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

Keeping Up with EMR Features — When to Get More Training

Ask any physician who has implemented an EMR whether he or she could benefit from additional training and you are likely to get an affirmative response. Training is usually viewed by medical practitioners as an expense rather than an investment. Since most consumer electronics are easy to use, it leads one to believe that EMRs can be learned intuitively and with a minimum of training. After all, when did you last read the manual for your latest smartphone? You just picked it up and it worked. What you could not use immediately you learned over time through a slow process of diffusion, or because your teenage son or daughter provided a tutorial.

Why is training so important? And can you forecast your training needs so that the costs become more predictable and you are able to build them into your practice budget?

The following diagram represents the level of effort that is required when transitioning through the various stages of EMR adoption and use.

• In the pre-EMR phase, paper processes are used dominantly. Little effort is required to use long tried and tested methods for documentation, orders and prescriptions.
• Readiness preparation results in an intense burst of effort for a period of time until the practice is ready for implementation.
• The implementation phase is one in which there is the greatest disruption to the practice. New systems are installed, old workflow is re-engineered to accommodate the EMR, and for a period of 6–12 weeks there is an intense effort with a loss of productivity as practice members learn how to use the technology.
• From that point onwards, the practice is dependent on the EMR and information technology in order to deliver care... indefinitely. Each time a new feature is introduced, or a practice begins to use a specific capability of the EMR, more training is required.

Training can be provided in a number of ways:

• Formal training — bringing in a vendor to provide advanced training on new features or to optimize use of existing features.
• Super users who are trained to provide support and assistance to clinicians and staff through on-site expertise.
• Small group learning — getting together with peers in order to share tips and learn from others.
• Online learning modules provided by the vendor or through online training sessions and webinars.

Ensure that someone in your practice is required to review new features when your EMR system is updated. The EMR vendor usually provides advance notice of any needed upgrade and will publish a list of updates and enhancements. If possible, this individual should have some clinical experience in order to provide appropriate updates to other members of the practice with respect to features that are going to be of greatest value. If you are using an ASP- or Cloud-based EMR system, updates can be more complex to monitor, as the EMR may be regularly updated without a report every time a small enhancement is made.

If you have super users in your practice, make sure that they attend vendor training sessions on a regular basis and are given adequate time to improve and maintain their EMR skills. This expertise will provide invaluable onsite knowledge in the event that someone from your practice needs assistance.

Finally, make sure that you have a process for training new clinicians and staff. Staff and clinician turnover is an inevitable part of running a practice; however, many practices fail to train new staff members to use the EMR and assume that these individuals will gradually figure it out. This approach can be costly and time consuming, particularly when data is incorrectly stored in the wrong section of an EMR. A 30-minute guerrilla program can be developed to provide basic EMR orientation, but these individuals all require some form of ongoing training to ensure they are utilizing the EMR correctly.

If you have any additional experiences or insights regarding training that you would like to share, click on the “Comments” link below.

eHealth 2012 — Dr. John Halamka’s Keynote

The eHealth 2012 conference kicked off with a keynote address from Dr. John Halamka, CIO, Beth Israel Deaconess Medical Center in Boston. Approximately 1,600 of the informatics and Health IT faithful are gathered in Vancouver for this three-day event. In a departure from previous years (which were much more technology focused), the program has become increasingly more focused on delivering value to clinicians and improving patient care and driving value in the healthcare system.

Dr. Halamka shared his experiences provided an in-depth review of his wife’s online medical record, explaining how data was captured and shared amongst multiple care providers as she recently underwent treatment for breast cancer. His wife is now in remission. The following are notes taken during Dr. Halamka’s presentation:

Challenges to Ensure Universal Adoption of EMRs

• Getting data into an EMR is not like writing a letter. Need to make data structured, but this adds time to the day — make data input simple.
• Form factor is important. There are 1,000 iPads in Beth Israel. Doctors and nurses have purchased the devices themselves. The form factor is right for healthcare.
• Technology must integrate into workflow.
• Care is team based. Technology must leverage the power of the care team.
• Strategy at Beth Israel — Agile continuous improvement of the EMR. Every time an organization undertakes a structured procurement, innovation in small companies is quashed.

Accessing Data in EMRs

• Getting to other record systems from within the EMR — Use one-click where possible.
• At Beth Israel, the patient record allows multi-disciplinary entries by multiple clinical team members into a shared record. It functions like a WIKI.

How to Motivate a Clinician

• Pay them more.
• Give them more free time.
• Public humiliation.

Data Capture

• Every click makes my day longer.
• Where do we need structured vs. unstructured data?
• Vital signs need to be structured.
• Medications need to be highly structured.
• Use of natural language processing holds great promise for narrative note interpretation.

Engaging Patients and Families

• In Boston, did a study with 12,000 patients who were allowed access to all data in their own notes. There were concerns about patient access and safety. Nothing negative happened.
• Passport to trust. Patients can see everything and can have a care plan designed specifically for them.

Memorable Quotes

• Computerized lab order entry — From the doctor’s brain to the patient’s vein in one step.
• Healthcare information exchange should be frictionless.
• We thought, “We will build cool technology and ‘they’ will come.” This did not work.
• Unless you innovate, you could become a Blackberry in an iPhone world.
• Innovation can be accomplished with creative policy and technical solutions.

The Challenge of Date and Time Synchronization

Have you noticed that almost every device, software application, and piece of equipment that is currently available has a built-in clock? No longer the exclusive domain of the trusty wristwatch, time keeping capability is pervasive. This very useful capability is used to date and time stamp documents, images and communications; it also synchronizes applications and organizes the chronology of events so that it is possible to identify errors and reconstruct scenarios. But what happens when the time and/or date stamp is incorrect?

There is a natural assumption that if a document (or email) is date and time stamped, the associated chronology is correct. While this may be true in a single application, for example the internal operation of an Electronic Medical Record system, with an increasing number of connected devices and applications the assumption may be incorrect. A May 23, 2012, article in The Economist titled “A ticking time bomb” pointed out the folly of this exact assumption. The author described the experience of an anaesthetist at the Massachusetts General Hospital in Boston. With multiple high-tech devices feeding data into a central clinical information system, the benefit is instant access to a wide range of information for split-second clinical decision making. In the article, the anaesthetist noticed that the time at which he had administered anti-coagulant therapy showed that his digital coagulation device was eight minutes slow. Human intelligence detected a technical error. If the anaesthetist had been replaced by a colleague who was not aware of the exact time of the initial anti-coagulant administration, the risk could have been catastrophic for the patient. All because the information fed into the EMR system was trusted as being accurate. The author states:

“Results presented recently at the CPSWeek conference in Beijing, are unnerving. Of over 1,700 devices checked, only 3% were found to be accurate to within three seconds. One in five were off by more than 30 minutes; one ultrasound machine was running 42 years (and some minutes) early. The average error was a staggering 24 minutes.”

This degree of inaccuracy is surprising. If the data in an EMR did not match the recollection of the physician, it would be impossible to say whether computer or the clinician were correct.

As more devices become interconnected, the risk of time and date discrepancy increases. Along with this discrepancy, the risk of medico-legal issues grow. It will be crucial to address this issue as a previously unintended consequence of technology adoption and use.

Share your experience with date and/or time discrepancies. Have you encountered this problem? Click on the “Comments” link below.

New Ratings Published on CanadianEMR

Rating data for EMR products is continuously updated on CanadianEMR. This data is collected through new users who register and complete a short satisfaction survey, and through existing users of EMRs who have previously submitted a rating and return to submit updated rating data.

A survey of EMR users has just been conducted in conjunction with OntarioMD, providing updated rating data for Ontario certified EMR products.

To view the latest ratings for EMR products, click here.

If you are a user of an EMR and have not submitted a rating, please take a few minutes to register on CanadianEMR and provide your feedback. Remember to register as a Rater, select your EMR, and submit a rating. It takes just five minutes and provides valuable feedback to colleagues and to the entire EMR market about your product and how it is performing.

Sign up and rate your EMR

Hiring an IT Consultant — Can You Trust the Guy Down the Street?

The majority of physicians I know are very protective of their personal workspace. They do not like outsiders traipsing through their practices, potentially compromising patient privacy. They also do not like having anyone mess with their computers, servers, EMRs, and billing software. After all, if it is not broken, why fix it? In a solo or small medical practice, it can be difficult to justify the expense of regular computer and network maintenance, particularly when it comes at a cost that exceeds the medical practitioners’ hourly revenue-generating capabilities. However, without maintenance, both short- and long-term costs of an EMR can be significantly higher.

It can also be very challenging to find the right IT support services for your practice. In some settings, choice may be significantly limited by geography and availability of skilled personnel. In addition, hiring an IT consultant requires a different approach compared to the hiring of a full- or part-time employee. An IT consultant is generally brought in to complete a specific task in an area in which he/she has domain expertise. They are expensive contractors and, as a result, it is important to find the right person for the job at hand. Medical practices have certain unique requirements from a workflow and patient privacy perspective and ideally your IT consultant should have a basic understanding of medical privacy rules and practice operations. In addition, to extract the maximum value, you should clearly define your expectations upfront to ensure that the work is completed satisfactorily and according to plan.

How can you limit your risk and find the most appropriate person to assist with your IT needs?

Consider the following:

• Do you need an IT consultant to support your hardware and computer network in your practice on an ongoing basis or do you intend to hire someone to assist your practice through the entire EMR selection and implementation process? In these two settings, your needs will be very different.
  • Pure technical support skills and services will be more widely available either locally through a small independent contractor or through a larger IT support company. These individuals know how to maintain hardware and networks and ensure that backups are done correctly in addition to replacing hardware components such as hard drives before they fail. Think of them as your preventive maintenance support. These individuals are also valuable to recommend new hardware (computers, printers, scanners, wireless routers) when these pieces of hardware need replacement as they work with technology and get to know the best and most cost-effective products.
  • Full service consultants are more difficult to identify and are in lower demand in Canada in comparison to the United States. These are individuals who have the skills and knowledge to conduct a full assessment of your practice (clinical and administrative needs) and lead the selection, product evaluation, implementation and early support when the product is implemented. In busy practices, the task of evaluation is frequently delegated to a staff member (medical office assistant or practice manager), the full service consultant would take over these roles on behalf of the practice. From a practical standpoint, hiring this type of individual is only cost-effective in a large practice (20+ physicians) in which there is a great deal of complexity and specific requirements that are may be difficult to meet. Smaller practices should carefully evaluate the costs of this type of employment contract as the time frames to select and implement EMRs are generally long (6 months+) and this could be an expensive proposition in addition to duplicating some of the support services that are available at no cost to the practice through a provincial EMR program (e.g. POSP, PITO, OntarioMD etc.)
• The most common scenario is one in which a practice will need an IT consultant to support the office network, computers and related hardware. How can you identify a trustworthy company or individuals to provide this kind of support service?
  • First, expect to spend some money for support on a regular basis. Having a consultant available only during a crisis does not make good business sense for either a consultant or for your practice. If your hardware gets to the point that it is riddled with viruses and hard drives are reaching the end of their lifespan, this is not a good time to call for help.
  • Speak to local colleagues in your area. Who have they used as an IT consultant and what is their experience? Quality of support, availability both on-site and by phone, cost of call outs as well as ongoing maintenance. Is the agreement for a certain number of hours per month or per quarter or do they have a fixed maintenance contract in which the consultant is paid a monthly fee to maintain the office hardware and network and is expected to do so on a regular basis?
  • If there is an EMR program in your province, speak with your designated practice advisor and find out if they can put you in contact with practices that use IT consultants. The EMR programs tend to remain agnostic and will not recommend individual contractors or companies, but they may know of practices that can provide some guidance.
  • Check references carefully. Do not miss this important step and ensure that when you speak with references, you find out whether they individual concerned has a good understanding of medical practice settings. Do not forget to ask the most important question, "Given the choice, would you hire this contractor again?"

Have you had experience with IT consultants? Do you have suggestions for colleagues? Add your thoughts by clicking on the 'Comments' link below

How Well Does Your EMR Fit Your Practice?

Are physicians using all the right criteria when selecting an EMR? This question was highlighted for me recently when looking to replace my car. You may see this as a rather strange and tenuous comparison, but hear me out and add your thoughts at the end of this post if you have had similar experiences.

When purchasing a car, there is almost a religious process that most people go through to identify the brand and model that suits them best. Consider the following:

• A car is one of the few major purchases that one makes on a regular basis (usually every 3–4 years).
• Needs change based upon one’s stage of life.
• Features are updated year-to-year and advances in engineering and safety that were once included in high-end vehicles become included as standard (e.g. air bags, proximity sensors, bluetooth, USB connectors, etc.).
• There are hundreds of options from which to choose, some more popular than others, but all seem to have some presence on the road.
• All vehicles go through a process of testing and certification before being made available commercially.

What are the common steps when choosing a car? Not presented in any rigid order:

• Consider your immediate needs. Large vs. small, sports vs. utility, import vs. locally produced, fuel consumption, etc.
• Search the newspapers for good deals, financing options, and dealer promotions.
• Narrow choice to a category or categories of vehicles.
• Research options on the Internet, read reviews, safety ratings, and consumer reports.
• Check features and specifications and compare to other similar vehicles in the same class.
• Talk to friends and colleagues who have purchased similar vehicles to learn about their experiences.
• Decide upon timing — when do you need the vehicle?
• Look into financing options — purchase or lease?
• Then comes the fun part — Visit the Dealers and Test Drive!
• You may drive many or just a single vehicle before making your decision. If you have done your research well, the test drive may simply be a confirmation of your decision.

The test drive is one of the most important stages of the selection process. It is the time you get to decide how the car feels when you drive it: comfort, amenities, braking, performance, spaciousness, etc. All senses are hyperacute as you experience the smells, visual feasts (or lack thereof), sound of the engine, and tactile sensations. Depending on your budget, you may choose at this point to add or remove features; however, it is also at this point that you may put the brakes on (literally and figuratively) and change your mind entirely about your choice. Why would you make that judgement call right at the time of decision making? Often it is because the vehicle just does not feel right. Despite your best attempts to identify exactly the features you want and need, when making that final decision, it can be the simple act of “feel” (hard to quantify as it is so personal) that makes the the decision for you.

When purchasing an EMR, even though the cost(s) can be as much as a car or significantly greater over the lifetime of the product, how much diligence is applied to the process of selection? Particularly since this is not a 3–4 year cyclical decision, but rather one that will have an impact on your work life for many years and perhaps decades? I recognize that it is not as much fun to drive an EMR in comparison to driving a car, but it is no less important.

The concluding recommendation in this article is that you should be test-driving your EMR. In fact, you may want to observe, use, and test it in more than one location (colleague’s practices) to ensure the EMR fits right and feels right for your style of practice. Do not miss this important step when making your decision and try to apply the same level of diligence as when purchasing a car. If in a large group, you may have no choice but to make concessions; however, whenever possible, trust your instincts and gut feelings. In the end, that may make the difference between an enjoyable ride or one that you may regret for many years to come.

What have been your experiences when selecting an EMR? Do you agree with the “selecting a car” analogy? What are the most important factors to consider when you make a decision?

EMRs and Crowdfunding — The Policy Connection

Those who read this blog will be aware of previous articles I have written about the EMR market in Canada — most recently an update on provincial EMR funding programs in Canada. First, let me clearly state that provincial EMR programs have played a critical role in advancing adoption of EMRs in Canada. However, the programs are governed by provincial legislation and policies; as such, it is their mandate to operate successful provincial programs — not look out for the health of the EMR industry as a whole. And therein lies the conundrum.

A healthy Canadian EMR industry needs competition, innovation, revenue, and growth opportunities for vendors and the ability for EMR vendors to sell their products unhindered across Canada. This is particularly important for the smaller provinces that do not individually offer sufficient market opportunity for some vendors to sell their products without taking significant risk. This is further compounded by dual language requirements if a product needs to be available in both English and French. Current provincial strategies require EMR vendors to develop and maintain provincial versions of their EMR systems. Even if differences between provincial versions are small, vendors must still maintain multiple code sets in order to ensure the quality of their products in each market. The drivers are perfectly logical. Each province requires EMR systems that are designed to meet their needs under provincial mandates and policies. However as discussed above, what is good for a province is not necessarily good for an industry.

So, where does Crowdfunding come into the picture, and how is it applicable to the discussion on EMRs? A May 2, 2012, article in the Globe and Mail titled Crowdfunding: Why Canada is far behind the U.S. describes a situation eerily similar to the challenges faced by the EMR industry.

According to the article:

Crowdfunding relies on social media platforms to bring entrepreneurs and companies together, not unlike an online brokerage firm. Among the companies developing an internet-based exchange is Durham, North Carolina-based Motaavi. One of the company’s co-founders is Nick Bhargava, who is originally from Edmonton. He has no intention of setting up shop back home in Canada.

Mr. Bhargava and his associates spent months lobbying Congress to make crowdfunding legal. That was no easy thing, but at least they could focus their efforts on one government: federal securities law trumps state regulations.

In Canada, Mr. Bhargava would have to seek rule changes in each of the 13 provinces and territories. He reckons that’s more trouble than it’s worth.

Sound familiar? According to the author, what makes Canada unattractive to entrepeneurs like Mr. Bhargava is that he would need unencumbered access to the entire country to turn a profit.

The value of the central regulator cannot be underestimated. While this role has existed for acute care and large provincial health IT systems under the auspices of Canada Health Infoway, provinces have developed much more provincially focused strategies for EMR programs, in many cases linked to provincial fee negotiations.

I would like to see a future with strong national EMR vendors competing vigorously for clients and innovating aggressively to enhance product features in order to deliver more efficient and higher quality care. Under the current systems and processes, I cannot see this happening without some fundamental changes in the way EMR systems are certified and sold. The alternative is less attractive. Canada will lag behind the U.S. in adoption and use of EMRs. Why? Because just as in the Crowdfunding business, the U.S. has a national regulator and strategies to encourage competition and sales of EMR systems across the entire market. Canada is just not ready to take that kind of leap of faith.

What is necessary to create a healthy competitive EMR market in Canada? Share your thoughts by clicking on the “Comments” link below.

Does Health IT Increase Ordering of Tests & Imaging?

The following article was written by Dr. Michael Barr for our sister site, AmericanEHR Partners. An excerpt is published here for your thoughts and input. Health IT is intended to improve efficiency and reduce duplication of ordering of tests and imaging studies. But is that the case?

A controversial study in Health Affairs this month has provoked a series of articles and public exchanges about the potential for health IT to reduce costs while improving quality. Why so much attention to this article? The conclusions of the study call into question whether health IT will result in lower healthcare costs. Here are some headlines:

• “Digital Records May Not Cut Health Costs, Study Cautions” (The New York Times, March 5, 2012 — requires login)
• “Doctors order more X-rays, not fewer, with computer access” (Washington Post)
• “Physicians Who Use EHRs Order More Imaging Tests” (iHealthBeat)
• “When EHR Critics Jump to Bad Conclusions” (InformationWeek Healthcare)
• “New study casts doubt on EHR cost savings” (EHRWatch.org)
• “Study Challenges Theory on Tie Between Electronic Access to Test Results, Cost Savings” (AAFP News Now)
• “Docs more likely to order additional imaging tests with electronic access” (FierceHealthIT)

The authors of the Health Affairs report (Danny McCormick, David H. Bohr, Stephanie Woolhandler, and David U. Himmelstein) concluded that:

• We found no evidence that office-based physicians with electronic access to imaging or blood test results order fewer imaging tests or blood tests, respectively. Indeed, at least for imaging, the reverse may be true: Facilitating physicians’ access to test results through computerization may increase diagnostic image ordering.
• Physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered. The electronic availability of lab test results was also associated with ordering of additional blood tests. The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key.

Their conclusions are based on analysis of the 2008 National Ambulatory Care Survey (NAMCS). The authors describe their methodology in detail, but many of the criticisms of the study are based on the source of the data and their extrapolation of the analysis to the policy implications offered at the end of their article...

Click here to read the full post and Dr. Barr's conclusions.