In a review of the 2006 Commonwealth Fund survey data clearer evidence emerges that use of Electronic Medical Records is linked to patient safety and ability to deal with adverse events. Canada continues to lag behind other countries, including the US. Key Findings from a January 28, 2009 Commonwealth Fund report:
Electronic medical record (EMR) usage ranges from nearly all physicians in the Netherlands to only 23 percent in Canada and 28 percent in the United States.
Physicians in the U.S. and Canada, the two countries where EMR use is lowest, reported predictably low use of associated computerized systems. For instance, only 15 percent of physicians in the U.S. and 6 percent in Canada used computerized systems to receive alerts to provide patients with test results.
In the United Kingdom, 88 percent of primary care physicians can easily generate lists of medications that patients take, including prescriptions from other doctors, compared with only 37 percent of doctors in the U.S.
The ability to generate medication lists promotes coordination of care among doctors and can help prevent medication errors.
Over three-quarters (78%) of primary care physicians with high IT capacity felt well prepared to care for patients with multiple chronic diseases, compared with only 66 percent of physicians with low IT capacity.
There is a strong relationship between IT capacity and patient safety: the greater the capacity, the more likely a practice has a patient-safety system in place. More than two of five (43%) physicians with high IT capacity had a process for dealing with adverse events, compared with 27 percent of practices with low IT capacity.
Thirty-one percent of primary care physicians with high IT capacity and 28 percent of those with medium IT capacity reported their ability to provide quality medical care had improved over the past five years. By contrast, just 22 percent of those with low IT capacity reported similar views.
Just as is taking place in Canada, US physicians are being advised to begin their early planning for EMR adoption and use. In an article, published in Health Data Management, US physicians are advised to begin planning for their incentive program funding by the 3rd quarter of 2009.
Health Data Management: February 23, 2009 - Physicians without an electronic health records system should start work soon to get one so they can qualify for Medicare and Medicaid incentive payments under the economic stimulus law, says Michael Mytych, principal at Health Information Consulting LLC, Menomonee Falls, Wis.
Those incentives start in 2011 and waiting too long means running out of time and not getting all the available incentives, he adds. "They probably should start by the end of the third quarter of this year or they won't be ready."
The new law will enable physician practices to receive at up to $44,000 per physician in incentive payments over five years, according to the legislation. Physicians meeting certain criteria, such as serving an underserved rural region and having a certain case mix of patients, could get more than $60,000.
Many physicians have no idea how long it takes to select, implement and start using an EHR, or to rollout the functions needed to meet the "meaningful use" requirements for incentive payments. Click here to read the full article
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During the past week, I have been working in Singapore with their Health Informatics Team. Not only does this afford me the opportunity to contribute to the Singapore eHealth program, it also provides exposure to different approaches and 'ways of working'.
There are certain approaches to problem-solving that work extremely well in Singapore. In many cases, these are logical and practical solutions. For example, a solution for taxi drivers and car owners to pay for parking or road tolls is a device in every vehicle that is linked to all parking companies or agencies responsible for tolls. A driver can park anywhere in Singapore and their individual account will be debited automatically through this wireless device. In addition to the convenience of being able to access and park in any location without needing to take out a credit card or look for cash, companies and agencies do not need parking attendants, always know how much capacity in their parking lots is being used and know the traffic flow volume on major routes, 'in real time'. In addition, because there is no need to collect payment at multiple points, there are no waiting lines and the overall traffic flow is more streamlined and efficient.
What a smart solution - all pivoting around centralization of system management data that can be used to open capacity where needed, identify problem areas and apply the right resources. It is cheaper, more efficient and allows for effective system management and planning.
With further funding to support EMR adoption by physicians (expected through additional funding recently received by Canada Health Infoway), it becomes even more critical to have high quality and relevant information available to physicians, system managers, vendors and funders. Just as described in the parking example above, this should be as seamless as possible.
I believe stakeholder groups need the following:
Physicians: Help with information on selection of an EMR (based on user-contributed ratings data), best practices from a multitude of sources to assist with implementation and use (and real people to help with the process) and the ability to benchmark progress. In other words, gauge where they are in comparison to similar groups of peers based on anonymous aggregated data.
System Managers: Provincial programs need to be able to measure uptake and use of EMR systems under their watch. In addition, they must be able to respond to identified problems and needs whether these are people or technology issues and quickly implement solutions.
Vendors: Vendors of EMRs need feedback regarding their products and services, recommendations on features and future user requirements and how their systems are performing in the marketplace. Market forces will prevail in a system in which there is transparency.
Funders: Governments need to know that scarce public dollars are being invested wisely and are delivering results.
It is not possible to accomplish this without real-time reporting capabilities. How does one measure progress, current state and plan for future needs when the only data available is years out of date?
The list I have provided is not intended to be comprehensive, however it is a beginning and if we could do the above, I believe we would be a lot better prepared for success than we currently are. If you have thoughts, comments or suggestions regarding this list or the concept of real-time reporting, please click on the 'Comments' link below.
Dr. Jessica Otte describes herself as a (soon to be) Canadian Family Practice Resident on her blog, dr. ottematic. She describes eloquently what her perceptions are of Electronic Medical Records and whether they will be useful to her when she enters practice.
'As someone who will be out in practice in my late 20s, I’m keen on using technology as much as possible insofar as it can help me better care for patients. While the paperless office may be still in the distant future, digital forms of charts, lab results, radiology, and consultants letters are easily incorporated into practice. I’ve done rotations in offices that are heavily IT oriented, and in old-school, “everything on paper” clinics. Is the level of care different? Probably not. But there may be less scut work, and the technophile in me will be happy.
More and more I realize that there is too much in medicine to “know.” I’m not a good rote learner. I’m better at figuring things out, spotting patterns, and teaching people. As the amount to learn becomes overwhelming, I find myself thinking of myself as an expert who can access and apply knowledge instead of as a walking medical encyclopedia.
There are several advantages that I am personally looking forward to.'
Ophthalmology is a highly advanced specialty from a technology perspective. In fact, laser eye surgery, corneal transplants, cataract surgery, retinal surgery are all dependent on technology of some form or another. So, why have ophthalmologists been late adopters of EMRs? Dr. Robert Schertzer is a glaucoma sub-specialist and a long time user of EMR. He describes his experience using an EMR, how specialists differ from GPs in terms of their use of an EMR and suggests why his colleagues have been resistant to adopting electronic medical records.
Listen to the Podcast
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There are many facets to Personal eHealth from google searches about a specific condition or medication to on-line delivery of health care services. I was intrigued by a recent announcement from the Hawaii Medical Services Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Assoction which provides health insurance to more than half of Hawaii's residents. Their new Online Care service connects individuals seeking medical care with participating physicians either by phone or online using Web-based videoconferencing or secure chat. The service is highly interactive, with individuals able to have a real-time conversation with a physician.
According to HMSA, "Online consultations are not meant to replace in-person doctor visits; they simply provide another health care choice for talking to a doctor about a non-urgent condition or getting advice or answers." In addition to providing advice about non-urgent conditions, physicians can also refill prescriptions, discuss medication discussions, or explain generic drugs.
One interesting aspect of the Online Care service is its use of Microsoft's HealthVault, a secure repository of an individual's health and medical infromation that is controlled by the individual, not by a healthcare provider organization. I have been following HealthVault for some time and will write more about it in future posts. The Online Care services uses HealthVault to store and retrieve personal health information. Since each person's HealthVault is controlled by them they can decide what information they wish to share and with whom they want to share it.
According to HMSA, participating physicians "have a great degree of flexibility, convenience and freedom while practicing online. These doctors can now see patients from home if they so choose. Doctors can also log on as they please; they don’t have to schedule a specific time and can work at any time of day for however long they choose."
What do you think of the Online Care service? It is a model that could work in Canada? Do you think that online delivery of specific healthcare services is a viable model? Can it offer real benefits to patients and physicians?
In an interesting and useful approach towards dealing with a persistent shortage of care providers, the Ontario Ministry of Health and Long Term Care has released a new web site aimed to support better system navigation called 'Health Care Options'. The web site states:
"Ontarians often don't realize there are alternatives to an emergency room visit, or where to find those options. Your Health Care Options Medical Services Directory is a user-friendly searchable database of walk-in and after hours clinics, urgent care centres, and family health care providers. By entering your postal code you can find out the hours and services available in your community."
The following was sent to me by a colleague who uses an EMR. The incident description has been modified, but is based on a real situation.
A patient is seen at one of Canada's foremost primary care clinics (but not yet using EMR).
A menopausal 52yr type 2 diabetic patient presented at her family physician's office with pelvic pain. A urine test was ordered and the patient was told she would be called if the results were abnormal. The result arrived the next day showing evidence of a urinary tract infection. The paper report landed in a pile on the doctor's desk. [EMR improvement: abnormal lab results cannot be ignored, and must be acknowledged. Messages to staff re action required are quick and easy. Another EMR improvement: if the lab report never arrives, the EMR can alert the doctor at some later date that the expected results aren't back.]
The patient, still in pain, calls the clinic two weeks later. The secretary bluntly told the patient that abnormal results are called out, so if she had not received a call, the test must have been normal. The secretary cannot call up the chart from medical records as it is too much work. [EMR improvement: looking up a patient's recent lab results takes about three seconds. The secretary would see red on the screen from the abnormal result, rather than just "seeing red".]
Later that day, the patient went to an evening clinic at a walk-in clinic. A urinary tract infection was diagnosed and Cipro ordered. The pharmacist warned the patient to "watch her sugars" because of a potential drug interaction with Glyburide, her diabetic medication. [EMR improvement: the prescribing physician would see the potential Glyburide interaction of "profound hypoglycemia" and the recommendation to use a different antibiotic.]
Several hours after taking the Cipro, the patient dropped into a non-arousable deep sleep. The family assumed that it was because she had been up for several nights with pelvic pain and was catching up. She could not be aroused the next morning. Paramedics found a blood sugar of 2.0 and were able to resuscitate the patient after 40 minutes. After a day in the hospital and a couple weeks of tiredness, the patient survived without damage. A fortunate outcome to a potentially disastrous situation.
Are doctors in 2009 practicing 'impaired' if they are not using EMRs and Information Technology to support their delivery of care? How often are these near-misses occuring? Is this a rare or frequent occurrence?
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