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

BC Workshop on Mobile Applications — June 18, 2013

The British Columbia Alliance on Telehealth Policy and Research (BCATPR) is holding its 6th annual workshop at St. Paul's Hospital in Vancouver on Tuesday, June 18, 2013. This year’s workshop theme underlines the importance of mobile and web-based telehealth applications that can be used by patients, clinicians, and health policy decision makers. It will include telemedicine, telehealth, mobile health technologies, remote monitoring, and web-based programs for chronic disease management.

Register here: Mobile applications to support behaviour change, clinical decision making and health service delivery

Using EMRs for Chronic Disease Management

In the past, I have written numerous articles describing the benefits and potential uses for EMRs for the management of patients with chronic diseases such as diabetes and congestive heart failure. In this context, EMRs are very good at performing repetitive tasks in a standardized manner such as reminders for patient recall or electronic tracking of lab results. At the same time, it has become abundantly clear that management of chronic diseases in 2013 is a team-based care process with the need to access or input information into some form of shared care record. This is not a simple task, but certainly can be managed more effectively using an EMR vs. a paper-based record.

One of the challenges with patients who suffer from chronic diseases such as diabetes is the fact that many of these patiens also have multiple additional co-morbid diseases such as chronic kidney disease, peripheral vascular disease, hypertension, etc. Each of these diseases has clinical practice guidelines that have been developed by expert groups (either national or provincial). Many disease states have different expert groups that devise the clinical practice guidelines, creating a great deal of difficulty when translating these rules and recommendations into an EMR system. For example, if the best practice for a patient with two co-morbid diseases is a specific dose of a certain drug for one disease and a higher (or lower) dose for the other disease, which one takes precedent? The same may apply to diet restrictions with variations in dietary guidelines for each of the diseases. Because clinical practice guidelines are developed for single disease states, and because the clinical presentation of each patient may vary, developing a rigid set of rules or guidelines is difficult for multiple disease states in the same patient — particularly when conflicting recommendations may need to be applied via the EMR.

The advantage in Canada is that physicians (particularly in primary care) have now been using EMRs for a number of years to manage these types of patients. How do you manage patients with co-morbid chronic diseases? What types of templates do you use? Have you found a way to manage this problem that could be of use to colleagues?

Please share your experiences by clicking on the “Comments” link below.

Does Pharma Have a Role in the EMR-Based Medical Practice?

Over the past 10 years, medical practice has changed dramatically. There are numerous factors that have resulted in these changes, including information technology, reimbursement reform, and the transition to the team-based care. Simultaneously, the relationship between physicians and the pharmaceutical industry has changed. The advent of academic detailing created new and less biased ways for physicians to receive information on drugs from non-industry pharmacists, information on drugs has been more widely available through a wide range of easily accessible and trustworthy websites, and EMRs/EHRs have integrated progressively more detailed information on drugs directly into clinical care with the ability to present relevant alerts at the time of decision making.

In addition, many physicians stopped seeing pharmaceutical reps in their practices. This was partly due to over-detailing (the same reps calling on doctors too frequently or different reps from the same company), uncertainty regarding the value of data being presented, limited time availability, and increasingly stringent guidelines governing the relationship between physicians and pharma companies. The net result was increased separation between pharma and physicians. A major focus for the pharmaceutical industry has been maintaining or increasing access to doctors and protecting brand name drugs against the onslaught of generics, which have eaten away at profits.

There are additional challenges that the pharmaceutical industry faces. Drug research and development cycles are long and costly, making it challenging to bring new drugs to market more quickly and efficiently. With the advent of personalized medication regimens and pharmacogenomics just around the corner, identifying the appropriate therapies for specific patients will not be possible without advanced technologies to support care decisions. As the dominant technology in a doctor’s office, EMRs are becoming the tools of choice for the majority of physicians in terms of documentation and clinical decision support. If a drug is not listed in an EMR’s drug database, it becomes difficult to prescribe. Similarly, without the processing power and logic of health IT systems to support decisions regarding personalized therapies, it will be almost impossible to prescribe the right drug for the right patient at the right time. Catch 22. In the majority of instances, you cannot prescribe the right “personalized therapy” without the right types of technology, and the EMRs are still a long way from being able to consistently support these types of clinical decisions. Getting access to the data in EMR systems for analytics is difficult for physicians. Use of this data by third parties for clinical research purposes, or to identify appropriate cohorts or patients for specific therapies, adds additional levels of complexity.

One of the areas that makes a great deal of sense in terms of collaboration between doctors and pharmaceutical companies is access to ancillary programs offered by brand name drug manufacturers that can be linked to therapies within EMRs. For example, a pharma company may offer a coupon program for low-income patients or additional educational or support programs for a particular therapy. These are difficult to remember at the time of the prescribing, but with an EMR, a physician could receive an alert at the time a drug is prescribed with the ability to easily print a coupon for a patient or an information sheet on an education/support program. This fits very effectively into the workflow of the physician, provides added value to the patient without incurring additional effort, and encourages appropriate utilization of drug therapies.

Building this type of capability into EMRs will not be easy; however, if done appropriately, there is significant value for all parties. Does Pharma have a role in the EMR-based practice? In this area, I strongly believe it does.

Do you agree or disagree? Add your thoughts by clicking on the “Comments” link below.

Using Technology in Clinical Practice

When I first began speaking and writing about technology use by physicians, EMR users were a minority. Over the past 10 years, Electronic Medical Records have become mainstream. New graduates would not consider joining or establishing a medical practice that does not have an EMR, and mobile tools such as tablets and smartphones have become almost ubiquitous amongst both physicians and patients. In Canada, we still face inconsistent adoption of EMRs within the provinces, and fragmentation in the EMR market. This is due to provincial certification strategies that have served to encourage adoption at the provincial level but have not been successful in establishing national standards for sharing information between EMRs or for ePrescribing. There have also been successes, particularly in the management of chronic diseases where EMRs are being used more extensively and more effectively to track, recall, and manage complex populations of patients.

In the last 10 years, technology has exploded, driven by smaller, cheaper devices and faster networks. Telehealth has become standard fare in remote communities and face-to-face videoconferencing is used extensively anywhere one has a wireless connection. Remote and home monitoring is being used to manage patients in their homes. Diagnostic imaging is now largely electronic, prescribing data is available via provincial repositories in some provinces. Medical practice websites, personal health records, and patient portals are used extensively. If we stopped for a moment to look back on the progress, it is quite remarkable how rapidly the transition has taken place.

However, as extensive as the explosion in technology has been, we are faced with a new problem. How do we use the technology effectively in our practices and integrate it into what we do? It is no longer about the technology; we are now getting into the application phase of making it real.

Between March 27 and April 6, the CanadianEMR Technology in Clinical Practice cruise conference will take place in Tahiti and the Society Islands. We will be joined by 70 attendees and their families, and the focus of the conference will be how to use technology more effectively in the delivery of patient care. One of our faculty will be preparing his presentations using Apple’s iBook publisher software to create materials that can be shared with attendees after the conference in a multimedia format combining video with text. The conference will also not just be about EMRs. In addition to cardiology and neurology topics, I will be as interested as other attendees in learning how our faculty are using diagnostic and monitoring technologies in their practices.

Are you using technology in innovative ways in your practice to deliver better care to patients? Share your experiences by clicking on the “Comments” link below.

Creating Online Communities of Practice to Support EMR Use

A number of years ago, while working with Vancouver Coastal Health on a primary care health IT strategy, I had the opportunity to lead a project to develop local peer support networks or physician user groups (PUGs). The principle behind the groups was to find a way to bring together clinicians with a wide range of skill sets ranging from none to highly skillful in relation to EMR use and health IT. However, as with many of these types of strategies, programs such as this are difficult to sustain over the long term.

The following summarizes lessons learned after 20 months of facilitating and supporting physician engagement through the Physician User Group strategy (2005 and 2007). Many of these learning points remain applicable in 2012, further supported by social media and mobile communication tools. It is important to note that the creation of these groups entailed both face-to-face meetings and online communication, leveraging local relationships and strengthening mechanisms to facilitate collaboration:

• There are multiple levels of engagement of clinicians. Physician User Groups are an entry-level engagement strategy to facilitate communication, build trust and credibility, and provide feedback into eHealth projects to ensure relevance of the projects to end users and to facilitate and organize thinking within a community.
• Time is one of the scarcest commodities that we have in the healthcare system today. Physicians work in a highly time pressured environment.
• It is not necessary to reach every clinician face to face. A very effective communication system exists amongst physicians in a community and the message will be disseminated informally and via email.
• It is important to initially understand the needs of the local group and allow concerns, issues, and desires to be openly discussed and documented. From the physician’s perspective: “What is in it for me and my local community?”
• The context then needs to be established in order to define what is doable and what is not and to seek involvement of clinicians in those areas.
• Once the group is established, the majority of communication takes place electronically.
• Leaders do not all need to be tech savvy. Strong clinical leaders who are respected by their colleagues and are seen as “more like me” are highly effective group leaders.
• Leveraging existing groups, e.g. departments of family medicine, and medical staff groups, is a very effective way to build your clinician member base quickly.
• One of the roles of groups is to facilitate communication amongst physicians in a peer-to-peer communications network.
• Leaders must have an easy mechanism to generate communications and distribute those communications to their members.
• Wherever possible in communication with physicians one should not use acronyms, as this creates confusion.
• The importance of accountability. It takes approximately two “cycles” to get buy-in and support from your members. It is necessary to prove to the members that you are responding to their needs and feedback, and that this is being integrated into the solutions and processes that are being developed.
• As face-to-face meetings are scheduled approximately every six months, it takes about one year to effectively establish a group.
• Meetings amongst group leaders are a critical part of sharing the lessons learned and providing timely and useful information and feedback to the IT resources and sponsors plus executive team members.
• Groups will evolve and change over time based on environment and needs.
• User groups enable physicians to organize themselves and structure their thinking within communities. Whether related to connectivity, eHealth information such as DI, Labs, Medications, or Electronic Medical Records, a standardized approach and fewer variables is easier to manage and more effective in achieving adoption and improved clinical outcomes.

I am currently reviewing a book titled Technology Enabled Knowledge Translation for eHealth. One of the chapters is focused on the building of electronic communities of practice. I will share observations and insights at a later date.

To add your thoughts or experiences with physician online communities, click on “Comments” below.

Health 2.0 and 3.0. Waiting for 4.0

This week I am attending the Health 2.0 conference in San Francisco. These events are a great opportunity to see what is new and emerging in terms of healthcare providers and patients. The conference attracts a wide range of sponsors and presenters ranging from pharmaceutical and insurance companies to highly innovative startups — all trying to tap into the growing demand for social interaction between patients and their care providers.

But, I almost wonder whether the term Health 2.0 is already old and tired. After all, this is already the sixth annual conference by this name. In the hyper-rapid world of web and mobile technologies, what is new and innovative one year is standard fare the next and ready to retire the following year. The fact that the idea of Health 2.0 has managed to survive is related to the demand for venues to examine the world of healthcare delivery through a new set of lenses. The term Health 3.0 has already been around for some time based upon the concept of the “Semantic Web” in which unstructured or semi-structured data (in this case, healthcare data) is managed in a way that provides logical meaning to the information. In a Health 3.0 world, data can be used to personalize the user’s experience so that the information is relevant to that individual. It is the difference between being able to view general information vs. information that is relevant to problems and diseases of that individual.

If Health 3.0 is all about using data meaningfully to personalize an individual’s view of information, am I already beginning to visualize Health 4.0? Is this the environment in which machines or software applications (programmed with some degree of artificial intelligence) are able to make decisions on behalf of patients in order to produce the best clinical outcomes? With insufficient doctors and nurses to manage patient care, it is easy to envision alternate mechanisms to provide care. However, who defines the outcome measures and who provides governance and oversight over the individuals that develop the software and machines to ensure that they function ethically and appropriately? The whole picture is somewhat Orwellian in nature. No matter how good the intention, the potential for harm is just as prevalent.

Let me return to the present. I am looking forward to the conference and will report back on innovative products and concepts, particularly those that can be incorporated into medical practice settings.

I look forward to your feedback and comments.

How Many Ways Can a Referral Get Lost?

This video (produced by HealthLink, a provider of health system integration services) highlights a number of very important issues related to health system efficiency and patient safety in the management of referrals.

From the referring physician’s perspective, what he or she wants to ensure is that a referral is going to be received, triaged, and booked as quickly and efficiently as possible with the appropriate specialist. Frequently, the referring physician does not have a personal relationship with the specialist to whom they are sending the referral. In contrast, 20+ years ago most referrals took place within a community in which specialists and family physicians knew one another personally. A phone call or note to a specialist was efficiently handled without involving too many additional staff in the process — perhaps one or two admin staff on the specialist’s side and one admin staff in the referring physician’s office. This is no longer the case. With many family physicians having limited personal contact with specialists and the addition of multiple levels of administration (booking clerks, specialty clinic triage systems), getting the referral to the right person is not a simple task. As more layers are added to the referral process, the risk of a referral being sent to the wrong department or simply being “lost” increases.

Duplication is also a significant issue. In order to ensure that a referral is received at the specialist’s clinic or office, it may be sent multiple times — email, mail, or fax — resulting in the need for repeated triage and/or inappropriate appointments being made for the same patient with different specialists for the same clinical problem.

Watch this video to learn about experiences in a hospital in New Zealand managing referrals electronically. What I find striking is the level of granularity that is required in the analysis when developing processes to ensure that the systems functions as safely and efficiently as possible.

Share your experiences regarding the sending and receiving of referrals. Based on these experiences, how could your referral process be made more efficient? Click on the “Comments” link below

Using Your EMR to Improve Quality of Care

Technology for the sake of technology has limited value, particularly in healthcare. The initial phase of EMR and information technology implementation by medical practitioners has been primarily focused on getting the technology in place and making sure it is deployed as comprehensively as possible. Once the EMR has been utilized for some time (1–2 years) and there is a level of comfort and familiarity amongst the users, there is usually a natural transition towards quality improvement and optimization. As with all adoption curves, there are always a small subset of users who tend not to progress in their use and remain “stuck” at a very basic level.

The questions then become much more focused on measurement. What metrics should be used to measure quality of care? How can these measures be applied consistently across a wide range of patients and clinical conditions? And how can one ensure that the measures are an accurate reflection of different components of care delivery? Ensuring trust related to measurements is key in terms of driving improvement initiatives. If users do not trust the results or if they believe the results indicate an unfair bias or reflect measures that are out of their control, they will discount the process, in the end not achieving any of the intended outcomes.

There are also two phases to quality improvement using measurement and analytics:

1. Internal: EMR users need to develop a level of comfort and trust with the measures before their performance measurements are made available either to peers or administrators. It can be quite startling to see the cold hard facts compared against one’s perception. Users need time to absorb the data and to make adjustments in order to improve performance before they are individually compared against peers in similar practice settings. During this phase, it is useful to collate aggregated performance data and use this as a baseline for group performance. What this data also provides is a benchmark measure against which users can compare their individual scores.
2. External: After sufficient time to analyze, absorb, and act upon the data (i.e. make changes to internal practices in order to modify patient management and measurable outcomes), EMR users can then be encouraged to continuously improve their clinical management practices by exposing the data more broadly. Using a graduated approach — practice level reporting, inter-practice and regional reporting, and then provincial reporting — serves two purposes. It allows providers to become progressively more accepting of their performance in comparison to peers and allows for a more refinable system in terms of progressively wider data reporting.

It is certainly possible to combine the two stages into a single phase; however, the risk of ostracizing providers is much higher — this is a significant change in the way that care is provided and measured. There are few providers who do not want to provide good quality care. If implemented too quickly and with insufficient planning, the result may be to discourage rather than encourage improvements in quality of care.

For the last few years, CIHI (Canadian Institute for Healthcare Information) has been working with groups and organizations across the country to develop a set of primary healthcare indicators that are increasingly being used as a reporting standard for clinical performance reported through EMRs. Expect this program to grow significantly by 2015.

A number of initiatives are also underway in the United States as part of the transition to EMR-based clinical care delivery. Health and Human Services (HHS) maintains the Health System Measurement Project that tracks critical government healthcare data in a number of areas. In addition, the Agency for Healthcare Research and Quality (AHRQ) is currently collecting information regarding current successful strategies and challenges regarding quality measurement enabled by health IT. The questions that are being asked to describe Health IT enabled quality measurement are well worth reading. In support of this work, AHRQ released a report entitled “An environmental snapshot — Quality Measurement Enabled by Health IT: Overview, Possibilities, and Challenges”. Download the .pdf

What is your experience with Quality Measurement using an EMR? Do you have any lessons or experiences to share? Click on the “Comments” link below to add your thoughts and feedback.

Building an EMR from Scratch — A Saskatchewan Success Story

The Medical Post January 31, 2012, by Deana Driver (Republished with permission)

(This article is one of a series titled 'The Innovators' - EMR success story: Sustainable rural care built from the ground up)

Dr. Werner Oberholzer can barely contain his enthusiasm as he shows a visitor the electronic medical records system that he and his colleagues created as a key component of their region-wide primary-care team, here in rural southern Saskatchewan. Thanks to the EMR, which Dr. Oberholzer and his colleagues built essentially from scratch, their Rural West Primary Health Care Team is an admirably smooth operation, despite consisting of more than 17 practitioners—including two doctors—working at three separate facilities. It’s also admirable because of the challenge of serving more than 7,000 patients spread over 14,000 square kilometres, an area more than twice the size of Prince Edward Island.

As soon as information is entered into a patient’s file on the EMR, Dr. Oberholzer or his wife and colleague, Dr. Nelly Helms, can read it online and determine what they wish to do for that patient. “I can pick a name of any member of my primary-care team and send instructions to them,” says Dr. Oberholzer, who is also on Saskatchewan’s provincial e-health committee. “We spent hundreds of hours to make these forms and templates. We changed them with the designers to suit our function. I scanned all these forms in for different reconciliation forms, the medication, dosages.”

Accessible information

He gives a patient with diabetes as an example. The nurse doing a home visit can hover her computer’s cursor over an information field — related to BMI or blood pressure, for instance — and a screen pops up to tell the nurse what information Dr. Oberholzer wants. If the patient needs to see a specialist, the team can easily print out a summary to send to that doctor. And with a few simple clicks, a summary of the patient’s medications, immunizations and other info can be sent to a pharmacist’s iPad.

The doctors maintain control over every patient’s record, and can block or narrow what other caregivers can see in the EMR. “My pharmacist can put the medications in,” says Dr. Oberholzer. “I can say, ‘I agree with that.’ ” As well, they can use the EMR to generate reports on any topic — for instance, their 20 most common diagnoses or tests, or the top drug allergies. In terms of the EMR system’s impact on the care he provides, Dr. Oberholzer says: “If you can’t measure it, you can’t manage it. If I don’t have a target goal to start off with, then I don’t know where I’m going.” Moreover, since each physician needs to sign off on the chart of every patient seen that day, “if I have a task yet to do for the day, it lets me know.”

Building care

In 1998, Drs. Oberholzer and Helms joined many other South African doctors and left their homeland to take up practice in rural Saskatchewan. They settled in Radville, where their health-care team has its main base. It’s in prime grain-growing country, about 90 minutes south of Regina, that abounds in unobstructed views of rolling hills and roads stretching for miles in all directions.

When they arrived, there was no other doctor in town. Almost immediately, Dr. Oberholzer began thinking about ways to improve health services for their patients. He began lobbying the province to build a new health centre, since the existing one was cramped and “literally falling apart.” (After 10 years, lobbying and fund-raising have paid off, as a recent groundbreaking ceremony kicked off what is expected to be “a one-stop shop” in a $12-million facility scheduled to open by the end of the year.)

As the doctors in the neighbouring towns of Pangman, Bengough and Coronach left their practices in recent years, the workload for Drs. Oberholzer and Helms continued to increase. Today, they each see from 45 to 75 patients a day and they have come to rely on allied health professionals for solutions. A few years ago, pharmacist Kim Borschowa and Dr. Oberholzer attended a chronic disease management workshop on clinical practice redesign that the Saskatchewan’s Health Quality Council hosted. Almost immediately they began collaborating on the care of their diabetic patients along with Leila McLurty, an experienced community health services manager who splits her time between Pangman and Bengough, who was also interested in providing better care. They all recognized that they needed to find a way to provide care to an ever expanding patient population (due to the physician exodus), spread over a large geographical area. Community meetings were soon held to determine which services were needed most.

A properly designed EMR would be crucial. In May 2010, the Rural West Primary Health Care Team officially launched. It consists of more than 17 practitioners including the two doctors, a dietitian, two pharmacists, a nurse practitioner, home-care and diabetes nurses, plus administrative staff. The team also teaches nursing, pharmacy and first-year family medicine students from the University of Saskatchewan who come for two to six weeks to experience rural remote medicine.

Going the distance

An unavoidable part of caring for so many patients over such a large area is the need to get behind the wheel. So, one day a week, Dr. Oberholzer drives several hundred kilometre to see patients — to Bengough then to Pangman, then back to Radville — often arriving home around 10:30 at night. Typically, Dawn Geiger, a team assistant who travels with Dr. Oberholzer to the communities, types patient complaints and information into the EMR after meeting with the nurses in the health-care centres and nursing homes. From its base in Radville, the team also provides 24-hour emergency care for the region.

The EMR is key to the team’s success, but so are the face-to-face meetings that build trust and knock down the walls of professional territorialism. “The EMR makes a big difference because, say I get a patient coming in and they don’t remember what they discussed with the doctor,” says Borschowa. “I can look it up and see that, yes, they discussed this.”

Dr. Oberholzer spoke at length about his team’s strengths at the recent Saskatchewan Medical Association meeting. Dr. Phillip Fourie, the SMA president, says Dr. Oberholzer “is well ahead of the curve. He’s where we want to go with primary health care,” adding the province lacks a province wide EMR system. Not that everything was easy with the team’s setup, far from it. The transition to the new EMR “was absolutely horrible because there was no one to tell us how to use this thing. The whole office was in an uproar,” recalls Dr. Oberholzer. But after six months of fine-tuning, all agreed the EMR and instant access to each other as caregivers is invaluable. “Now that the team is in place, we’ve brought access and health care to areas where they thought it was not possible or sustainable,” says Dr. Oberholzer. “And we’ve empowered the health-care providers within the team to perform to the best of their abilities to promote higher quality medicine. We can now design the care around what the patient needs instead of forcing the patient into a model that’s not suitable to him or her.”

To sum up his approach, he says, “Anything that doesn’t change goes stagnant. You either make it better or you leave it.”

Deana Driver is a freelance writer in Regina.

The Importance of Physician-to-Physician Communication

If you asked the average physician whether it was more important to be able to communicate with hospitals or physicians within the community to whom they refer patients, my guess is that the vast majority would choose physician-to-physician communication. The most recent podcast published on CanadianEMR was a frank discussion with Dr. Mark Dermer entitled Should Physicians be Forced to Adopt EMRs? In this podcast, Dr. Dermer makes the point that physician-to-physician communication has never been part of the national IT strategy. This is evidenced by the fact that EMR-to-EMR interoperability standards have never been clearly defined. This critical limitation is reducing growth of the market and adoption of EMRs.

Why is it so important? Most community-based physicians (where 80% of the care is delivered) spend a significant part of their day referring patients or responding to consultation requests. As a result, even with the best EMRs currently available, these referrals are created digitally and either printed or faxed to the receiving physician's office. There they are printed or received as fax/scanned documents into the EMR (if one is used) and when a report is created, the whole process is repeated as these reports are digitized, printed, and transmitted all over again. What a waste of time and energy.

How could we have missed this fundamental requirement for an EMR? The ability for providers of care to communicate and collaborate with one another!

Some may argue that it is too complex having EMRs communicating with one another directly through point-to-point communication. In this regard, I agree. However, there are many intermediary third-party information exchange providers who specialize in taking data from one system and translating it into a format that can be received by any other system to which it connects. These information exchanges are widely available and in each U.S. state are being deployed to handle exactly these issues.

Physicians communicate with and refer to a wide number of clinicians and ancillary care providers. An information exchange should be able to handle all of these communications needs and options. Perhaps at the beginning, a smaller number of connections are provided, but over time the use of the information exchange needs to become ubiquitous such that sharing of information is not an issue.

We should limit the development of proprietary provincial information exchange capabilities in favour of universal messaging standards that allow vendors of EMRs to build once and use many times. One can only hope that common sense prevails.

To add your thoughts or feedback, click on the “Comments” link below.