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

Conversion from one EMR to Another - What are the Options?

If you are currently using an EMR and wish to change, adopting a new EMR system will require significant thought and planning in terms of data conversion strategies.

There are a number of mechanisms to convert data from one EMR to another:

1. Simple conversion: Manually re-enter the data into the new EMR. This is a time and resource intensive process, but does have the advantage of being able to clean the new data at the time of entry. There will be no unmatched fields or data conflicts. At a minimum, it should be possible to export the old records in the form of a .pdf file and attach the individual .pdf files to the patient record in the new EMR for reference purposes;
2. Vendor direct conversion: The new vendor undertakes to convert data in the old EMR system to the new system. This is usually a one-off process and can incur significant cost if the data structure in the old EMR is significantly different to the new system requiring a great deal of custom mapping between different data fields;
3. Conversion according to accepted data standards from EMR to EMR. In an ideal world, if all systems store data in a standard format i.e. exactly the same format and field in both systems, it should be a much simpler and less costly exercise to convert from one EMR to another. In the UK, this has been done using the GP2GP system. (Note: Using GP2GP, not all data is converted from one EMR to another and a data limit is imposed in terms of the amount of information transferred between systems. However sufficient data is transferred to have a fully functioning EMR patient record in the new system);
4. Third party conversion: Companies or organizations that have expertise in data conversion provide a service to convert EMR from one system to another. The challenge that these companies face is related to the way that data is collected and stored in the original system by the users;
5. Hybrid conversion: Certain discrete data is transferred from one EMR to another e.g. lab and demographic data and this is combined with a .pdf file for each patient record which is then attached to a patient record in the new EMR system.

(The prior is a summary of a presentation given in Vancouver on December 27th by David Ulis, Program Director for the Physician Office System Program in Alberta).

Does this cover the spectrum of data conversion? To add your thoughts and comments, click on the 'Comments' link below

Scanning Documents into an EMR and Paper Chart Storage

An article in the October issue of Technology for Doctors deals with the management of external paper and historical paper charts. Inputting this data into the EMR is extremely time and labour intensive. So what is a practice to do in the transition to the EMR? Read on....

Escaping the tyranny of paper is harder than most doctors imagine – even after an EMR system is implemented. Family practices often go into an EMR conversion believing they’ll finally be rid of paper going forward, and only have to worry about storing historical patient files. But storage costs for thousands of paper patient files can be expensive. By law, family practices need to retain patient records on-site for 10 years after the last visit. To avoid these costs, many practices are scanning them to create space-saving digital records, and they often assume this task can be handled by hiring temporary staff to scan old files over the course of a few months.

.....Most doctors have an average of 1,500 patient files each to scan, and many of these are several inches thick for longstanding patients with complex conditions. But few family practices have the high-end equipment needed to handle the job. “We didn’t have a proper scanner for our student to do that volume,” says Blankenstein. “We had a multi-function scanner, fax and photocopy machine that we needed for our regular office tasks. If she scanned all day, then we couldn’t use it for anything else. Doing the job in-house would have entailed buying another expensive machine, but we didn’t have the office space for another piece of equipment.” There were also some longer-term paper issues that came as a big surprise, he says. Even after the initial year-long teething pains of converting paper for an EMR are finally over, family practices need to consider that many laboratories can’t or won’t upload results digitally. They need to either make arrangements to scan these reports on an ongoing basis, or partner with select labs that can provide information electronically.

Read the full article in 'Technology for Doctors'

Scanning and data input is one of the high interest areas on CanadianEMR. How have you approached the challenge of managing your paper records and incoming paper results and reports. To add your comments, click on the 'Comments' link below

US - Lack of Standards Limits Exchange of Lab Data

As reported in Healthcare IT News - the ability to exchange lab data will significantly limit the ability to demonstrate 'meaningful use' of Electronic Records in the US. Standards are viewed by many as a drudgery - boring, repetitive work that needs to be done by the technically inclined in order to connect systems and processes. However, without standards for lab data (as they are finding in the US), the ability to share information is very limited.

WASHINGTON – The HIT Policy Advisory Committee's information exchange workgroup learned Tuesday just how difficult it's going to be for doctors to exchange electronic lab results to qualify for federal "meaningful use" bonuses. Physicians can earn a potential $44,000 under the American Recovery and Reinvestment Act (ARRA), beginning Oct. 1, 2011, but they will have to show meaningful use of data, including the use of electronic laboratory results. One of the problems is that state laws regulate the exchange of electronic laboratory results, and standards don't exist to allow this information to flow easily between labs and physician offices.

According to experts, labs are required to pay for the exchange of data, so they build connections with larger providers first – leaving small physician practices on their own, since there aren't enough lab results to justify the interface. Physicians encounter barriers in exchanging lab results electronically | Healthcare IT News.

The same lessons can be applied to Canada.

I see this as part of a broader information exchange requirement - once we have lab data, how about a mechanism to send and receive referrals and consultation reports?

Add your thoughts and comments by clicking on the 'Comments' link below

Upcoming Podcast - Request for Feedback on Conversion of Paper Charts

One of the areas that physicians and medical office staff are consistently challenged by is that of patient chart conversions. Some think that they must scan all their paper charts into the EMR, others are simply at a loss as to how to go about getting the relevant pieces of patient data into the EMR in a cost effective manner.

What has been your experience? As a user of an EMR, how much did you scan into your EMR when you got started? What are the relevant pieces of data that should be entered or scanned? Did you find a cost effective mechanism to get the relevant data into the EMR?

Your feedback will form the basis for an upcoming podcast. Please submit your comments and let me know if you may want to participate in the podcast.

How curbing clicking may boost benefits of EMRs

In an interesting article published by the College of American Pathologists, clicking can be a major impediment to efficiency in the EMR. Dr. Berkowitz makes some recommendations regarding the redesign of systems in order to make them more efficient in terms of design.

“Clicking takes much longer than flipping.” And that, says Lyle Berko­witz, MD, is why electronic medical records should be redesigned to be more efficient. EMR systems do not take full advantage of the organizational functionalities, search proficiencies, or visual capabilities of computers, says Dr. Berkowitz, clinical associate professor of medicine, Feinberg School of Medicine, Northwestern University, and medical director of clinical information systems, Northwestern Memorial Physicians Group, Chicago. (Dr. Berkowitz spoke about EMR inefficiencies at the Physicians’ IT Symposium at the 2008 Healthcare Information and Management Society conference, in February.)

Doctors are comfortable with paper charts, Dr. Berkowitz explains, because they can be reviewed so easily. Lab results, for instance, are often printed and clipped to a paper chart, so the physician can quickly review the results and look at the last note or compare them to old results by simply flipping through a few pages. “A lot of analysis and scanning is going on during this process, but it is all at virtual speed in the physician’s brain,” he says.

The physician finishes the review by initialing the front page of the results, writing or stamping an interpretation on it, and putting it into an outbox for an assistant to complete and file. “In a typical EMR scenario, however, the same workflow may take much longer because each step requires extra clicks and scrolling......

So how to get there?

Vendors need to view workflows not as individual tasks, but as a series of related tasks combined with thought processes that allow users to interpret data, draw conclusions, and make decisions, Dr. Berkowitz says. And they need to pay more attention to the wants, needs, and frustrations of their current clients, rather than focusing on the requests of potential customers who use paper-based systems. Also shaping the future of EMRs are organizations such as the nonprofit Szollosi Healthcare Innovation Program, of which Dr. Berko­witz is program director. The orga­ni­zation is “creating prototypes of new user interfaces to help stimulate vendors and others who are developing the EMR systems of the future,” he says. The end result, Dr. Berkowitz concludes, may be an EMR that looks very different from current paper or electronic systems. “This may be scary for vendors used to showing physicians something that looks familiar,” he says, “but vendors will be much more successful if they can move away from the paper-based paradigm and take real advantage of computers.”

To read the full article, go to: College of American Pathologists - Newsbytes - May 2008.

To add your thoughts or comments, click on the 'Comments' link

Scanning, Resolution, Format and Document Management

The importance of clear guidelines and principles for scanning documents continues to grow in importance as more physicians and practices move to EMR. There are currently millions of paper patient records that exist either in back room storage or in secure facilities for practices that have made the transition to EMR. While the go-forward approach (enter key data and critical doccuments into an EMR) works for a new EMR implementation, this still does not resolve the issue of the volumes of paper records that must somehow be stored according to College guidelines for the retention and storage of records. For example in British Columbia, medical records must be stored for a minimum of 7 years plus the age of majority. In some cases, this could be as long as 25 years (for a newborn infant).

The advantage of the EMR is that once a practice has fully transitioned, there is limited to need to access the paper records which can then be moved off site, freeing up expensive office space. However records may not be destroyed and still require storage. It is my understanding that if a full electronic version of the record exists and can be reproduced accurately and in its entirety, then a paper copy is no longer required.

Some key questions keep coming up on CanadianEMR.

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 medical legal requirements or precedents that can help guide the development of these policies?

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.

Adobe acrobat (.pdf) and Tagged Image Formet (.TIF) seem to be the most common formats that are easily readable. Are there other formats that physicians or EMR systems are using?

Your thoughts and comments are welcome - click on the 'Comments' link below

Transfer of Patient Data. What do you do if your Vendor goes out of Business?

The following question and commentary is provided by Dr. David Vincent. As it is an issue that is great importance, I have posted it on his behalf.

"I have a concern that I would be interested to see if others have a solution to. I have used EMR for almost four years now. I have spent 100's of hours inputing data for CPP maintenance. My concern is that if my vendor ceases to support his program, which isinternet based, for reasons of bankrupcy, non compliance re provincial standards. Or should the Ontario government finally get to the point where they are seriously supporting physicians in acquiring and maintaning EMR, and the program I use does not "work" with their system, I have no way that I am aware of, of moving all the work I have done into another EMR software. Most companies will only guarantee migration of patient demographics,and nothing else. This is a big disincentive for me to change programs as all this time I have personally spent would be lost.

AS I get deeper into this process I am worried that if I had to change programs for any reason that the task as I see now of reentering all that information would be so daunting that I would likely give up Family practice and start something new. This is the big "time" gamble of going into full EMR, with one of the many companies that provide it. In the future I don't see how all of the current EMR companies will survive as EMR evolves and the government fully supports it and therefore will have their own standards. The company I work with does give me backup files in pdf format when ever I ask for them, so I can at least have a local back up. Are the leaders at the government/policy level looking at this issue so that when the time comes, people like myself, will have some way of transferring data to a new program that will not take 100's of hours again?

I would think that vendors should have to show how they are going to deal with this issue before becoming an approved EMR vendor. Or alternatively does anyone know of a software program that could convert this information into another program? I would appreciate any comments or advice anyone may have on this issue. Dr. David Vincent."

To comment on this posting, please click on the 'Comments' link below.

Health Level 7 - releases Verion 3 Standards

Health Level 7 announced that it is releasing to its 2,000-plus members a suite of standards that will be the organization's most definitive specifications to date. In creating the new standards - collectively called Version 3 Normative Edition 2005, or V3 - HL7 researchers focused on semantic interoperability and universal application to ensure that the standards have wide impact but also can be tailored to accommodate regional variations.

In the quest towards the interoperable electronic health record, no single factor is likely more important than standards. Standards mean that one program can speak to another and one system can speak to another. Standards are also the 'dry' part of the equation. EMR is more juicy, but in order to function effectively, needs to operate in a way that allows individual systems to communicate with one another.

Link: Health Level 7.

To comment on the standards movement or the importance of standards, please click on the 'Comments' link below.

Which is the Best Scanning Software for a Physician Office?

There has been some discussion on this site about scanning methodolgy and format in which documents should be scanned (.pdf or TIF) format. Which is the simplest or storage space efficient format to store documents and which scanners are physicians using? In addition there has been some discussion regarding the speed of scanning use a flat-bed or document feeding scanner.

I am sure we are just beginning this debate as we continue to live in a paper world. Every physician office is going to have to come to terms with how to manage paper reports that need to be digitized and attached in a EMR system.

The other side of the equation is the software you are using to scan information and why you have selected that specific scanning application. Was the scanning software bundled with your scanner and you have not tried anything different. How satisfied are you with your scanning software? Did you purchase a separate 3rd party scanning application and has this been more efficient? What are the features that you have identified that make that software application a good solution for your office?

To share your thoughts, please click on the 'Comments' link below.

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

This is a very interesting article published in JAMA relating the role of Computerized Physician Order Entry as a cause of error. Many issues are discussed as potential causes of error.

Results:  We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. JAMA -- Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors, March 9, 2005, Koppel et al. 293 (10): 1197.