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

Mobile Tools for EMR Access - Phones and Tablets

Patient data is increasingly available to clinicians through a wide variety of tools and form factors. As high speed Internet through Wifi and 4G become ubiquitous, access and speed are no longer an issue. In parallel, physicians are increasingly using EMRs as their primary tool to document, manage and treat patients and as a result, it is not surprising that they should want to access clinical data using a mobile phone or tablet. Blackberry appears to be back in contention as a device for business users, but the majority of mobile devices used by doctors are smartphones with the Apple iPhone the device of choice.

A recent survey, conducted by AmericanEHR Partners with 702 verified physicians within the U.S. between October 10, 2012, and December 8, 2012, revealed the following:

• The most popular brand of smartphone used across respondents was Apple’s iPhone.
• The most popular clinical apps were Epocrates, Medscape, and MedCalc.
• Twice as many non-EMR physicians use a traditional mobile phone compared to EMR users.
• One-quarter of non-smartphone users intend to buy a smartphone in the next six months.
• Both EMR and non-EMR users spend 15–16 hours a week on their smartphone.
• 35% of respondents use their smartphone to research information on medications daily.
• The least common smartphone activity for business purposes is Tweeting (5%).

I recently spent some time in Singapore working with a team on the national medication and allergy systems. As a result, I was able to observe how the public uses mobile devices for everyday access. What surprised me were the number of people (physicians and non-physicians) who carried larger phones such as the Samsung Galaxy Note. Called 'Phablets', these devices merge the mobility of the smartphone with the screen size of a tablet and provide greater screen size which is critical for viewing a large amount of information without the need to scroll. For the past year I have been carrying an iPad mini when I travel or if I am unable to carry a laptop with me. Tethering the tablet to my iPhone, I am able to access the Internet (as well as any other app that requires a login).

An exciting evolution that we will see more prevalent in the next 12-24 months is remote access to one's EMR using a mobile phone or tablet. A September 2012 blog post on CanadianEMR titled, "Should I Access My EMR Using a Mobile Phone?" highlighted security and access precautions as well as advice to reduce the risk of health data breaches.

If you have an EMR or are considering implementation and would like to have remote access through your phone or tablet, speak to your EMR vendor (or potential systems provider) about mobile apps or whether they have a preferred mechanism for access to the EMR using a web-browser on small form-factor devices.

Do you have any experience using your mobile phone to access your EMR? Click on the 'Comments' link to share your thoughts or comments.

To purchase a copy of the AmericanEHR Mobile Use in the Medical Space, click here

BC Workshop on Mobile Applications - June 18, 2013

The British Columbia Alliance on Telehealth Policy and Research (BCATPR) is holding its 6th annual workshop, at St. Paul's Hospital in Vancouver on Tuesday, June 18, 2013. This year’s workshop theme underlines the importance of mobile and web-based telehealth applications that can be used by patients, clinicians, and health policy decision makers and will include telemedicine, telehealth, mobile health technologies, remote monitoring and web-based programs for chronic disease management.

Register here: Mobile applications to support behaviour change, clinical decision making and health service delivery

What is the Next Phase for EMRs in Canada?

One of the questions that I am frequently asked about EMR systems is to describe what I see as the future of EMRs in Canada. With many provinces now achieving a critical mass of EMR users, we will now be able to do things with EMRs that in the past were very difficult to achieve. There are some key EMR features that I would like to highlight.

• Usability: EMRs will get easier to use. This will take place at variable rates depending on which EMR system you are using. Those with active user groups who can provide constructive feedback to vendors will benefit the most. As the focus shifts from getting physicians to adopt their first EMR system, to EMR optimization, it will become more important for vendors to focus on the usability of their systems and they will dedicate a greater proportion of their resources to improving their products;
• Mobility: EMRs are traditionally accessed using a laptop or desktop computer. The laptop is sometimes carried by the physician from room to room or can be attached to a wall mount or mobile cart. Because it is best to access one's EMR using a large monitor due to the large amounts of information that need to be accessed, it is not practical in many settings to use tablets or even smartphones on a consistent basis in the examination room. However, outside of the medical office, the needs are completely different. When accessing one's EMR remotely, the ability to view specific information using a mobile app or even a browser with secure access, are extremely valuable to clinicians who may need to look up a lab result or write a prescription. The next phase of EMR use will see a much wider range of mobile apps for both look up purposes and for the management of medications and clinical notes;
• Security: Some clinicians are likely to be using regular email for communication with colleagues and patients. This is not ideal from a security perspective, but often practicality trumps security, particularly if the process is time consuming and makes the messaging more difficult. The next phase of EMRs will incorporate easier to use and more streamlined secure communications to transmit information to colleagues (secure referral or consultation) or to communicate with patients through integrated patient portals;
• Analytics: As physicians move through the early challenges of EMR implementation and achieve a level of optimization of their internal office setting, they will become far more focused on the ability of EMRs to improve patient care. This will dovetail with pay-for-performance programs in which provincial programs will expect to see measurable benefit for the dollars invested in healthcare. In a paper-based practice, this would be extremely difficult to accomplish, however using an EMR that incorporates analytic capabilities, it will be possible to generate status reports for populations or individual patients with a click of button.

What other features do you think will be prominent in EMRs in the next 5-10 years? Add your thoughts or comments below.

Using EMRs for Chronic Disease Management

In the past, I have written numerous articles describing the benefits and potential uses for EMRs for the management of patients with chronic diseases such as diabetes and congestive heart failure. In this context, EMRs are very good at performing repetitive tasks in a standardized manner such as reminders for patient recall or electronic tracking of lab results. At the same time, it has become abundantly clear that management of chronic diseases in 2013 is a team-based care process with the need to access or input information into some form of shared care record. This is not a simple task, but certainly can be managed more effectively using an EMR vs. a paper-based record.

One of the challenges with patients who suffer from chronic diseases such as diabetes is the fact that many of these patiens also have multiple additional co-morbid diseases such as chronic kidney disease, peripheral vascular disease, hypertension, etc. Each of these diseases has clinical practice guidelines that have been developed by expert groups (either national or provincial). Many disease states have different expert groups that devise the clinical practice guidelines, creating a great deal of difficulty when translating these rules and recommendations into an EMR system. For example, if the best practice for a patient with two co-morbid diseases is a specific dose of a certain drug for one disease and a higher (or lower) dose for the other disease, which one takes precedent? The same may apply to diet restrictions with variations in dietary guidelines for each of the diseases. Because clinical practice guidelines are developed for single disease states, and because the clinical presentation of each patient may vary, developing a rigid set of rules or guidelines is difficult for multiple disease states in the same patient — particularly when conflicting recommendations may need to be applied via the EMR.

The advantage in Canada is that physicians (particularly in primary care) have now been using EMRs for a number of years to manage these types of patients. How do you manage patients with co-morbid chronic diseases? What types of templates do you use? Have you found a way to manage this problem that could be of use to colleagues?

Please share your experiences by clicking on the “Comments” link below.

Radiation in Medical Diagnostic Imaging

This presentation was recently given by Dr. Brett Heilbron at the 2013 Technology in Clinical Practice Cruise Conference. Learning objectives for the session were to understand the risks associated with ionizing radiation, identify ways to optimize patient benefit and minimize risk, and to discuss some of the controversies around medical imaging radiation. The presentation focuses on the use of a common technology in clinical settings — medical diagnostic imaging — and provides some guidance regarding this controversial topic.

To add any thoughts or comments, click on the “Comments” link below.

Tips to Selecting the Right EMR for Your Practice

Selecting the right EMR for your practice is one of the most important business and clinical decisions you can make. With a range of potential EMRs available in each province, how should you choose the right system for your specialty and practice size?

In addition to viewing EMR information and rating data on CanadianEMR, the following tips are provided to assist you with EMR selection:

1. Are you ready for an EMR?
2. Is the EMR appropriate for your specialty?
3. Is the EMR appropriate for your practice size?
4. Ensure you receive sufficient training.
5. Post implementation support.

Are you ready for an EMR? Assess your practice’s readiness to adopt an EMR system and develop a list of requirements for your practice. Evaluate both your own and your staff members’ readiness from a computer use and commitment perspective, and ensure that all members of the practice have reasonable expectations about what the EMR will do. If a provincial EMR program is available in your province, you may qualify for funding support either as a GP or specialist. The better prepared your practice is, the more likely you will be successful with your EHR implementation.

Is the EMR appropriate for your specialty? Not all EMR systems are designed to work well for every specialty. For example, ophthalmology-specific systems provide highly specialized functionality that is not appropriate or necessary in a primary care setting. There are a number of important considerations when selecting a specialty specific system, including:

• Templates that are designed to capture information specific to that specialty in a format and according to a workflow that is appropriate. Templates should be easily customizable by the clinician or practice.
• The ability to connect diagnostic devices directly to the EHR so that data from the devices can be automatically imported into a patient’s record, e.g. spirometry readings for respirologists or EKGs for cardiologists.
• For surgeons, schedule synchronization between the EMR and the hospital OR booking system. This is usually conducted through a third-party software; however, it is worthwhile checking with EMR vendors whether they offer this capability.
• Quality of consultation reports — review what a typical consultation report looks like to ensure that you are comfortable with the output and the format.

Is the EMR appropriate for your practice size? EMRs are generally designed for certain practice sizes. Systems that work well in practices of 1–3 physicians are not necessarily the right type of EMR for a larger multi-specialty practice of 25 or more. EMRs for large practices have to be able to support larger numbers of clinicians and staff working on the system (and sometimes the same patient record) simultaneously. More complex EMRs frequently are a higher cost as the hardware to support the system needs to be higher performance. Ask EMR vendors for information on the size of practice in which their software is typically used.

Ensure you receive sufficient training — Make sure that training is a key factor in your selection process. Some vendors skimp on training in order to reduce the purchase price of their software, but this can be a big mistake that will ultimately cost more in the long run. When you do your reference checks and site visits (with existing users of the EMR you are considering), ask physicians and staff how much training they received and what they would recommend as ideal for that product. Onsite training is preferable initially rather than online training, as you will have the opportunity to test and learn the software in the exact setting in which it will be used. However, even with comprehensive initial training, it is not possible to learn everything you need to know about your EMR. As a result, you should include follow-up training in your budget to learn how to use the more advanced functionality. Even with adequate training, getting the most out of an EHR means that you will need to practice as much as possible so that the commonly-used features become second nature.

Post implementation support — It is critical that you understand what is included in your contract in terms of post-implementation support and maintenance. You will need to know support levels offered by your EMR vendor and which level of support you need to ensure the ongoing operation of your practice. These are frequently spelled out for you through the provincial EMR programs such as PITO and OntarioMD. Confirm how frequently updates are typically released and your role in terms of installing them — this is not an issue if you purchase a cloud-based EMR system, as the updates are managed centrally by the vendor. Ask current users what their experience has been in relation to vendor availability and responsiveness to support requests as well their responsiveness to concerns and requests for enhancements.

Do you have any other feedback or suggestions? Click on the “Comments” link below.

Does Pharma Have a Role in the EMR-Based Medical Practice?

Over the past 10 years, medical practice has changed dramatically. There are numerous factors that have resulted in these changes, including information technology, reimbursement reform, and the transition to the team-based care. Simultaneously, the relationship between physicians and the pharmaceutical industry has changed. The advent of academic detailing created new and less biased ways for physicians to receive information on drugs from non-industry pharmacists, information on drugs has been more widely available through a wide range of easily accessible and trustworthy websites, and EMRs/EHRs have integrated progressively more detailed information on drugs directly into clinical care with the ability to present relevant alerts at the time of decision making.

In addition, many physicians stopped seeing pharmaceutical reps in their practices. This was partly due to over-detailing (the same reps calling on doctors too frequently or different reps from the same company), uncertainty regarding the value of data being presented, limited time availability, and increasingly stringent guidelines governing the relationship between physicians and pharma companies. The net result was increased separation between pharma and physicians. A major focus for the pharmaceutical industry has been maintaining or increasing access to doctors and protecting brand name drugs against the onslaught of generics, which have eaten away at profits.

There are additional challenges that the pharmaceutical industry faces. Drug research and development cycles are long and costly, making it challenging to bring new drugs to market more quickly and efficiently. With the advent of personalized medication regimens and pharmacogenomics just around the corner, identifying the appropriate therapies for specific patients will not be possible without advanced technologies to support care decisions. As the dominant technology in a doctor’s office, EMRs are becoming the tools of choice for the majority of physicians in terms of documentation and clinical decision support. If a drug is not listed in an EMR’s drug database, it becomes difficult to prescribe. Similarly, without the processing power and logic of health IT systems to support decisions regarding personalized therapies, it will be almost impossible to prescribe the right drug for the right patient at the right time. Catch 22. In the majority of instances, you cannot prescribe the right “personalized therapy” without the right types of technology, and the EMRs are still a long way from being able to consistently support these types of clinical decisions. Getting access to the data in EMR systems for analytics is difficult for physicians. Use of this data by third parties for clinical research purposes, or to identify appropriate cohorts or patients for specific therapies, adds additional levels of complexity.

One of the areas that makes a great deal of sense in terms of collaboration between doctors and pharmaceutical companies is access to ancillary programs offered by brand name drug manufacturers that can be linked to therapies within EMRs. For example, a pharma company may offer a coupon program for low-income patients or additional educational or support programs for a particular therapy. These are difficult to remember at the time of the prescribing, but with an EMR, a physician could receive an alert at the time a drug is prescribed with the ability to easily print a coupon for a patient or an information sheet on an education/support program. This fits very effectively into the workflow of the physician, provides added value to the patient without incurring additional effort, and encourages appropriate utilization of drug therapies.

Building this type of capability into EMRs will not be easy; however, if done appropriately, there is significant value for all parties. Does Pharma have a role in the EMR-based practice? In this area, I strongly believe it does.

Do you agree or disagree? Add your thoughts by clicking on the “Comments” link below.

Can Decision Support Systems Improve Patient Care?

Clinical decision support is used in a wide range of instances to guide care decisions. Clinical decision support tools include drug-drug interaction checking, automated alerts, templates, and order sets. How can these tools be optimized to improve patient care? How should you determine whether the tools are appropriate in your specific practice setting?

 

This presentation took place on the 2013 Technology in Clinical Practice Cruise Conference. View a selection of photos of Tahiti from the cruise.

Tips, Tricks, and Best Practices to Maximize Use of Your EMR

Implementation of electronic medical records does not necessarily mean that the systems are being used effectively. Using EMRs optimally requires extensive optimization. This presentation provides a number of useful tips trick and best practices to assist practices with the optimal use of their EMR systems.
 

 
This presentation took place at the 2013 Technology in Clinical Practice Cruise Conference.

iPhone, Android and Tablets — Driving Clinical Value from Mobile Devices

The rapid adoption of mobile devices by clinicians and integration of apps into the clinical workflow has created significant opportunities for these devices to become primary tools in the diagnosis and management of disease. This presentation provides an overview of the drivers behind adoption, what clinicians are using, and how one can drive more value from these tools. This presentation took place at the 2013 Technology in Clinical Practice Cruise Conference. View a selection of photos of Tahiti from the cruise.

A subset of data is presented from the just published AmericanEHR Partners report: Mobile Usage in the Medical Space Report – 2013. Click here for more information and to obtain a full copy of the report.

The following list of recommended Apps was submitted by conference attendees:

• Epocrates – http://www.epocrates.com/
• MetrO – Subways of 400+ cities around the world – http://metro.nanika.net/index.php?p=Z
• Medcalc – Medical calculators – http://medcalc.medserver.be
• Medscape – Available in the iTunes store
• ICDMeister – ICD-9 Coding tool – http://icdmeister.com/iphone/
• American Medical Association – Online CPT Code lookup – https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do
• UpToDate – http://www.uptodate.com/home/uptodate-mobile-access
• Evernote – http://evernote.com (Apple)
• QxCalculate and PediSTAT – http://www.qxmd.com
• Lexicomp – http://www.lexi.com
• Dropbox – https://www.dropbox.com/
• iHeadache – http://www.iheadacheapp.com
• Cardiology Calc – Available in the iTunes store
• Good Reader – PDF reader for iPhone and iPad – http://www.goodreader.com/goodreader.html
• HanDBase – Database manager – http://www.ddhsoftware.com/handbase_iPhone.html
• Pocket Informant – Contact manager for iPhone and iPad – http://webis.net/wp/pocket-informant-pro/
• Sono Access – Interactive Ultrasound learning app – http://www.sonosite.com/education/sonoaccess
• My Fitness Pal – To recommend to patients – http://www.myfitnesspal.com
• StatCoder – Framingham Risk Calculator and Lipid Guidelines – http://www.statcoder.com/
• Essence of Anesthesia Practice – Fleisher & Roizen – http://www.us.elsevierhealth.com/article.jsp?pageid=7739

Physician Ethics and Inappropriate Access to Medical Records

How does one prevent snooping of patient records through a hospital, regional or local clinical information system? Reading an article in The Medical Post earlier today title, 'Suspension, $22k fine for doctor who snooped into patient files' I was brought back to some work that I had done in 2006/2007 as a participant on the British Columbia eHealth provincial privacy working group. At that time we had many discussions regarding the privacy of patient information and the risk of inappropriate access by medical professionals.

The Medical Post article describes a situation in which an Edmonton physician at the Misericordia Hospital accessed the medical records of three patients with whom she did not have a physician relationship. The access took place via a hospital computer after a colleague failed to log out of a computer terminal. The disciplinary action was brought against the physician by the College of Physicians and Surgeons of Alberta and it was found that she was aware of the inappropriate access as well as the fact that she would not leave a fingerprint trace of her access as she used another physician's login to access the records.

This is one of those potentially avoidable situations that is unfortunate for both the patients and the perpetrating physician. After the fact identification of privacy breaches are the norm in today's world, in large part because the mechanisms to identify inappropriate actions generally take place through either a complaints or post-event audit process. It is very difficult to avoid breaches such as this particular example which appears to have had a calculated element to it, although the physician in question did not 'disclose or make use of the information' in any way. In addition to the fine, the physician received a 60 day suspension and was also ordered to attend an ethics class.

As EMR/EHR/Clinical systems become more commonplace in hospitals as well as variety of other clinical settings, this incident raises a flag in two areas:

1. All clinical team members should receive more extensive training on appropriate access to and use of electronic health information, including the ethics related to inappropriate access, and
2. Clinical systems need to integrate more effective mechanisms to both identify inappropriate behaviours early through real-time analytics as well as integrate warnings and alerts that deter inappropriate access in advance of the actions occuring.

If this physician was aware of the risks and realized that her behaviour was going to be detected, I doubt that she would have proceeded.

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

PS Suite EMR Acquired by TELUS Health

TELUS Health announced today its offer to acquire the electronic medical record business (PS Suite EMR) operated by MD Practice Software LP, a member of the MD Physician Services Group and a subsidiary of the Canadian Medical Association. Closing of the transaction is scheduled for Monday March 4, 2013. (Financial terms of the agreement were not disclosed)

TELUS has invested over $1 billion in healthcare over the past five years in multiple sectors including claims transaction processing through the acquisition of Emergis, pharmacy systems and now EMRs. Over the past year, TELUS has acquired Wolf Medical Systems in Western Canada and KinLogix in Quebec. According to data provided by TELUS, as a result of the acquisition of PS Suite, TELUS Health will provide EMR solutions to 9,000 physicians across Canada. With provincially certified solutions in the four largest provinces, this will provide TELUS with a strong footprint in Alberta, British Columbia, Quebec and Ontario. EMR market consolidation has accelerated over the past three years led initially by QHR Technologies and more recently by TELUS Health. See October 2012 CanadianEMR Article 'Consolidation in the Canadian EMR Market'

What does this mean for the EMR market in Canada and for practices that currently use the TELUS Health EMR products?

I had an opportunity to discuss the acquisition with Dr. Brendan Byrne, VP Physician Solutions for TELUS Physician Solutions. The following is a summary of that conversation.

AB: "With the acquisition of PS Suite EMR, I see one of the challenges being how you will maintain three different EMR products, although they are in three different markets. Do you plan to transition users to one primary EMR system?"

BB: "No, we will be supporting users in each of the markets served by the three products. Our focus is to maintain and focus upon physician relationships. TELUS Physician Solutions has been structured as a single business unit with three products. We have 300 employees across the business unit and over the next 3-5 years we plan to support each of the systems as we analyze the strengths of each platform. Our objective is to develop a next generation world-class solution over that time as the next evolution of our EMR strategy."

AB: "What are your plans in terms of getting all of the product teams working together?"

BB: "We see this in four phases. Phase 1 will be a period of stabilization including taking over the operations of PS Suite. Phase 2 will be focused on discovery in terms of product decision making. During phase 3, we will begin to introduce new collaboration services, such as building connections between EMRs and pharmacy systems and phase 4 is our national platform development. Many parts of these phases will run concurrently."

AB: "You have some unique challenges, for example in Ontario PS Suite is offered both as an ASP and as a local server version of the product. Will you continue to support both versions? In Alberta, with Wolf Medical and PS Suite both being offered as provincially certified EMRs (2 of the 3 certified solutions), how do you plan to manage the products in the same province?"

BB: "In Ontario, approximately 13% of physicians use the ASP (Cloud) based version of PS Suite. The majority of physicians continue to use the Local Server version of the product. We will continue to support both versions. Similarly, in Alberta we will continue to support both PS Suite and Wolf Medical."

AB: "What insights can you provide about the market? As the dominant provider in Canada in terms of market share once the acquisition is complete, what do you see as the next area of focus for EMRs?"

BB: "Up to this point, I believe we have spent too much time focused on regional issues. We need to move beyond regional performance and focus more on patient outcomes rather than EMR products."

AB: "If one looks at the user demographics for the three EMR products within your business unit, your customers are dominantly primary care physicians. Will primary care continue to be your main focus?"

BB: "We see that the next phase of growth in the EMR market in Canada is going to be through the specialties. We are already investing in and building capabilities to support the sub-specialties such as pediatrics and psychiatry. This will be a key strategy for us."

AB: "How do you define success as the TELUS EMR vision evolves?"

BB: "Success will be having more doctors using more of the functionality than what they have today. Too many doctors are not fully realizing the benefits of their EMRs."

With the acquisition of PS Suite from the Canadian Medical Association, two important dynamics will be unleashed. Canada's EMR market is beginning to mature and what we see is the emergence of a small number of dominant EMR vendors. At the same time, with the sale of the EMR business division, the Canadian Medical Association will be free to return to its role as a powerful independent advocate on behalf of Canadian physicians. Both, in my opinion, represent a movement in the right direction for Canadians.

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

Powering Primary Care - New BC Initiative

Technology (including EMR) is an important enabler as we strive to improve patient care and reduce waste within the healthcare system. However, if isolated from policy, legislation and compensation, EMRs alone cannot solve the problem of limited access to care. 'A GP for Me' is a joint program between the Government of BC and the BC Medical Association, created through the General Practice Services Committee (GPSC) which has been put in place to assist approximately 176,000 patients who cannot find a family doctor.

A February 23rd article in the Vancouver Sun provides further details on the $132 Million program. One of the stand out features is the designation of funding for telephone consultations with patients in order to more efficiently manage care without needing to bring that patient into the office for a face-to-face consultation in order to be compensated. (Until now this was the only way a fee-for-service physician could be paid to manage a patient unless they were covered under a different program e.g. chronic disease). What this equates to is up to 500 telephone consultations with patients per year at $15 per consultation (with critera that will need to be followed). However, it is an important recognition of the capability to manage patients effectively using the most basic form of telemedicine, the telephone.

I believe that there is one element of this strategy that has not been addressed. After a number of years of working as a part-time family physician in a walk-in clinic, I am convinced that convenience will continue to win over quality 9 times out of 10. What I mean by this is that even with a family physician, unless there is a mechanism to link a patient to a doctor or practice and place some accountability on patients to attend their 'new' family physician for the majority of care, we will not really solve this problem. Granted, the +/-176,000 patients may find a family physician, but if patterns of access to healthcare do not change, their new family physician will be utilized just like the 'old' family physicians and become the repository for copies of lab results ordered by walk-in clinics, visits to Emergency Departments and requests from 3rd parties for documents or from lawyers for medical legal reports.

Don't get me wrong. I believe this is an excellent step in the right direction. My only concern is that people do not change their behaviour patterns very easily. I believe that patients will continue to attend any walk-in clinic that is convenient for the majority of their episodic care. With all of the additional primary care capacity being created within the healthcare system, effective utilization is a necessity.

Do you have any thoughts or experiences you would like to share? Click on the 'Comments' link below.