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

Integrating Patient Generated Data — Can the Information Be Trusted?

As personal health records (PHRs) and patient portals become more widely available, it is not hard to anticipate that more data will be integrated or at least available for integration with a physician’s EMR. In this context, if medical data is collected by knowledgeable individuals (e.g. with Diabetes Mellitus) and shared via a patient portal or email with a care provider, of course it should be trusted... right? Yes in certain cases, but not always. It is highly dependent on how the data within the EMR is going to be used and who else may be using the record.

Here are some important points to consider:

• What kind of data will be collected by patients and how will that data be shared with a provider or entered into the EMR?
• If devices are used to collect the data, e.g. glucometers or weight scales, how frequently are the devices calibrated and checked for accuracy?
• Is the information being used to monitor trends as supportive information, or is it critical data that could impact life-and-death decisions?
• Is there an element of manual error that can be introduced when data is collected, e.g. through transcription from a device to a spreadsheet (which is then emailed to the provider), or is the data reported directly from the device to the EMR?
• When data is shared by a patient with their care provider, how frequently is data reviewed before being accepted into the EMR?
• Can the data be rejected if it is felt to be inaccurate (e.g. calibration issues) and what is the follow-up process, e.g. office visit, telephone call, home visit, etc.?
• How is the data segmented in the EHR (i.e. kept separate from other results and information)?
• What is the single source of truth for critical healthcare information? An example of this is a new medication allergy. Consider a patient who has no history of allergies to any medications. That individual is prescribed a number of medications due to an acute respiratory infection, treated at the local hospital. One of the medications prescribed is an antibiotic called Moxifloxacin. The individual develops a skin rash and decides to discontinue all medications. He reports to his primary care physician (through the patient portal) that he has developed an allergy to Moxifloxacin. Should that information be integrated into the EMR? Can it be trusted as a source of truth?

Electronic Medical Records (although quite limited in terms of the sharing of information in a doctor’s office) are really information exchange systems. When operating effectively, they are designed to share information between multiple sources, effortlessly and securely. As a result, it is highly likely that an individual’s personal health information will exist in multiple locations and in multiple health information systems. This may also cause conflicts. Generally, the primary care physician’s EMR is considered a trusted, if not the most trusted, source of information. As a result, information stored in the physician’s EMR needs to be as accurate as possible because of the potential for that information to be propagated electronically to other systems through shared records, referrals, or consultation reports where information is automatically abstracted from the EMR.

While this is a hypothetical example, it is true that with any computer system, the quality of information that you get out is directly proportional to the quality of information that goes in.

The question is not whether patient generated data in an EMR can be trusted, but rather what policies and procedures need to be put into place to ensure that data is collected, transmitted, shared, and accessed in accordance with best practices. Integrating clinical data from any source requires adjustments to workflow and care delivery processes. These need to be carefully thought through before proceeding.

Do you use an EMR and integrate patient generated data? What are the pros and cons? Share your experiences and thoughts by clicking on the “Comments” link below.

Using Your EMR for Clinical Research

The following article was written by Will Underwood for AmericanEHR Partners and is re-published on CanadianEMR. Will Underwood, MPH is a Senior Associate, Center For Practice Improvement & Innovation, American College of Physicians.

One of the advantages of using an Electronic Medical Record (EMR) is its ability to simplify research activities to the point that even small medical practices can do their own research, either to support quality improvement activities within their practice or purely for research purposes. Determining what type of research you are interested in — and how you want to use the results — has implications in terms of needed functionality for your EMR and research policies that your practice needs to maintain. If you are interested in performing research using your EMR system, you should make sure that it records patient consent as a structured data field. In addition, the EMR should have flexible and easy-to-use reporting features. It should allow you to set up prompts that can alert you to patients that may be eligible to participate in the studies you are undertaking.

The first thing you should decide is how you want to use the results of the research. If you are just looking to use results for quality improvement purposes that are limited to your practice, you are generally not required by regulation/law to undertake an ethics board approval process and the requirements that related to patient consent are more flexible. However, if you are looking to publish the results and/or are conducting prospective research you may need to go through more rigorous processes.

The second thing you should determine is whether you intend to do a retrospective study (in which you will be using data that has already been collected) or a prospective study (collecting information going forward). Most randomized clinical studies are prospective in nature, although they may use retrospective data as part of the inclusion and exclusion criteria.

When dealing with research data, one of the best ways to ensure protection of patient confidentiality is through the analysis and use of de-identified or blinded data. This also has the benefit of simplifying the ethics review process.

Regardless of the type of research you are interested in, it is critical to ensure that you are entering the data as structured elements in the EMR system. I have worked with a number of practices that had been diligent in typing in all of the details of the encounter and relevant test results, but, as they were entering it in as free text, were unable to use the data to run reports without a manual extraction process. While some systems are starting to use natural language processing techniques to search through free text entries, this data can be less accurate and is difficult to combine with standardized data fields limiting analysis. For more guidance on using standardized data fields, read “Why Templates Are Essential When Using an EHR” and “Data Entry Strategies — Using Templates.”

Another critical component within a practice is to ensure that the data is recorded using the same data fields so that diagnoses (e.g. Type 2 Diabetes) are recorded consistently. This tends to be more of an issue when practices or providers have customized their EMR in order to create new or alternate fields that are incorrectly mapped to an equivalent field within the system. This can make it difficult to correctly identify data for extraction when running reports, especially when relying on the reporting capabilities found in most EMR systems in which relevant fields have been pre-mapped for a particular condition.

When evaluating an EMR system from a research perspective, you should determine how difficult it is to combine or separate data elements that you would want to include in aggregated data reports. You should also determine the system’s ability to produce reports that combine different data types — for instance a clinical diagnosis, plus a prescribed medication, plus a particular lab result. If you are interested in the process measures, you will also want to ensure that the system can incorporate demographic and payer information in the reports.

In conclusion, if you are interested in using your EMR for research you should plan ahead, both when selecting an EMR system (as they differ substantially in terms of how they handle data reporting and research requirements) and when implementing and using your EMR. Entering data into your EMR in a standardized and consistent manner will be critical to successfully using your EMR for research purposes.

Have you had experience conducting research via your EMR? Add your thoughts by clicking on the “Comments” link below.

Olympics Highlight Dangers of Social Media

The growth in the use of social media tools over the past two years has been astounding. There is nothing like an Olympic Games to highlight the benefits (and the risks) of social communication. A Vancouver Sun article published July 31, “Social media Games turn into five-ring circus”, highlighted that two athletes have already been sent home from the summer games: a Swiss soccer player and a Greek triple jumper for posting threatening or racist Tweets.

“In February 2010, during the Vancouver Games, Twitter was sending 50 million 140-character tweets per day; now, it’s over 400 million, and they are everywhere, washing over vessels big and small, changing the way the Games are run.”

The power of small 140-character messages in undeniable. What is also astounding is that the world is one’s moderator and critic. Even with 400 million Twitter messages being sent per day, those that were felt to be threatening or inappropriate were quickly rooted out and action was taken. And herein lies the risk for healthcare. If one has a medical practice website, Facebook account, LinkedIn account, Twitter account, etc. and uses these for information dissemination to patients, it is critically important that everyone within a practice should conform with an official communications policy regarding the content and context of specific social media communications. Assume that what you publish through social media will exist and be identifiable at some point in the future.

For more useful information on social media and its use in medical practice, read the following articles:

• Use of Social Media by Physicians
• 2062: The Good Old Days of Social Media
• Help I Can’t Take This Any More — How to Manage Information Overload

What are your experiences using Social Media? Add your thoughts by clicking on the “Comments” link below.

The Demise of Small and Solo Practice

What does the future hold for small and solo GP and specialist practices in Canada? Are solo practices slowly moving towards extinction or is there a future for this traditional form of care? Programs designed to bring together primary care practitioners in groups through primary care care networks have been developed in multiple Canadian provinces, supported by a technology infrastructure. In many cases, the EMR has been the glue that has allowed for cost and resource sharing amongst practices while still maintaining the independence of one’s own office. The networks, in combination with provincial funding support to adopt an Electronic Medical Record have allowed GPs as well as some specialists to maintain their solo practices for the near term. However, the shift towards accountable and measureable care as well as cost pressures on health systems that are being filtered down to doctors is making it more difficult to sustain a practice without the ability to pass on the increasing overhead as well as maintain increasingly stringent reporting requirements.

Although the U.S. healthcare system is structured differently, perhaps we should take a look south of the border to see what is happening in small practices, as there may be some indication of what we could expect to see in Canada. In an article in TechTarget, titled, “Small practices, solo docs air EHR implementation, meaningful use woes” at a recent U.S. House of Representatives Subcommittee on Investigations, Oversight and Regulations’ hearing, the message came through loud and clear.

“If declining reimbursements don’t kill them, electronic health record (EHR) implementation and meaningful use compliance will finish the job.”

Small and solo practices are under great pressure due to increased regulation, declining Medicare reimbursement, and increasingly more stringent reporting requirements. Add to this penalty programs associated with adoption of ePrescribing and EMR (initially supported by incentives) and the need to make the upfront investment before being able to claim the incentives and practices are struggling to survive. This is not just in primary care — typically more well-off specialties, such as cardiology, are having a similar challenge. The result of all of these factors is a trend towards joining larger groups or hospitals that have additional resources to manage reimbursement, reporting, and compliance.

What has been astounding in the U.S. is the speed with which these national programs are being applied. EMR adoption is growing rapidly and certain specialties (such as family practice) are reporting that over 65% of their members have now adopted EMRs. The next phase is optimizing the EMR to work more effectively.

Provinces are evaluating the application of Meaningful Use measures in order to track and report on patients with Chronic Disease as well as preventive care measures. Although the Accountable Care Organization (ACO) structure does not exist in the same format in Canada, we are moving towards care that can be tracked and measured as governments strive to extract value from scarce healthcare funds.

What has been your experience? Are you in solo or a small physician practice? Do you believe your practice structure is sustainable? Share your thoughts by clicking on the “Comments” link below.

Pros and Cons of Wireless and Local Networks

Physicians are mobile workers. Some may work in more than one practice location; others may use multiple examination rooms in a single clinical setting. However, one feature common to all physicians is that they move around during a clinical examination. Unless a physician has an administrative job, they are usually not restricted to a desk and a single computer. This creates certain challenges when it comes to hardware in the examination room and throughout a medical practice. A good needs analysis is necessary to determine whether one should have a wireless or wired local network, or a combination of both.

With the growth in availability of smaller, faster, and lighter wireless tablets from a wide range of manufacturers such as Apple and Samsung, and mobile phones with larger screens (the new Samsung Galaxy S3 has a 4.8 inch HD screen), physicians now have more choice than ever regarding tools that fit the mobile form factor. Wireless networks and access points have matured significantly over the past five years and bandwidth is generally no longer an issue unless one is accessing extremely large files, such as radiology images. The new Apple iPad with retina display is being used increasingly in hospitals to view images due to the high resolution screen and there have been regular reports of a soon to be released Apple iPad with a 7–8 inch screen. Sure to be a hit for physicians who do a lot of prescribing.

However, there are some important steps that you should follow if you plan to install a wireless network in your medical practice:

• Talk to your existing (on intended) EMR vendor to ensure that their EMR product works well on wireless networks and what the minimum bandwidth requirements might be. This may be your primary determinant as to whether you go with a wireless or wired network implementation.
• Wireless may be your network of choice if you are using an ASP- or cloud-based EMR. In these types of systems, the EMR is hosted outside of your practice at a remote location and is accessed through the Internet or a secure network connection.
• Unless you have a very small office space that requires a single wireless access point and you are comfortable installing it and setting up the wireless security, bring in an expert to do the installation. They will ensure that you have sufficient wireless coverage throughout the practice, install signal amplifiers (if needed), and will set up your wireless security for the maximum level of protection.
• Do not install an unsecured wireless access point in your practice that is connected to your office computer(s). Using sniffer software, it is possible for hackers to easily gain access to your system and anyone else who connects to the network within your practice.

Wired networks:

If you are running a server in your practice, you certainly can install a wireless router, but this is something that will require consultation and advice from your vendor. Wired networks have some distinct benefits. They are fast, stable, and have high availability. They are also secure in that your practice can function as a closed environment if you are not connected to the Internet or an external network. If you are connected to the Internet, you will need to install a firewall (as you would with any wireless network). Wired networks also tend to be more costly to install initially and do require maintenance and some ongoing cost.

Have you had any experience using wireless access points in your practice? Share your thoughts by clicking on the “Comments” link below.

Managing Paper Documents in Your EMR — Scan and Fax

The paperless office is a misnomer! There is a constant flow of paper into every medical practice from multiple sources including hospitals, consultants, and other non-automated service providers. In many cases, clinical information is digitized in the form of Word documents and other digital formats printed and re-digitized by scanning the documents into the EMR. In the distant future, medical practices may become completely paperless when all data and documents are delivered electronically into EMRs or are transmitted from EMRs through information exchanges to other parts of the healthcare system. In the present state, we could aim for paper-light offices at best, by methodically reducing the amount of paper we receive and generate.

One of the greatest sources of paper is the volume of historical paper charts that exist in medical offices and storage facilities. As practices migrate from paper records to EMRs, many of the paper charts need to be partially or completely digitized and archived or incorporated into EMRs. What are the principles and guidelines that practices should follow in terms of scanning and archiving these records?

The advantage of the EMR is that once a practice has fully transitioned, there is limited need to access paper charts. They can then be moved off site, freeing up expensive storage space. However, records may need to be retained for legal purposes or based upon organizational/practice policies.

Some key questions arise regarding document scanning and retention:

1. What is the best format in which to scan a document for inclusion in an EMR?
2. Is there a required minimum resolution?
3. What are the most commonly used formats?
4. Is the size of the document (in Megabytes) an issue?
5. Are there any existing legal requirements or precedents governing these guidelines?

As a basic principle, a scanned record needs to be non-editable. In other words, once it has been scanned, it must not be possible to modify the record or document in any way. In addition, the document must be readable. This is where the question of resolution comes in. The higher the resolution of the scan, the larger the file. So there is a trade-off between document size and resolution. But is there a minimum that is acceptable?

In order to optimize integration of documents from external sources into EMRs received via fax, if you are not currently using a fax server, this should be a top priority. Click here for more information about fax servers.

In terms of scanning, Adobe Acrobat (.pdf) and Tagged Image Formet (.TIF) seem to be the most common formats that are easily readable. Are there any other formats that practices or EMR systems are using for scanned documents?

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

Medication Compliance — Ensuring Patients Take Their Prescribed Medications

Ensuring medication adherence is a huge challenge for clinicians who spend a lot of time taking histories, examining, developing treatment plans, and, ultimately, deciding on a course of management that often includes medication. Patients do not pick up their medications for a wide variety of reasons, e.g. too costly, forgetfulness, lack of motivation, etc. and without the ability to reconcile what was prescribed with what is dispensed, it is very difficult to ensure that care is being consistently delivered as intended.

A study published in the Journal of General Internal Medicine suggests that by linking an EMR with a pharmacy system, patients are more likely to pick up their medications vs. non-integrated systems.

In the retrospective study, conducted between 2007 and 2008 through Kaiser Permanente in Colorado, patients with newly-ordered medications for high cholesterol, diabetes, and hypertension were monitored for compliance. The study found that approximately 7% of patients did not fill their new prescriptions for anti-hypertensives, 11% for diabetes medication, and 13% failed to pick up cholesterol-lowering medications. The term used in the study is primary non-adherence and according to the authors, prior research when no EMR was used has demonstrated primary non-adherence as high as 22%.

Do you believe your patients would adhere to their medications if they were prescribed directly to a pharmacy using an EMR or would there be no difference?

Add your thoughts by clicking on the “Comments” link.

Lab Data in EMRs — The Quality Conundrum

Lab data is cornerstone diagnostic and monitoring information that is now commonplace in EMR systems. In fact, it is unlikely that any comprehensive EMR sold in Canada will not have lab interfaces in order to directly import lab data into the EMR for review and interpretation. The ordering of lab tests, however, remains a primarily paper-based function. In other words, lab tests are ordered using a standardized paper requisition, which is handed to the patient, who then takes it into his/her lab of choice from a list of locations printed on the back of the requisition slip. Once at the lab, the requests are manually entered into the lab's patient tracking system and the process becomes automated from that point until the results are delivered electronically into the patient’s record within the EMR. The current uni-directional system will ultimately transition to a bi-directional capability to order lab tests and order sets directly from the patient’s chart within the EMR; however, we are not there yet.

Blood and serum testing equipment within a laboratory are regularly calibrated to within extremely fine levels of tolerance to ensure that the data is accurate. Labs expend a significant amount of their resources maintaining the quality and accuracy of their data reporting. However, normal ranges may also differ slightly from one lab to another depending upon the equipment and reagents that are used to conduct the tests. Labs go to great pains to ensure that the output of their work is presented in a way that provides the greatest value to clinicians who depend on that information for decision making. Information in reports also frequently includes narrative comments from laboratory specialists. This metadata is provided to enhance understanding or interpretation of the results. Together, the data, metadata, and format of the reports are fine-tuned to minimize the risk of making an error when interpreting that data.

Two weeks ago, while attending an educational meeting, I was approached by a representative from one of the large lab companies in British Columbia. We had a very interesting discussion about lab data and reporting of that data via EMRs. Our conversation led to an interesting conclusion. Although the lab can report results with a high level of control through a paper report or a website in which the lab controls the layout and presentation of the information, once that data is transmitted directly into an EMR, they no longer have control. From that point onwards, the presentation of data is related to the way that the EMR system has been designed. When data is further analyzed, graphed, and interpreted through the EMR as clinical decision support information, use of the raw data takes on a different context. It is critical that lab data in the EMR is presented accurately, but equally important that the context is also correctly displayed — something that concerns lab companies. An issue that might arise within an EMR system relates to lab data from multiple laboratories. For example, if your EMR receives lab data electronically from two private labs as well as a hospital lab, are all of the results comparable? Issues may arise where different normal ranges are used by different laboratories for the same lab values. Fortunately, lab data is usually standardized sufficiently that these small variations may have limited clinical impact when interpreted, even if the data is provided by different labs; however, the risks remain — particularly if results are grouped together and plotted on a single graph. In a paper world, each lab result is provided individually in a report that naturally separates the use of the data and alerts the clinician to the source of the information.

I will be exploring this issue in a future article. In the interim, if you have had experience using lab data within your EMR, have you encountered any situations where data has been incorrectly presented or presented in a way that made the data difficult to interpret? Share your experiences by clicking on the “Comments” link below.