Softwords Newsletter

April 1996

Playing Medical Ping-Pong...It Takes Two to Play

At A&L, we believe that technology is one of the keys which will help unlock a less troubled future for the medical community of Ontario. So, we have been striving to create procedures that will help you deliver world-class medical care more efficiently.
Our thinking extends beyond the bounds of technology to attitudes and basic approaches. We would like to share some of that thinking with you in a series of articles that we will publish in Softwords over the next few months.
Some of our thinking has come out of listening to people who use Ontario medical services. Some from interviews and discussion with people in various positions in the medical community, and some of our thinking is the result of articles written in newspapers and magazines. For example, in a column called "Feedback, I Say, I Say" (The Medical Post, October 10th, 1995) written by Patricia Mark, she states;

To governments, I say, "I will do my best to educate and advise." To my patients, I say, "Make your choices and be aware of the possible outcomes. I will take neither credit nor blame for the decisions you make in order to maintain your health." I AM NOT RESPONSIBLE. YOU ARE.

In a seemingly unrelated article, titled, Gzowski's Canada, Borrowed Jammies, (Canadian Living, February 1996) written by Peter Gzowski, he tells of his experiences getting tests done in an Ontario hospital and he states;

I worried about a lot of things when I was in the hospital- maybe some of them too much. But one of them wasn't money. I like it that way, don't you?

In these two articles we thought we saw the root of some of the problems which underlie the Medical Profession. These kinds of comments could easily represent views on who is responsible for medical care of a patient. One view saying, in effect, patients are primarily responsible. The other suggesting, it's nice not to have to be responsible, especially financially.
In our opinion, medical professionals regularly make important decisions, and those decisions have consequences which bear responsibility onto decision makers. Decisions are accepted or rejected, and enacted with care or lack thereof, and that too bears responsibility onto decision makers. And all of it, under any circumstances has a cost in financial terms. That too, in our opinion, is a shared responsibility of decision makers.

We believe a part of the light at the end of the long and dark tunnel of the Medical Community is education. In this sense, if we are to retain the medical system as we know it (whether it is the best idea or not is a separate issue) then something has to be done. But one thing is for sure in our books... attaining medical care is a two-way partnership. Medical Ping-Pong requires two players... Ping... you describe your symptoms, discuss your main concerns and any hunches. Pong... your doctor makes a diagnosis and tells you about treatment options. Ping... you state personal preferences and\or ask about options. Pong... your doctor restates options and how they relate to you. Ping... you accept one of the recommended suggestions or learn more about what you can do. You both win because you end up with the treatment plan best suited to you.

In this issue we have included an Insert to hand out to your patients to assist them in attaining better health care. We call it the A&L Caring Approach. You are free to photo copy it and hand it out to patients as you see fit. Its purpose is to help educate patients in becoming more involved and pro-active in health concerns and in attaining quality health-care.

Life is self-generating, self-sustaining action. Each life is an individual's and relies the individual (or guardian) to care, be concerned and take appropriate pro-life action. Everywhere in the world, Health Care is a growing concern. Health costs and demands are rising. This is true whether you live in Ontario and are covered by OHIP, or whether you live somewhere else and are covered by private insurance companies or HMOs. So, we have tried to put together some guidelines that may help you have a better partnership with your patients. (You may photocopy these guidelines and hand it out with the A&L Caring Approach.)

Dear Patient...

The first important guideline in Being a Concerned Medical Consumer, is to work in partnership with your doctor. Like all partnerships, there has to be a common ground based on common goals, shared effort and mutual understanding. If you and your doctor work together, better health and better care will be the result. You will both gain from your partnership. Frankly, the quality and the cost of medical care will often depend more on you than your doctor. Here are three guidelines to follow...
A) Work in partnership with your doctor.
B) Take an active part in medical decisions.
C) Become skilled at obtaining quality medical attention.
Let's breakdown the first guideline into a few easy-to-follow suggestions. There are five ways to be a better partner, partner...

Take care of yourself. In fact, take great care of yourself and your loved ones. No doctor would prefer that you be sick. When problems do arise (as the complexity of life will ensure), you and your doctor want a return to good health ASAP.

Take note of health concerns. When you first observe a problem, use the Caring Approach sheet and jot things down when they come up. These are often early signs that may help your doctor make more accurate diagnoses. It will also aid in managing the problem down the road, especially recurring problems. Be specific in your note taking on symptoms. Mark down when, how long, how painful, under what circumstances... for each problem. Note, as well, anything unusual that could possibly be related. Do you have a good medical book you could refer to to better understand the problem? Assuming it is not an emergency, keep a eye on it. Update your notes. Is your problem getting better or worse? Staying the same? (Make sure you date all entries.) Do you have a hunch as to what the problem is?
What can you do? Lots. As a partner, you may be able to manage a lot of minor problems, everyone has them. Learn whatever you can. Buy a couple of recommended books. (Does your doctor have a good book that he would recommend?) Note whether anything you have done seems to help. Set a definite time by which you will seek professional help if things do not significantly improve.

Prepare for office visits... Get the most you can from each visit with your doctor. Most appointments are 10-15 minutes or less. The better organized you are, the better partnership you have. Bring your Caring Approach sheet with you. Prepare a check-list of concerns and write them on your Caring Approach sheet. Write down your main complaint, and maybe even your fears or hunches. These are often helpful. If you have any questions, write down the most important 2-3. (A doctor may not have the time for many questions. But maybe he or she has hand-out articles or recommended reading you could do.) Be sure to write down on your Caring Approach sheet a list of any medications you are taking, or conditions you have.

Be an active partner. State your main concerns, symptoms and share your fears and hunches. Be straight with your doctor. As a partner, embarrassment is not going to make us hold anything back. And if you have no intention of filling out a prescription, let your partner know. Getting alternative treatment? Let them know that too. Your partner needs to know what is going on with you in order to offer you the best advice. Know what is going on. If a drug test or treatment is recommended, get as much information as you can. Be a curious partner. If necessary, take notes. Write down diagnosis, the treatment, follow-up plan and anything that you should or should not do at home.

A&L Caring Approach

Step 1. Be a good scientist, partner. Be Observant.

When did your problem start?
What are the symptoms?

Where is the pain? Dull ache or stabbing pain? How long does the pain last? Under what conditions?

Do you have a temperature? Are you able to measure your Blood Pressure?
What is your pulse per minute? Number of breaths per minute?

Think back as best you can. Have you ever had this problem before? Yes No
What did you do about it?

Have you sought medical attention before, concerning this problem? What was done?

Have there been any recent changes in your life? (Stress, medications, food, exercise, etc.)

Does anyone at home or at work have these symptoms?

Step 2. Be a curious partner. Learn more about your problem.

Do you have a medical book or guide at home? Note useful page numbers concerning your symptoms for easy reference.
Are there books or articles you could refer to?
Is there advice from others (lay or professional) that seems to make sense?

Step 3. Be a pro-active partner. Have an action plan.

What do you think the problem is? Why?

What have you been doing (or will you do) to treat yourself?

When do you think you should call your doctor? (Medical books may have good suggestions.)

Step 4. Good scientists measure changes. Evaluate your progress.

Are your actions working? (Are you getting better?)
Have there been any changes?
Are there other things that would account for these noticed changes?

A&L Caring Approach (con't)

Good partners prepare. Before your doctor visit:

Complete the Caring Approach sheet and make sure you take it with you to your appointment.
Take a list of medications and a record of your last visit for similar problems.


During your doctor visit:

State your main problem first.
Describe your symptoms. Use the Caring Approach sheet you have with you.
Describe past experiences with the same problem.


Partners can't be expected to remember everything. Write Down:

Temperature and blood pressure if it is taken.
The diagnosis. (What is wrong with you.)

What might happen next. (Prognosis)

Your self-care plan and what you can do at home. (Or, what you shouldn't do.)

In cases where drugs, tests, and treatments are suggested, ask the following:

What's its name?
Why is it needed?
What are the costs and risks, if any?
Are there alternatives?
What if I do nothing?
How do I take this drug?
How do I prepare for these tests?
How long will this take?

When the visit is concluding, ask:

Am I to return for another visit?
Am I to phone in for test results?
Are there any danger signs I should look for?
When do I need to report back?
Is there anything else I need to know about this?
Thank your partner and wish them a good day.


Next Issue... Taking Part in every Medical Decision

WCB Claims and Balances

The Query language built into the A&L Medical System, as we have mentioned many times, is one of the most useful and powerful features of the software. The Query Language is something a little more sophisticated than many of the other computer tasks we engage in on a daily basis. The Query Language can be intimidating to users who are unfamiliar with its syntax, but it allows for flexible analysis of the database records from many perspectives. Which means that the database records and files can be used in numerous ways. The Reports Module of the A&L Medical System does much of this, but in a fixed or rigid format. Because each office is unique, often there is a need for specialized utility of the database information. Thus, the Query Language or the TCL Mode allows you to generate ad hoc reports, on the basis of open variables that you stipulate to reveal different aspects of the computer data that would not be otherwise available. In other words, the Query Language is a way to access information you have entered in the various files (patient files, for example) and generate a written report. For example, patient records can be searched by birthdate to show all patients of a specific age, but the same records can also be searched by postal code to show all patients who live in the same county or district. The output of these queries of course can be viewed on the screen or printed as a report.

All of this is possible in the TCL mode (Query Language) of the A&L Medical System. The commands and parameters of the TCL Mode are unique to it, so you must set a command and then the conditions carefully to accurately set boundaries for the search.
To go the the TCL mode, simply...

Type the letter [T] at any Main Menu of the A&L Medical System and press the [ENTER] key.

A colon prompt (::) will be displayed. The number of colons can vary and do not matter. At this prompt, type your entry in CAPITAL LETTERS, on one line. The TCL language will isolate the data you wish to analyze.

So, for example, if you wanted a list of patients who have been billed through the Workman's Compensation Board, including their names, phone numbers as well as a balance (even if $0.00) then you would type in the following.

LIST MSF310 PTN.NAME PTN.PHONE TRANS.BALANCE IF BILL.CD = 'W' (PE)

(PE) will send it to the printer. If you wish to view it on the screen, leave it off the command line. After you have finished using the TCL Mode, type the word [RETURN] at the colon prompt and press the [ENTER] key to return to the main menu.

The World of Imaging

Your patient charts have distinct sections. A page or two of patient information and demographics, and then pages of progress notes, lab investigations and requisitions, consult letters etc. Are you thinking that you would like to rid yourself and your office of much or all this paper? What of X-rays, photographs or even sketches you have made in patient notes?

It started out as a simple idea. A&L visited many clinics, offices and hospitals with one question in mind. What could we do to make life better for medical professionals? Even offices that were fully computerized and had the latest technology?

Well, to get an answer to this, we extended our visit at many places (those that would let us) and simply watched how a typical day was spent. We watched patients enter, wait, be treated and leave. We watched other patients take their place in endless waves. We watched office staff take down names, make appointments, make calls to specialists, re-shuffle appointments, still smile at others who arrived hoping they could somehow be squeezed in to see the doctor. We noticed the number of calls and interruptions. We noticed piles of files and charts on the left, on an unused portion of the desk. We noticed a different pile of files and charts on the right, piled in the corner. We followed charts around the office from both of these piles. We watched what happened when mail was delivered and we took out our stop-watches...

Time was spent on the phone... time was spent on patients... time was spent trying to politely re-shuffle appointments after cancellations or after the doctor whispered he would not be available tomorrow. Time was spent on cleaning rooms to quickly prepare for the next patient. Time was spent... on many, many things... but we were amazed. Consistently, 30% or more of staff time was spent getting, moving, handling, filing, re-filing those charts... those files... especially the in and out piles that most offices have. If you could watch how a typical day was spent, we think you would be amazed too.

Pushing paper, moving paper, getting files, replacing files, checking files, filing files, re-filing files, looking for files... charts... get the idea?

This was the beginning of the Document Console. Would your office be better with less paper pushing, less filing and re-filing? Want to venture in that direction but have been concerned about costs? Security? Seeing 60 patients a day and wondering if or how an imaging system will handle your 5 to 8,000 patients without slowing down? Wondering if the computer can really be used for x-rays? Consultant letters and hand written notes? Wondering what you would accomplish by going paperless or even partially paperless? Looking for window based billing software and a relational database program that you can scan notes or bits of consults into? (Or, anything else in hard-copy for that matter.)

Want to see what Document Imaging and less paper can do? Let us show you the joys, the costs and the limits of going paperless. Seeing is free.

Death and Taxes in Ontario

Someday we will not equate these two terms in the same sentence, nor with the same cynicism toward what is certain in the world. After paying more than your fair share of taxes for so long, it is difficult to realize that most of our grandparents did not pay income tax at all. Tax was considered stealing. That it became legalized only made it all the more despicable.

Doctors in Ontario have had to pay back anything that exceeded a government set ceiling limit. In the last five months, this has been approximately 10% per month. As of February, any billing amount left over was to be paid in full. This left some doctors paying clawbacks of 50%, (some more, some less) but all noticing the pinch like never before.

So, for February, if billed claims totalled $25,000, your actual payment was $25,000 minus a Lump Sum (say, $9,500), then your total payment was $15,500. You should note that the $9,500 deduction is only shown on the OHIP message area, it is not part of the A&L Medical System calculated figures.

So, as far as taxes go, make sure that these clawbacks are taken from your taxable total. They should not appear as part of your 1995 Taxable Income. Remember that lump sum deductions do not show up in the same way as the line by line deductions that OHIP normally uses. For example, if you should have received payment of $300,000, check to see that the lump sums are deducted from it. If OHIP deducted $20k against your claims for '95, this should be deducted from the $300,000. Lump sums are shown on the R.A. message area which is located at the end of each R.A. Report. You've paid enough, don't pay more than you have to.

Backups, Backup, Backups...

Which is which?
Perhaps this will help. There are probably three different backups that your office takes, or should take.

The Submission Backup...
is a copy of the claims that are on your submission diskette. That is it. There is nothing else included except the claims you are sending to OHIP.

Backup Complete System Files
is a complete copy of all data, files and entries made in the A&L Medical System program. We suggest that you take this backup everyday in case of an emergency. This copy can be used to Restore the A&L System with all your most recent entries. It is a necessary part of securing your office against unexpected loss due to power outs, power surges, a faulty computer component, a burnt-out Hard Drive, etc.

Both are necessary. Both have a proper, useful role, and we hope you see that they are quite different from one another.

MOH, OMA and A&L... Sharing the Vision

CFRB, CFTO and twelve other newspaper, television and radio stations were present to hear about how the A&L HERO* Transactional Network and the Ministry of Health's Smart System will be the vision of the future. The need for a province wide health-care network has long been recognized by both the public and the private sector. Neither side has the resources to do it alone, yet it is vital to the well-being of the Ontario health care system. The A&L HERO* and the MOH Smart System will provide medical practices with a single integrated solution to office automation-- a propriety network that puts medical offices on-line.

The MOH, the OMA and A&L have the same vision as to which direction health-care technology is going. A transactional health-care network is seen as a way of linking health care providers together, using computer and communication technologies. The goal is to have all health care providers share consumer specific clinical information, including demographic data, medication profiles, test results, and healthcare plans.

With A&L HERO*, all billing processes are automated, thus reducing time spent on submitting claims. It has extensive error checking systems, therefore, virtually eliminating rejections and re-submissions. Immediate retrieval of patient information and remittance advice files allow for effortless searches and file management. An Accounting Module tracks all transactions including the MOH, insured and private claims. General statements, invoices, lab requisitions and prescriptions can all be quickly viewed on the screen and\or printed as reports or forms. Lab requisitions are accessed with the click of a mouse. Laboratories are on-line allowing tests to be requested electronically, via computer. Writing prescriptions is just as easy with an on-screen prescription pad. Medications, inter-actions and any required information can be accessed through look-up tables using mouse clicks and electronic check-boxes. Prescriptions are transmitted directly to pharmacies, eliminating errors and redundancies that may be life threatening. Scheduling as well is completely computerized. The visual approach to electronic scheduling supports multiple physicians and variable appointment time lengths. There are checks for conflicts and over bookings, automated re-booking features and over four separate status ratings for appointments.

A&L HERO* also has a robust e-mail system that puts doctors in-touch with each other. And currently, access to the Internet is being set-up to make A&L HERO* the health-care specific, electronic highway with bulletins, essays, discussion groups, research postings and electronic classrooms.

All this will work hand in hand with the Ministry's Smart Card and Smart System. It has been estimated that by using the information highway, the health care system could eventually reduce costs by $6 billion, while increasing the quality of care to all Canadians. A&L HERO* has the ability to make this figure a reality. The Ministry's proposed Smart System concept focuses on three priorities: health care, planning and administration. It will provide electronic claim processing, error reports, health card validation and MOH communications. The development of the Smart System concept will result in users, providers and government sharing responsibility for management and control of health care. It will coordinate patient care and referral, provide continuing education for providers and consumers, reduce duplication of services, reduce the administrative burden of care delivery, and manage access through real-time checking eligibility.

The OMA has been meeting with the Ministry to discuss the details of the new Smart System. In the Primary Care Reform, the OMA states that they endorse the use of informatics to create a provider-based patient database with the family doctor of a patient's choice to promote screening, periodic health exams and appropriate on-going care.

As you can see, the MOH, the OMA and A&L have a very similar outlook on the direction of technology and the health-care system. It has been a long and dark tunnel for the Health Care industry everywhere in the world. In Ontario, it is hoped that a Transactional Network which all providers are connected to is the light at the end of that long and dark tunnel.



Softwords is a bimonthly newsletter published by A&L Computer Software Ltd., (905) 886-8066.© Copyright. Reproduction of Softwords without written permission is strictly prohibited. For information, questions or suggestions concerning the publication, please contact or write the Editor, David Haisell at the address above or at postmaster@anl.com.


* HERO is a registered trademark of HTN Inc.