Part 3 of a three-part series of articles written by a veteran software developer who has worked extensively in the EMR industry. The article series is published on his behalf. His comments are directed broadly at the industry. Read Part 1 Read Part 2
How We Got Here
EMR systems arose out of a cottage industry. The first systems were written by a doctor who had learned some programming, or a university student working on a side project. Most of these started out as simple systems used in a single practice or by a specific specialty then grew in complexity to encompass new needs. This frequently happens with first generation software in any industry. People see a need and create programs to fill that need. Eventually, as the market matures, the better software gains market share and others drop by the wayside. The winners eventually bring in professional developers or are bought out by software companies. Usually the founders move on or are given advisory roles. As the organization becomes more professional, the software does too. This leads to a second generation of software, much improved over the first generation and which continues to evolve as companies fight for market share. Most software companies make money from new sales and from upgrading existing customers to new versions.
This did not happen in the Canadian EMR sector. Initially it was because demand was low. Purchasing an EMR system was an overhead cost to the practice that did not pay off in increased profit. Then, in order to get doctors to start using EMR systems, the provinces started funding the purchase of EMR software. While well intentioned, this has had a negative effect on EMR software development and prevented the industry from maturing.
It is my belief that as doctors are not paying directly for the software, there is no incentive for them to make sure they are getting value for the money. Timelines on qualifying for funding only make this worse. If someone else is paying the bill and you have a limited time to buy, you are not going to be as diligent in your evaluation and you are not going to wait for something better to come along. This is a sales person’s dream, selling a product that people need to buy according to a deadline and for which someone else is footing the bill.
In order to qualify for funding, EMR software has to meet a set of requirements and pass certification. Not only does each province has its own requirements and certification process, when the requirements are updated the software must be updated to meet the new requirements and then be re-certified. In Ontario, new specifications have been released every two years. I was involved with meeting one of the re-certifications which took nine months of planning and work to make the changes. This was for a single province. As a result, EMR companies are forced into cycles of software upgrades in order to meet the next round of requirements. In between these rounds, they have releases to fix bugs and add features requested by users.
The funding structure discourages companies from developing new versions and does not encourage them to make better software. For example, Ontario pays doctors $600 a month for support costs, spread over three years. This encourages EMR companies to lock clinics into three year support contracts. Unlike other software companies, EMR companies do not have to come up with new versions of the software to generate new revenue. They receive income from the support contracts. This method of funding also reduces the incentive for EMR companies to develop software that does not require much support. While software support is a cost to the vendor, support fees are a major source of income and are budgeted into their business plan, so generally they continue to release new versions of the existing product.
The Path Forward
The Canadian medical system is an odd hybrid. Doctor’s clinics are businesses, but they receive almost all their income from provincial medical programs on a fee per service basis. As fees are fixed, clinics generate profit by keeping costs down. For a clinic to purchase an EMR system, they have to justify the investment in terms of cost saving. I know there are arguments that EMR systems make for better medicine and I agree, but a clinic has to make a profit or risks shutting down.
The Single EMR Solution
A single, standard EMR system that could be used in every clinic across the country would have a number of benefits. Doctors and other personnel moving from clinic to clinic would not have to learn a new EMR, provinces would not have to test and certify multiple EMR systems, etc. The question is how could we achieve this?
The Government Program Option
Having government pay a company to develop and support a single Canadian EMR system would seem to be a good solution. Ultimately our taxes are paying for EMR companies to develop and support EMR systems, so why not simplify things and pay a company directly? Unfortunately it is a very dangerous approach. There are a number of scandals related to government funded software projects. It would be naive to expect that one could be avoided when creating a Canadian EMR system. I would not get involved with such a project and I would not recommend anyone else to do so for this reason.
The Open Source Option
I am a big fan of open source applications. I use them in my work every day, and I am a contributor to a couple. I would love to see an open source EMR system that could be used in every clinic across the country. Open source would allow better integration with external systems; however, successful Open Source projects are those used by the very people who contribute to them. This is why the best Open source projects are tools for software developers — they have an interest in making their tools better. However, I believe that doctors should not try to be programmers just as programmers should not try to be doctors. This can prevent good programmers from contributing to an Open Source EMR.
Changing the current system
I can only see two things that can be done to improve the current system — common standards and changes in the funding formula.
Provinces need to coordinate not only their standards for EMR software, but the timing of new standards. EMR companies should be able to submit the same version for approval in each province and not have to modify a system that is approved in one province in order to receive approval in another. If the standards were consistent across provinces, approval in one province would automatically mean approval in the other province. This would help break the cycle of releases that EMR companies are trapped in. In addition, improvements in EMR systems need to be implementable without impacting the certification status of that system. For example, if an improvement is made to a screen design or workflow, it should not be considered a functional change that results in the EMR no longer being in compliance with certification. This discourages vendors from improving their products.
If funding for support is reduced or canceled altogether, EMR companies would need to include support in the initial cost of the system. This would make support a cost to the vendor, not the customer. EMR vendors would then have to develop better software in order to reduce costs.
These two reforms to provincial funding will help, but to be truthful I can’t see anything that will radically change the landscape. I think we are stuck with the systems we have available until a new company arrives on the scene and takes over the market.