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

The Complexity of Data Migration

Two weeks ago, I participated in the POSP education session "From Choosing to Using Your Complete EMR Solution 2". A good part of the day dealt with the issue of data migration and the maintenance of the quality of information as a practice transitioned from one EMR to another. What is quite clear from the presentations and discussion is that data migration is no simple task and requires data cleaning, the mapping of data from fields in one system to another to ensure that the information is transferred to the right place in the new EMR and also a process to validate the data in the new system and make sure that it is correctly transferred. This process can take months of work and is very time consuming and costly.

My personal experience with data captured in an EMR highlights the importance of having a robust data transition process and using an EMR that is well supported in Canada. In 2001, I selected and implemented an electronic medical record system that had been developed for the US market called CliniFlow. At that time, the functionality offered by CliniFlow was extremely sophisticated and I was impressed by the capabilities it would offer from a patient care perspective. Based upon a commitment by the company to bring CliniFlow into Canada and develop a full Canadian version of the product, I agreed to be the first implementation site in Canada.

A laboratory interface was developed to deliver private lab results into the EMR and in conjunction with the BC College of Pharmacists, permission was obtained to fax prescriptions directly to pharmacies with a unique identifier for each prescription. I began the process of implementing CliniFlow soon thereafter.

Between 2001 and 2003, existing patient data was migrated to the EMR and I was well on my way to implementing the EMR. However, there were still two unanswered questions from the EMR vendor. When would they make the official commitment to fully supporting the EMR in Canada and when would they commit to development of a Canadian billing module integrated with the EMR?

Despite the initial work and use of the system in my practice, the vendor decided not to officially enter the Canadian EMR market. Not having an officially supported EMR left me in a difficult position. Should I shut down CliniFlow or should I develop an alternative strategy that would allow me to continue using the system while at the same time reducing the risk of my data being held hostage in the EMR or incurring significant cost when and if I was able to transfer the data to a new EMR system? My solution from late 2004 was to run a hybrid practice. To use the most useful features in CliniFlow, while at the same time maintaining a complete paper chart for each patient in which I recorded encounter notes, the information that I was most fearful could not be transitioned to a new EMR particularly as much was stored as discrete data elements. Copies of reports and non-laboratory information were scanned into CliniFlow and the original copies were kept in the paper record.

Was this an ideal solution? Not by any means. After fully implementing CliniFlow, I made a conscious decision to step back to a hybrid practice in order to ensure I did not become a hostage of an unsupported EMR system.

I hope this serves as a useful lesson for others who may be considering the implementation of an EMR system not supported in Canada. In 2004, this was a problem, but is much less of an issue in 2010 as there are many highly functional EMRs available in most provinces.

What features did I continue to use in CliniFlow up until the time that I closed my medical practice in 2007? The list is extensive and includes:

• Medication profiles;
• Lab results and graphing for chronic disease management;
• Allergy lists;
• Drug interaction checking;
• Transmission of prescriptions direct to pharmacy;
• Management of incoming documents;
• Remote access to clinical information from home;
• Notifications and reminders;
• Problem lists.

Although not an ideal solution and one that required more work than either electronic or paper alone, what this approach allowed me to do was maintain the integrity and completeness of each patient record without fear of being unable to transition the data from CliniFlow to a new EMR.

What has been your experience with data transition from one EMR to another? I am interested in your comments and feedback regarding challenges and lessons learned.

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iPad and EMR - Where is the Value?

The iPad was released today in Canada in addition to the UK and 7 other countries. iPad fever is very much alive and many of the early purchasers of the iPad are developers and content companies who will commit their energy and resources to the development of applications. A significant number of those will be focused on healthcare.

But, where is the value for tools like an iPad when it comes to the EMR? EMRs that are purely browser-based should function on the iPad. Data input using the software keyboard may be more difficult than using a regular keyboard. In addition, the iPad is designed to function with finger movements and gestures. As a result, we are likely to see new and novel ways to capture and enter data.

I believe that the iPad is going to perform extremely well as a prescribing device. The iPad represents a whole new genre of computing devices. Other companies are not sitting idly by, so watch out for a wide range of new tablet sizes, features and functionalities from companies such as HP, Dell and Acer.

Medical evaluation websites are also developing as the demand for these applications grows. For example, see iMedicalApps.

What is your experience? Are you using an iPad for medical care?

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Lab Result Portal Launches in BC for Patients - MyeHealth

One of the trends that we are beginning to see in Canada is organizations that are leveraging their existing technology services to provide information to directly to patients.

I often hear from patients that they would like to be able to see their most recent lab results without having to contact the doctor's office or come in for a visit. A growing number of hospitals and EMR vendors are providing this service directly to patients through patient portals and a new service that has just launched in British Columbia is 'My eHealth' which provides patients with secure Internet access to their lab results through Excelleris (a joint venture between Life Labs and BC Bio).

My ehealth is a free service for BC patients and is available in 4 languages. Click here to view the 'MyeHealth' web portal

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How do EMR Vendors Differentiate their Products and Services?

Recently I have the opportunity to talk to a lot of different people in the US and Canada regarding EMR adoption and use. What strikes me is that although the two countries are on different pathways in terms of their national strategies for electronic health records, the need to encourage better outcomes and measure performance are recurrent themes in these discussions.

Determining the right measures and desired outcomes is not easy. In fact, setting the sensitivity levels so that the objectives are achievable is even more complex. Currently in the US, there is a great deal of work underway to refine the Meaningful Use criteria understanding the the entire electronic health records industry is going to undergo change of unprecedented proportions over the course of the next five years. The trend towards rewarding outcomes is undeniable and it is beginning to filter across the border.

In Canada, funding programs to support EMR adoption by physicians have tended to focus on functional requirements with certification programs for qualified systems. Outcomes based incentive programs have been established and managed by other provincially established entities. There has not generally been a close correlation between outcomes and EMR adoption, although information technology and EMRs have been seen as critical enablers. An example of this in British Columbia would be the PITO program which is tasked with supporting adoption of EMRs by the province's physicians, the Impact BC - Practice Support Program operated by the General Practice Services Committee in conjunction with the BCMA and Ministry of Health Services and the Full Service Family Practice Incentive Program. The objective of all of these programs collectively is to improve outcomes and delivery of care. It is also highly likely that we will see some of the concepts of meaningful use introduced and integrated into existing programs.

In an environment in which EMR vendors are increasingly providing software that is similar in terms of features and the ability to support specific outcomes and reporting, how will vendors differentiate themselves from their competitors? As the market matures and the products become commodities, a different set of rules will govern success.

For example, EMR vendors will need to:

• Identify highly specific niches so that they can provide a service not provided by other companies, for example focus on sub-specialty needs or areas that may not be well served such as ophthalmology, oncology or the management of clinical trials;
• Compete on service, support, training and providing a consistent high quality experience for users of their product(s). Just as Apple always scores highly in reagards to user satisfaction, it is quality, simplicity and reliability that differentiates Apple from competitors;
• Provide additional value added services to support the EMR e.g. telephony services (through digital lines - VOIP) or integrated transcription services.

At the moment, we are still bogged down in achieving a critical mass of EMR adopters, but at some point, we will shift from choosing EMRs based upon functional features to products that are able to consistently support their users based on quality measures and will be able to grow as the users needs evolve.

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Funding for 15 Beacon Communities Announced in US

Vice President Biden and U.S. Health and Human Services Secretary Kathleen Sebelius today announced the selection of 15 communities across the country to serve as pilot communities for eventual wide-scale use of health information technology through the Beacon Community program.

The $220 million in Recovery Act funding is being awarded to a number of high profile programs to enhance their success and create a series of national demonstration projects featuring health IT adoption and use.

Read the full announcement: Beacon Community Program

Understanding the Psyche of EMR Users - A Step in the Right Direction

I was recently listening to a medical colleague speak about his experiences related to EMR adoption and use. He made a very interesting point. He explained his role as an internist as one of continuously looking for problems. When presented with a clinically challenging diagnosis, it is the role of the physician to be thorough and identify everything wrong with the patient, no matter how minute the problem. It is this attention to detail that allows one to make difficult diagnoses.

This very characteristic is problematic for physician users of EMR solutions. Physicians are trained to identify what is wrong, not praise what is right. As a result, show any EMR to a physician and they will always be able to point out features and functions that are not quite right for that physician's practice. The EMR is too slow, there are too many mouse-clicks, the workflow is wrong, the templates are missing key information, the system does not really support the way that 'I' work. These are all commonly heard complaints.

By nature of our training, physicians are perfectionists and when it comes to clinical management of patients, there should be no compromises. These are hard boots for any EMR to fill.

The other challenge for EMRs is that they are still early in development. Certain capabilities may be streamlined, but many require years of work and optimization in order to meet the needs of the majority of users. This need for optimization and improvement never stops.

The question that we should be asking is whether the EMRs provide features and functions in order to meet the majority of needs of physicians as users? In other words, is the EMR good enough? Rather than focus on everything that is wrong about an EMR, if physicians are able to select systems that are matched as closely as possible to their needs, is that enough? Without a doubt, I would say yes to this question.

There is no doubt that EMRs vary with respect to their speed, functionality, applicability to specialty needs and according to a myriad of features and functions. There is not one that is perfect. However, there are many that are good enough to significantly improve the function of medical clinics, initially getting the internal house in order and as more advanced capabilities become commonplace such as E-Prescribing and information exchange, adding these capabilities to a more smoothly functioning practice.

Pilots describe a 'glide path' as the final path followed by an aircraft as one is preparing to land. Choosing an EMR is like being on a glide path. The airstrip may be far ahead, however it is important to ensure that the system is good enough to ensure a safe landing.

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