Peer Leader Tips

Tip from an OntarioMD Peer Leader: Opening a Second Instance of Your Accuro® EMR

This month’s tip comes from Dr. Cody Jackson, a family physician from London, Ontario. Dr. Jackson uses Accuro® EMR. To better manage his inbox, he always has a second instance of the EMR running. Although this increases demand on your computer, it makes charting significantly faster and easier. You no longer need to flip between different tabs in the same window and you can look at a patient’s CPP while simultaneously looking at any documents in your inbox. This makes it easier to update CPPs and understand a patient’s medical context while still reading documents in your inbox. To open a second window, hold the ALT key while clicking on a button/selection. Talk to one of OntarioMD’s staff to find out how you can do this with the EMR you use.

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Tip from an OntarioMD Peer Leader: Virtual Care Resources – Patient Education

This tip comes from Dr. Keith Thompson, an OntarioMD Physician Peer Leader in London.

The arrival of COVID-19 in Canada has resulted in a large increase in virtual visits. Many physicians didn't have a clear idea of what a virtual visit was and needed help to make sense of some of the tools available to them. OntarioMD understood this and developed OntarioMD.vc to provide physicians with some context around virtual care and curated lists for common and specialized tools such as:

Video Visit Platforms
Direct-to-Patient Virtual and Digital Tools
Virtual Clinics
Virtual Care Tools Integrated with Certified EMRs

I'd like to give you an example of one the direct-to-patient virtual tools that I use – the iMD Health Patient Education Platform. Full disclosure – I'm the CMO for iTelemed Canada, a video visit platform which has a partnership with iMD. OntarioMD has included the tool on OntarioMD.vc, but does not endorse the tool or any other.

iMD is a medically vetted source of trusted information approved for the Canadian market (e.g., Diabetes Canada) that you can easily fit into your patient conversations before or during a video visit or phone visit. You can share patient-friendly information on more than 2,100 medical topics with them during a video visit platform that offers integration with iMD by sharing your computer screen. COVID-19 is the hot topic right now. I can also share the information with the patient by email after a phone visit.

Diabetes Example

I go through the steps of providing a patient handout about diabetes using iMD in a short video. This is a summary of the steps:

The first thing I do once I've logged into iMD is select Educate a Patient.
I enter information about the patient (gender, age).
I select Diabetes from a list of topics. Information about diabetes comes up from different sources. I select Diabetes Canada.
I can narrow down what the patient and I are talking about – goal setting, for example. A handout called "Managing My Diabetes – My Action Plan" comes up.
I can save this page by clicking on an icon at the top right of my screen.
After I do that, I can send the page to the patient securely by email by clicking on send. (NOTE: Obtain consent from the patient before sending them an email. You can do this by having the patient fill out a form available from the CMPA and keeping a copy for your records.)
A box pops up and I can write a note to the patient (without personal health information), insert their email, and check a box to send a copy to myself if I want.
I can also bookmark the page for use with other patients.
The patient will get a notification in their inbox and can access the handout as many times as they want on the public website.

Eventually this process will be integrated with my EMR. iMD is a great resource for patient handouts from reputable sources and I prefer sharing these handouts with patients rather than them consulting "Dr. Google" and accessing misinformation. iMD offers other features as well, but I will save those for a future tip.

iMD is available to physicians as a free subscription. All you need is a computer and an Internet connection.

If you have any questions, you can watch a 'how to' video or access a quick reference guide on the iMD website. As an OntarioMD Peer Leader, I can also answer questions on the tool, using virtual care in your practice and many other topics. Simply contact peer.leader.program@ontariomd.com or provide some details of what you'd like help with by filling out the contact form.

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EMR Advantage® Virtual Care

This tip comes from Carolyn Shields, an OntarioMD Clinic Manager Peer Leader in Ottawa.

Virtual care has been widely embraced by physicians who are finding it useful during the current pandemic. Physicians are receiving very favourable feedback from their patients about virtual care. Many of your patient encounters can continue using virtual care seamlessly from both the physician’s and patient’s end. Many EMRs have integrated virtual care tools. The following tips are for users of EMR Advantage, but most certified EMRs offer some integration with virtual care tools.

EMR Advantage has the ability to send a mass email to your patients with an alert that you are offering virtual care. This is a great way to introduce your patients to virtual care and start a conversation about using it when appropriate.

Through EMR Advantage’s virtual care platform, you can continue documentation within the EMR and leverage the many features on Insig®. Insig is a virtual care solution that directly integrates with EMR Advantage and allows your practice to offer phone, video and messaging appointments to patients. The solution also offers: 

Faxing of prescriptions to the patient’s preferred pharmacy (if the patient does not have a preferred pharmacy, prescriptions are redirected to a pharmacy that delivers for free)
Emailing of medical documents directly to the patient or clinic, i.e., Medical certificates, DI requisitions
Physician-curated medical questionnaires
A non-fragmented patient chart
Practicing medicine in a non-emergency environment
Integrated note and integrated questionnaire to EMR Advantage®

What the provider sees:

What the patient sees:

EMR Advantage users can contact Canadian Health Systems Inc. at 1-888-225-8310 x 3 to schedule a demo and discuss your virtual care needs so you can complement the excellent patient care your clinic already provides. 

You can also ask your local OntarioMD representative for advice on leveraging all the features of your EMR. Peer Leaders, who are very experienced EMRs, are also available to assist you with tips and tricks. Simply contact support@ontariomd.com to ask for help.

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Three Time Saving Tips for Your EMR

This tip comes from Ibrahim Omar, an OntarioMD Nurse Practitioner Peer Leader who practices in Kitchener, Ontario.

Technology is only as good as its user, and a tool like an Electronic Medical Record (EMR) is no different. EMRs not only save our trees by making our work environment paperless, but they can also save us time. From my years of practice, I’ve realized that we clinicians need to work proficiently in order to save time. I am happy to share some time saving tips and tricks that help me work more efficiently in my day-to-day busy clinical practice and that I hope you will find useful as well.

Stamps/Templates:

Many providers find themselves typing or dictating large pieces of text that reoccur based on common patient visit types. I like to use stamps/templates because they can increase efficiency in many ways. Stamps can be useful for specific conditions, e.g. for urinary tract infection, upper respiratory infection, etc. Meanwhile, templates can be used for chronic disease management (CDM) e.g. diabetes mellitus, chronic heart failure, asthma, etc. You may find both very useful in the following ways:

Streamlined documentation

Could be in SOAP format
Easy to view patient data for quick reference
Standardization of data

Helps with accurate patient data retrieval from one’s EMR for clinical as well as research purposes

Speeds up the charting process

In a few taps or clicks
Used as prompts for specific questioning and decision-making support tools that provide alerts and reminders to providers during patient care
Customizable so one can devise prefilled templates or stamps to match your unique workflow

Before selecting an EMR, you should make sure that the EMR allows for the creation of stamps and customizable EMR templates.

Laboratory Requisitions:

Prefilled lab requisitions can be another time saving aspect of one’s EMR use. I save prefilled lab requisitions for both frequently ordered laboratory tests and seldom ordered laboratory tests. For example, my saved laboratory requisition form for diabetes mellitus contains prefilled: HB A1c, FBG, ACR, lipids, etc. Saved requisition forms can still be altered based on each patient’s needs. On the other hand, I can access multiple investigation forms and print/fax with one click in a given patient encounter. For instance, when ordering a sexually transmitted screening, one needs to have three forms: HIV requisition, public health labs (hep C, syphilis, etc), and a general lab requisition. All these three laboratory requisition forms can be saved under one sub-heading called “STD screening” and printed/faxed altogether.

Favourite List of Medications:

Having favourite lists of more frequently prescribed medications saves me time from searching medications and typing prescription instructions, dosage, form or frequency again and again. Some of the advantages of creating favourite lists are:

They can be saved by disease name or the words which the prescriber can easily remember e.g. clindoxyl1:3 or acneclindoxyl
They are useful for compound medications, e.g. having different topical cream compounds
Multiple medications can be saved under one umbrella term or diagnosis e.g. for h pylori treatment
It helps in shared decision-making with the patient
List of medications can be based on best demonstrated evidences

I hope that making use of these three simple tips will save you some valuable time and help improve your daily workflow process!

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APP OF THE MONTH: COVID ALERT

This tip comes from Dr. Chandi Chandrasena, an OntarioMD Peer Leader who practices family medicine in Ottawa, Ontario.

I was asked to highlight one app for this issue of OntarioMD's Digital Health eTips newsletter. I jumped at the chance as I have many apps that I can write about.

So, as I sit at my crowded "sit/stand desk" in my pyjamas at 1:00 in the afternoon…..

Come on, don't tell me that you aren't in your PJs while calling your patients for their virtual visits!

At least I have a clean T-shirt on for when I have to switch to virtual video on the fly. There are many different video platform options, but that is the topic of a different article.

So, as I sit in my office and think of all the apps that are out there, I would be remiss if I didn't explore the COVID Alert App developed by the Government of Ontario/Health Canada.

Download here:

iOS App Store | Android Google Play Store | Click here for more information

How it works:

Essentially, the app uses Bluetooth signals to exchange random codes with nearby phones that also have the app installed. It uses the strength of the Bluetooth signal to determine how close you are to another. If you are closer than 2 meters for more than 15 minutes, then the app will record an exposure and random codes will be exchanged.

If someone that you've come into close contact with later tests positive for COVID-19, they will receive a one-time key from their local health authority that they enter into the app. This one-time key allows them to upload all the random codes on their phone to a central server.

Daily, when you have an internet connection, your app will download a list of random codes from people with a positive diagnosis and if it matches the codes already on your phone, you will get an alert. The app will also provide guidance based on your local public health unit.

An exposure is defined as having spent more than 15 minutes at less than 2 meters with someone over the past 14 days.

Languages:

The COVID Alert App is available in French and English.

Privacy:

PRO:

It uses Bluetooth and not GPS, thus location cannot be identified.
Android phones need location setting for all apps. Thus, Google may have access to the location. For Android phones, the user would have to use the lowest accuracy option for location and turn off the Google location history.
No collected personal info.
It uses the new Google-Apple system, which is fully decentralized because all data is stored locally on the user's phone.

CON:

If you have a small circle of contacts or live in a small town, privacy may not be so absolute.
If you go to Luke's diner for coffee every morning and only talk to Luke, I suspect you will know who you were exposed to really fast! Kirk!
An argument can be made that this strict privacy policy hinders true contact tracing and will lessen the potential of this app.

Who should download it?

PRO:

It is designed to be used everywhere in Canada and everyone is encouraged to download it. Currently, it is being piloted only in Ontario.
This app is useful for bordering provinces/towns to download. For example in Ottawa, there is a lot of cross border traffic with Quebec as many people work and live on both sides.
This app will help in identifying casual exposures for contact tracing. Those with whom you may have interacted on transit, in the malls, restaurants or bars.

CON:

Must have a smartphone and not everyone does.
Does not work on iPhones running iOS versions below 13.5 or Android phones running version older than 6 (this is a big criticism of the app).

Does it work?

This is the million-dollar question. For it to work, it has been estimated that 60% of the population has to download and use it.

As per a recent article in the Toronto Star (August 5, 2020), less than 4% of Canadians have downloaded the app. It has had 1.3 million downloads so if we assume that all these are in Ontario then only about 6.78% of the Ontario population has downloaded the app. So at the moment, we need to further encourage more downloads.

The other component for this to work is that the key code given by the local health unit for positive diagnosis has to be given in a timely manner. It is not clear how patients get the codes to enter into the app. Who gives it to them? Do they call public health? Does someone email them? How long does that take?

PRO:

If we can get uptake, this is an app with potential.

We should be asking our staff to download the app so that if they have a positive contact outside of the clinic/hospital, they will know to get tested and quarantine.

CON:

Onus is on the positive testing person to enter the one-time code into the app and follow through. If they choose not to, then the app is not useful.
Public health cannot put in the codes to let you know of exposure; it comes from the positive patient only. This is because the random codes are only stored on the user's phone.
We may want to consider reminding staff and docs to turn off the app when in the office/hospital as you will be in contact with known COVID patients and you don't want unnecessary alerts and cause anxiety to your contacts.
It doesn't look at secondary tracing; for example, if you are in contact with a known positive exposure (who has not gone for testing), there is no way for you to know that you have been exposed. It only gives you an alert when your contact goes for testing and tests positive.
I am unsure how the patients get the codes and whether they get them in a timely manner.
I am unsure what the guidance is for positive tests. Do they tell you to get tested immediately (which is what I would expect) or do they tell you to monitor symptoms and quarantine? The website only states the guidance will be given based on your local health unit.

Overall, it seems that this app has potential, but there are a lot of unanswered questions. At the moment, I'm unsure if it will have a significant impact on contact tracing and preventing spread, but it is a work in progress.

I will be downloading the app. It can't hurt and if I have a positive exposure, then I would just go for testing and take the necessary precautions. We have to start somewhere.

Dr. Chandi Chandrasena is a family doctor practicing cradle to grave medicine in Ottawa. She is Co-owner of a 7 doctor FHO and is currently the IT Lead.

She is an OntarioMD Peer Leader and has no conflicts to declare.

She has an iPhone 11 but not the Pro (as she couldn't afford the extra $800 for another lens). She does not receive any financial compensation from the app mentioned here much to her chagrin. She gives talks on Medical Apps for Physicians at various conferences and also talks about Medical Apps for Patients.

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Using handouts in your EMR

This tip comes from Dr. John Crosby, an OntarioMD Peer Leader who practices family medicine in Cambridge, Ontario.

“When I’m educating my patients about their conditions, I like to use patient handouts. I find it really useful to store and generate patient handouts using my EMR so I can access them easily. I simply access the handouts from ‘Handouts’ from the main toolbar of my PS Suite EMR.

Figure 1: Handouts from the main toolbar of my PS Suite EMR

The ones I’ve already saved appear on the left of the screen:

Figure 2: Handouts already saved

I can add PDFs, Word documents, or images by importing them from the scanned files I've saved on my computer or from the Internet. I can import these files in two ways:

I go to ‘Handouts’ on the main toolbar, locate the PDF I downloaded from the Internet from where I saved it on my computer, and drag and drop it into my list of handouts. The handout will be saved with the same file name it was saved on my computer or I can rename it.
I can also go to ‘Handouts’, choose ‘Edit’, then ‘Import Handout” and then find the PDF or other document.

Figure 3: Handouts window

When I need to give a handout to a patient, I can do this while I’m in their chart. I go to ‘Handouts’, select the handout, then click ‘Print’ or ‘Email’.

Figure 4: Rename, then email, fax or print the handout.

Another thing I do is import a handout as a custom form. This is a more advanced feature of my EMR and I or another Peer Leader would be happy to demonstrate at OntarioMD’s virtual conference on October 1 how we customize a handout as a custom form for each patient by entering notes or using text fields that stamp in information for that specific patient.”

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