incredibly useful.  I'm going to start exploring these more, and I will ask my OSP to customize these a bit.  The Oscar Service Provider (OSP) I use is NERD (Northwest Electronics and Design).  They're awesome.

I will be making more updates to this blog, so please stay tuned!

Where does OSCAR in Alberta go from here?

The billing module works really well.  We find new little glitches here and there, but I'm happy to report that the vendor is very responsive and usually has any glitches fixed literally within minutes - hours at the most.

So now - we just have to get a Lab module built for OSCAR in Alberta.  This will bring OSCAR up to normal functionality compatible with the rest of the Country's OSCAR capabilities.

BUT the POSP office has essentially disallowed this unless OSCAR becomes something called "VCUR compliant".

Officially, "VCUR" stands for Vendor Compliance and Usability Requirements.

This is a set of functional, technical, security and privacy requirements for an EMR solution developed through a process of stakeholder consultation that was led by the POSP (Physician Office System Program).

Overall - the idea is totally reasonable.  BUT - the idea appears to have become corrupted by a bloated bureaucracy without a rudder.

VERY recently, the POSP program appears to have been suspended for new users.

See: http://tinyurl.com/d6v9zzx

What does this mean for a new EMR Vendor to want to get OSCAR "VCUR certified" so that Alberta Health Services will allow Lab uploads into OSCAR?  Nobody knows.


Having said that, we have had the VCUR manual reviewed by Professional programmers, and it should not be too unreasonable to ensure that OSCAR adheres to the VCUR requirements.  The process of getting OSCAR VCUR certified, however, will probably require the cooperation of high level Government Personnel and the support of the AMA.  One way or another, we'll get the support we need.  

THE ALBERTA BILLING MODULE IS READY!!!!!

Yes.

Really!

I can't believe it either!

It's done!

And it works very, very well!

The Alberta Billing Module for Alberta is ready, and it works beautifully.  The billing module is slick, modern, and fits beautifully into a Physicians workflow.  The appearance is austere (a compliment) and pleasing to the eye - much like what we expect from the Mac expectations of world class industrial design (the billing module is platform independent).

To use the billing module, you simply do your normal chart entries into OSCAR....then when you're ready to bill the encounter - you just hit the "B" button on the patient's name on your daysheet and make a couple of quick selections from your billing preferences (which you can easily set up).  Then hit the submit button and your patient is billed!  The hole process takes just a few seconds per patient, which amounts to about 6 minutes total daily time for a very busy and complex daysheet like mine.

I have just submitted my first billing daysheet through OSCAR in it first live beta test.  A couple more daysheets with an integrated (rather than a test) module, and it will be ready for prime time!

The Alberta OSCAR billing module will be available as a "plugin" for OSCAR.  This is clearly the best way to do this.  Ongoing R&D will then be funded and OSCAR will remain strong into the future.

I've been using Firefox 16 with OSCAR and its integrated billing module plugin - and it works very well.  Only a couple of minor modifications needed and it'll be ready to roll out!

It's been a LONG time coming - but now OSCAR is going to be ready and appropriate to start marketing for Alberta adoptees.


How do you get the billing module for OSCAR?  And how do you get OSCAR?  Stay tuned.  I should have all of the detailed information available by the end of the month.

Wel done guys!  Very well done!


John Fernandes

UPDATE ON THE ALBERTA BILLING MODULE - NEW MODULE IS BEAUTIFUL!!!!!

Well - I've been trying to get a billing module going since I started using OSCAR in 2009.  Since that time, I've been a lot of money and time trying to get a functional billing system going with no luck.  As a result of my efforts since 2009, at least 5 programmers have been hired and paid for - with no results.

I spoke to a friend about the rotten luck I've had with programmers - and he opined that my experiences were not unusual in the industry.  The reason, he conjectured, was that the field of programming is sorely in need of going to the next level.  In other words, they need to become "PROFESSIONALS".  What they need is a Professional Society to help them achieve a minimal set of standards for their administration and conduct.  The Professional society would be self policing and self funded - much like Physicians, Nurses, Engineers, Lawyers, etc.

But I digress.

When I was asked to look at a demo of a billing program for ALBERTA OSCAR today - I was expecting very little.  In fact, I was expecting to be disappointed with another iteration of the rather disappointing billing screens that are used for Ontario and BC.

I was rather hoping for a much better type of billing screen for Alberta - but I had long almost given up on this....and had learned through disappointing recurrent experiences that programmers are more likely to NOT deliver on promises than to come through.

To say I was blown away and impressed as hell is a considerable understatement!

The billing screen for Alberta OSCAR is a beautiful and modern thing to see.  The design, the thoughtfulness in the presentation and organization of the fields....the awareness of a Physician's workflow and billing needs - appears to have all been considered!  These guys are impressive!

The billing screen has the look of an elegant presentation with clean lines, easily readable fonts and a very modern feel that folks have come to expect and associate with higher end computing environments like those seen on a Mac.  The older and "outdated" 1980's look and feel that one sees on OSCAR is gone on the new Alberta OSCAR billing screen - and it has been replaced with this new modern look and feel.

There is still more work to do, and a private billing module will be added.  But what I have seen today has renewed by enthusiasm and restored by faith in the programmers!  These guys have really come through, and I'm exited to see what they churn out in the next month or two!

More soon!

JF

Update on the Alberta Billing and Labs module for OSCAR



Well - after my 4th kick at the can to get this done, I have learned a lot with my latest failure.

Basically, the Programmer that was hired to do the job - took the money and then basically quit due to personal problems (a divorce).    This was my 4th try at getting this done with no success.  Apparently, almost half of the necessary coding was done - but half of nothing is still nothing.....so I'm back to square one.

The NERD folks are amazing - and they got unfortunately "taken" by the well respected programming company as well.  NERD lost their own time, money and efforts on this project and they realized that the scope of the project was beyond their abilities.  They donated a heck of  a lot of effort to this project, and I will be forever grateful to them.

NERD decided that creating a billing/lab module for Alberta is beyond their scope.

This is a sign of a great company that is run by great people.  The most important thing a company can do is to define and limit their scope - and to stick with what they do well.  Steven Jobs did EXACTLY the same thing on his "Apple" product development mountain retreats - with eventually spectacular success.

The NERD folks are still my OSCAR providers, and I am proud to have them.


So I stepped back to analyze the problem from a wider perspective.

Basically, the problem is that other than my own personal convenience - there is no "incentive" out there to get a billing/lab module done.  Programmers have a LOT of well paying oil companies to choose from in Alberta, and when they run out of Oil Companies, there are innumerable industries with deep pockets ready for them with welcoming arms.

Also: apparently, Programmers have to eat and they don't like living in homeless shelters.

Some people in the Open Source community may be critical of the programming community's aversion to poverty, but it seems somewhat reasonable to me as I type this from my comfortable chair in my nicely appointed office in a nice house in an upscale community in one of the world's most expensive cities in a fabulously wealthy province in the best country in North America with the highest standard of living on the planet and possibly the universe.

OSCAR is spectacularly successful as an open source project largely because of the amazingly generous contributions of the folks from McMaster.  Their personal contributions as well as the contributions of the OSCAR community and McMaster keep OSCAR constantly growing and evolving to be the success that it is.

But doing a billing/lab module for each province is probably beyond the scope of the abilities of the OSCAR community at large right now, and this will not be likely to change over the next few years.  B.C. has a billing module as well as a lab module, but I understand that both of them have something to be desired.

Ontario's billing/lab module is apparently better, but both could also apparently use improvements.

Also; getting a billing/lab module built to a high standard is only part of the challenge.  Maintaining it and evolving it are also necessary and expensive.

With programmers busily picking the low hanging fruit out there (i.e.. OIL INDUSTRY) - there just is not enough lack of competition for their skills and time to keep their prices down and their focus on OSCAR billing/lab module development.

So - what are we to do?

The answer is already underway and will be probably operational within the next 3-4 months.  A company is simply going to develop a commercial "plugin" for OSCAR for profit.  Open source enthusiasts (of which I am one) may clamour that this violates the precepts of the much touted open source concept - but at the end of the day, we have to get real.....this is not a violation of the open source concept at all.

You can't have something for nothing.  Programmer need both payment and incentive.  These fine folks (the programmers that are building a billing/lab module for Alberta) seem to be motivated and they possess the necessary expertise to get a billing/lab module built for OSCAR in Alberta.  It will function as a plugin - and these folks may replicate this process for other Provinces.

Therefore, for a modest cost - you can have a high end, always evolving and maintained Billing/Lab module for your Province for OSCAR.  Open source pundits may disagree with this approach, but quite frankly, I've been going at this since 2009 and I have not seen a better or more viable solution.

Rather than burning their underwear in protest and screaming epitaphs about how this approach may violate the open source spirit - we open source enthusiasts should consider a better approach for the viability of the open source concept - which is to embrace this commercial "plugin" approach - and accept the inevitability of an eventually strengthened overall product that will always remain at its core, "open source".

So I'm going to give this a try and I'm going to promote this approach for Alberta.

There is  a lot of interest in OSCAR in Alberta - and the only thing holding the deployment of OSCAR back from widespread deployment in this province, is the lack of a billing/lab module for OSCAR.

Well - it is now on the way (for a modest fee)!

We will see where this new approach takes us!

Stay tuned for an update within a month.