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

National Post - Avoid the boondoggle!

To be successful in Canada with Health Information Technology including EMRs, we need to get back to basics. This is not about getting projects completed or getting treasury departments and bean counters off the backs of those who need to deliver on commitments. This is about care for Canadians and making sure that we use our resources well. In summary, extracting clinical value for the benefit of patients (unfortunately an often forgotten stakeholder in this equation).

The following is an excerpt from a just published article that I wrote for The National Post.

National Post - April 12, 2010: It’s hard to know exactly how many dollars Ottawa and the provinces have spent so far on the grand plan to bring electronic health records (EHR) to Canada’s health-care system. Supported by Canada Health Infoway, the federal-provincial agency promoting EHR, a rough count suggests the total to date runs to at least $2-billion, with much more to come. The last federal budget alone committed another $500-million. As Terence Corcoran stated in a recent column, “EHR is one of those great blue-sky ideas that seem sound and logical.” The objective is to have built an electronic health record for every Canadian — from prescription history to hospital visits, from family doctor records to major surgeries. As a physician and long time proponent of the use of information technology in health care, I am frustrated by the lack of progress on EHR, despite the billions spent.

Read the full article - Avoid the boondoggle

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NEJM -- Accelerating the Use of Electronic Health Records in Physician Practices

In a January 21, 2010 Perspective piece in NEJM, authors Steven Shea, M.D., and George Hripcsak, M.D., describe the practice of incentive payments from hospitals to support physician adoption of EMRs (EHRs in the US). Payment of incentives for this purpose is exempted from the Stark amendment to the Omnibus Budget Reconciliation Act of 1989, which prohibits hospitals from offering physicians incentives for providing referrals or admissions.

This is not a simple as it sounds and raises many questions from a governance and data stewardship perspective that carry over to Canada in terms of EMRs and the ownership of patient data.

North Shore Hospital System on Long Island in New York recently announced that it will pay an incentive of up to $40,000 to each physician in its network who adopts its electronic health record (EHR) — paying 50% of the cost to physicians who install an EHR that communicates with the hospital and 85% of the cost if the physician also shares de-identified data on the quality of care. This payment would apparently come on top of the $44,000 incentive that the American Recovery and Reinvestment Act of 2009 (ARRA) has authorized Medicare to pay each eligible health care professional who uses certified EHRs in a meaningful manner. Full Article: NEJM -- Accelerating the Use of Electronic Health Records in Physician Practices.

I asked a colleague in the US whether any guidance had been provided or precedents established with respect to the following scenarios, (which I believe are all highly likely). According to his feedback, all of these issues have been raised, but there are no clear answers.

1. What happens if the physician terminates their relationship with the hospital in question (for whatever reason) but continues to provide care in the same geographic area? Would they have to give back the EHR to the hospital or the money that was provided by the hospital as an incentive?
2. What happens if the physician or practice provides care for patients in a number of different facilities that are competitive with one another. Can they use their EHR for these other facilities?
3. What is the policy in terms of ownership of the patient records? Does the physician, clinic, or hospital own the records?
4. How can the physician get their information out of the EHR if they decide to join a new group and wish to transfer their patient's records at the same time?
5. Have any policies or approaches been developed for historical access to patient records for medical legal purposes after a physician has left a practice with a specific EHR?

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

Alberta to Offer Medical Information Online to Patients

An article published today in the Globe and Mail highlights clinical information that will soon be able to patients in Alberta.

KATHERINE O'NEILL
From Friday's Globe and Mail October 17, 2008

Albertans will soon have their personal health information at their fingertips around the clock. The province is set to become the first jurisdiction in Canada to allow residents to access the often sensitive and private information online. The Progressive Conservative government plans to start slowly, at first offering only a bit of information such as vaccination records.

However, the end goal is to post everything, including prescriptions, X-rays and laboratory test results. “It's really going to help having all this information in one spot,” said Jody Nickerson, a high-school teacher and married mother from Edmonton. The 32-year-old, who is six months pregnant and has a 15-month-old daughter, Charlie, said it's a lot of work managing her young family's health care with all the appointments, tests and vaccinations. And sometimes Ms. Nickerson doesn't have all the information she needs, including simple details such as Charlie's blood type. Link: globeandmail.com: Alberta first to offer medical information online.

What are your thoughts on the access to information by patients through personal health records or EHRs? Will this make your job easier or more complex? What could be the impact of patient access to information such as lab results before the physician has had a chance to review the findings.

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

What is the Physician's Responsibility with regard to the Paper Chart in an EMR-based Practice?

I received this question from a practice manager regarding the responsibility of a group of physicians with respect to stored paper charts when some of the physicians leave a practice that has implemented an EMR system. It poses a challenging issue.

"Please can we have your advice on the following situation:

If associate doctors in a clinic which computerised their records decide to separate and move into a new office location in the same city approximately 18 months later, is it reasonable for them to ask for copies of ALL paper charts? Who is responsible for payment of these copies? Surely all the relevant and pertinent data should have been incorporated into the EMR prior to their departure rather than putting the onus on the remaining physician(s)?

Is there a recommended time frame for computerising EMR?

I would greatly appreciate your feedback."

The practice that retains the paper charts has a responsibility as the steward of that chart until the record requirements of the College of Physicians and Surgeons in that particular province have been met. For example in British Columbia, the requirements are the Age of Majority (18 yrs) plus 7 years for patients that have left that practice. However for patients who are still active, it is necessary for physicians to retain the paper chart indefinitely or until the patient passes away.

If part of the chart has been entered into an EMR (set a start date, enter important information and go forward from a point in time using the EMR), then it is necessary to keep the old paper record in storage, either at the practice or off site in a secure storage facility. The old paper chart still remains part of the legal record even if the patient record has been partially digitized on a go-forward basis in the EMR.

The physicians in this situation are in a difficult situation. They are required to retain the original paper record even though there is sufficient data in the EMR to manage the patient going forward. However they are required to send a copy of the patient record to the requesting physician according to College guidelines. Who bears the cost? Is it the requesting physician? Is it the patient?

What are your thoughts? To add your comments, click on the 'Comments' link below

CMA Journal: Getting to the Electronic Medical Record

Ken Flegel, MDCM MSc Senior Associate Editor, CMAJ has written a very thougtful editorial on the Electronic Medical Record in terms of patient safety and the ownership and stewardship of the clinical data.

"By custom, the medical record has been stored as a paper file in the physician's office. The keeper of the record has been the physician — a banality in which lie 2 deeper concepts: one of ownership and one of access. Lately, it has come to be understood that the physician and the patient own the information in the record jointly and that each is entitled to control the access by third parties, though normally for different reasons. But now, driven by need and abetted by technology, much about the medical record is changing, raising new questions about how ownership and access are affected.

Obviously, the only way to restore coherence is by moving from the paper record to electronic storage and linkage. The essential quality of the electronic record is that it can allow all significant information to be accessible in one place at the same time. It can be searchable. It can possess a kind of algorithmic intelligence. If well designed and efficient, it can be organized and user-friendly.

There is a clinical need — one might say imperative — to proceed. Patient safety is the principal reason. For example, an electronic record could inform a physician not to prescribe a drug that is contraindicated by the patient's history. Emergency visits are another standout circumstance where access to the complete record will avoid harm, to say nothing of time and money. The question, then, is who shall keep the records and who shall own them? Although the keeper is likely to change to encompass a virtual network of health care providers, ownership should remain with the patient.1 But ownership here means the ability to grant privilege to others to contribute to or gain access to the information. It does not mean the patient can change the record (although there could be a place for him or her to add comments).

Who will have the ability to make or alter an entry? Are we each about to become holders of our own somatic Wikipedia?

Click here to read the full article: Getting to the electronic medical record -- Flegel 178 (5): 531 -- Canadian Medical Association Journal

What I read into this is a growing acceptance of the need for a transition from the old ways to the new and a change of thinking in terms of how we share information in a much more fractured environment. Technology and EMRs are some of the important keys to this puzzle.

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

Physician Responsibilities in the Transition to Electronic Medical Records

The College of Physicians and Surgeons of British Columbia has published an article in the December 2007 edition of the College Quarterly titled: "Considerations During the Transition to Electronic Medical Records" A short excerpt is provided.

• The implementation of an EMR will necessitate process changes in your practice. Processes designed on the movement of paper charts should be assessed and altered accordingly.
• Protection of personal health information is of paramount importance. Assess the security risks in your office. Security policies and staff education should take place to address specific concerns.
• Physicians may choose either to scan paper records electronically in a “read only” format, e.g. pdf, or to start entering data from day one of their new EMR. Either way, the College recommends that paper records be kept in close proximity for at least six months. Unless they are completely scanned into the EMR, paper records must be kept indefinitely if the patient continues to attend. If the patient has left or moved, paper records must be kept for at least seven years from the date of last patient contact (or until the patient reaches age 26 for patients under 19).
• Physicians must ensure that complete medical records (paper, electronic or a combination of both) are accessible at all clinical decision points and for the duration of the retention period prescribed under Rule 13 of the Medical Practitioners Act.
• EMRs must be able to be printed promptly if required.
• Each practice must identify in writing the level of access by any authorized persons utilizing EMRs.
• If your EMR is located on a server in your office, ensure that the server is physically secure and robust backup procedures are in place.

Numerous commercial EMR products are available. A suitable EMR program must have the following attributes:

• Audit trail for information entry;
• Capability of physicians to provide sign off on documentation, orders and prescriptions using electronic signatures or equivalent authentication;
• Regular backup of data; and
• Effective recovery protocols.

Download the College Quarterly article (.pdf)

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

College of Physicians and Surgeons of BC - Data Stewardship Framework

Last week, the College of Physicians and Surgeons of BC published a Data Stewardship framework document. This was the culmination of months of work and draws upon experience in Alberta.

The importance of this type of work cannot be underestimated. By providing a framework and reference point for both those designing the systems and those using the data for primary use (care of patients), it is a bit easier to synchronize the process of design and delivery.

The historical model and practice of managing confidential patient information is changing dramatically as a result of advances in information technology, including the implementation of electronic medical records (EMR) and the concept of an electronic health record (EHR). However, the requirement for a physician to protect the integrity of a patient’s medical information remains an unchanged professional obligation. In November 2006, the Council of the College appointed an ad hoc committee on Privacy and Data Stewardship in response to a number of diverse information management issues surrounding medical records. The document was developed with the support of the College of Physicians and Surgeons of Alberta, and reviewed by the Canadian Medical Protective Association. Council endorsed the framework in May 2007. The framework in its current format is intended as a reference guide for physicians as they contemplate a shift from paper to electronic data storage in their practice. The principles outlined within reinforce the need for compliance with professional standards. It is also intended for ehealth planners and vendors who must consider the safety and integrity of personal health information as their top priority. The document, while comprehensive, does not address all of the transition issues associated with ehealth. Further consideration will be given to privacy issues, patient concerns and consent, disclosure, and the secondary use of shared data. Specific and relevant components of the content will be communicated more succinctly to physicians over the coming months.

Link: College of Physicians and Surgeons of BC - Data Stewardship Framework.

I encourage interested physicians to download this document and read the sections that are of most interest. For designers and developers of Health IT systems (particularly in British Columbia) this document is a must read.

As a physician visitor to CanadianEMR, do you think that privacy or data stewarship is less of an issue or more of an issue? Do you think that there is enough protection in the system for patient information? Does the creation of framework documents such as the one referenced in this article reduce anxiety about privacy?

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

Managing the Medical Records when a Physician Leaves an EMR Based Group Practice

An interesting question has recently come up in terms of ongoing access to an EMR when a physician leaves a practice/retires or when a group medical practice dissolves.

From a shared care perspective, there are well defined benefits in having a electronic medical record system that can be shared amongst multiple physicians in a group practice such as the ability to provide on-call or cross coverage for patients and remote access to the record. However the assumption in all of this is that group practice is the way of the future and EMRs will be a core infrastructure component. BUT, what happens if the group practice dissolves or a physician retires or leaves under good or bad circumstances?

In the paper world, it was much easier to separate out which patients belonged to which physician. These paper records could then be removed from the filing system (or might in fact be stored separately even in a group practice), the physician would take his/her charts and move to a different location. Not so in an EMR based practice. It may not be as clear which patients belong to which physician in this situation. In addition, shared records within group or potentially multi-disciplinary practices make the boundaries of ownership of the physical record less clear.

How does a physician take his or her records and move to a new practice? What are the financial and business implications of doing so? If the EMR is ASP-based (remote server), can the patients be transferred to the new location by changing the rules on who is allowed to access that record? What happens to the original record if other providers have had access to that record and need to retain a local copy or a copy that they can view up to the time that the departing physician has left the practice for medical legal purposes. What happens if the entire practice dissolves and the physicians all go in separate directions. Who takes on responsiblity for transitioning the patient information so that each physician has an accessible copy of their patient's medical records so they can continue to provide care in that new location.

These are the types of issues that challenge the very best laid plans. Physicians are a mobile workforce and over the course of a career it is unusual for a physician to only work at one location and in conjunction with a fixed group of associates. We need to build some flexibility into the processes to ensure that physicians can leave and still appropriately retain copies of medical records or retain access in situations that are appropriate.

If you have experienced a change in your practice that resulted in having to deal with one or more of these issues, please share them by clicking on the 'Comments' link. (If vendors have had experience with this situation, this is a specific instance where vendor feedback is welcomed to ensure that the commentary is balanced)

CPSO Policy- Electronic Medical Records - Maintaining the Patient's 'Story'

Over the past 2 years I have become increasingly involved in information governance and stewardship. This last weekend I had an opportunity to spend some time with colleagues from across Canada who are similarly involved in EMR adoption in their respective provinces.

A policy of the College of Physicians and Surgeons of Ontario (CPSO) was brought to my attention and an excerpt is included below with a link to the full policy as listed on the CPSO web site. What is important is the requirement that the Electronic Medical Record must contain the 'story of the patient'. This suggests that certain EMR systems may be too structured and may not be able to reproduce the history and clinical findings in a way that allows for clear interpretation. In addition, the systems must be able to capture the 'nuances' of the encounters. Any physician will confirm that the ability to capture a narrative is very important in certain circumstances to ensure that nuance is correct and this is sometimes impossible using templates and drop down menus with very structured data entry.

It is very important to remember that policies of licensing bodies and legislation will require a certain level of performance both by the physician and by the system that is being used to capture information. It is these policies and legislative requirements that will govern the way in which performance will be measured if medical legal issues arise or complaints are made regarding care that is provided.

Electronic Records

All of the principles discussed in this policy apply equally to electronic records. The records must contain the story of the patient. While there is some debate about the preferred format of electronic records (e.g., template-based records vs. voice dictation-based records), an electronic format will be adequate if it can capture all the pertinent personal health information and allows the user to centralize the essentials of the patient’s story on several screens. If the format cannot do this, it is probably not satisfactory and the physician should consider using an alternative system.

The College recognizes some limitations of electronic records at the time of writing this policy. In many cases, the printable version of the electronic record does not readily enable a reviewer to understand the whole patient record and is, therefore, of limited use.

Furthermore, some of the systems do not readily allow the physician to capture nuances of the patient encounter. Physicians using such systems must ensure that each record entry captures the unique aspects of that particular patient encounter. The College is aware that this is a developing area and that there is great potential for electronic record keeping to enhance the practice of medicine. Physicians have an obligation to provide printed copies of electronic records when asked to do so. In order to ensure they can be understood, some physicians provide the print-out from the electronic record together with a dictated summary to provide an overview of the patient’s story.

Specific requirements for physicians who maintain electronic patient records are set out in sections 18-21 of Ontario Regulation 114/94, listed in Appendix A

The College notes that residents frequently retain patient information on PDAs and laptops in order to track workload and for educational purposes. Issues about storage, deletion of records and privacy of health information can pose the same problems in this context as discussed elsewhere in this policy, and those who are using records in this fashion are cautioned to ensure that they are doing so in adherence to the policy.

Link: Policy- Medical Records

As a user of an EMR system or someone considering the purchase and implementation of an EMR, have you considered the College requirements in your province relating to Electronic Medical Records? Recognizing that this is currently in evolution, would you like to be kept up to date on developments in this area? Have legislative and governance requirements been on the radar for you or is there too much noise out there that is difficult to sort out as you run a busy medical practice?

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