I am not sure if we are at the transition point and ready to enter the “last mile” of EMR adoption in Canada, but my “spidey sense” tells me we are close. Ten years ago, if one referred to the “last mile”, it was generally in relation to high-speed connectivity; that has now largely been resolved by ubiquitous high-speed Internet access and private secure networks such as the PPN (Private Physician Network) in British Columbia.
My reference to the “last mile” refers to the last remaining groups of adopters of EMR as well as the final pieces of functionality that need to be in place in order for technology to be well integrated with clinical care.
In the latest issue of Technology for Doctors Online, Mike Martineau (a longtime friend and colleague) wrote a thoughtful commentary titled “The concept of eHealth has ‘Jumped the Shark’”. In his commentary, Mike questions whether eHealth as a concept is becoming irrelevant. I agree with his thinking in this regard. As technology has become more intertwined with the care delivery process, it has changed from an add-on to an integral component of good clinical practice. In 2013, it is still possible to deliver care in a paper dominant format in specific care settings (more on this later), but it is becoming difficult to do so and peripheral tools such as mobile phones, tablets, and diagnostic devices are becoming tightly integrated with the way that caregivers function. In the last 10 years, I have observed a large number of physicians in their use of technology, both within Canada and internationally. The quickest and most efficient technologies are generally used most frequently. If the mobile drug interaction app works better than the equivalent capability in the EMR, the mobile tool wins out. Similarly, tools that work more efficiently within the EMR and are tightly integrated with clinical work flow become the defacto tools of choice. The same applies irrespective of the clinical setting. With telehealth and patient portals becoming a standard of care in addition to online appointment booking services, provincial surgical wait times reporting, email communication with clinical providers, and a wide range of other technologies that enhance efficient access to information, the terms eHealth and mHealth are becoming irrelevant. These are just tools and they are being used to deliver care — period!
Now, more on the the paper dominant format of some clinical practices...
In the last year, I have returned to clinical practice in a more consistent manner. Since 2007, I have focused my attention primarily on technology and consulting and have had the opportunity to work with some very smart people across Canada and the U.S. and internationally on national and regional IT projects. During this time I continued to provide clinical care on a part-time basis, doing walk-in clinic shifts and working in a few different settings. Some of the clinics were paper-based and most recently I worked in a well-run clinic that used one of the provincially funded EMRs. This has allowed me to keep in touch with the needs of clinical providers at a very grass-roots level. One of the reasons for returning to more consistent practice has been a sense of frustration with a walk-in clinic style of practice. The EMR makes walk-in clinic work easier due to the ability to easily review prior notes and clinical investigations; however, the very nature of this episodic type of care means that one never gets to know one’s patients. In addition, expectations are frequently difficult to meet due to the fact that many patients attend more than one walk-in clinic, resulting in fragmentation of their medical information (including lab results and other diagnostic information).
After completing some additional training in 2012, I have begun working in an addiction medicine practice, focusing initially on opiate and related addictions. Many of my patients have concomitant mental health issues, which, in conjunction with addiction management, makes the implementation of an EMR difficult for a number of reasons. Management of addictions is team-based. Counselors and physicians (plus additional care providers) need to work closely together to support complex patient needs. Although there is a family practice component to the care of these patients, the practice functions more like a specialist clinic than primary care. In addition, the need to access Pharmanet during patient encounters benefits from tighter integration with an EMR. Another big hurdle is medication management. Any opiates prescribed by physicians in British Columbia need to be written on a provincially sanctioned duplicate prescription pad. As a result, even with an EMR, a secondary paper prescription is required for opiates or opiate replacement therapy, with no current mechanism to integrate that information in the EMR without the need for duplicate data entry.
As I explore the pros and cons of an EMR in this setting, I will share my experiences and lessons learned on the CanadianEMR blog. Keep tuned for the next instalment.