Sunday, April 11, 2010

Updated PEI eForms

I've updated the PEI eForms which can be used with OSCAR.

Download OSCAR eForms for PEI.

This allows you to print out a variety of forms and recs used in PEI directly from the eChart pre-populated with patient information.


You can download other forms for OSCAR here too.

Tuesday, December 29, 2009

Automated No Show Letters to Patients

Patients that fail to attend clinics can be a big problem.

This script can be run on a regular basis to print out letter for patients that fail to attend.  It will  search for patients that have missed an appointment and print out a letter to them.

The first letter will be a warning letter only.

Subsequent letters for the same patient (on future runs) will do two things:

1.  It will mark them as 'Inactive' and 'SU' roster status (for suspended) in the demographic list.  This prevents them from making any further appointments until the staff update their status.

2.  It will print letter informing them that they will remain suspended until they pay the fee for the missed appointment.

Instructions for implementing this script are available on the technical blog.

Online New Patient Registration

Coding in new-patient data into OSCAR is very time consuming, especially for new clinics taking on a lot of patients.

I recently wrote and tested an online registration system that displayed the number of spaces available, and allowed patients to register all of their details online when space was available.

You can view our implementation from my clinic home page.

The patients enter not just demographics, but their medical history, medications, allergies, social history, family history, and preventions history (eg: date of last PAP).  This is then imported into OSCAR so it is all available in the appropriate sections of the EMR when they come to visit.

We registered over 2500 patients in two months using the system, and it was fantastic.  It saved me hundreds of hours of staff time as checking data is far, far faster than entering it by hand.

You can read how to implement this on your server, including downloading the scripts for free (they are open source) on the technical blog.

Walk In Clinic Swipe-Card System

The fabulous thing about OSCAR is how you can customize it to do just about anything.

For example, I have written an add-on that you can set up to run your Walk In Clinics.  You simple swipe the patient's PEI Health Card through a card reader attached to your keyboard and all of their information is entered into OSCAR and they are given the next time-slot in the Walk In Clinic appointment screen.  Automatically.

You can see how this is implemented, including downloading the software required for free (it's open source!) on the technical blog.

Run complex searches for CPP and encounter data using Report by Template

Report by Template is a key feature of OSCAR and is available through the Admin tab in the main screen.

It allows searches to be run on the OSCAR database using templates that can be created by the user.

This template allows you to perform complex searches for data in the CPP and encounter sections of the eChart.   It includes:

  • Multiple search strings combined with AND/OR operators.
  • Exclusion of patients already on a chronic disease register from the search.
  • Searching of patients by registration status.

I use this search to periodically check for patients with conditions that may have accidentally not been added to our chronic disease registers (for example, patients with diabetes).

You can use this search by clicking on the 'Add Template' link in the Report By Template page on OSCAR and then copying and pasting this text into the box.  Click on EDIT to save your changes, then DONE to use the template.

Note: Searches using this template can take a long time to run and use a lot of resources.  You should save them for when the server is not in heavy use.

Thursday, June 11, 2009

How many patients do I have?

One of the great strengths of OSCAR is the incredible search tools built into it.

These tools, called Query by Example and Report by Template, allow users to search for any combination of information on the database.

One of the things that amazed me when I came to Canada was that many of the GPs I spoke to did not know exactly how many patient they had.

With OSCAR not only can you quickly find out how many active patients you have, you can find out how many of them have not been to see you in the last x months or years. Useful to pick up 'phantom' patients who have moved away, or diabetics who have been lost to follow up for example.

To find out how to set up OSCAR to run searches like this and many more, visit this post's technical version over on tech.oscarpei.net.

Sunday, March 8, 2009

Paperless

Well, having spent a week scanning in old patient charts I have now set up a paperless medical practice using OSCAR EMR.

Reports, letters, and results are now being scanned into the patient's electronic record after they have been checked and all patient encounters and prescriptions are being handled via the EMR as well.

No more paper charts!

Anyone in PEI interested in seeing how a paperless practice works should visit me downstairs at the Sherwood Medical Center, Charlottetown.

Friday, February 20, 2009

High Scoring OSCAR not on CanadianEMR


OSCAR users have been questioning why CanadianEMR is shutting out OSCAR from it's reviews.

Despite scoring very highly from user reviews, those reviews do not appear on the Canadian EMR website.

CanadianEMR claim on their site to be a good source of information for physicians considering which EMR to choose.
CanadianEMR is an authoritative and widely recognized national resource for physicians, medical office staff, healthcare planners, government organizations, and vendors of EMR systems.


However, when asked why the reviews of OSCAR - the free, Canadian, open source, EMR - were not appearing on their website, Alan Brookstone of CanadianEMR had this to say:
I have had this discussion with the OSCAR team. They are aware that there is a monthly fee to participate (that is partly what subsidizes the service in terms of support and development), however feel that they cannot put together sufficient to support the monthly payment ($349/month).

It would appear that Canadian EMR is only an 'authoritative' source of information on EMRs if you pay them lots of money.

That sounds an awful lot like paid advertising to me.

Interestingly, CanadianEMR does not provide a 'value for money' score for rated EMRs but does provide a 'support experience' score. Clearly, companies that charge a lot of money for a system are going to have more customer support than an open-source system that is free to download. Nonetheless, OSCAR scores well compared with the other top 10 paid-for EMRs in the CanadianEMR website.

Alan does say he is working on a way to allow non-paying software like OSCAR to receive reviews, and he provided us with the above 'unverified' review statistics that are, sadly, not available on their website.



Link

Sunday, January 4, 2009

OSCAR Installation Costs

OSCAR EMR is open source software. Which means you can download, install, and use it for free. For ever.

Richard Stallman, very much the face and voice of the Open Source movement, is keen to point out that open source means free of restrictions (like free speech) rather than free of cost (ie: not free beer!).

OSCAR software is both, in that you won't pay a cent for the software. However, it does have costs associated with it in terms of time and equipment. These costs will vary enormously depending on where you start from (ie: how much time you have already spent learning how to set up, run, and use computers yourself, and how much equipment you have already purchased).

In this section, we'll look at how those costs vary for different OSCAR installation scenarios.



1. The Zero Cost Scenario

Office size: single physician office, one receptionist, one nurse. 1500 patients.

Baseline IT: The physician is very IT savvy and knows how to set up and maintain a linux server. She already has a computer set up in her office, the nurse's office, and at the reception desk. All three computers are connected to the internet and each other via a local area network, have a laser printer and a label printer already installed. Her receptionist has used an EMR before in a previous job, and her nurse is quite computer literate.

Installation Plan: The physician decides to use a spare PC that she has at home as the server. It has a large enough hard drive, enough memory (RAM), and a fast enough processor to meet the minimum specifications for running Oscar (as listed in David Daley's excellent installation how-to). She downloads and installs the (free, open source) Ubuntu operating system on the server and then installs OSCAR (again, following David's instructions).

She plans to do this, and test the installation over the weekend. She searches online for any information she needs, including a free PDF copy of the OSCAR user manual.

She plans to see the patients in her room mainly, with the computer, and use the two examination rooms (without computers) as needed.

She plans to book no patients for Monday so she can train the staff in the use of OSCAR. She instructs her receptionist to enter the details for the patients for the rest of the week on Monday afternoon, and to enter other patient details as they are booked in. She expects to add one hundred patients per week for the first three months and have almost all patients to be on the system by the end of one year.

Total cost: $0

Ongoing costs: $0


Note: Although there are opportunity costs to this installation (the lost billings from Monday, losses due to the system being slow while the staff get used to it, and the cost of the receptionist's time as she enters patient demographics into the system) these should be compensated for by efficiency gains very rapidly.

Note 2: Had she not had a spare PC to install OSCAR on, the cost of a PC with the minimum specifications for a small office installation (eg: Dell Inspiron 530s) can be as low as $450 including taxes.



2. The Low Cost Scenario
Office size: three physician office, two receptionists, two nurses. 4500 patients.

Baseline IT: The physicians are computer literate, but they do not know much about setting up linux servers. They already have computers set up in their clinical rooms, their offices, and at the reception desk. All computers are connected to the internet and each other via a local area network, have access to a laser printer and a label printer (some of them to a central printer). Their receptionists have used a computerized billing and appointment system but not an EMR. The nurses are computer literate.

Installation Plan: The physicians plan to purchase a server with OSCAR pre-installed and to have a local IT expert set it up for them and provide regular support. They have discussed backup options with their IT provider, and have opted for a rotating backup to a series of USB keychains. One of them will store the backup discs securely in a safe at home.

The IT provider arrives as planned, sets up the OSCAR server and connects it to the existing computer network. The physicians close the office for the day to allow the installation and training.

They instructs their receptionists to enter the details for the patients for the rest of the week on Monday afternoon, and to enter other patient details as they are booked in. They expect to add two hundred patients per week for the first three months and have almost all patients to be on the system by the end of one year.

Costs:
Hardware: One server with Ubuntu pre-installed with surge protection and battery backup $1400
Time for IT installation and training: 7 hours @ $85/hr = 595
TOTAL SETUP COST: $1995

(Cost per physician: $665)

Ongoing Costs: Basic IT support package $200/month

Note: Again, the opportunity costs should be compensated for by efficiency gains after the first few weeks.




3. The High End Scenario
Office size: five physician office, four receptionists, one manager, three nurses. 10,000 patients.

Baseline IT: The physicians are computer literate, but they do not know much about setting up linux servers. They share a single, old, computer which has internet access but no printer. The reception has a single, old, computer which has access to a printer but it too is old and in need of replacement. The computers are very slow due to their lack of adequate memory (RAM) and their old processors.

Installation Plan: The physicians discuss their needs with an OSCAR-familar IT specialist who they commission to purchase and install the system.

The specialist recommends that they need to install computers in each of the seven clinical rooms, and that they should purchase a rack server with OSCAR pre-installed. He recommends a separate backup server system.

They plan on installing the computer network first, which should take about two days. It will disrupt the working of the clinic as the system is installed, and will involve a telecom engineer installing CAT5 cables running to each of the rooms.

Once this first phase is completed, the IT specialist installs the servers. This does not disrupt the working of the clinic.

For phase three, a temporary receptionist is hired to relieve the main reception staff who take it in turns to enter demographic details for all 10,000 patients. The IT specialist oversees the reception staff training for this phase. This takes three months.

Finally, the IT specialst returns and trains the staff in the use of the clinical system and a go-live date is picked.

The entire process takes around six months.


Costs:
Hardware:
Rack server with Ubuntu pre-installed $4,000
Surge protection and battery backup $1,000
Backup server $2,000
18 workstation computers @ $400/each = $7,200
18 monitors @ $200 each = $3,600
11 small laser printers @ $80 each = $880
11 small label printers @ $250 each = $2,750
1 large laser printer/copier $750
Installation of CAT5 network system (50 connection ports) $2,000
Router box $500
Locking rack cabinet $1,200
IT specialist time ($100/hr) 40 hours = $4,000
3 months full time receptionist cover $7,000
TOTAL SETUP COST: $36,880
Cost per physician: $7,376

Ongoing Costs: IT support package $500/month






Summary
An IT savvy physician with a reasonable IT setup already in place can install and run OSCAR EMR essentially for nothing.

However, offices that have no IT systems (or systems that are so old as to be obsolete) will require significant outlays in harware and installation to provide adequate internet access to their staff and physicians. This is because without near-patient internet access, OSCAR cannot function. This is true of all EMRs.



Caveat! These examples are entirely hypothetical. Although the hardware costs are reasonably accurate at the time of writing, IT support costs can vary dramatically.

Introduction to OSCAR EMR

Welcome to OSCARPEI.net - the website for family physicians in Prince Edward Island interested in using the OSCAR Electronic Medical Record.


What is OSCAR?
OSCAR EMR is a fully functional, open source, electronic medical record that is used by nearly 500 family physicians across Canada. OSCAR EMR is CMS 2.0 spec. government certified for funding in Ontario. It was developed by the family physicians at McMaster University in Hamilton, ON.


Why computerize?
The fact that computerization provides family practice doctors and their patients with significant advantages has been shown in numerous studies over the last ten years.

There are three main advantages:

1. Safety
Computerization offers major safety features. This explains why medical insurers in the US offer discounts on medical insurance premiums for physicians that use an EMR.

The safety advantages include:


  • Legibility: no more calls from the pharmacist asking if you really meant to prescribe HRT to Mr Smith, no more huddling round trying to work out what the chart says.

  • Availability: no more hunting for missing charts, no more re-scheduling patients because the chart is not available.

  • Organizational: the OSCAR chart is automatically indexed and date ordered. No more misfiled entries.

  • Clear medication, allergies, and medical history - avoid diagnostic and treatment errors with clear, legible summaries on one page.

  • Drug dictionary: OSCAR's automatic interaction checking means safer prescribing and no more calls from the pharmacist to say that the drug you just prescribed interacts with the other medication the patient is taking.

  • Chronic medication management - more and more patients are on multiple, complex, medication schedules. OSCAR's prescribing system allows you to easily monitor your patient's medications, increasing safety and improving chronic care.

  • Lab results: OSCAR can import lab results automatically into the system. This means faster results delivered straight to the patient chart and reduces the risk of medical errors and adverse events due to delays.


2. Chronic Disease Management and Prevention
Not only does OSCAR have chronic disease flowsheets that can be used to keep track of, for example, diabetes care, but you can use OSCAR to do things that just were not possible before. For example, running searching for patients on particular medications, or keeping an up-to-date disease register, or running searches for all patients with a cholesterol above 4.0, or all diabetic patients who are not taking a statin.


3. Efficiency
Seeing more patients with no more effort. (Or, seeing the same number of patients with less effort = less burnout, better recruitment and retention).

  • Medication refills: these visits account for a large proportion of family practice workload. With OSCAR's repeat prescribing system, you can check and re-issue prescriptions in seconds instead of minutes.

  • Consultation referrals: OSCAR can quickly and automatically generate referral letters for you. You save time dictating and checking letters, the patient gets seen sooner, and you reduce the risk of letter's going astray.

  • (Pharmacists have efficiency savings too as they receive legible prescriptions!)


Fee-for-service doctors could see increases in their billings of 10% or more for the same effort once OSCAR is up and running properly. Salaried systems could see a 10% improvement in patient throughput or an improvement in burnout rates with better recruitment and retention. If PEI has 10% of patients unable to find a family doctor, then introducing OSCAR across the province over the next 2-3 years could solve the problem of orphan patients without the need to recruit more physicians.




Common questions about OSCAR

Isn't this going to cost lots of money?

Actually, OSCAR McMaster is free. The software is free. Updates are free. A server installation takes around an hour from scratch, so installation costs are low.

Basically, you only have to pay for the hardware the server runs on and the time it takes someone to install it for you. That hardware can be purchased for as little as a few hundred dollars or you can rent it (usually for under a $100 a month).

The server is a linux server, so ongoing support costs are low. It is not uncommon for linux servers to be running for months or even years without the need for anything other than regular, automated, software updates.

Of course, OSCAR requires accessible computers with internet access. If your clinic lacks these, then it can be costly to install them. See examples of the cost of installing OSCAR.

The real question is how much money does it cost to NOT have OSCAR? With the very low implementation costs, the potential for increased efficiency, the potential to solve the problem of orphan patients (with the attendant knock on costs for emergency departments and secondary care), and the potential to reduce medical errors, the costs of not implementing OSCAR EMR are incalculable.


The hospital EMR cost $12 million and took years to implement. Are you really telling me that OSCAR only costs $1000 ?

Family practice is not like hospital practice. Hospitals are huge organizations with a mobile workforce operating over a large area requiring massive numbers of terminals, wiring, wireless systems, and so on.

Family practices are small units that operate largely in a static environment. They are much easier to provide an IT solution for.

What about getting all of our patients onto the new system?

This can be very time consuming. However, the simplest and cheapest way to do this is to simply enter each patient's demographics in the system as you encounter them. OSCAR can use a card reader to enter the demographics directly from their PEI Health Card.



Can't we just use the Hospital EMR in the medical practices?

That's not a good idea. Family practice EMRs have very different requirements. Good family practice requires systems for chronic disease management, chronic medication prescribing and monitoring, and regular visits spread out over a long time with a small number of providers.

Hospital EMRs are designed for acute care by a large number of providers over a short period of time. That's why few (if any) family physicians use hospital EMRs for their family practice encounters even if they have access to it.

But is OSCAR safe? Don't you need to pay for secure computer systems?

OSCAR is very safe. It is CMS 2.0 Spec. Ontario Government Certified for Funding in part because it is safe.

Ironically, open-source software is safer than the much more expensive proprietary systems. Linux is an open-source operating system and it is much less vulnerable to computer viruses. That is why most web-servers in the world use open source servers: in fact, you rely almost exclusively on open-source security every time you use the web. You're bank relies on open-source SSL to keep your online transactions safe.


What about the support staff in the family practice? They are worried OSCAR will make them redundant.

Support staff have no need to worry about EMRs. In fact, EMRs tend to result in more staff being employed because the patient throughput increases.

I've worked in over fifty family practices in the last 10 years. I've not seen one where the introduction of an EMR resulted in a reduction in the number of support staff.

In fact, support staff workload changes little when an EMR is introduced. In most installations, the paper chart is retained for correspondence and workflow reasons.

The only significant change in support staff workload occurs in practices that are totally paperless. In such practices staff no longer have to pull charts but instead have to scan letters and other paper documentation into the electronic charts.

We don't have computers in the clinical rooms, can we still use OSCAR?

You can use a netbook computer (about $400) with a wireless connection (about $100) to access the medical record securely over an SSL connnection from the clinical rooms.

Another method is to set up a single 'consulting room' for each doctor for EMR-heavy visits (eg: medication refills, chronic disease management) and then use smaller clinical rooms for examination-heavy visits (eg: abdominal pain).


I can't type very fast and I'm not very computer literate. Won't an EMR slow me down?

OSCAR is a web-based EMR. That means that you access the program the same as any other internet page. Anyone can learn to use the internet, and anyone can learn to use the basic features of OSCAR.

Also, being web-based, OSCAR can be used with voice-dictation software. You could even dictate your notes and have them transcribed into OSCAR by a secretary at the end of the clinic.


I already have an EMR on my system, but I don't use it. Why should I use OSCAR?

OSCAR is written by doctors for doctors (with the help of professional programmers). There are some EMRs that are written by software teams with little knowledge of how family physicians actually work.

Even better, if you don't like bits of OSCAR you can ask to have them changed. If you don't want to wait for the team of volunteers to get round to making the changes you have asked for, you can make the changes yourself or pay someone to make the changes for you. That's the great thing about open source software: you can build on it and modify it any way you like (so long as you make your improvements free to other users too).


I have heard horror stories of EMR vendors going out of business or dropping support for their EMR leaving physicians with no access to their medical records. Could that happen with OSCAR?

Again, this is the fantastic thing about open source software. You can't get locked out. Even if everyone else in the world stopped using OSCAR, you would still be free to carry on using it and modifying it to your heart's content.

Also, the data is stored using a standard MySQL database, which is also open source. So you can export that data relatively easily if you needed to.

(Of course, if you decide to pay a private company to host your installation for you, then you should make sure that you have easy access to a backup copy of your data in case anything was to happen).