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

Health Reforms Not Keeping Pace with Needs — Health Council of Canada

Saskatoon, SK (May 23, 2013) – Today, the Health Council of Canada released “Progress Report 2013: Health care renewal in Canada”, highlighting the progress achieved by governments in five key areas: wait times, primary healthcare and electronic health records, pharmaceuticals management, disease prevention/health promotion, and Aboriginal health.

The report finds that, overall, efforts at reform are not keeping pace with the changing healthcare needs of Canadians. There is variability of access to services across the country.

The report specifically highlights primary care and electronic health records:

• Canadians have not received 24/7 access to primary healthcare services.
• The Health Council’s analysis of the 2012 Commonwealth Fund Survey showed that the percentage of practices providing after-hours care remained below 50% for all provinces except Ontario.
• Although progress has been made overall in implementing EHRs and EMRs, physicians are slow to implement.
• In the 2012 survey, 57% of Canadian physicians reported using an EMR, but use varied across the country; this was an increase from 2006 where only 23% of physicians were using EMR.
• As of March 2012, EHRs with the six core components (registries, diagnostic imaging, drug information systems, lab test results, clinical reports, and immunizations) were in place for 52% of the Canadian population.

Clearly, there is still a lot of work that needs to be done to improve the adoption and use of EMRs and EHRs.

To obtain further information from the Health Council of Canada, click here.

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.

CMPA Highlights the New Realities of Medical Care

The September 2012 edition of CMPA Perspective provides a sobering reminder to physicians regarding the “New Realities of Medical Care”. The healthcare system has changed significantly even in the last decade, in large part due to fiscal restraints, questions about long-term sustainability, an aging population, alternate models of care, and the impact of technology on care delivery.

In the article, the CMPA highlights a number of areas that I would like to touch upon:

1. Technology and Medical Advancements
   
   • There are two aspects to technology advancement that stand out. Diagnostic and treatment modalities that have been enhanced through the addition of new technologies and the informatics based technologies such as electronic health records, personal health records, clinical decision support tools, and a myriad of other advancements that enable new mechanisms to document, diagnose, monitor, and treat patients. Each of these creates significant challenges for clinicians. It is difficult to keep up with medical advancements in a specific specialty area. The addition of new technologies, diagnostic tools, and modalities to collect and share information increase this challenge. In addition, it is not good enough to simply be using these tools. Just as a clinician could be held accountable for not using a stethoscope correctly or missing obvious findings of ischaemia on an EKG, as CMPA states, “Irrespective of the setting, a physician who relies on technology for treatment and care should be knowledgeable and experienced in its use.” As more practices adopt and use Electronic Medical Records, there is clear evidence developing that physicians using EMRs and related technologies will be required to be competent in the use of these tools. This will mean updating and maintaining skills regarding the use of the EMR just as with any other clinical area of competence. Although it is still early days and some functionalities may not yet be common practice in EMRs, the day is coming when it will become a medico-legal imperitive to be competent and aware of the capabilities of the EMR to assist with diagnosis, alerts, recall capabilities, and other decision support tools that are provided as components of the tool.
2. Patients as Partners
   
   • Patient-centred care is the new paradigm in care delivery. When healthcare information became widely available through the Internet, it was not uncommon to have patients arrive at the doctor’s office with a stack of printouts (some trustworthy and some not) that would then be deposited on the doctor’s desk with a request to review the information and provide feedback on the most relevant management or diagnostic options. In many cases this was treated as a nuisance by physicians who were time-pressured and did not trust much of the information. This has changed significantly. With the advent of patient portals, personal health records, mobile apps for a wide range of diseases, and better sources of information on the Internet, it is time to leverage the knowledge, expertise, and time that patients have to manage their own health in order to achieve better outcomes. Patients are much more engaged in their health and are willing to seek input from social networks, other disease sufferers, and a wide range of sources in order to ensure that they are receiving the most appropriate care. Using tools that provide an appropriate level of interactivity with their care providers (i.e. not unfettered access), patients can be engaged to research, monitor, and manage their health much more effectively — all supported by new technologies. Because of the shortage of primary care physicians in Canada, there may still be some flexibility to avoid taking on “ePatients” who demand access via the Internet or through a patient portal connected to the EMR; however, the window is narrowing. Soon all physicians will need to use EMRs and other patient-centred tools. Prepare for this and leverage the energy of your patients to help manage them more effectively.
3.  Fiscal Challenges and Restraint
   
   • When I am asked by students whether they should consider pursuing a career in medicine, this is one of the points that I bring up. It goes something like this, “Get ready to do more with less. Governments are financially strapped and are facing unprecedented challenges to provide care for their growing and aging populations. This means that budgets for healthcare will be stagnant or reduced over time. If you choose an area of medicine that is dependent on resources, for example a surgical specialty, choose carefully. Your ability to practice is not only dependent on your clinical expertise, but also the availability of resources to provide care. If regional authorities are trying to control budgets and close hospital beds and operating rooms, that means your ability to operate will also be restricted. If you are passionate about a specific area of medicine, follow your heart, but be aware of the fiscal realities and plan accordingly.” The fact that fiscal restraint in the healthcare system is highlighted in a CMPA article is clear evidence that the responsibility of physicians to do what is appropriate for patients extends beyond a pure understanding of clinical needs and into a new realm. You must now be aware of the fiscal environment in which you work and balance your code of ethics against the challenges of doing more with less. While the courts will take into account the fiscal environment, you will be measured against your peers in terms of the standard of care and whether what you provided was appropriate and acceptable.

I highly recommend that you read the article in CMPA perspective. If you have thoughts or insights, please click on the “Comments” link below.

Using Your EMR for Clinical Research

The following article was written by Will Underwood for AmericanEHR Partners and is re-published on CanadianEMR. Will Underwood, MPH is a Senior Associate, Center For Practice Improvement & Innovation, American College of Physicians.

One of the advantages of using an Electronic Medical Record (EMR) is its ability to simplify research activities to the point that even small medical practices can do their own research, either to support quality improvement activities within their practice or purely for research purposes. Determining what type of research you are interested in — and how you want to use the results — has implications in terms of needed functionality for your EMR and research policies that your practice needs to maintain. If you are interested in performing research using your EMR system, you should make sure that it records patient consent as a structured data field. In addition, the EMR should have flexible and easy-to-use reporting features. It should allow you to set up prompts that can alert you to patients that may be eligible to participate in the studies you are undertaking.

The first thing you should decide is how you want to use the results of the research. If you are just looking to use results for quality improvement purposes that are limited to your practice, you are generally not required by regulation/law to undertake an ethics board approval process and the requirements that related to patient consent are more flexible. However, if you are looking to publish the results and/or are conducting prospective research you may need to go through more rigorous processes.

The second thing you should determine is whether you intend to do a retrospective study (in which you will be using data that has already been collected) or a prospective study (collecting information going forward). Most randomized clinical studies are prospective in nature, although they may use retrospective data as part of the inclusion and exclusion criteria.

When dealing with research data, one of the best ways to ensure protection of patient confidentiality is through the analysis and use of de-identified or blinded data. This also has the benefit of simplifying the ethics review process.

Regardless of the type of research you are interested in, it is critical to ensure that you are entering the data as structured elements in the EMR system. I have worked with a number of practices that had been diligent in typing in all of the details of the encounter and relevant test results, but, as they were entering it in as free text, were unable to use the data to run reports without a manual extraction process. While some systems are starting to use natural language processing techniques to search through free text entries, this data can be less accurate and is difficult to combine with standardized data fields limiting analysis. For more guidance on using standardized data fields, read “Why Templates Are Essential When Using an EHR” and “Data Entry Strategies — Using Templates.”

Another critical component within a practice is to ensure that the data is recorded using the same data fields so that diagnoses (e.g. Type 2 Diabetes) are recorded consistently. This tends to be more of an issue when practices or providers have customized their EMR in order to create new or alternate fields that are incorrectly mapped to an equivalent field within the system. This can make it difficult to correctly identify data for extraction when running reports, especially when relying on the reporting capabilities found in most EMR systems in which relevant fields have been pre-mapped for a particular condition.

When evaluating an EMR system from a research perspective, you should determine how difficult it is to combine or separate data elements that you would want to include in aggregated data reports. You should also determine the system’s ability to produce reports that combine different data types — for instance a clinical diagnosis, plus a prescribed medication, plus a particular lab result. If you are interested in the process measures, you will also want to ensure that the system can incorporate demographic and payer information in the reports.

In conclusion, if you are interested in using your EMR for research you should plan ahead, both when selecting an EMR system (as they differ substantially in terms of how they handle data reporting and research requirements) and when implementing and using your EMR. Entering data into your EMR in a standardized and consistent manner will be critical to successfully using your EMR for research purposes.

Have you had experience conducting research via your EMR? Add your thoughts by clicking on the “Comments” link below.

Update on Provincial EMR Funding Programs

Many of Canada’s provinces now operate EMR funding programs to support the purchase of EMR products by physicians. Some of the programs have already been established for some time and have been through multiple iterations (Alberta, Ontario). Others are much earlier in their evolution (Manitoba and, recently, Quebec). In the short space of this article, it is not possible to do a detailed review of a single program, let alone multiple provincial approaches to EMR funding. As a result, what I would like to do is offer selected observations of the programs — what they have done well, and what I believe they could do to make themselves more successful. For individuals who are considering a funding application, please contact your individual program directly.

What have the provincial programs done well?

• By raising the visibility of EMR as an important component of care transformation and facilitating the adoption of individual EMR systems by implementing certification programs, the provincial EMR programs have raised the bar significantly in meeting the needs of early users.
• Funding provided by the provinces, in addition to funding provided by Canada Health Infoway, has created valuable peer support networks that have been critical in advancing adoption and use of EMRs through collaboration and education. It is not possible to improve practice performance without this type of collaborative network.
• The implementation of EMRs has forced discussion by many of the provincial colleges and licencing authorities to better understand issues relating to privacy and the sharing of clinical information using electronic systems. Certain provincial colleges (BC, Alberta) have developed data stewardship policies outlining the physician’s responsibilities in terms of information management in an electronic setting.

How could the provincial programs improve?

• Each of the provincial EMR programs has invested significant funds and resources to develop implementation and support strategies as well as educational programs and each has valuable lessons learned from their program. Through my work in different provinces, it is evident that there is limited sharing of the knowledge, resources, and expertise to reduce duplication of effort and reduce mistakes already well learned through the more mature programs.
• By moving away from certification programs focused on functional requirements to certification of the messages transmitted by the EMRs with a focus on achieving clinical and operational outcomes (Meaningful Use of EMRs), it will be possible to future-proof certification to a greater degree by facilitating information exchange rather than EMR functionality.
• Wherever possible, standardize the messages for information exchange across all of the provinces. It is not sustainable for EMR vendors to support different messaging requirements for referral/consultation, chart transfer, or ePrescribing in each of the provinces in addition to supporting other functional requirements for each provincial program. This will reduce the cost for vendors, allowing more resources to be applied to important usability improvements that need to be made to each of their systems.

If you have any additional observations on the provincial EMR programs that you would like to share, click on the “Comments” link below to add your thoughts.

TED — Paddy Ashdown: The Global Power Shift

I try, whenever possible, to listen to the TED talks as I find them a fascinating and eclectic mix of ideas and concepts with broad application. Paddy Ashdown is a British politician and diplomat who served with the United Nations and as a negotiator on behalf of the UN in Afghanistan. He states, “Everything is connected to everything” (12:58 of the presentation). “The paradigm structure of our time is the Network... the most important thing about what you can do, is what you can do with others... resulting in a shared destiny.” These are lessons that can be applied to the healthcare system.

So, what does this have to do with healthcare and, more specifically, health IT? In a traditional model, acute, community, and primary care function independently with loose connections between the sectors. Each has its own oversight, budget, and governance. Sometimes the sectors communicate with one another, but frequently they do not, resulting in duplication of services (e.g. lab results and diagnostics), ineffective hand-offs (hospital or ER discharges), and poor coordination of care (particularly in primary care).

The reality is that in a healthcare system struggling to sustain itself with unlimited demand for services, we can no longer afford silos. In the words of Paddy Ashdown, as patients we “share a common destiny”. The barriers are artificial — created by historical structures, processes, and policies.

In order to “fix” the healthcare system, we have to turn many of these accepted norms upside down and place the patient at the centre of the re-engineering process.

What are your thoughts? Click on the “Comments” link below. 

Future Practice — Why I Love My EMR

Published in a web-only format, Future Practice is a Canadian Medical Association publication that provides feedback from users of EMR systems and an update on the adoption and use of EMRs in provinces across Canada. In an editorial, Dr. Jeffrey Turbull, President of the Canadian Medical Association, highlights the need to focus on solving clinical problems through a “bottom-up approach that is needed to accelerate the adoption of electronic health records — one that focuses on the needs of physicians and others delivering front-line services.”

Topics in this issue:

• Why I LOVE my EMR
  
  • Physicians from across Canada weigh in on the benefits of EMR systems.
• EMR funding in Canada: current status
  • This summary covers EMR programs in 5 provinces: Alberta, BC, Ontario, Manitoba, and Saskatachewan.
• E-prescribing (whatever its form) remains elusive in Canada
  • E-prescribing is one of the high value capabilities of EMR systems that significantly improve the speed and benefits of automated medication management.
• Life on an electronic island
  • Dr. Steve Pelletier narrates his experiences and frustrations using an EMR system that is not connected to healthcare system at large.

Download a .pdf copy of Future Practice

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

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.

Why can't we Accelerate EMR Adoption in Canada?

You would think that with almost 10 years of history promoting EMR adoption, Canada would be further ahead than we currently are. Why is this and what can be done accelerate adoption and use of EMRs?

I believe there are a number of contributing factors:

1. Failure of policy.
2. Inability to build consistent momentum amongst clinicians (Support and facilitation needs to be progressively ramped up. Every time programs or momentum slows, it becomes twice as difficult to engage clinicians the next time around.)
3. Persistent gaps in the system (In particular, the ability to electronically prescribe medications)
4. Failure to apply national coding and interoperability standards. (Without the ability to exchange information between systems and between providers, the value proposition for adoption of EMRs is just not high enough. The longer this is delayed, the higher the barriers to success.) 

Of these four factors, the most important is 'Failure of policy'. There is a lack of national leadership in terms of direction setting, creation of programs to encourage the use of information technology and EMRs and creation of the overall environment within which technology supported care can flourish. It is simply not enough to create a single entity such as Canada Health Infoway, endow it with the responsibility to manage a single segment of the healthcare system (namely the EHR) and believe that the job is done.

With billions of dollars committed to encouraging the adoption and use of health IT and EMRs, I find it hard to understand why we do not have a role in Canada similar to the Office of the National Coordinator for Health IT in the US.

Can we be successful without strong clinical leadership and a national coordinator for Health IT in Canada? Perhaps, but this is not a sure thing and it is going to be very difficult to synchronize efforts across multiple provinces and get buy-in from physician organizations and groups across the country.

We are dropping the ball in Canada. No individual in a leadership position (in ministries of health at the provincial or national level or Canada Health Infoway) should be satisfied with the status quo. We should be admitting the existence of a serious problem, convening all stakeholders and developing a national strategy that enables us to move the health IT agenda forward.

Do you agree or disagree? To share your opinion, click on the 'Comments' link below