Peer Leader Tips

Protecting Patient Privacy in your CPP

This Peer Leader tip comes from Dr. Kellie Scott, a family physician in St. Thomas. Dr. Scott uses TELUS PS Suite.

The Cumulative Patient Profile (CPP) is an important tool in any medical chart. In primary care in particular, the CPP can be where we store some very private and personal information. The CPP is also used to communicate with other care providers, and you may not wish to share ALL the information stored in your CPP with others when you send a referral, for example.

As well as being able to mark certain charts private (for example so that a particular person working in your office cannot access a family member's chart) and being able to mark a certain note private (if a sensitive issue was discussed that needs to be documented, but is not necessary for everyone accessing the chart to be able to read), TELUS PS Suite EMR allows you to mark items in the CPP as private.

This feature means you can see all the details you'd want to track in a CPP, but the specialist receiving your CPP as part of a referral doesn't receive irrelevant private information that the patient may not want shared in that context. Think about referring to a general surgeon for a mole to be removed, or to a hematologist to ask for an opinion on some bloodwork abnormalities – they do not need information about previous suicide attempts or chlamydia infections, or child abuse and the patient may not expect you would be sharing this information with that provider.

Using this tool, here is an example of what I see when I look at the CPP:

a screenshot of what a doctors CPP displays and it lists patients medical history

And here is what gets sent with the referral when I attach a CPP:

A CPP screenshot of a patients past healthy history that contains only the relevant information for the specialist to see.

This is turned on by simply clicking on the CPP item and then choosing Patient à Modify Health Problem Privacy and you can set who has access to that problem within your clinic as well.

A screenshot of the CPP demonstrating how to modify health problem privacy.

You can also decide to share the Reminders and Risk boxes (or not) in the printed CPP in the Settings à Preferences à Printing menu.

A screenshot of where to select the reminders and risk boxes in the CPP.

When attaching the profile, there are also options for the format of what you are attaching. The "Short Format" is the most economical in terms of space and paper.

A screenshot of an example of the short form of a patience profile.

Other EMRs may be able to mark certain information in the CPP as private as well. Contact OMD at peer.leader.program@ontariomd.com and get help and other tips from a Peer Leader in your area.

Reference:

https://help.pssuiteemr.com/5.21/on/en/Content/03_User/EMR_general/Making_note_private.htm

Top

Adding a Patient Photo to Your Charts

This Peer Leader tip comes from Dr. Kellie Scott, a Family Physician in St. Thomas.

Not only does a patient photo in the chart reduce medical error,1, 2 it can improve patient interactions for you, your patients, and your practice staff too.

I first recognized the value of patient photos in the long-term care setting. In one home I worked in, they used photos of the residents not only in the chart to ensure accurate medication administration, but they also used photos of the residents when they were younger to display outside each person's room. This would help some with memory impairment find their way to their rooms. I found it also helped staff remember that the older person they were about to interact with was once younger and healthier and had a full life prior to being dependent on the care of others in the long-term care facility.

Photos help ensure you have the right chart open to avoid documentation in George Senior's chart when you're actually talking to George Junior. Your staff can also avoid embarrassment we've all experienced by phoning and asking to speak to George Junior, who is actually a 2-year-old! For an in-person visit, staff can more easily identify the patient in the waiting room, facilitating connection. With many of our visits currently being over the telephone, the visual cue and reminder of what the patient looks is also beneficial. Staff may not have met the patient before, and having a photo in the chart as a reference humanizes the interaction for staff.

For a locum or a new physician just getting to know their patients, a physician covering their colleague who is on vacation, or a specialist reviewing lab work on a patient they've only met once, the photo can jog your memory and put the clinical information you are reviewing into context.

A photo can also help in your clinical assessment, for example, has the patient gained or lost a significant amount of weight? Do they look unwell compared to their usual appearance? Might they look a little jaundiced today or is that normal for them? Is there a bit of proptosis that is new, or some loss of the lateral eyebrow hair? Is that facial droop new?

Adding a photo to the chart is easy. First, you need to capture the image. There are several ways to do this:

Your reception staff can be equipped with a simple digital camera with a USB cable or SD card to transfer the files to the computer.
I use TELUS PS Suite as my EMR so my staff or I can use the TELUS EMR Mobile App to take a photo, which gets saved directly into the chart (but you'll still have to save it to the desktop to get it to the right spot in the chart in the next step).
You can take a screen shot during a virtual visit (ask the patient for permission before you do it, so you don't surprise them with camera shutter sound!) Use CMD-SHIFT-4 on a Mac or CTRL-ALT-F10 on a PC to take a screen shot.
Another option is to get the patient to email you a photo of themselves, which you would handle like any other email attachment.

Once you have the photo, the next step is to get it into the chart.

In TELUS PS Suite EMR3, simply drag the photo from the desktop or folder where it is saved and drop it on the demographics bar inside the records window. For instructions on how to do this using Accuro®4 and OSCAR EMR5, please see the links below.

This Peer Leader tip comes from Dr. Kellie Scott, a Family Physician in St. Thomas.

Not only does a patient photo in the chart reduce medical error,^{1, 2} it can improve patient interactions for you, your patients, and your practice staff too.

Adding a photo to the chart is easy. First, you need to capture the image. There are several ways to do this:

Your reception staff can be equipped with a simple digital camera with a USB cable or SD card to transfer the files to the computer.
I use TELUS PS Suite as my EMR so my staff or I can use the TELUS EMR Mobile App to take a photo, which gets saved directly into the chart (but you'll still have to save it to the desktop to get it to the right spot in the chart in the next step).
You can take a screen shot during a virtual visit (ask the patient for permission before you do it, so you don't surprise them with camera shutter sound!) Use CMD-SHIFT-4 on a Mac or CTRL-ALT-F10 on a PC to take a screen shot.
Another option is to get the patient to email you a photo of themselves, which you would handle like any other email attachment.

Once you have the photo, the next step is to get it into the chart.

In TELUS PS Suite EMR³, simply drag the photo from the desktop or folder where it is saved and drop it on the demographics bar inside the records window. For instructions on how to do this using Accuro®⁴and OSCAR EMR⁵, please see the links below.

Demographics Bar without photo:

Image of a demographics bar without photo

You'll be prompted to save a new portrait:

Image of a demographic bar that has a prompt to save a photo image

Once saved, the photo will be there every time you open the chart:

Image depicts what a demographic bar looks like with a patient image attached

To update or change the photo, just drop a new photo over the old one and it will be replaced (if you want to save the old photo, you'll need to save it first and drop it into a note as a paperclip for future reference).

Peer Leaders like me can help if you have any questions about how to add photos to your charts. Contact peer.leader.program@ontariomd.com to request help.

References:

Top

Patient Engagement and Education – Pre-visit Questionnaires

This month’s tip comes from Dr. Megha Poddar, an endocrinologist in Toronto. Dr. Poddar uses pre-visit questionnaires with her patients as an opportunity to gather information before seeing patients and deliver information and education.

Using digital tools such as pre-visit questionnaires is a great way to obtain necessary clinical information prior to the patient visit. Questionnaires can be sent via email, text message or completed on a waiting room device in the office.

I use the pre-visit questionnaires in the TELUS' Collaborative Health Record (CHR). Other OMD-certified EMRs may have similar tools.

Using CHR's pre-visit questionnaires, you can:

Obtain patient consent
Triage the reason for the visit
Disseminate education materials prior to the visit
Improve efficiency in your workflow (e.g., build out encounter notes, prescriptions, patient education, scripts as per the patient's presenting issue)
Have pre-set billing templates
Provide access to e-booking
Understand the nature of the visit and patient needs prior to the visit
Collect high-quality patient reported data for research and quality improvement

Image of a phone that displays a CHR questionaire

Using digital pre-visit questionnaires bridges an often-missed opportunity to gather information before seeing patients and deliver information and education to them. Embedding videos and links to websites within your intake questionnaire is a great way to engage and educate your patients while they are helping you be more efficient in clinic. You can also score various data points (such as PHQ-9 or pain scores) and trend them over time to help visually see how patients are doing. Lastly, using pre-visit questionnaire scoring, you can set up alerts if a patient’s health is declining and they need to be seen urgently (see below). Learn more about setting up scheduled, mass or recurring questionnaires in the Collaborative Health Record.

screen shot of an alert being set up, triggered when a patients health is declining

OMD's knowledgeable staff or other Peer Leaders can show you how to use questionnaires in your EMR if they're available. Contact support@ontariomd.com or peer.leader.program@ontariomd.com to request help.

Top

Tip from an OMD Peer Leader: Four Virtual Care Pearls

This month's tip comes from Dr. Noah Crampton, a family physician in Toronto. Like many physicians, Dr. Crampton began offering more virtual care since the COVID-19 pandemic began. He has distilled his experience into four valuable pearls of wisdom for clinicians:

Pearl 1: Ensure privacy above all else
Pearl 2: Practice good "Webside" manner
Pearl 3: Reflect on the best visit format (phone, video or messaging) for your patient and their reason for the visit. - Does patient need to come into the clinic?
Pearl 4: Work with your admins to find the right workflow if you're doing virtual and in-person appointments in the same clinic

Pearl 1: Ensure privacy above all else

When conducting phone or video visits from the clinic or your home:

Make sure you're in a private room. If you're at home, consider placing a sign outside the door to indicate that a virtual visit is in progress to prevent unauthorized individuals from opening the door.
Set the audio volume on your device at an appropriate level in an ideally soundproof room or while using your headphones.
If using video, avoid pointing the camera toward a door or window in case someone walks in or walks by inadvertently.
Encourage patients to use their own device in a private location rather than at work or in a public place. Confirm the patient's location if it appears odd.
A patient may want to include a family member or caregiver during the virtual visit. If so, know who is participating with the patient. Establish the patient's level of comfort about sharing personal health information and follow the same principles as with in-person visits.
At start of visit, have the patient confirm their identity:

Ask for their full name, date of birth and one other key piece of information such as postal code.
Consider asking the patient to show their OHIP card on video

Obtain the patient's consent. Read the following consent statement to the patient, have the patient respond in agreement, and then document this is in the clinical note:

"Informed verbal consent was obtained from this patient to communicate and provide care using virtual and other telecommunications tools. This patient has been explained the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. We have discussed that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and patient understands the need to seek urgent care in an Emergency Department as necessary."

Protect your privacy too!

For video visits (particularly if at home), don't have any identifiable items as part of your backdrop.
For phone visits from your own private phone, you can call patients so that the number displays as a private number to your patients.

Dial #31# before any number.
Note: Some patients have private call blocker on, you may need to ask your receptionist to call the patient to tell them to disable the private call blocker.

Pearl 2: Practice good "Webside" manner

For video visits:

Have a professional neutral space behind you as a backdrop.
Consider displaying a hospital ID badge.
Turn off all visible and audible computer notifications, which create noticeable distraction
Makie extra effort to engage with the patient at all times and assure them that they have your full attention. Use appropriate eye contact, body language and attentiveness.
Collect or create patient education resources and links to share after the encounter to replace what you would normally show to patients when you are seated in the same room

Pearl 3: Reflect on the best visit format (phone, video or messaging) for your patient and their reason for the visit. Does the patient need to come into the clinic?

Using your best judgement, consider the right type of contact for the right patient, at the right time, for the right problem.

Pearl 3a: Assess which patients are suitable for virtual visits:

Are there any language barriers that could negatively impact the virtual visit? If so, does the patient have adequate interpreter support to participate?
How far is the patient travelling to see me? Do they have mobility issues? Would a virtual visit be more patient centred?
How tech savvy is the patient? Do they use an internet-enabled computer or smartphone and have email? If required, is assistance available?
What is the patient's cognitive capacity? If required, do they have a caregiver who can support them?
Is the medical issue a simple follow-up? Or is a more complex physical assessment required?
Am I delivering 'bad news'? And if so, would an in-person visit be more appropriate?
Would a virtual visit avoid the need for patients to take time off work?
Would a virtual visit help avoid the cost of parking for my patients?
Does the patient feel the benefit of an in-person visit exceeds the risk of leaving their home? Would you be putting the patient at risk by asking them to come to the office for something that could be handled over the phone or by video?
Is the medical benefit to the individual patient of coming for an in-person assessment worth the risk to you and your office staff during COVID-19?
Could further delay in the provision of in-person care result in a worse outcome for the patient?
Will offering care remotely lessen the burden on acute care hospital facilities?

In many circumstances, telephone is adequate, and can be the better communication option for:

Patients are not tech savvy, or if technical difficulties are occurring with the video visits
Low acuity visits, and with patients with whom you already have a relationship
Transferring calls to physicians from reception and placing patients on hold until the physician is ready.
Conference call technology, which could be useful depending on your practice.

Modality	Pros	Cons
Video	• Allows family members and/or caregivers to be involved in the visit • Allows for eye contact and body language assessment • Can be suitable for sensitive topics • Facilitates deeper understanding of the patient's home or work environment • Facilitates a limited physical exam • Useful for assessing dermatological issues and other visually observable physical issues (e.g. wound healing, gait, etc.) • Increases access for remote, rural, or homebound patients	• Depending on the solution, technical difficulties can arise unexpectedly • Requires reliable WIFI connection • Requires someone to schedule the video visit • Requires that both the patient and the health care provider are available at the same time

Pearl 3b: Which reasons are suitable for virtual visits?

Consider the types of health concerns that are suitable for phone and video visits and those that are better for in-person visits. Try your best to determine at the beginning of the interview with each patient if the reason for the visit is appropriate for a virtual visit.

Here are some examples, but you should always use your own clinical judgment:

Follow-up care for chronic conditions, e.g. DM visit without the physical exam component
Follow-up to an in-person visit within last 2 weeks
Cold/flu/sinus symptoms (ensure you review COVID-19 screening protocols)
Minor skin infections
Conjunctivitis
Nausea/vomiting/diarrhea
Minor injuries/aches and pains
Skin conditions like a rash or bug bites (photos submitted in advance provide resolution that is much better than the resolution of even a high-quality video camera)
Urinary issues / simple UTIs
Sleep or mood problems
Medication questions
Review of test results (e.g. lab, imaging) and specialist reports
Contraception advice
Mental health
STI screening and counselling
Travel medicine

These examples are generally NOT appropriate for virtual visits:

Any new and significant emergency symptoms such as "crushing" chest pain, worsening shortness of breath, loss of neurologic function and psychiatric emergencies such as high-risk suicidality. They may also include ear pain, cough, abdominal/gastrointestinal symptoms, musculoskeletal injuries or conditions, most neurological symptoms and congestive heart failure, depending on the phase of re-opening from the pandemic.
Certain controlled substance visits: For example, prescription changes for unstable or relapsed patients taking narcotics (including opioids, benzodiazepines and stimulants).

Pearl 4: Work with your admins to find the right workflow if you're doing virtual and in-person appointments in the same clinic

In many clinics, virtual visits will often be scheduled between in-person encounters:

Provide simple and straightforward instructions on a generally safe screening process for determining suitability for the visit format to your receptionist and triaging nurse.
As a team, consider your daily workflow. It may be appropriate during the pandemic to stagger in-person and virtual visits to help spread out patient traffic to your clinic, rather than doing all in-person visits as a block.

Resources:

There are many webinars to help you use virtual care when appropriate:

OntarioMD (OMD): https://www.ontariomd.ca/pages/watch-physicians-demonstrate-virtual-care-tools-and-submit-your-questions-during-ontariomd%E2%80%99s-webinars-on-march-20.aspx
College of Family Physicians of Canada: https://www.youtube.com/watch?v=ydWRCCz8dmg
University of Toronto, Family & Community Medicine: https://www.dfcm.utoronto.ca/covid-19-community-practice
Canadian Medical Protective Association (CMPA): https://www.cmpa-acpm.ca/en/education-events/cmpa-podcasts/podcast-virtual-care

The CPSO's Telemedicine Policy (2014) outlines general expectations for physicians practicing medicine via telephone, email, and audio and video conferencing: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Telemedicine
https://fmrac.ca/fmrac-framework-on-telemedicine/
Adopting and Integrating Virtual Visits into Care: Draft Clinical Guidance for Health Care Providers in Ontario, Health Quality Ontariohttps://quorum.hqontario.ca/Portals/0/Users/170/54/10154/Draft%20Clinical%20Guidance_Adopting%20and%20integrating%20virtual%20visits%20into%20care_V1.pdf?ver=2020-03-13-091936-370
Royal College of Physicians and Surgeons of Canada: http://www.royalcollege.ca/rcsite/health-policy/advocacy/virtual-care-task-force-e http://www.royalcollege.ca/rcsite/documents/about/covid-19-resources-telemedicine-virtual-care-e
CMPA: https://www.cmpa-acpm.ca/en/covid19
Canadian Medical Association: https://www.cma.cahttps://ontmd.sharepoint.com/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf
https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2020/providing-virtual-care-during-the-covid-19-pandemic
Emergency triage to virtual care: https://otn.ca/wp-content/uploads/2020/06/Providing-Access-to-Emergency-Services_Urgent-Care-Virtually-May28_2020-1.pdf
Treating mental health through virtual care: https://otn.ca/wp-content/uploads/2020/06/Virtual-Care-for-MHA-During-COVID-19-v6.pdf

Top

Tip from the CMO: Saving Your Favourite Websites into Your EMR

We all have them! Those websites that we always go to. Most of us save them in our web browser and add them as favourites. But what happens when you are at a different station? The websites are no longer there.

TELUS PS Suite EMR has a functionality that allows you to save your favourite website to your EMR that you can tailor for whoever will use them. You can save the websites as private (just you) or public (all of the clinic). This tip is a game changer for some users.

HOW TO DO IT:

Go to the main Toolbar of PS Suite and choose: HELP
Then choose: EXTERNAL RESOURCES (see Figure A below). This will show you what has already been saved. The top section has been pre-saved and is for all PS Suite EMR users. The middle section is PUBLIC and every user in your clinic will see this. The bottom section is PRIVATE and only you will see them.
Once you choose EXTERNAL RESOURCE, a pop-up window opens. From here you can manage your Public and Private websites (you can add or delete or rename them).
To add a new one, choose RESOURCES (from the top right-hand corner) (see Figure B below). This will allow you to see a drop-down menu and you can pick NEW PUBLIC or NEW PRIVATE. Once you pick one of these choices, you can enter the URL you want to save. In my example, I am choosing to input PRIVATELY (see Figure C below). Once I enter the URL, I press SAVE and now it is in my PRIVATE list of resources.

Any EMR Station I log into will have these websites available for me and now I can access them with just a few simple clicks.

Figure A:

Screen shot image showing saved favourite websites in your EMR

Figure B:

Screenshot demonstrating how to Save Your Favourite Websites into Your EMR

Figure C:

Screenshot demonstrating how to save your favourite websites into your EMR

If you don’t use TELUS PS Suite EMR, ask your OMD representative if you can do with your EMR. Simply contact support@ontariomd.com to ask for help.

Top

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.

Top

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.

Top

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.

Top

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!

Top

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.

Top

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.”

Top

Peer Leader Tips

Modality

Pros

Cons