CanadianEMR: EMR Comparisons, Ratings and Expert Discussions

Sophisticated 10-12 Physician Practice Established in Ontario

The following has been submitted by a colleague in Ontario and describes the layout and configuration of a new practice that has been established to bring a number of smaller groups of physicians together in a shared care setting.

"The practice is designed to be a very open space with shared work "pods" where the physicians and nurses spend most of their day. The pods have 8 workstations that are used by physicians, nurses, our usher who moves patients around and residents when they are there. There is never more than 4 docs for the 12 rooms on one pod and we have 2 identical pods on each side of the building. Our offices are shared between 2 physicians since we end out spending very little time there. The physicians never have less than 3 examination rooms to work with at any time, so this makes for good throughput of patients - very efficient and quick. Our wait time is under 10 minutes for patients as a result of this (in fact we are usually ahead of schedule during the day) We have 90 workstations and about 60 printers so no one waits for a workstation or walks to get what they printed.

 

There are 24 identical examination rooms (12 per pod), 2 large treatment/emergency rooms, 2 nursing areas that can allow 3 nurses to work at once per pod We have about 10 offices for allied health professional and are starting to hire. We have just brought on a PHD in kinesiology as a health educator for our patients and as well to start our cardiovascular risk management program and do our research. We have our own ambulatory BP monitors and will be getting Holter monitors exclusively for our patients. EKG, PFT, and ambulatory BP are all integrated into our EMR.

We have a total of 14,850 square feet and occupy 55% of the whole building. Overall we are happy and have been able to let in 500 new patients since we moved (December 20, 2007) without adding any physicians or any additional hours of work. We are actually allowing people to call in every 6 weeks or so to get a spot on a first call basis and close the lines at 250. Once these patients are signed up and appointments are given we assess our capacity to take on new patients.

On a good day we see just under 400 patients and at most we have had about a dozen patients at any one time in the waiting room with 8 docs and 5 nurses working. Although I suspected that space was a big limiting factor in the whole improvement process, I never realized exactly how important it was. We are using the same EMR in the same way as we did for the last 2 years and in the past we often had one hour wait times in the waiting room and could not even dream of taking on new patients.

My final conclusion is that EMR's alone are not enough to make a difference and as much effort and investment needs to be made into the space to make real differences!"

This is an example of an efficient practice redesign. The evidence can be seen in the new practice layout and the ability to open capacity and reduce wait times while increasing physician satisfaction.

To add your thoughts or comments, please click on the 'Comments' link

Standardization in a Multi-Physician Clinic - Office Layout

Working together in groups has never been more attractive than right now for physicians. The ability to share costs and overhead, cover one-another for on-call and pay-for-performance programs for Chronic Disease Management (such as the Complex Care program in British Columbia) make the multi-physician clinic a very cost-effective way to practice. Adding an EMR into this environment provides additional capability to do pro-active recall, prescribe electronically and automate repetitive functions.

The following series of images was submitted by a colleague who has recently established a group practice.

What I particularly like about this set up is the very effective use of wall mounted monitors in order to maximize examination room and desk space for clinical use. Using space effectively (and cost-effectively) is one of the key challenges when designing a medical practice, particularly if you have a limited room size.

With the shift in patterns of practice from solo to group and with physicians making a significant investment in the infrastructure (EMRs, telephone systems, office equipment etc.) there are many more physicians who are re-thinking their work environment. I have always been struck by the difference between dental offices and medical offices in terms of the investment in furnishings and equipment that make a practice environment comfortable for staff and patients.

With practices such as this being developed, physicians are making a quantum leap forwards. Welcome to the medical office of the future.

If you would like to add comments or thoughts, click on the 'Comments' link below.

How Important is Line-of-Sight when Setting up Computers in the Exam Room?

The images in this posting were provided by a colleague who describes the importance of sight lines in relation to the setup of computers in the examination room.

He states: "I believe the sight lines to the patient and to the computer EMR are such that I don't believe interferes with the patient physician dialogue or interaction. I just have the computer table at 90 degrees to the wall as in the 2 exam rooms in the pictures. I hope it is helpful to anyone setting up. As an aside, I have put the BP machine in the corner which makes it easy to see without turning away from the patient (it is behind the white light stand)" (Click on any image to enlarge)

Have you had any experience with evaluating sight lines in your exam rooms? Should this be part of the usability analysis of configuring exam rooms?

To share your thoughts or experiences, please click on the 'Comments' link

Exam Room Configuration - Example 12

This is the power exam room table in the left corner of the room. The picture is taken from the door. Notice the placement of the Integrated Diagnostic System. Traditionally this was placed on the wall behind the bed. The short Health Professionals complained that they could not reach it over the new larger tables, therefore it was moved to the head. Minor problem with this placement is that you have to turn your head to read the dial when taking the BP.

This picture is to the left basically behind the door. Not optimal location, but this rooms are smaller than normal. The focus is on the modular furniture that is adjustable (height), has a tack board, slots and shelves in the overhead bin, cables can be run down the back for the computer equipment (no holes to drill) and the patient is just off to the left of the physician when seated. A task light could be added under the overhead, but we didn't feel that was necessary.

This picture is taken from the desk location. It would be in front of the door when you enter. This is all modular furniture. In this configuration, the doors are keyed. Notice in the first picture that there are no taps on the sink.

The foot pedals have replaced the taps (second picture) for infection control. The staff think this is great. No hands! We did not go with the electronic faucets because there is a requirement to have hot, cold, or warm water. The modular cabinets come with the cut-out for the pedals. This furniture is manufactured by Herman Miller.

The exam rooms in these pictures are less than the 10x10 foot that would be standard in Canada. Our new rooms that will be in our expansion will be the standard which will allow the configuration to be improved (not happy with the patient behind the door).

If you would like to comment on any of these exam room configurations, please click on the 'Comments' link

Efficient Office Design - The Impact on Productivity

This is an interesting article in Family Practice Management and has some tips on office design to improve efficiency, plus includes diagrams of office layouts.

Establishing a practice is a challenge in today's health care market. To survive in this competitive environment, you need to create the best possible setting for you, your staff and your patients. This includes not only architecture and aesthetics, but also technology and furnishings. All of these can affect your efficiency and workflow, which will have a significant impact on your overall productivity. These factors can also affect how comfortable patients feel in your practice, which could influence how likely they are to return to you for future care. Link: Efficient Office Design for a Successful Practice - May 2007 - Family Practice Management.

To add your thoughts or comments, click on the 'Comments' link.

 

Exam Room Configuration - Example 11

The following images have been provided by a very well established practice in Ontario that has been using Electronic Medical Records for over 10 years. Many of the computers in the practice are thin clients (which depend on a central server for processing capabilities). The following is an image of one of the communal work areas. There are 4 seats and three thin clients seen. The single empty spot is the area used by a physician who uses his laptop and then takes it home in the evenings. (No medical data exists on the laptop - all is stored on the central server). These communal work areas are very effective for collaboration and support amongst colleagues. It is very easy to take a few minutes with a colleague to learn new skills or discuss how to use the EMR more effectively.

This image demonstrates a hallway configuration that allows a physician to log on to the central server while reviewing a patient record or talking on the telephone. This is also a 'thin client' which does not require that a full desktop computer be accomodated, thus saving space. One of the advantages of thin clients is reduced cost as the processing power resides on the server with minimal requirements at the client level.

These images provide two views of the doctor's exam room, the first from the doorway entering the room and the second from behind the doctor's chair. Two chairs are placed alongside the doctor's desk for the patient and a family member. The monitor can be swivelled to demonstrate information to a patient.

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Exam Room Configuration - Example 10

The following configuration has been provided by the director for a family health team in the Ottawa region. Click on the images to view full size.

"We have been looking for a modern examination room layout for our upcoming renovations and expansion to our clinic. We have just added 2 new rooms as a temporary measure (to our capacity problems) and had a number of professionals working on this. These rooms presented a challenge because they are about 9x8 feet. I hope our new configuration will be 10x10 feet.

We are using commercial furniture in this trial for the following reasons:

• Prices are in line with custom made millwork finishes that are standard will be around for some time since these companies tend not to change them very often.
• Many more "little" features come built in.
• The designers can make it fit your location and requirements.

I'll try to supply some real photos in the next few weeks, but you can see from the photo (taken from brochure) the look we are trying for. The drawings that are attached show you the layout of the rooms with breakout of the furniture. In addition, sinks are being installed with foot controls only (for infection control). These cutouts for the foot controls come precut  in the furniture. The colour of this furniture has been designed to match the examination table top cover, floor and wall colours for a calming effect. The same colour scheme will be migrated throughout the clinic. Due to the size of these rooms we were not able to design a good location for the garbage that meets our infection control goals. We hope this can be solved with a little bigger rooms."

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Exam Room Configuration - Example 9

The following is provided as an example exam room configuration in a new clinic that is being built by physicians in Rockland/Clarence Creek, Ontario. A group of physicians from the two communities have come together to build a new clinic streamlined around a model that provides efficient access to care in a collaborative care model under the funding program that has been established in Ontario.  A perspective artist's rendition of the clinic can be seen at left. Click on the image to see a larger view.

When developing the clinic, the physicians and designers wanted to ensure consistency in terms of examination room layout and as a result, have designed the exam rooms to be identical to one another. As you can see from the example clinic layout, the rooms are large (10' x 12') giving 120 sq ft. of floor space. The average exam room is in the range of 75 to 100 sq ft, so these rooms are quite spacious. In addition, a sink is placed at the foot of the bed in each room to facilitate examinations without needing to walk across the room. All rooms have a desk with a printer and fixed station with adequate space for two chairs side-by-side next to the desk. The door opens towards the foot of the exam table protecting the privacy of a patient who may be undergoing an examination. Click on the image to see a larger view.

While this is a simple layout, it is extremely functional and provides plenty of space for physician and patients.

If you would like to comment on this configuration, click on the Comments link.

Computer Setup - Example 8

This exam room configuration is provided by a BC physician. Our office was custom designed to be used exclusively with an electronic medical record.  We have four rooms, three of which are set up identically, and the fourth is used as a procedure room. 

By having a standardized set up, we minimize the time it takes to stock each room as well as finding specific items.  Each workstation is equipped with a sliding keyboard tray, 17 inch flat screen monitor turned in the portrait orientation as well as a HP 1012 LaserJet printer.  By turning the monitor lengthwise, we are able to read one scanned letter-sized page at a time, which helps to mimic a "page turn".  In addition, it allows better sightlines with the patient while at the same time being able to look at the computer screen.  Most patients are actually comfortable sitting somewhat further away than the traditional examination room, but can pull up their chairs to the desk if they wish.  A printer in each room is invaluable for rapid printing of prescriptions, requisitions for investigations as well as patient education materials. 

The rooms surround the central hallway where there is an additional workstation for both physicians and MOAs.  This also where the adult and baby scales, drug samples, patient information pamphlets, and wet lab is located. We use MedAcess for our EMR.  This integrates very well for a fully paperless office.  We are able to upload paper documents which have been scanned into PDF format.  Data from PathNet, which carries the laboratory results from the private laboratories, seamlessly uploads twice a day.

 

Billing can also be done from any of the office terminals.  The local network also contains resources such as commonly used forms (Handicapped parking), patient tests (Mini Mental or colour testing plates) and patient information.  In addition, internet access from any computer allows for the ability to connect to our local health authorities computer as well as various medical sites while the patient is in the room with us.  As a result, we minimize the amount of time we have to run in and out of rooms, and also maximize the use of the few spare minutes we may have between patients.

If you would like to comment on this configuration, please click on the 'Comments' link below.

Computer Setup - Example 7

This exam room configuration demonstrates the computer setup in a primary care office. The desk is curved and indented so the patient and screen are beside each other.  This means the physician can see the patient and the computer screen in the same glance.  There is no necessity to move one's body when glancing from patient to screen.  The patient feels more the centre of attention.

As well, there is an ergonomically correct (height and orientation) keyboard drawer.  The keyboard and mouse are not on the desk...liberating space and easing comfort.

There is room to the right for a small printer (in this case the HP 1012 laser printer which has a footprint of only 15").

I find this is the only really workable way to be entering data with the patient the centre of focus and not the computer.  Of course the screen can easilly be tilted for patient viewing although I find I'm happy to not share my notes as I make them most of the time!

If you would like to comment on this configuration, please click on the 'Comments' link below.