Fall 2015 (Volume 25, Number 3)
With a Little Help...
By Philip A. Baer, MDCM, FRCPC, FACR
“Oh, I get by with a little help from my friends /
Mmm, going to try with a little help from my friends /
Yes, I get by with a little help from my friends.”
– The Beatles, "With A Little Help (From My Friends)"
Sgt. Pepper's Lonely Hearts Club Band, 1967
Every patient is different, but while catering to those differences, a rheumatology office has to employ a system for getting through the workday efficiently and in a timely fashion. I like to think some of this stems from rules I have established and honed over the years.
However, the greatest efficiencies come from learning from colleagues, and implementing their best practices in my own office. Many of my peers have shared ideas generously over the years, and I thank all of them. Three in particular stand out because of the sheer ubiquity and utility of their contributions to Canadian rheumatology practice.
Prescribing medications is a daily—if not hourly—task when seeing patients. Education about therapies is crucial to reduce patient non-adherence, and to enable patients to take complex antirheumatic medication regimens properly. With medication frequencies ranging from QID to Q6 months, and multiple routes of administration even for the same medication, this is no simple task. Chronic versus acute management can be entirely different
(e.g., gout), resulting in avoidable poor treatment outcomes even in a well-understood disease with multiple effective therapies. Relying on handouts delivered by pharmacists with the dispensed prescription is unsatisfactory, as balance is often lacking and meaningless drug interactions are too often highlighted. Prescription information from industry is limited to drugs currently “on patent”, and has its own issues. Thankfully, our own Dr. Andy Thompson has created and continuously improved the rheuminfo.com website. I hand out these medication sheets with every prescription, and personalize them by scribbling notes in the margins.
Biologic and targeted therapies are a key component of every rheumatologist’s practice. Access to the right medicine at the right time has been problematic from the outset, given the costs of these therapies and the limited dollars available to pay for them in public and private formularies. However, again at least in Ontario, access has improved dramatically. I now have a frequently updated, one-page form for each of the three major rheumatic
diseases which asks only for enough pertinent data to allow a rational decision about whether the patient qualifies for biologics. None of this would have happened without the leadership of Dr. Carter Thorne, and his ORA Exceptional Access Program (EAP) Committee that expended years on building a trust relationship with the provincial public formulary body. Rheumatologists are now the envy of other specialties which use the same targeted therapies. Work continues, led by Dr. Thorne and Dr. Jane Purvis, to extend these simplified forms and criteria in a pan-Canadian fashion to all private payers.
Finally, the EMR system has become the lifeblood of the office. While I knew the move was inevitable, I saw limited benefits until rheumatology-enhanced EMRs with clickable homunculi, automatic calculators of composite disease activity measures, and other rheumatology templates were developed. Compared to the thousands of GPs who were more readily adopting EMRs, the limited number of practicing rheumatologists made persuading vendors to create enhanced rheumatology modules a tough proposition. Fortunately, our own Dr. Vandana Ahluwalia spearheaded this work through the ORA EMR committee, and I silently thank her every day for enabling me to work using a viable rheumatology EMR system with all its long-term advantages.
In my capacity as Rheumatology Section Chair at the Ontario Medical Association (OMA), I meet regularly with other medical specialist leaders to discuss practice issues. I never leave without a sense of great satisfaction at what rheumatologists have been able to accomplish in these areas compared to other medical subspecialists. But, these benefits did not come spontaneously—they are the product of hard work. Use these creations daily, perhaps be inspired to create other tools to share with your Canadian rheumatology peers, and do not forget how the efforts of a few dedicated colleagues has made such a difference to how each work day proceeds and succeeds.
Philip A. Baer, MDCM, FRCPC, FACR