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

Epocrates Study - One in five physicians likely to purchase Apple iPad

AppleInsider - This week, Epocrates Inc., the developer of mobile applications used by more than 900,000 healthcare professionals worldwide, revealed a new study of more than 350 clinicians conducted in the wake of Apple's iPad announcement. Among those surveyed, 9 percent said they plan to buy an iPad when it is immediately available, and another 13 percent intend to purchase one in the first year. In addition, another 38 percent of respondents said they are interested in the iPad, but would like to obtain more information about the product before they decide whether or not they will purchase. With a belief the iPad will gain traction in the health care community, Epocrates also announced this week that it intends to customize its clinical reference application, which is already available for the iPhone and iPod touch, for the iPad.

One in five physicians likely to purchase Apple iPad - study.

Do you think that the iPad will be popular amongst physicians? If you are already an iPhone user, would you consider purchasing an iPad?

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

Speech Recognition in an EMR

The following comment on use of Speech Recognition in an EMR was submitted by Ep Papp and is published on his behalf.

Your article on speech recognition in ones EMR is not accurate in what is available and the ease of use. I have been using the Toshiba portégé tablet M200 and recently upgraded to the m700. In a quiet environment such as ones office the array microphone on the Tablet is accurate enough without using any USB device. I use Dragon Professional Medical upgrading regularly as available. With the latest version the accuracy is incredible and the speed great if a powerful enough computer. If one needs a USB microphone check out the new Revolabs wireless which is the size of a tube of lipstick and can be clipped to a pocket or lapel or worn on a lanyard and the off/on is a simple push button on the microphone. It works great even though Nuance is not aware of its existence or at least does not confirm its incredible accuracy even though I have communicated with them several times. We have chucked our Plantronics USB over the ear units which are good but very cumbersome especially if you are in/out of examination rooms etc.

The Revolabs unit has totally revolutionized the use of speech recognition in the EMR. I have enjoyed this for years and seen extra patients and dictated more detailed notes in the time saved by its use compared to typing or the handwriting recognition of the tablet. This is still a useful function for physician tasks in the Clinic or meeting environments (esp if connected remotely to ones office and unable to use the voice recognition software).

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

Smartphone Adoption by Physicians - Knowledge on Call!

The verdict is in: Smartphone technology is on the rise amongst physicians. Those who had previously adopted PDAs are finding it a small step up to a Smartphone with greater functionality and a decent display for text, video and image files. Expect to see many more Smartphone healthcare applications in the coming years. The following article published January 5, 2009 in American Medical News highlights this phenomenon. While the article speaks to adoption by American physicians, similar changes are taking place in Canada.

'According to New York firm Manhattan Research, doctors are adopting mobile technology more quickly than is the general public. The group published a report in September 2008 saying 54% of U.S. physicians own a PDA or smartphone. Separate research by Dallas-based Diffusion Group predicts that by 2011, 70% of physicians will own a smartphone or PDA. That compares with only about 20% of physicians who have adopted electronic medical record systems, though there's hope that increased smartphone use will raise that number. Already, developers are creating EMRs that operate from a cell phone.

AMNews: Jan. 5, 2009. Knowledge on call: Finding new uses for smartphones ... American Medical News

Do you use a Smartphone? Do you agree that components of the EMR will move to the EMR and accelerate adoption of Electronic Medical Records?

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

Budgeting for Unanticipated Costs when Implementing an EMR

When implementing an EMR, there are a number of unanticipated costs that become apparent during the installation process. Computer stations and EMR software are the basic building blocks, but there are other components needed in order to make the overall system usable.

Just to give an example, additional pieces of hardware such as Uninterrupted Power Supplies (UPS), additional cabling drops, extension USB cables to reach printers, switches (if running more than one device out of one network jack) and wall brackets for laptops or docking stations for tablet PCs. All of these items add to the overall cost of the implementation and may be necessary. There is nothing worse than carefully budgeting on a number for a large expense such as an EMR only to find that you run over by $5000 to $10,000 because of these unanticipated expenses.

As a ballpark estimate, I would suggest that you add an additional $500 per workstation in your initial budget (Laptop or desktop) to provide some leeway in terms of these additional costs. If you are installing 10 computers, add $5000 to your budget. If you don't spend the money, it just goes back into the practice account. This is a much better scenario than having to find an additional sum of money that you had not expected to pay out.

Does this number seem reasonable to physicians who have implemented an EMR - $500 per station? Is it high or low? What unanticipated costs did you experience when implementing your EMR?

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

Thick Clients vs. Thin Clients in the Physician Office

This is essentially a question of needed functionality when deciding what hardware is needed in the physician office. If you have had experience in this regard, please add your thoughts and comments at the end of this posting.

According to Wikipedia, "A thin client is a computer (client) in client-server architecture networks which has little or no application logic, so it has to depend primarily on the central server for processing activities." Link: Thin client - Wikipedia. "A thick client (also known as a fat client) is a computer that performs the bulk of any data processing operations itself, and relies on the server it is associated with primarily for data storage. Although the term usually refers to software, it can also apply to a network computer that has relatively strong processing abilities. Link: Client (computing) - Wikipedia.

Computers in the exam room are used primarily to access the Internet, enter and retrieve information from the Electronic Medical Record and print handouts and forms for patient care. This function could be delivered quite effectively by a 'thin client' computer. The advantage of this would be the reduced cost and maintenance (thin clients are cheaper), the ability to simply plug another thin client into the network connection should the unit malfunction and the smaller footprint of the thin client. (The computer casing tends to be much smaller than the average PC and would not take up as much space in the exam room). Perhaps there are other areas in the office that could also be served well by thin clients - e.g. PC in the hallway or in the nursing station.

Despite the potential uses of 'thin clients' , most offices also have zones that require more traditional PC functions and the ability to do a significant amount of data processing. For example, the computer that is used to scan external reports into the EMR. Scanning generally requires a fast PC with local scanning software. Other areas that would likely require more traditional PC function include the physician desk. A physician may have additional clinical decision support tools or software that is needed for additional tasks such as image management or publishing.

My question are these: If you are a physician user of EMR, are you already using a combination of thin clients and thick clients in your practice? If so, do you see performance differences between the different computers? Can you add further insight to the 'thin client' vs. 'thick client' debate? If you are not yet using an EMR, does this premise make sense? Set up an office with a combination of both types of computers allowing for the different functional requirements in different areas with the associated lowering of cost?

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

Data Storage and Redundancy - Loss of data due to Hardware Failure

"PENDLETON, Ore. (AP) — The crash of computer hard drives has vaporized thousands of digital X-ray files, and St. Anthony Hospital officials are busy providing patients with new X-ray information. The hospital has sent letters to 900 patients to tell them that a hard-drive failure by General Electric led to the loss of more than 5,000 archived images. General Electric provides the hospital's imaging equipment and stores its digital X-rays." Link: OregonLive.com: NewsFlash - Pendleton hospital loses X-rays.

It is not just small physician practices that are at risk of catastrophic data loss due to hardware failure. As you will note from this posting, hardware failures occur in large hospital systems. The loss of data resulted from the crash of computer hard drive(s) - plural. Even the best laid plans to ensure that data is recoverable are sometimes not sufficient. I am sure that there was a backup and redundancy plan in the Pendleton, Oregon hospital, however it failed. As a result, thousands of patients X-ray images were lost and somehow need to be recovered. Not only does this have health risks associated, the medico-legal issues are significant. It is no longer possible to measure the growth in the size of a tumour against the baseline X-ray because the baseline no longer exists.

This is similar to earthquake preparedness in terms of the response. When there is a major earthquake (especially in North America), thousands of people run out and purchase survival kits, ready action plans and ensure that they are prepared for impending disaster. Similarly, every time we learn of one of these incidents relating to hardware failure and loss of data, many make a concious effort to upgrade hardware and develop backup and redundancy plans to ensure that data is recovereable in the event of a catastrophic failure. However, studies of physician offices running EMR systems have demonstrated that the vast majority are ill prepared to restore their patient information from a backup tape or disc if they are running their own server locally in the clinic. Even if regular daily backups are being done, few test (and retest) their ability to restore data to the system from one of these backups. Access to a remote database is clearly an advantage in this situation using an ASP EMR system. Someone else (an industrial strength provider) then has the responsibility to ensure that the data is backed up and is restorable in the event of a hardware failure.

Have you ever suffered from a hard drive failure or inability to restore data in your EMR? Share your experiences or lessons learned by clicking on the 'Comments' link below.

Tablet PCs - Slates vs. Convertible Laptops

The following comment is posted on behalf of Dr. Shelin Tkatch:

I am a solo-practitioner ob/gyn about to embark on EMR in the office. The likely software vendor will be Optimed. I plan to use a tablet pc as my input device and am trying to decide between a “pure slate” device like motion computings LE 1600 which comes equipped with an optional extended battery life of up to 7hr, an integrated eraser in  the digitizer pen, and optional medical word recognition software. One of my main concerns is whether the absence of an integrated keyboard will hamper me and speed of service availability.

The alternative under consideration  is the Toshiba portege M200, which has a keyboard, battery life of 4.5 hrs and since Toshiba is a big seller in Canada it can hopefully be serviced quickly. They both weigh about the same. I plan to use the tablet to write my notes while with the patient, just as I currently do, and then dictate letters as necessary using an  Olympus digital recorder, my pc and dragon speak, again just as I currently do.

Does anyone out there have any experience/advice regarding tablet pcs?

Dr. Shelin Tkatch

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

Using a Laptop as a Fixed Station

One of the problems I face in my clinic is a lack of space. Although my exam rooms are quite spacious, they are not huge and would not accomodate a desk for a desktop PC. This requires some creativityso that computers are not intrusive, but are accessible when needed.

Actually, this was the primary reason I looked for a wireless solution. I set up the clinic with a wireless VPN (Virtual Private Network) to ensure a high level of security on the wirless network. As workstations, I have been using a DELL Laptop and a Gateway Tablet PC (Motion M1300) for clinical data entry. Unfortunatly, neither of these units have met my expectations. I have found it difficult to physically carry the laptop from room to room. I also have limited space to place the unit while doing the physical examinations. The Tablet PC has not met my expectations in terms of handwriting recognition, although the technology is improving rapidly.

I am aware of some physicians who have begun using Tablet PCs quite effectively using the Journal note taker or other software that meets their needs, but this has not been my experience.

Recently I decided to move back to fixed PCs in each exam room hard-wired to the network to ensure maximum speed and stability. When I looked at the potential solutions, the best option was a Pentium 4 laptop with a 15" screen which I could wall mount on a bracket which would allow me to tilt and rotate the laptop for most effective use. I have just ordered laptops through DELL Canada. (This worked out very well as I was able to get a 10% discount (by being a CMA member) and free shipping (due to a promotion). In the end the laptops have not cost any more than similarly configured desktop PCs with flat panel monitors.

My current challenge is working out how to effectively mount the laptops on the wall. There are a number of brackets available for keyboards or monitors which can be wall mounted, however I have been unable to find many reasonable solutions for laptop computers.

I am working on some current hybrid solutions to mount the laptops and as soon as the units are installed, I will post images to demonstrate what I have done and provide feedback on the how the units work.

If any visitors to CanadianEMR have had any experience in this regard, please post your comments by clicking on the 'Comments' link below.

Wireless - Is it ready for mainstream?

This is an interesting topic and one that I hope will generate discussion from physicians who are either for or against the use of wireless networks for EMR.

Despite the additional cost associated with wireless devices - laptops, tablets etc., some physicians are choosing wireless over wired networks with fixed desktops in exam rooms. The arguments against wireless include issues relating to blind broadcasting of wireless data and security, risk of damage to laptops or tablets, theft, cost (for the price of a wireless laptop, one could purchase two or three fixed desktop computers) and speed. Wireless networks (especially 802.11b) tend to be slower than 10/100 wired networks. The arguments for wireless include the mobility provided by the device, ability to use a wireless Tablet PC with pen input and equivalent cost to multiple fixed stations if using a single mobile computer.

If you have implemented a wireless network, please share your experiences. Similarly, if you have strong arguments against wireless, your comments will be appreciated. Please click on the 'Comments' link below to share your thoughts.

USB Microphones & Wireless High Speed Access

The following comments were e-mailed to me by Dr. Jack Behrmann, a paediatrician in our community. Jack has been an avid user of information technology for years. To view Dr. Behrmann's practice web site, go to:
Dr Behrmann's home Page

"I have recently installed iFido the wireless Internet service advertised by the Fido group in my office. I am very impressed and amazed. It is faster than my cable service at home !. I am currently paying $20 a month for the first six months increasing to $32 a month after that as I have a Fido phone. . The speed is phenomenal but there is a gigabyte limit of 20 gigabytes. For receiving e-mail and similar transfers this is more than adequate. It took me exactly 10 minutes to install and the reception is excellent.

For those doing voice-recognition I have always read that having an excellent microphone would be very valuable. I finally upgraded my microphone and am simply amazed at how much better the voice-recognition is. This is currently being written by voice. If anybody is thinking about this this is well worth it and I would be happy to give some advice in that regard. I have mine on a desk top stand which removes the need for it to be around one's head which I find to be quite tiring after a while. My productivity on voice-recognition has improved considerably since I did this."

If you have any experiece with USB microphone technology or high speed wireless internet access, please click on the Comments link below.