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How Do Patients Use the Primary Care System? A Lesson for Health IT

Over the last year I have been working one day per week in a busy walk-in clinic in which all physicians and staff use an EMR. As with any EMR-based practice, there are ongoing challenges associated with using technology effectively in a clinical setting. Some features of the EMR work well and others are mediocre. Working in the clinic serves a number of purposes. It allows me to keep up with current clinical practices and maintain my skills. It is also a useful reality check in terms of care delivery in an urban primary care centre irrespective of technology.

The intent of this article is not to examine the use of the EMR system in the clinic, but rather to provide my observations regarding use of the primary healthcare system by patients:

• There are a lot of patients who cannot find a family doctor. During every clinic shift I am asked by at least five patients whether I am accepting new patients. Working a single shift per week, I am not able to provide the type of comprehensive primary care and continuity this demands, so I decline. It is nationally estimated that five million Canadians cannot find a family doctor. This number feels realistic.
• Availability wins over quality 9 times out of 10. The number of patients who attend a multitude of walk-in clinics for their day-to-day care is astounding and has serious negative implications for the healthcare system. Even though many BC patients may identify one individual as their “family doctor”, they often see many other physicians in walk-in clinics for a variety of clinical problems including medication renewals, minor medical conditions, sensitive issues such as sexually transmitted infections, and — in some cases — for all of their medical care. Thus, the “family doctor” becomes the repository for reports, lab results, and specialist consults they had not ordered but are cc’d. This situation creates an increasing disjointed way to provide care. In a world of EMRs, it is not possible to provide a comprehensive summary of a patient’s medical care, as the information exists in multiple charts across multiple practices. Without the ability to link patients to providers (through accurate patient and provider registries), it is not possible to create the one-to-one relationship needed for successful use of patient portals and personal health records. The core information is generally incomplete.
• There is no accountability on the side of patients for over-use of the healthcare system. On numerous occasions, I have seen patients during my clinic shifts who have seen one or more primary care physicians for the same problem on the same day because they ‘did not like/trust’ the recommedations of the other physician(s). Not only is this a terrible waste of scarce healthcare resources, it also creates an administrative challenge for the practices. The first practice to submit a claim for the visit to the provincial payment agency (MSP) gets paid and the other claims submitted are rejected. While it is possible to request payment in situations that a patient has been doctor shopping, the process takes place after the fact and requires additional effort and explanation in order to get paid for providing a requested service.
• Some very sick people are receiving their primary care at walk-in clinics. I also find the severity of illness surprising for a number of patients. I have diagnosed patients with spontaneous pnemothorax, pulmonary emboli, and muscular dystrophy to mention a few conditions that I can recently recall. These individuals should be receiving their care in a setting that provides greater continuity. They are also difficult diagnoses to make, particularly in settings where the physician may be seeing a patient for the first time. An EMR helps if a historical record exists for that patient.

Bottom line — we can implement EMRs and a wide range of information technologies in medical practices, but there are policy, utilization, and access issues that are fundamental in an efficiently functioning healthcare system. These issues (and I have listed just a small number) are barriers to effective use of health IT. While it may not be possible to “fix” the broken system, there appears to be a lack of recognition that these problems exist. We have to do a deep dive into the problems, optimize the delivery of care, and then apply technology to these improved business processes.

The alternative, as Bill Gates once stated, is as follows:

“The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.”

Canada 2010 National Physician Survey Results — 16.1% of Physicians Use EMR Alone

The 2010 National Physician Survey Results are now available online. The numbers tell an interesting story regarding the adoption and use of EMRs.

There are a few provisos to keep in mind:

• The 2010 data is already over six months old, so numbers are likely a little higher than reported.
• The adoption rates refer to all physicians (GPs and Specialists) and do not separate out eligible providers based upon role, e.g. exclusion of ER physicians or Radiologists.

A total of 16.1% of physicians report using Electronic Medical Records instead of paper charts. This compares to 9.8% in 2007 (21.5% of GPs and 10.1% of specialists in 2010 vs. 12.3% and 7% respectively in 2007).

The major change was in the number of physicians reporting the use of paper charts alone (37.6% in 2010 vs. 57.9% in 2007).

A total of 34.1% of physicians reported using a combination of paper charts and EMR in 2010 vs. 26.1% in 2007. With the reduction in numbers of physicians using paper charts alone, this clearly indicates that physicians are on the move in terms of their transition to EMR. But the rate of change is still disappointing and is in part reflected by a lack of coordination of national strategy with regard to encouraging EMR adoption. Some provinces have had programs to encourage adoption for 10 years and others have yet to begin.

The numbers by province also tell a tale regarding provincial effort. Alberta is the leader in terms of physician use of EMR alone at 27.7% followed by:

Ontario — 19.8%,
BC — 18.8%,
Saskatchewan — 17.8%, and
Manitoba and Nova Scotia — 17.6%.

Only 4.2% of physicians in Quebec report using EMR alone.

I am sure there will be much analysis and report on the NPS 2010 data; however, it is clear that after 10 years of effort across a select number of provinces, we are still far from a critical mass of users.

Much more work needs to be done to collect information and report on adoption of EMRs and to encourage meaningful use of information technology and EMRs.

What do you think of these numbers? Add your thoughts by clicking on the “Comments” link below.

Problems with the Québec Electronic Health Records Strategy

A May 5 article in The Gazette by Kevin Dougherty indicates that all is not well in Québec in terms of the province's electronic health records strategy. Québec's Dossier de santé du Québec (DSQ) was expected to be in full operation by 2010, but, according to the author, in 2011 it is only 38% complete. In light of the obvious challenges encountered in Québec — including conflicts between the province and Canada Health Infoway, which resulted in a loss of $52 Million in federal funding — it is not surprising that the strategy is struggling.

However, there are two key inaccuracies in the article that stand out:

• According to the author, auditor-general Renaud Lachance, in his fourth report on spending on the Dossier de santé du Québec states, “Other provinces started by computerizing personal health records, then developed a system to allow access to the records from anywhere in the province.” This is incorrect. No other province has an implemented personal health record strategy and the provinces did not begin with the PHR. From the article, I am unsure whether there is a clear understanding of the Personal Health Record.
• Agnès Maltais, the Parti Québécois health critic in an appeal to health minister Yves Bolduc “estimated that family doctors will be able to see 20 per cent more patients once the system is up and running.” This is grossly misleading. There is no published evidence that demonstrates the ability for family doctors to see 20% more patients with the implementation of an EHR. (Note, this is not an EMR in the doctor’s office — Québec is just in the process of establishing an EMR program for providers).

If the article incorrectly quotes politicians and the auditor general, I withdraw my comments above. However if the author is correct, I believe this is another example of misinformation, a lack of understanding of strategies being rolled in other provinces, and a prime example of Canada's go-it-alone provincial electronic health record strategies. The provinces are not talking to one another regarding lessons learned and best practices. The tragedy is that the taxpayers are footing the bill for this lack of coordination.

Where is the public debate and consultation? Why is there no mechanism amongst the provinces to share expertise and reduce wastage of public dollars? Under Canada’s equalization of payments program, as a “have-not” province, Québec received $8.5 Billion in equalization payments in 2010/2011. This means that a portion of my tax dollars as a British Columbia resident are actually subsidizing the Québec EHR strategy!

What are your thoughts? Is Québec unique or is the report reflective of what is happening in all provinces? How can we correct the situation? Click on the “Comments” link below to add your thoughts.



Are Canada’s EMR Policies Causing a Backlash?

At CanadianEMR, we receive information and feedback from many sources: physicians who submit EMR ratings, users’ comments on the CanadianEMR blog, communications from media and industry representatives, feedback from practice managers and administrative staff. As a result of all of this feedback, we function to some degree as an early warning system. Even if comments are not explicit, it is possible to draw conclusions from overall feedback.

Recently, a number of physicians from across Canada have shared similar concerns (some users and some who are not yet using EMRs). I have great respect for these individuals, they are excellent clinicians, and those with EMRs have worked very hard to integrate the systems into their practices. However, many of these individuals have expressed frustration regarding the functionality of their current EMRs and the inability of their vendors to focus upon usability issues. Some of these individuals have described the issues as support problems; however, delving deeper it is clear that the challenges are more an inability of vendors to enhance features and functions, for example problems with prescribing and medication management or workflow within the EMR. These are described as support issues, but they reflect an inability or lack of vendor capacity to enhance their products. A single vendor could simply indicate a business problem with that company. However, these issues are related to multiple vendors in multiple provinces and all are provincially certified EMR systems.

It is challenging for any EMR vendor to sell their product in multiple provinces in Canada. The requirement to support different provincially certified versions and keep those systems in conformance is costly and very resource intensive. Vendors are faced with a dilemma. With the majority of resources expended on meeting and maintaining provincial certification requirements, there is little remaining for product enhancements.

In a free and open market, if a consumer is dissatisfied with a product or service, it is within their right to change to another supplier. This is how market dominance is won and lost.

The conclusion reached by these individuals is to look for options outside of the provincially certified EMR systems. Some are looking at Open Source systems. Whether their usability questions could be answered by a different solution will have to be individually decided. However, the irony of this situation is that in an attempt to create greater stability, the provincial certification programs may be feeding a groundswell movement towards EMR systems that do not have to meet provincial certification.

What is your experience? Do you agree with these observations or not? Add your thoughts by clicking on the “Comments” link below. (Vendors and non-physicians are encouraged to participate in this discussion. - Ed)

Are You Feeling “Boxed-in” by Your EMR?

The following was submitted by a reader of CanadianEMR:

From time to time I consider moving offices. In my 29 years of practice I have worked in 4 offices. In the past it didn’t matter if I was going to a group practice or going solo. I would just take my charts with me. It was a bit labour intensive but it didn’t require any great planning. Now that I have been using an EMR for the past 6 years consideration of moving has a lot of restrictions. No one wants to change EMR vendors and deal with the hassle of data transfer and the potential for lost information. The area I work in is very urban. However, the uptake of EMR systems in my area has been slow. Most of the new clinics have been walk-ins that have stayed with paper charting. A few of the traditional family practices have taken up EMR but everyone seems to be using a different vendor. The Health Region chose an EMR for its outpatient clinics and provided some funding for a few private clinics to use the same vendor. That vendor developed its product outside of Canada. It complies with the basic requirements set out by the government for its PITO funding but there are enough differences that switching from the program to another vendor can be difficult.
 
It seems to me that the more EMR vendor choice provinces provide funding for the more boxed in physicians become. If everyone is using the same software then you don’t have to worry about moving in with a new group of doctors. Your software will be compatible. Alberta reduced the number of EMRs they would fund a few years ago. Other provinces are going to have to do the same. Having an expanded list of vendors negatively affects doctors mobility, locums, staffing and relief help. I expect in 20 years there will be far fewer vendors of EMR software across the country. It wouldn’t surprise me to see some provinces make cash settlements with vendors to amalgamate programs.
 
As physicians we get attached to our EMRs. We don’t want to switch to another brand. Specialists and GPs each have their own reasons for picking a particular EMR. We try to pick one that will allow us to practice the way we want to. However, the data we use should be able to be sorted out (stored) in an orderly way. The dashboard we choose to look at the data with should be allowed to vary but behind the scenes everything needs to be stored identically. There is no reason why an EMR cannot be developed that is flexible enough to meet the needs of all users. The sooner we get to a Universal EMR in provinces and perhaps even country wide the more freedom we as physicians will have to move our practices and join with others. Presently too many of us are boxed-in.

What are your thoughts? Do you feel boxed-in and unable to change? Have EMRs increased mobility of physicians or reduced the ability to move to appropriate work settings?

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

Health IT and EMR Predictions for 2015

In 2000, it appeared that EMRs were poised for rapid adoption in Canada. Countries such as the UK, Denmark and New Zealand had already solved many of the challenges associated with computing in primary care with EMRs widely adopted and used by general practitioners. Over the past 10 years, this number has grown progressively reaching close to 100% in all of these countries. With a great deal of international experience to draw from and committed national and provincial funding EMRs should have been widely adopted. But this has not been the case.

Without a national approach to data communication standards for EMRs, ePrescribing and referrals and consultations, big gaps have remained that hinder the adoption and use of EMRs. Complicated by provincial certification requirements, specialist needs with respect to EMRs, the geographic diversity of Canada and a lack of widespread reliable high-speed connectivity to support ASP-based EMR systems, we have continued to see adoption in fits and starts. A growing number of practices and networks have begun to derive significant value from their EMRs, an example of which is the Associate Medical Centre in Taber, Alberta (Listen to the Podcast with Mike Brand and Audrey Wiebe).

I would like to make 5 predictions for the period 2011 - 2015. Please feel free to add your thoughts or comments to this blog whether you agree or disagree, or perhaps would like to add a prediction of your own.

Prediction 1: Canada will solve the problems associated with referral and consultation between EMRs. There are sufficient users of EMRs to justify a concerted national effort to establish national approaches and standards in order for information to begin flowing between GPs and Specialists and also between EMRs and other clinical sites. Success will depend on a national strategy that is supported by all provinces such that EMR vendors do not have to develop different referral protocols for each province

Prediction 2: We will continue to struggle with ePrescribing through EMRs. The lack of national acceptance of electronic signatures coupled with the absence of a national body overseeing ePrescribing (such as Surescripts in the US) will continue to hamper the widespread adoption and use of ePrescribing and medication reconciliation information. Provincial programs will continue to fragment the use of ePrescribing as systems are designed to meet the requirements of provincial systems vs. all systems meeting a single national ePrescribing standard.

Prediction 3: Use of tablet computers and smart phones to access and interact with EMRs will become widespread. The development of special apps to access specific components of EMRs (e.g. lab results, patient contact information) will make the smart phone a standard tools in the physician's use of EMRs and will significantly increase the value proposition of EMRs.

Prediction 4: Physicians will struggle with the growing prevalence of social networks and the challenge associated with maintaining personal and professional boundaries as Facebook and other social networking tools become the preferred mechanism for communication by many patients. Widespread use of social networking tools will require provincial licensing bodies to develop new policies and guidelines regarding the appropriate use of these tools.

Prediction 5: Without widespread and transparent quantitative satisfation data on the adoption and use of EMRs, selection and optimization of EMRs will remain difficult for physicians and their practice teams. The need to benchmark and measure one's progress against that of peers will either limit adoption and use (if these data are absent) or will significantly enhance the ability to guide EMR adoption and use.

Please feel free to agree or disagree with anything that I have said. Add your thoughts by clicking on the 'Comments' link below.

Status of EMRs in Canada and Barriers to Adoption

Where are we in Canada with respect to EMR adoption and use? This was the theme of a recent edition of Healthcare Information Management and Communications Canada (the official journal of COACH and ITAC Health)

In the lead editorial, Dr. Jeff Turnbull, President of the Canadian Medical Association states:

"It is the CMA’s view that future HIT investments need to be directly tied to achieving specific goals....The proposed investments are built around accomplishing 3 interim goals:

• Significant adoption of EMRs by primary care and specialist physicians in ambulatory settings;
• Accelerating the exchange of health information to support the majority of health care transactions; and
• Increasing the effective use of EMRs and related solutions to meet pressing health and system issues."

Click here to download the article (.pdf)

In an article by Dr. Mark Dermer entitled, Electronic Medical Records Adoption in Community Practice: Canada’s Standing and Infoway’s Responsibility, he states:

"At this juncture in the eHealth journey we Canadians should feel concerned and embarrassed by how we compare to other industrialized nations in the degree to which our community-based physicians use EMRs....The concern about Canada’s state and standing is shared by its physicians.

So if the physician community recognizes the problem then why have doctors not embraced EMRs and exploited them to improve the quality, safety and sustainability of Canadian healthcare? There are three answers to this essential question:

• The degree of personal cost to the physician
• Insufficiencies in the available electronic record offerings
• Poor leadership from jurisdictions and Infoway

Click here to download the article (.pdf)

The 3rd article I would like to share is one that I wrote entitled, Barriers to the Adoption of EMRs in Medical Clinics. A short excerpt is presented:

"EMR adoption still struggles to gain momentum despite all of the perceived benefits. Why is this and what are the barriers to adoption? There is no simple answer to this question. Rather, there are a number of challenges that together create compelling reasons why many not to adopt EMRs. In order to encourage widespread adoption, it is important that we clearly understand these barriers and develop/implement strategies to overcome them.

In order to separate barriers into understandable elements, I have placed them in the following categories, beginning at a system level and focusing in on challenges at the practice level.

• Policy
• Process
• Privacy
• Professional
• Perception
• Practice

Click here to download the article (.pdf)

To view and read all additional articles in HIMCC, click here

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

Infoway - Health Care IT Solution Providers Information Session

Following a much anticipated event held by Canada Health Infoway on October 28th, the following information and slide decks were posted.

The event was an information session for health IT vendors to provide up-to-date information on:

• Infoway's investment strategies and the potential business opportunities they provide;
• the evolution of Infoway's architectural blueprint;
• Infoway's progress around providing certification services; and
• the recently launched public education campaign.

Why anticipated? Well, because they were supposed to shine a light on the fate of some $380 million in funding that is to be dedicated to uptake and use of EMRs by physicians and other frontline providers.

What is my impression, having gone through the slide decks? I am totally underwhelmed! Instead of clarity, there is more of the same old Infoway spin on what a great job they are doing.

What caught my eye in particular?

1. In the Business Update presented by Trevor Hodge, Senior Vice President, Canada Health Infoway, what little detail exists on the new funding for EMRs (see slides 19-24), there is almost zero detail on what is going to take place with EMR vendor 'specifications'. Exactly what is going to be specified and how will it take place? That is what people need to hear. A 12-18 month time frame for this to occur? Come on now, Infoway has had almost 2 years to brew up some strategies in terms of what needs to happen with the funding. Why is this going to take so long and will it help users and patients or simply become more noise as vendors, programs and physicians try to make sense of what to do?
2. One bright light in Mr. Hodge's presentation. On slide 22, he makes reference to 'Regional Health Data' exchanges for services such as referral management. However, when I went through the next slide deck by Ron Parker, Group Director Solution Products Group entitled "The Next Iteration of the Infoway EHRS Blueprint" (slides 16 or 18), there is no reflection of any external health data exchanges (other than the HIAL). I am not sure if this is an error or whether external health data exchanges actually do not really fit into Infoway's vision. While this may seem like a small item, it is actually quite a glaring omission.
3. Next was Shelagh Maloney's presentation on Infoway's certification services. While I agree with the concept of certification, what is wrong with this picture? After 2 years and the development of seven different certification categories, only 1 solution has been certified? TELUS health space powered by Microsoft HealthVault. Ms. Maloney states, "Infoway is currently in discussion with a number of vendors who are interested in certification, particularly in the consumer health application, drug and DI domains." I think we have to do better if we are going to build a vibrant EMR/EHR/Health IT market in Canada.

Click here to learn more: Health Care IT Solution Providers Information Session - Canada Health Infoway

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

Practice Solutions in Alberta - Delays lead to Discontent

On September 15, 2010, the Alberta POSP (Physician Office System Program) published a notification on their website regarding Practice Solutions Software, one of three VCUR 2008 EMR solutions available in Alberta that are eligible for reimbursement through POSP.

The notification states:

"At present, Practice Solutions is experiencing difficulties implementing their EMR solutions in the Alberta market. POSP is working very closely with Practice Solutions to ensure they have the strategies and practices in place to successfully deploy EMR solutions.

POSP is taking the following actions:

• POSP continues to meet regularly with Practice Solutions senior management and sales teams to review project status.
  
• POSP has assigned resources to work directly with Practice Solutions sales (change management), deployment and migration teams to discuss clinic-specific─and broader─issues.
  
• Practice Solutions has assigned a Data Management Project Manager to work with POSP’s Data Management Leader to manage the process, including weekly meetings."

POSP also describes a number of steps being taken to communicate with Alberta physicians and resolve these issues plus interim steps agreed to by POSP and Practice Solutions.

Read the notification

This was followed by a September 17, 2010 letter to members (.pdf) from Dr. Christopher J.(Chip) Doig, President of the Alberta Medical Association. In an excerpt from this letter, Dr. Doig states:

"Below, I will outline the information we have to date and the Alberta Medical Association’s (AMA’s) position as one of the responsible parties for POSP under the trilateral master agreement.

...55 Alberta physicians using Practice Solutions have informed us of significant problems with successfully completing deployment of the EMR. Notwithstanding substantial efforts by POSP and personal intervention by the trilateral co-chairs of the POSP Committee, an effort we recognize and appreciate, the vendor has not resolved these concerns. Some of the physicians have stopped moving forward with the EMR because of problems encountered.

As POSP physicians were notified in an email bulletin from the program this week, for the time being Practice Solutions has agreed to halt the sale and deployment of its product in Alberta – presumably until there is a resolution of these problems."

In the letter, Dr. Doig also offered an apology from the Alberta Medical Association to inconvenienced members and recognized some responsibility shared by the AMA as one of the trilateral parties who sponsor POSP.

The most important part of Dr. Doig's letter outlines the actions being undertaken to resolve the issues, including:

• A clear determination of what went wrong and what will be done to help those affected;
• A strategy to prevent problems with this and other EMR products in the future;
• How best to move forward.

While embarrassing for the affected organizations and distressing for physicians and practice team members affected by breakdowns in the rollout of an EMR system in an organized manner, there are lessons that can be learned from this occurrence. Given the oversight intended by a program such as POSP, this situation should never have arisen, however it did. What are the lessons learned and what should we be cognizant of going forward?

1. Large IT projects (such as provincial EMR programs) are complex, multi-faceted and have a certain risk of failure. While it is extremely unfortunate that individuals (in this case physicians and practices) become the collateral damage, this is not the first large project to encounter difficulties and it will not be the last;
2. Sometimes the only way to effectively resolve a complex issue is to be completely transparent, air the issues in public and determine an accountable and documented process to resolve the problems;
3. Regular and clear communications are a critical component of projects, particularly when problems occur. It is often a breakdown in communications that result in situations becoming extreme;
4. There is a need for comprehensive independent user-generated data to monitor the performance of EMR vendors across Canada and programs in each jurisdiction. Without metrics and real-time measurement of performance, it is impossible to anticipate and respond to problems before they trigger the need for extreme responses.

I would like to invite readers of this blog to submit responses and comments. I have presented the facts above as available through the public record. Share your thoughts by clicking on the 'Comments' link below.

(All comments are moderated before publication - Ed)

EMR vs. EHR - The Canadian Medical Association takes a Stand!

Published in Technology for Doctors, this article highlights the strategy that has been adopted in Canada to focus on EHRs vs. EMRs in physicians practices. It is time to shift the focus to the end-user and encourage widespread adoption and use of EMRs.

The Canadian Medical Association’s recent Health Care Transformation in Canada report calls for a fundamental change in the way healthcare technology is developed. The CMA wants information technology development to shift from building an information superhighway for healthcare to practical applications of technology at the point-of-care. “The focus has been on building systems for electronic health records (EHR) instead of electronic medical records (EMR),” says Dr. Anne Doig (pictured), president of the CMA.

The two terms are often used interchangeably but they’re very different, she says. “EHR describes broadly accessible records of information about a patient that are accessible across medical practices and contain information that might be germane to any practitioner looking at the individual. An EMR is a longitudinal record of a patient that a doctor maintains over time, and is the equivalent of a chart.”

Read the full article in Technology for Doctors

What are your thoughts? Do you think that the EHR is where we should be focusing our attention and energy or should the national focus shift to end-user adoption and EMRs?

Add your comments, by clicking on the 'Comments' link below.