CanadianEMR: EMR Comparisons, Ratings, Directory Services and Expert Discussions

Epocrates Study - One in five physicians likely to purchase Apple iPad

AppleInsider - This week, Epocrates Inc., the developer of mobile applications used by more than 900,000 healthcare professionals worldwide, revealed a new study of more than 350 clinicians conducted in the wake of Apple's iPad announcement. Among those surveyed, 9 percent said they plan to buy an iPad when it is immediately available, and another 13 percent intend to purchase one in the first year. In addition, another 38 percent of respondents said they are interested in the iPad, but would like to obtain more information about the product before they decide whether or not they will purchase. With a belief the iPad will gain traction in the health care community, Epocrates also announced this week that it intends to customize its clinical reference application, which is already available for the iPhone and iPod touch, for the iPad.

One in five physicians likely to purchase Apple iPad - study.

Do you think that the iPad will be popular amongst physicians? If you are already an iPhone user, would you consider purchasing an iPad?

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As Health Information goes Digital, Patients may Spot Unpleasant Surprises

A recent article in the Huffington Post pointed out an important issue regarding digital health records.

When Kaiser Permanente started giving patients online access to their medical records nearly five years ago, it offered the same lab reports doctors saw—complete with warning flags highlighting any abnormal results. The capital letters – such as “H” for “high” -- alarmed many patients. So now the giant health plan has modified the policy for most of its members. It displays lab results in a more neutral way, showing patients how they compare to normal ranges and advising them to contact their health practitioner with any questions. The experience at Kaiser reflects the sensitivities that can arise over how much medical data patients should be entitled to view and how quickly—a debate that’s intensifying as medicine enters the digital era.

As Health Files Go Digital, Patients May Spot Unpleasant Surprises

One of the fears of physicians is that providing their patients with access to online health information may increase workload because of examples as described above? It is easy to become alarmed by information that is not well explained.

Do you think this is a legitimate concern? How can these types of issues be addressed?

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Speech Recognition in an EMR

The following comment on use of Speech Recognition in an EMR was submitted by Ep Papp and is published on his behalf.

Your article on speech recognition in ones EMR is not accurate in what is available and the ease of use. I have been using the Toshiba portégé tablet M200 and recently upgraded to the m700. In a quiet environment such as ones office the array microphone on the Tablet is accurate enough without using any USB device. I use Dragon Professional Medical upgrading regularly as available. With the latest version the accuracy is incredible and the speed great if a powerful enough computer. If one needs a USB microphone check out the new Revolabs wireless which is the size of a tube of lipstick and can be clipped to a pocket or lapel or worn on a lanyard and the off/on is a simple push button on the microphone. It works great even though Nuance is not aware of its existence or at least does not confirm its incredible accuracy even though I have communicated with them several times. We have chucked our Plantronics USB over the ear units which are good but very cumbersome especially if you are in/out of examination rooms etc.

The Revolabs unit has totally revolutionized the use of speech recognition in the EMR. I have enjoyed this for years and seen extra patients and dictated more detailed notes in the time saved by its use compared to typing or the handwriting recognition of the tablet. This is still a useful function for physician tasks in the Clinic or meeting environments (esp if connected remotely to ones office and unable to use the voice recognition software).

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eHealth Policy - The Benefits of Foresight

For the past 18 months, I have been working very closely with the American College of Physicians (ACP), a professional association in the US representing 129,000 Internal Medicine specialists, students and residents. This has been a very enriching experience. I'll share more about this work at a later time.

In 2008, the ACP prepared an eHealth policy statement entitled E- HEALTH AND ITS IMPACT ON MEDICAL PRACTICE (.pdf). Reading it today, almost 3 years later, the majority of the document remains spot-on in terms of the current state of eHealth and physician health IT.

A segment refers to Personal Health Records (PHRs). In light of Revolution Health's decision to shut down their PHR (for which they had only attracted approximately 6,000 members), this is an insightful piece.

Current PHR use remains low among patient-consumers and varies among PHR providers. Kaiser Permanente reported in 2005 that 6% of their Kaiser Permanente Northwest region were registered users of their Kaiser Permanente HealthConnect application; the system had been in place since 2002. Cigna reported in a 2007 story on PHR usage that their adoption rate since the launch of its myCIGNA.com to its 7 million subscribers averages less than 9,000 per month.

A study conducted by UNC-Chapel Hill identified three skills needed by consumers using PHRs:

• Basic computer literacy, e.g., navigation skills, typing/entering data into a system, managing files;
  
• Basic understanding of medical/health concepts and terms; and
  
• Experience with personal recordkeeping, e.g., observation and collection of personal health habits and clinical information. Attitudes that are likely important to increased consumer PHR use include a sense that creating, maintaining, and updating a PHR is worthwhile, and that the sharing of information through PHR applications carries no greater risk to the privacy, confidentiality, and security of their protected health information (PHI) than the technologies deployed in current electronic health information exchanges.

The policy recommendation by the ACP is as follows:

• ACP believes that patient portals or PHR applications provide the greatest benefit to patients when used collaboratively with physicians.
  
• ACP believes that there may be value in physician review and analysis of summarized information in a patient’s connected or freestanding PHR, and that an emerging responsibility may be one of periodic review, analysis, and a resulting set of actions by the physician.
  
• ACP believes that payers should compensate physicians for the additional work of accepting, reviewing, validating, and analyzing data from a PHR, as well as the additional work of responding to this information, which may include deleting, modifying, or adding medications or other treatments.

I believe that physician interaction and integration with the EMR in the physician practice are critical dependencies for successful adoption and use of Personal Health Records, something that was predicted by ACP in 2008.

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Evaluating EMR Usability - Often Ignored but Critical for Success

When all is said and done and an EMR is installed in a physician practice, success or failure relating to actual use of the product is a function of 'usability'. If the product is not easily usable, either it is only partially utilized simple tasks become a frustration and require far more effort than should logically be required. Apple understands usability. Pick up any Apple product and it just works, logically and simply. The same cannot be said about many EMRs. The majority of effort with respect to EMR development has been devoted to technical functionality and meeting provincial or local requirements. Sometimes the results are not pretty. The products perform the task, but not always with the minimum numbers of steps and also not always in line with the workflow of the provider or administrative user.

Part of the reason for the lack of usability engineering, is the current focus in the market. If EMR products are engineered in order to be able to collect certain data or perform specific tasks in order to qualify for incentive funding, vendors have no choice but to build in the bells and whistles or face not being conformance approved.

I have not seen any incentive funding applied to achieving usability performance targets. Because usability is difficult to measure and evaluate, I can understand why this is the case. In 2009, I interviewed Dr. Clifford Goldsmith, a usability expert on the challenges relating to EMR - Listen to the Podcast

In an effort to address these challenges, the US is tackling usability:

Healthcare IT News reports: The Commerce Department's National Institute for Standards and Technology (NIST) plans to develop standards to help evaluate the ease-of-use of healthcare IT systems. In a notice on a federal contracting Web site, NIST announced it was looking for companies to create a "usability framework" for health IT systems. The job would require "development, refinement and harmonization of HIT usability standards and certification processes. Among the services sought in the contract, NIST wants a firm that can delve into "human factors analysis" and "cognitive task analysis," ways of analyzing how people react to software instructions. NIST also wants its contractors to develop some general theories about health IT design features and to evaluate those theories via "usability" testing. Ultimately, NIST was to create a "well-defined usability evaluation process that includes a roadmap for implementation and indicates where policy decisions are required."

Government to test ease of use for health IT systems

Should we have a similar capability in Canada? How much of a focus should be placed on usability in comparison to technical functionality?

Stories of Success - HIMSS | ASQ

A series of hospital-based case-studies has been published in the US by HIMSS and co-sponsor American Society for Quality (ASQ). 16 submissions were selected. The initial 6 have been published and the remainder will be availble in late February - Read the details: HIMSS - ASQ Stories of Success.

NEJM -- Accelerating the Use of Electronic Health Records in Physician Practices

In a January 21, 2010 Perspective piece in NEJM, authors Steven Shea, M.D., and George Hripcsak, M.D., describe the practice of incentive payments from hospitals to support physician adoption of EMRs (EHRs in the US). Payment of incentives for this purpose is exempted from the Stark amendment to the Omnibus Budget Reconciliation Act of 1989, which prohibits hospitals from offering physicians incentives for providing referrals or admissions.

This is not a simple as it sounds and raises many questions from a governance and data stewardship perspective that carry over to Canada in terms of EMRs and the ownership of patient data.

North Shore Hospital System on Long Island in New York recently announced that it will pay an incentive of up to $40,000 to each physician in its network who adopts its electronic health record (EHR) — paying 50% of the cost to physicians who install an EHR that communicates with the hospital and 85% of the cost if the physician also shares de-identified data on the quality of care. This payment would apparently come on top of the $44,000 incentive that the American Recovery and Reinvestment Act of 2009 (ARRA) has authorized Medicare to pay each eligible health care professional who uses certified EHRs in a meaningful manner. Full Article: NEJM -- Accelerating the Use of Electronic Health Records in Physician Practices.

I asked a colleague in the US whether any guidance had been provided or precedents established with respect to the following scenarios, (which I believe are all highly likely). According to his feedback, all of these issues have been raised, but there are no clear answers.

1. What happens if the physician terminates their relationship with the hospital in question (for whatever reason) but continues to provide care in the same geographic area? Would they have to give back the EHR to the hospital or the money that was provided by the hospital as an incentive?
2. What happens if the physician or practice provides care for patients in a number of different facilities that are competitive with one another. Can they use their EHR for these other facilities?
3. What is the policy in terms of ownership of the patient records? Does the physician, clinic, or hospital own the records?
4. How can the physician get their information out of the EHR if they decide to join a new group and wish to transfer their patient's records at the same time?
5. Have any policies or approaches been developed for historical access to patient records for medical legal purposes after a physician has left a practice with a specific EHR?

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Shopping for Health Software, Some Doctors Get Buyer’s Remorse

In a January 29, 2010 Huffington Post Investigative Fund Report, reporter Emma Schwartz points out some of the dark side of computerizing medical offices.

Computerizing American medical records within five years is a key goal of federal health policymakers, who have committed to dispense billions of dollars in stimulus money to doctors and hospitals that make the transition in the coming years.There are numerous examples [quoted in the article] of what can go wrong during a move to digital systems, highlighting some of the challenges for individual medical practices making the conversion.

The Bush administration first set the goal of putting most Americans’ medical records online by 2015. By 2006, the industry had begun to receive some oversight through the Certification Commission for Healthcare Information Technology (CCHIT), a nonprofit organization contracted by the government to certify electronic health records. The commission reviews whether companies’ products meet the operating standards they promise. It does not evaluate the firms’ financial viability, although since 2008 it has asked companies to voluntarily disclose their number of customers and how long they have been in business.

Mark Leavitt, chair of the certification commission, said evaluating the financial stability of a company poses many challenges. For example, he noted, even a big, financially successful company could decide to discontinue a software system that didn’t pan out. And merely certifying the firm’s financial strength could give doctors “a very misleading sense of security” about the future of the product they bought, he said.

Shopping for Health Software, Some Doctors Get Buyer’s Remorse | The Huffington Post Investigative Fund.

As the EMR industry matures in the US and Canada, consolidation will take place. Despite best efforts at predicting the winners and the losers, there will almost certainly be some margin for error. As Mark Leavitt states, evaluating the financial stability of a company poses many challenges. The sense of security associated with vendors being selected as a provincially certified EMR systems in Canada also provides no guarantee that these product will be available indefinitely as a result of dynamic changes shifts in the market.

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Coming to a Clinic Near You - Prescription kiosks ready to roll in Ontario Hospitals

What a compelling value proposition! Jan 30, 2010 - Steve Arnold reports in the Hamilton Spectator that hospitals across Ontario will soon have drug-dispensing machines with the capacity of a full-scale pharmacy in their emergency wards. The devices, the product of an Oakville company, are being touted as a way to get needed prescriptions to ER patients, even in the middle of the night. Equipped with a telephone and video link to a live pharmacist, all the patient does is slip a prescription into a reader and then talk to the pharmacist who instructs the machine to prepare the medicine you need. Once the pharmacist is certain you have a legitimate prescription, that the machine has prepared the right potion and it won't interact with anything else you're taking, the drugs are released.

Think of the extension of this capability to larger medical clinics. Not only is there a convenience factor for the patient, but the clinic generates some revenue from leasing out the space and a pharmacist is able to extend their expertise directly to the patients within the clinic.

Do you remember when travel booking web sites first launched and the travel industry was trying to gauge the impact on their business. I can see this type of technology and service having a big impact on physicians, patients and pharmacists in the future. If I were a pharmacist, I would be thinking very carefully about this trend.

Prescription kiosks ready to roll in Ontario Hospitals

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Establishing Realistic Expectations when Implementing an EMR

Over the years I have spoken with many physicians, practice managers and change management consultants about the process of EMR implementation. What makes for a successful implementation? How can a practice improve their chances of success?

Through all of those conversations, there are certain discussions that always come up. One is about defining a clear set of requirements for the practice and ensuring that all the necessary requirements are met as implementation proceeds. Some of these requirements relate to deficiencies and readiness to adopt the EMR e.g. ensuring that all members of the practice have foundational computer skills, can type and use the internet, email and a word processor. Other requirements are operational in nature such as ensuring there is an individual who has been designated to be the practice champion or lead and understands the level of commitment that will be required through the implementation.

One of the requirements that does not get enough attention is the understanding and adjustment of personal expectations prior to implementing the EMR. There is obviously certain system functionality that needs to be present e.g. the EMR allows the physician to generate prescriptions electronically or record notes using free text fields, drop down menus and templates.

The unspoken expectations (and some of the most important to consider) relate to personal changes that individuals may have to make after the EMR is implemented. For example, a physician may expect that they will be able to continue charting patient notes in the same way they did in the paper record - in narrative format. In order to create dependable and accurate patient records that allow information to be extracted for patient recall or analysis, some rules regarding data entry may have to be applied. Certain data may have to be recorded through coded templates, other data through drop-down lists. If the physician in question expects not to have to change some of his/her practices regarding note taking, the result for the practice can be extremely negative. I am aware of instances in which a physician has refused to use the EMR post implementation to record clinical notes because it does not match their style of practice.

It is not difficult to see that if unresolved, this can create a significant problem for the clinic and for other team members.

When setting expectations, think very carefully about what you expect to remain the same post EMR implementation and what you do not wish to change. Then make sure you discuss and validate these expectations with colleagues, the EMR vendor and other team members before proceeding. It is best to be forewarned and aware of what you may have to change once your practice has move to an EMR.

Share your experiences: If you have implemented an EMR, did you deal well or poorly with physician and practice expectations? Is there anything you would differently if you had a chance to do it again?

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A Hiccup for Personal Health Records - Revolution Health Discontinues their PHR Service

A couple of years ago I created a Personal Health Record on the Revolution Health web site in the US. This was more of an experiment than a need to create a PHR for myself, but I was very interested to see how PHRs worked and how they could be used by 'consumers' of healthcare.

Revolution Health Group was launched in the US in July 2005 by Steve Case, who previously co-founded America Online. There was much fanfare at the time about the company and the impact it was going to have on the healthcare - much the same as what AOL did for personal Internet use.

This morning I received the following email from Revolution Health:

Thank you for being a loyal user of the Revolution Health Personal Health Record. Unfortunately we will be discontinuing this service as of the end of February 2010 and removing all records, information, and data from the Revolution Health Web site.

So that you don't lose the information you've entered into the system, we strongly suggest that you download your personal records as a PDF to print and save for future reference. To do this, simply follow these instructions:

Log in to your Personal Health Record
From any page of your record, click on the "printable version" link on the top right corner of any page. When you see a pop-up box asking you to "Select the following sections to include in your print out," simply make sure that the sections you want to print and save are checked and then click the "Submit" button.
Once the PDF is created (this only takes a moment), you can print directly from it and/or save it to your computer. To print the PDF, click on the printer icon at the top left of the page. To save it, click on the disk icon to the right of the printer icon.
If you encounter a problem printing or saving your records, please e-mail our customer service department at CustomerCare@revolutionhealth.com for assistance. Even after the Personal Health Record is no longer available, Revolution Health and our partner sites will continue to offer you the same great health information and community pages as always. We hope you continue to visit Revolution Health often to take advantage of our offerings.

Thank you,
The Revolution Health Team

Unmet expectations? Difficulty to reach a critical mass of users of the PHR? Inability to develop a sound business model that was actually generating revenue for the founders? Too much competition from the likes of Google and Microsoft? The answer is probably a combination of the all of the above.

Healthcare is a tough environment and in order to have a truly valid Personal Health Record, it needs to connect the patient with their healthcare providers (hospitals and physicians). Knowing that 80% of healthcare is provided outside of the acute hospital setting, the real challenge in building a solid value proposition for PHRs is how to connect them meaningfully to their physician's EMR. While this is a concept that I believe makes sense, Revolution Health is an early victim of setting the bar too high and expecting people to change too quickly. In 20 years time, will Personal Health Records be a key mechanism for patients to connect with the healthcare system and their care providers? In my opinion, a resounding yes. However, it is just going to take longer than initially projected and we don't yet understand the Political, Policy and Privacy implications and drivers that will be necessary to make it happen.

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Does Computer use in Patient-Physician Encounters Influence Patient Satisfaction?

A study just published in Canadian Family Physician by Lelievre & Schultz reviews the impact of computer use in the physician office on patient satisfaction. Topics analyzed include patient compliance, health outcomes, perception of physician competence, and the physician’s ability to communicate in terms of patient satisfaction.

Findings from the study include the following:

1. Concerns about computer use negatively affecting patient-physician relationships and patient satisfaction are largely unfounded;
   
2. Most patients had no preference for whether computers were used or not;
   
3. Computer use actually seemed to have a positive effect on overall satisfaction;
   
4. Other studies have shown that patients’ main concerns about computer use have to do with privacy, but in this study only 3.4% of respondents were concerned about a "negative" or "very negative" effect on privacy. 

To read the full study, click here

What are your thoughts? Do you think that computers have a positive or negative influence on patient satisfaction? Can you share any of your own experiences or anecdotal stories regarding experiences relating to computer use in relation to the patient encounter?

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US - Senator Grassley Questions Hospitals about Health IT

A letter written by a US senator to hospitals, following a similar letter to major Health IT vendors in October 2009 questions the reporting practices and relationships between hospitals and vendors, particularly in regard to the restricted sharing of experiences and information about EHR products through contractual agreements. In addition, he questions the financial relationships between hospitals and EHR vendors in terms of royalties and discounts for promoting or discussing specific EHR products.

WASHINGTON January 20, 2010 --- Senator Chuck Grassley has sent letters to 31 hospitals nationwide asking about their experiences in implementing the $19 billion federal health information technology program launched last year. “Given the taxpayer investment and the investment of the health care system overall in the information technology industry, the more Congress and others overseeing implementation of this program dig into the problems and work to get them sorted out now, the better,” Grassley said. “Hospitals are on the front lines and their perspective will be very valuable in this effort, so I look forward to hearing what they have to say about expanded use of health care information technology.”

Grassley said that his survey of hospitals is based on concerns brought to his attention in recent months, including administrative complications, formatting and usability issues, errors and interoperability. Some health care providers have told him that software is producing incorrect medication dosages because it miscalculated body weights by interchanging kilograms and pounds, for example. And, some of those providers have expressed frustration about the response, or lack of, they get when they take those kinds of problems to the vendors or the hospital administration.

Click here for more details

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