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

Improving Medication Adherence with Technology

Writing a prescription is one of the most fundamental tasks that physicians do on a daily basis. However, whether patients take their medication is difficult to determine. According to an article in Mayo Clinic Proceedings (2011), approximately 50% of patients do not take their medication as prescribed. There are many reasons for poor medication adherence: complex drug regimens, communication issues between doctor and patient, and too many providers involved in patient care, resulting in confusion and inadequate explanation of side effects. Thus, there is no single solution to this problem. EMRs are very good at tracking what has been prescribed for patients; however, they suffer the same limitations after the prescription has been written.

EMRs provide access to more comprehensive information at the point of care regarding medication usage and potential interactions that can be identified before writing the prescription. In this way, they are able to contribute to medication adherence; however, there are some very interesting technologies that allow real-time tracking of medication adherence, including the following:

• Proteus Digital Health — ingestable sensors that are integrated with medications and transmit information to a sensor that is placed on the abdomen. The sensors are powered by digestive enzymes and data captured in the abdominal sensor can be transmitted to a device such as a smartphone.
• Smart pill bottles, such as those developed by AdhereTech. The bottles are wirelessly enabled and transmit data when the bottle has been opened. A sensor inside the bottle keeps track of how many pills or how much liquid is remaining and transmits this data to a central source where it is compared against the patient’s medication regimen and then sends the patient a reminder or notification if they have forgotten to take their meds or have not taken the correct dose.
• A mobile app developed by Mango Health that allows users to keep track of their medications and earn points for which a variety of gifts can be claimed.

This is a very dynamic and exciting area that will see significant growth in the next few years. Although these types of technologies are still in testing phases, imagine a future where you could look at your patient’s medication profile in your EMR and be able to see whether they have been adherent to their medication regime from data that has been transmitted by pill bottles to your system.

Will this help or hinder the care of patients? Do you see this type of technology being disruptive or additive to your daily workflow? To add your thoughts, click on the “Comments” link below.

Mobile Tools for EMR Access — Phones and Tablets

Patient data is increasingly available to clinicians through a wide variety of tools and form factors. As high-speed Internet through Wifi and 4G becomes ubiquitous, access and speed are no longer an issue. In parallel, physicians are increasingly using EMRs as their primary tool to document, manage, and treat patients. As a result, it is not surprising that they should want to access clinical data using a mobile phone or tablet. Blackberry appears to be back in contention as a device for business users, but the majority of mobile devices used by doctors are smartphones — with the Apple iPhone the device of choice.

A recent survey conducted by AmericanEHR Partners, with 702 verified physicians within the U.S. between October 10, 2012, and December 8, 2012, revealed the following:

• The most popular brand of smartphone used across respondents was Apple’s iPhone.
• The most popular clinical apps were Epocrates, Medscape, and MedCalc.
• Twice as many non-EMR physicians use a traditional mobile phone compared to EMR users.
• One-quarter of non-smartphone users intend to buy a smartphone in the next six months.
• Both EMR and non-EMR users spend 15–16 hours a week on their smartphone.
• 35% of respondents use their smartphone to research information on medications daily.
• The least common smartphone activity for business purposes is Tweeting (5%).

I recently spent some time in Singapore working with a team on the national medication and allergy systems. As a result, I was able to observe how the public uses mobile devices for everyday access. What surprised me were the number of people (physicians and non-physicians) who carried larger phones such as the Samsung Galaxy Note. Called “Phablets”, these devices merge the mobility of the smartphone with the screen size of a tablet and provide greater screen size, which is critical for viewing a large amount of information without the need to scroll. For the past year, I have been carrying an iPad mini when I travel or if I am unable to carry a laptop with me. Tethering the tablet to my iPhone, I am able to access the Internet (as well as any other app that requires a login).

An exciting evolution that we will see more prevalent in the next 12–24 months is remote access to one’s EMR using a mobile phone or tablet. A September 2012 blog post on CanadianEMR titled, “Should I Access My EMR Using a Mobile Phone?” highlighted security and access precautions as well as advice to reduce the risk of health data breaches.

If you have an EMR, or are considering implementation and would like to have remote access through your phone or tablet, speak to your EMR vendor (or potential systems provider) about mobile apps or whether they have a preferred mechanism for access to the EMR using a web browser on small form-factor devices.

Do you have any experience using your mobile phone to access your EMR? Click on the “Comments” link to share your thoughts or comments.

To purchase a copy of AmericanEHR Mobile Use in the Medical Space, please click here.

Radiation in Medical Diagnostic Imaging

This presentation was recently given by Dr. Brett Heilbron at the 2013 Technology in Clinical Practice Cruise Conference. Learning objectives for the session were to understand the risks associated with ionizing radiation, identify ways to optimize patient benefit and minimize risk, and to discuss some of the controversies around medical imaging radiation. The presentation focuses on the use of a common technology in clinical settings — medical diagnostic imaging — and provides some guidance regarding this controversial topic.

To add any thoughts or comments, click 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.

Powering Primary Care - New BC Initiative

Technology (including EMR) is an important enabler as we strive to improve patient care and reduce waste within the healthcare system. However, if isolated from policy, legislation and compensation, EMRs alone cannot solve the problem of limited access to care. 'A GP for Me' is a joint program between the Government of BC and the BC Medical Association, created through the General Practice Services Committee (GPSC) which has been put in place to assist approximately 176,000 patients who cannot find a family doctor.

A February 23rd article in the Vancouver Sun provides further details on the $132 Million program. One of the stand out features is the designation of funding for telephone consultations with patients in order to more efficiently manage care without needing to bring that patient into the office for a face-to-face consultation in order to be compensated. (Until now this was the only way a fee-for-service physician could be paid to manage a patient unless they were covered under a different program e.g. chronic disease). What this equates to is up to 500 telephone consultations with patients per year at $15 per consultation (with critera that will need to be followed). However, it is an important recognition of the capability to manage patients effectively using the most basic form of telemedicine, the telephone.

I believe that there is one element of this strategy that has not been addressed. After a number of years of working as a part-time family physician in a walk-in clinic, I am convinced that convenience will continue to win over quality 9 times out of 10. What I mean by this is that even with a family physician, unless there is a mechanism to link a patient to a doctor or practice and place some accountability on patients to attend their 'new' family physician for the majority of care, we will not really solve this problem. Granted, the +/-176,000 patients may find a family physician, but if patterns of access to healthcare do not change, their new family physician will be utilized just like the 'old' family physicians and become the repository for copies of lab results ordered by walk-in clinics, visits to Emergency Departments and requests from 3rd parties for documents or from lawyers for medical legal reports.

Don't get me wrong. I believe this is an excellent step in the right direction. My only concern is that people do not change their behaviour patterns very easily. I believe that patients will continue to attend any walk-in clinic that is convenient for the majority of their episodic care. With all of the additional primary care capacity being created within the healthcare system, effective utilization is a necessity.

Do you have any thoughts or experiences you would like to share? Click 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.

When Your EMR is at Fault, Who is Liable?

I was recently directed to an article published in Medscape in July 2012, titled “Malpractice ‘Discovery’ Dangers in Your EMR”. The premise of the article is that a new category of liability is emerging that was not considered prior to the use of EMRs. According to Ronald Sterling (the quoted expert), “Anything could be a malpractice issue, from the product itself, the way it was set up, or how you have been using it.” His argument continues as follows. If a software upgrade to an EMR system affects the data that is being stored for a patient and data is lost, or if there are design flaws in an EMR or the EMR is either used or set up incorrectly, this could be identified during the discovery phase of a malpractice lawsuit. If errors were discovered in the patient record that are the result of a system error, it could call into question the accuracy of other documents stored in the EMR.

Clinical decisions are generally made based upon the evidence available at the time of a medical encounter. The history, examination, clinical findings, investigations, and supportive documentation are the currency of healthcare and the way that information is woven together tells the clinical story. The paper chart (despite its deficiencies) tells a chronological story that is often easier to assemble after the fact than an EMR. This is no fault of technology. It is more an indication of the format of the paper record as a narrative story. Reading the narrative, it is possible to piece together a timeline in the management of a patient. EMRs, on the other hand, provide superior data capture capability. It is possible to record notes as narrative text or as discrete data using pick lists and templates in addition to images and audio files. Even though an audit trail is created as the data is collected, it is harder to piece together exactly what a physician had available at the time of decision making. This may seem illogical; however, it is due to the way in which each EMR assembles the clinical data (in other words, what was present on the screen) in conjunction with other information that was accessed at the same time. Having access to provincial viewers or regional systems enhances the ability to make clinical decisions — no need to wait for lab tests or diagnostic investigations — but it also makes reassembly of the data much more difficult at a later date. Without taking a screenshot of the provincial or regional system (a contravention of privacy policy) and pasting that into the patient’s record, it is not possible to accurately recreate what the physician saw at the time that was used to make the clinical decision. If additional findings are recorded in the EMR, that is solid evidence that those pieces of information were used to support clinical conclusions. What is more difficult to prove (or disprove) is what was not seen.

All of this sits within a grey zone. EMRs are getting better all the time, but they are far from mature or complete. Key functionality is still not seamless, including the ability to manage medication renewals and prescriptions electronically and bi-directionally with pharmacies, or the ability to send referrals to any specialist or receive consultation reports back into the EMR. Usability and human factors in the design of EMRs are also not yet optimal. In the interim, it is important to understand the pitfalls in order to minimize the risk of missing key information or being guided to the wrong decision.

The following should be considered:

• Does your EMR allow you to record meta data? Meta data includes telephone messages, inter-office communications such as instructions to staff, or multiple unsuccessful attempts to contact a patient who has abnormal mammography and needs follow up investigations. If this data is not recorded, time-stamped, and linked to the patient chart, it may be difficult to prove that the actions took place;
• Is the EMR presenting data correctly, in particular laboratory information? There is a careful and painstaking process that takes place both from the laboratory as well as EMR vendors to ensure that the correct information is presented in the EMR. However, software updates or patches can affect EMRs in unforeseen ways. Although a rare occurrence, there have been instances where data fields have been mismatched within the EMR. These are dangerous situations and are usually quickly identified and corrected. However, you should trust your clinical judgement — if some data does not appear to be correct, do not take it for granted that the EMR is right. Check with the lab and the vendor. You may be the first to identify a problem.
• EMRs are dynamic tools that change from time to time. Ensure that you learn how to use new features and functions by receiving additional training or learning from colleagues through your practice or local user groups.
• Use templates appropriately. A common error is to use templates that include negative findings as a default setting. When using a template, you should only enter information that is actually collected during the clinical encounter. If the negative findings are saved during each encounter, a review of your EMR will not only display identical data for different patients, it will also give the impression that you actively recorded the information when in fact the template should have remained blank.

There is no perfect mechanism to avoid these kind of issues; however, a heightened sense of awareness and diligence, plus adequate training, will go a long way towards reducing your risk.

EMR Strategies When Planning Retirement

If you are planning for retirement, the last question you may be asking yourself is whether you should implement an EMR system before you close or pass on your practice. In some cases it may not be practical to implement an EMR. Your decision may also depend on whether you are a specialist or family physician, in a solo practice or a larger group. If in a larger group, the decision may already have been made for you. In some cases, physicians who plan to retire and do not want to adopt an EMR being implemented by a group decide to use the opportunity to opt out and move on to other activities. Specialists, particularly those who do not have long-term relationships with patients and provide episodic care typical of specialty practice, can have tens of thousands of charts with some patients having been seen only once. The practicality of re-digitizing all of those records and entering them into an EMR is daunting and in most cases unnecessary for specialists. The following article in the Ontario Medical Review is worth reading: “EMRs and the Late Career Physician”.

One of the big challenges that physicians face when closing a medical practice is developing a succession strategy. Is it possible to find someone who will take over an existing practice? In most cases, for family physicians, particularly those in solo practices, this is no longer an option. There is such great demand for family doctors that simply hanging up a shingle plus advertisements in the local newspaper is enough to bring a steady stream of patients. For female doctors, the demand is even greater.

An earlier article that I wrote on this topic received the following comment: “I think you are missing the fact that many established practices have either a) significant goodwill, and b) an established community presence. I would have thought that these play a far more important role in purchase considerations. The incoming doctor would, in most of my experience, usher in their own changes to the admin anyway.”

Transferring a practice to another physician (versus selling it for real money) is unfortunately the most likely transition if you can find someone to take over your practice. The motivator for the outgoing doctor is generally to maintain continuity of patient care for all the patients that have been treated over the years. However, even this is unusual if the outgoing physician is still running a paper-based practice. With 50–60% of Canadian doctors now using EMRs, I am not aware of a single new graduate who would consider going into a practice with paper charts.

Consider the following:

1. If you plan to work as a locum after retirement or do a shift on a regular basis in a walk-in clinic, you will likely be working with an EMR. As a result, it is good practice to hone your computer skills and get up to speed on electronic medical records. You may be fearful of computers and feel that they will interfere with the patient encounter; however, many patients now expect your practice to be computerized and are surprised when you are still using paper charts.
2. Continuity of care for your patients is an incrementally greater problem If you do not have an EMR. Even if you cannot transfer your patients, it is easier to generate pdf files for each, store them on a number of discs for security purposes, and transfer digital copies of patient records that can be attached to a patient’s file in a new physician’s EMR. If are unable to find someone to take over your practice, you should get ready to try and transfer as many patients as possible and accept that a significant number are not going to find a new physician.
3. Chart storage is expensive and it is a significant amount of effort to find, package, and send out charts as they are requested. If you decide to go down this pathway, there are a number of companies that provide chart storage and will scan your paper records for easier retrieval. Click here for the list of companies in the CanadianEMR Resource Directory.
4. Patient safety: over many years, one accumulates a great deal of information, reports, lab results, etc. Implementing an EMR is a very good opportunity to summarize the face sheet in your charts and do a careful review of your patients before entering the data into the EMR. While this process generally happens during the yearly physical, there are patients that fall through the cracks and implementing an EMR provides a good opportunity to get current with your patient's problem lists and medications.
5. If your practice has aged with you, you likely have a predominance of older patients with concomitant co-morbid disease. EMRs are great for the management of chronic diseases. If you are not taking advantage of incentive payments for Diabetes and other chronic conditions, you should seriously consider an EMR — if only to optimize your payments in the last few years of practice. If you have a slick system in place for reminders — ensuring you do not miss your chronic disease payments — it will also make your practice more attractive to a new physician.

There are still a number of are good reasons to implement an EMR in your pre-retirement years. There is nothing better than being able to leave your practice in the capable hands of a physician who will look after your patients with good quality information at their fingertips.

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

How Do Canadian Primary Care Physicians Rate the Healthcare System?

Every three years the Commonwealth Fund publishes an international health policy survey. The last was published in 2012. The Health Council of Canada has produced a short video commenting on the Commonwealth Fund survey.

Click here for more information.

The Impact of Mobile Devices on Health Information

Few technologies have had as much of an impact on health information as mobile phones. It is unusual these days to walk into an examination room and not find a patient on their mobile phone, looking up information, playing games, or communicating. Mobile phones are pervasive — with many lower income patients forgoing other needs in order to own a smart phone. What this does is place access in both the care provider and patient's hands pre, post, or during the encounter. With a wide range of excellent mobile apps and mobile-optimized healthcare websites freely available to both clinicians and patients, the patient management dynamic is shifting in ways that could not be anticipated as recently as two years ago. Home research and printing of articles by patients has been replaced by the immediacy and accessibility of mobile device access to the same information during or after a clinical encounter.

Electronic Medical Records provide physicians with more effective mechanisms to collect and evaluate lab results, identify patients at risk, or document clinical information. However, from the perspective of the patient, EMRs are provider-centric tools that do not provide access to information or empowerment, unless there is a patient portal and the portal is effectively used within the practice.

In contrast, mobile phones plus high-speed Internet access are pervasive and empowering for patients. Mobile apps are being used for smoking cessation, weight management, diet control, and exercise tracking. Similarly, patients are turning to their devices as a primary mechasnism to search for health information or ask questions of their support communities through sites such as patientslikeme. The information is often high quality and relevant and balances the power equation in the clinical encounter. Although physicians retain an edge in being able to recognize good quality health information, the gap is narrowing rapidly.

Mobile phones are the differentiator. If clinicians can find a way to leverage their patient’s energy and desire to find information and apply it to their health, mobile devices hold the potential to become powerful clinical tools in the management of many conditions. If physicians ignore this trend, they do so at their own peril.

Have your patients used their phones to share health information with you? Do you have any anecdotes or tips to share? Add your thoughts by clicking on the “Comments” link below.