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

A Bird's-Eye View on the Status of Healthcare Technology

For the last few years, as we all head back to work after a (hopefully) relaxing summer, I have shared some thoughts and insights on the health technology market and where I see it heading. Here are five insights and predictions for 2013/2014:

1. Big Data becomes last year’s buzzword. It seems as if every event, conference, and publication has had a chapter or section devoted to Big Data. However as reality has set in, big data has also meant “big challenges”. Making sense of terabytes of data requires not just incredible processing power, but also good quality comprehensive substrates to analyze. While an organization like Kaiser Permanente may be able to analyze big data collected through a closed system that extends from primary care to intensive care, the same is not true in Canada where large chunks of healthcare information sit in standalone databases, making it difficult to use predictive analytics to provide useful real-time clinical insights.
2. eReferral and data interoperability become the new buzzwords driven by a growing army of EMR-enabled physicians. With many provinces nearing or surpassing a critical mass of users of EMRs, physicians and their practice teams are becoming more sophisticated. Gone are the days where it was sufficient to optimize the EMR in one’s clinical practice. The demand will shift to data sharing and true interoperability between providers and systems. Get ready for a wide range of requirements driven by clinical users who are more focused on care than technology.
3. Mobile technology starts to become really useful. Consumers are already using mobile apps and devices such as fitness trackers to manage their health and demonstrate success. This is more than a fad and the advent of wearable technology will result in literally thousands of new applications and devices that will have a significant impact on patients and encourage physicians to integrate them more effectively into patient care.
4. Telehealth becomes more commonplace facilitated by reimbursement programs that recognize the value of treating patients at a distance. Many physicians and organizations are now using maturing telehealth technologies to consult with patients and facilitate follow up visits without bringing the patient into the office for a face-to-face encounter. Companies to watch include Vancouver-based startup Medeo.
5. The message becomes the foundational building block of a maturing EMR market and healthcare system. Ten years ago, provinces focused on developing functional specifications and certifications for EMR systems. As the provincial programs evolve further, with a growing need for data interoperability between EMRs and other clinical systems, the focus will shift towards standardized messaging so that information can easily be shared and reproduced. Functional specifications will become less relevant and less important.

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

Embracing Patients as Partners — Leveraging Patient Interaction Tools to Improve Your Practice

By Eric Gombrich – Healthcare globally and here in Canada is undergoing a massive transformation. Patients are becoming more engaged with their own healthcare and are looking to consumer technologies like tablets, smartphones and mobile applications (apps) to better manage their health outside the doctor’s office and in between visits.

According to a recent survey of 2,000 patients by Digitas Health, more than 50% of patients who suffer from a chronic disease are actively looking for new ways to manage their health and were very interested in incorporating medical devices and apps into their plan.

This demand should come as no surprise as most Canadians now rely on mobile phone apps for a wide variety of day-to-day activities including banking, shopping, communications and entertainment. In fact, there are now more than 100,000 apps available for health & wellness. The fact that Canadian patients want to take advantage of these mobile technologies to manage their health is a natural extension of the technology and experience Canadians have come to rely on.

Similarly, leading healthcare providers are also looking to new solutions that enhance shared decision making between doctors and patients, streamline interaction beyond the office visit, and embrace the patient and their personal network of support in taking a more active role in managing their condition (provided it is done in a controlled way that keeps the physician involved in the process).

After all, as healthcare organizations move to outcome-based and pay-for-performance plans that reward physicians for improved results, patient compliance with care plans become that much more crucial to a physician’s success. If managed properly, patients and their self-defined support networks can be a tremendously valuable resource to assist a practice in achieving improved outcomes at a lower cost.

For example, at the Black Creek Community Health Centre in Toronto, health coaches — under the guidance of the doctors — now use a mobile app to deliver a personalized health coaching program for patients living with Type II Diabetes. In collaboration with health coaches from York University’s Kinesiology program, physicians in the Health Centre are able to prescribe personalized wellness plans for their patients and monitor their progress. Patients enrolled in the program track their biometric measurements, meals and exercise using smartphones, and receive remote coaching to improve outcomes. Furthermore, they get the education, motivation and encouragement they need to sustain the behavior changes necessary to be well. The impact is profound for both patients and providers, including reducing HbA1c levels by as much as 2x insulin alone, with no additional effort by the physician.

Also underway at the Beth Israel Deaconess Medical Center, a teaching hospital of the Harvard Medical School in Boston, is “Passport to TRUST”, a new healthcare initiative that’s providing patients with their own interactive personal care plans or “passport”.

When given easily understandable personal care plans that they can share with those who are supporting them, patients are much more likely to comply with their physician’s recommendations. Combined with personal health coaching that provides them with the education, motivation and support they need to follow the plan and make sustainable life changes, outcomes are improved and the burden on our healthcare system is lessened; It’s being proven in Boston, and elsewhere. Best of all for physicians, those at Beth Israel are reporting significant reductions in phone calls to their practice, saving almost 3 hours per day.

In this mobilized, social-networking culture, patients have made it clear that they want a different level of service from providers, and options beyond the standard office visit and long waits between tests and follow-up appointments. Physicians who embrace properly designed solutions that enable them to deliver such services will see improved patient satisfaction, improved outcomes and improved operating efficiencies and financial performance.

Eric Gombrich is Senior Vice President & General Manager, Health Solutions Group at NexJ Systems. For examples of NexJ solutions, see NexJ Connected Wellness and NexJ Health Coach.

What Are the Gaps in Your EMR?

EMRs have now been used in Canada for some time — in some practices, 10 years or more — but, more importantly, by a large number of non-techy middle and late adopters. These are the physicians who have adopted EMRs because they saw the writing on the wall that an EMR will be the future primary mechanism in which patient information is recorded and information is generated and shared. EMRs are also complex software applications and as anyone who has used an EMR will attest, they certainly are not perfect. Each has its own strengths and weaknesses and all have their gaps. Some of the gaps are related to functionality that should be in the EMR, but is not built in — the responsibility of the vendor. Other gaps are completely out of the control of the vendor and are related to provincial or national requirements such as standards for data sharing, processes for referral and consultation, etc.

That being said, from the user's perspective these differences are immaterial. You need the tools at your fingertips that allow you to do the job at hand. If you have used your EMR (or EMRs) for one year or more (i.e. you are through the implementation and orientation phases), what are the gaps in your system?

To provide some broad categories, these gaps could be related to any of following:

• The ability to easily enter information into the EMR
• Data queries and the ability to generate reports from your EMR
• Communication
• Information sharing with colleagues or patients
• Usability
• Investigation ordering
• Information privacy
• Templates
• Medication management
• Workflow
• And any others you can think of...

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

How Will Canada Achieve E-Prescribing?

In the five years from 2008 to 2012, E-Prescribing in the United States became mainstream. According to health information network operator SureScripts, in 2008 only 1 in 10 physicians E-Prescribed. By 2012, this number had increased to greater than 2 in 3 physicians E-Prescribing (69% of office-based physicians). Click on the image to view progress during this period.

It is important to note that the adoption of E-Prescribing in the United States has taken place rapidly, with 380,000 office-based physicians actively prescribing — this in a country with 5 times the number of state jurisdictions and 10 times the number of physicians as Canada. So, how did they do it and what lessons can we learn?

• The Canadian Medical Association and the Canadian Pharmacists Association released a joint statement on E-Prescribing in May 2013. The Statement highlights the principles, vision, and benefits of E-Prescribing. In the document, the definition is as follows: “e-Prescribing is the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient’s pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software.”
• In the U.S., E-Prescribing is defined more broadly than in Canada. I believe this to be largely responsible for setting expectations and determining measures of success in the U.S. program. The Clinician’s Guide to E-Prescribing (developed by The Center for Improving Medication Management) defines E-Prescribing as the use of a computer, handheld device, or other hardware with software that allows prescribers to:
  • With a patient’s consent, electronically access information regarding a patient’s drug benefit coverage and medication history.
  • Electronically transmit the prescription to the patient’s choice of pharmacy.
  • Receive electronically transmitted prescription renewal requests from a pharmacy when the patient runs out.
  • Support the entire medication management process: prescribe, transmit, dispense, administer, monitor.

While there may be different approaches in Canada regarding statement 1, namely the need to access information regarding a patient’s drug benefit coverage, the important differentiator is the description of a continuum of care, as in the last statement. Prescribe and transmit are just two components of a system that needs to function as a closed-loop in order to be successful. If we do not include electronically transmitted prescription renewal requests in the definition, key functionality (e.g. the need to reconcile the prescription renewal with prescribed medications — particularly if additional prescriptions have been written by a different prescriber — will not be built into the core systems.

We are on the right track; however, the U.S. must have done something right to have achieved the high levels of adoption of E-Prescribing that are currently in place. The definition is just a small piece of a big and complex system, but it is an important component.

My recommendation is to revisit the definition of E-Prescribing and ensure that it is sufficiently comprehensive that success can support the entire medication management process — prescribe, transmit, dispense, administer, renew, and monitor. If this is not done in advance, we may achieve 100% success, but end up with only half the needed systems and processes.

Share your thoughts on E-Prescribing. Should we revisit the definition or do you think we have enough to achieve our goals in Canada? Click on the “Comments” link below.

EMR Information Sharing — It’s all About the Message

Canadian Healthcare Technology reports that eHealth Ontario will be launching a proof of concept information exchange “to demonstrate how data within EMRs can be securely and efficiently delivered to other authorized clinician EMRs, clinical repositories and healthcare research organizations”.

This is an important step in the right direction; however, I am not sure why it took so long to get here and why we do not have health information exchanges universally implemented across Canada, not just in proof of concept form in Ontario.

I have written about this frequently in the past and I will say it again. Physicians (and other clinical team members) are information exchangers. That is what we do all day long — exchange information with other organizations or clinical providers to facilitate care of patients. Rather than a proof of concept (which has a limited lifespan and mandate), why not just implement a health information exchange (HIE). There is extensive experience in the United States as well as countries such as New Zealand, Australia, and Denmark in the implementation of HIEs. One should not have to prove the concept — the concept is correct. Rather, identify best practices and short circuit the process by making this a permanent project.

In essence, it is all about the message. Now that we have a critical mass of clinicians using EMRs, it is time to focus on standard messages (take a lesson out of Denmark’s book regarding which messages they are using and how the messages have been standardized). I am not trying to simplify a complex set of tasks. Due diligence will need to be done — however there should be enough worldwide knowledge and vendors of HIEs that are sufficiently experienced to implement a solution.

The big challenge is the lack of standardized data in EMRs in Canada. This will require extensive data mapping to ensure compatibility of the message between systems.

My two cents: We may as well get started.

What are your thoughts? Are we overdue for health information exchanges? Is there value in a pilot project or should we just get the job done? To add your thoughts, click on the “Comments” link below.

The Big (and Small) Data Conundrum

In a CMAJ article titled “Big data’s dirty secret” (Webster, June 6), the author highlights the barriers to leveraging big data in Canada and points to “technological limitations stemming from mismanagement by government e-health agencies and commercial turf battles” as an important cause of this problem. Webster also cites others who have had challenges with the data generated from EMRs currently used in Canada including Patricia Sullivan-Taylor, manager of primary health care information (Canadian Institute for Health Information) and Alex Mair, director of health system use for Canada Health Infoway, the organization responsible for developing and implementing Canada’s health Infostructure. According to Sullivan-Taylor, each EMR system produces different types of data, something that was not resolved before EMRs were installed in physician offices. Mair also acknowledges that progress has been slow in using “big data” and the resultant inability to gain insights into clinical data is a key gap for clinicians.

While I agree with many of the concepts and comments in the article, I would like to add further clarifications. Mario Bojilov recently published a concise overview of big data and defines it as “data sets that — due to their size (volume), the speed they are created with (velocity), and the type of information they contain (variety) — are pushing the existing infrastructure to its limits”. Big data, in healthcare, seems to have become synonymous with data analytics, “a process of inspecting, cleaning, transforming, and modeling data with the goal of highlighting useful information, suggesting conclusions, and supporting decision making” (Wikipedia); however, I belive it is misleading to broadly think of EMR systems in physician offices as generators of big data. While large networks of clinical users on a common EMR can certainly generage large amounts of data, many of the current limitations apply equally to “small data” as they do to the high velocity, volume, and variety of big data.

Simply put, there are many EMR systems that cannot effectively be used to generate insights from small collections of data, never mind big cumulative data sets. For example, EMR systems that record information in narrative format (not as discrete data) are unable to generate analytic reports for patient populations because they were not designed to function as analytical tools right from their early genesis. EMRs that collect data in highly structured formats are able to output information that can be queried using analytical tools that are either built into the EMR systems or third-party software that is able to take data sets generated by EMRs and provide data analysis as an integrated functionality or outside of the clinical system. However, taking data from multiple EMRs and merging it together is not possible. Why, you might ask? Well, because each EMR system has been built using proprietary data structures without any coordinated national effort to define national data standards for EMRs. The reason that Interac bank machines work is that all the messages and data structures are the same — irrespective of which bank you may use. The same cannot be said for EMR data. One of the great technology successes of the UK’s defunct National Program for IT was a project called GP2GP through which a patient’s electronic health records can be transferred directly and securely between GP practices. This was made possible because of standardized data structures.

As provincial EMR programs begin to wind down, starting with Alberta in 2014, and provinces transition to a support and optimization role for users of EMRs, the lack of data standards for EMRs is going to become a greater and greater problem. Short of completely redesigning existing EMRs using the same data structures and standards for all systems, it will be a nearly impossible task to reverse modify the EMRs used by 70% of target physicians. We are stuck with what we currently have. The policy failures of the past — insufficient support for clinical leadership in the early stages of EMRs and a lack of focus in developing and implementing standarized data structures and clinical messages for EMR systems (nationally and provincially) — have created the current pickle we are now in.

Before we can fully utilize and gain insights from big data, we had better sort out small data in EMRs. This needs to begin with a focus on data quality, the management of patient populations at the practice level, and ensuring that the clinical messages passed between EMRs use nationally-accepted standards so that data is interoperable and usable by other systems.

What do you think? Are there other priorities to consider in order to make data more usable by multiple EMRs? To add your thoughts, click on the “Comments” link below.

Updated BC College Guidelines on EMR Use

The British Columbia College of Physicians and Surgeons has reminded physicians about the change to the retention of medical records as defined under section 3-6(2) of the Bylaws under the Health Professions Act. The Act has been amended to reflect the change to the Limitation Act. College registrants are now expected to retain medical records for a minimum period of 16 years from the date of last entry or from the age of majority, whichever is later, except as otherwise required by law as of June 1, 2013.

Highlights from an updated College Guideline on EMRs:

• 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 16 years from the date of last patient contact (or until the patient reaches age 35 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 section 3–6 of the Bylaws under the Health Professions Act.

Click here to download a full copy of the updated guideline.

Can Decision Support Systems Improve Patient Care?

Clinical decision support is used in a wide range of instances to guide care decisions. Clinical decision support tools include drug-drug interaction checking, automated alerts, templates, and order sets. How can these tools be optimized to improve patient care? How should you determine whether the tools are appropriate in your specific practice setting?

 

This presentation took place on the 2013 Technology in Clinical Practice Cruise Conference. View a selection of photos of Tahiti from the cruise.

iPhone, Android and Tablets — Driving Clinical Value from Mobile Devices

The rapid adoption of mobile devices by clinicians and integration of apps into the clinical workflow has created significant opportunities for these devices to become primary tools in the diagnosis and management of disease. This presentation provides an overview of the drivers behind adoption, what clinicians are using, and how one can drive more value from these tools. This presentation took place at the 2013 Technology in Clinical Practice Cruise Conference. View a selection of photos of Tahiti from the cruise.

A subset of data is presented from the just published AmericanEHR Partners report: Mobile Usage in the Medical Space Report – 2013. Click here for more information and to obtain a full copy of the report.

The following list of recommended Apps was submitted by conference attendees:

• Epocrates – http://www.epocrates.com/
• MetrO – Subways of 400+ cities around the world – http://metro.nanika.net/index.php?p=Z
• Medcalc – Medical calculators – http://medcalc.medserver.be
• Medscape – Available in the iTunes store
• ICDMeister – ICD-9 Coding tool – http://icdmeister.com/iphone/
• American Medical Association – Online CPT Code lookup – https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do
• UpToDate – http://www.uptodate.com/home/uptodate-mobile-access
• Evernote – http://evernote.com (Apple)
• QxCalculate and PediSTAT – http://www.qxmd.com
• Lexicomp – http://www.lexi.com
• Dropbox – https://www.dropbox.com/
• iHeadache – http://www.iheadacheapp.com
• Cardiology Calc – Available in the iTunes store
• Good Reader – PDF reader for iPhone and iPad – http://www.goodreader.com/goodreader.html
• HanDBase – Database manager – http://www.ddhsoftware.com/handbase_iPhone.html
• Pocket Informant – Contact manager for iPhone and iPad – http://webis.net/wp/pocket-informant-pro/
• Sono Access – Interactive Ultrasound learning app – http://www.sonosite.com/education/sonoaccess
• My Fitness Pal – To recommend to patients – http://www.myfitnesspal.com
• StatCoder – Framingham Risk Calculator and Lipid Guidelines – http://www.statcoder.com/
• Essence of Anesthesia Practice – Fleisher & Roizen – http://www.us.elsevierhealth.com/article.jsp?pageid=7739

PS Suite EMR Acquired by TELUS Health

TELUS Health announced today its offer to acquire the electronic medical record business (PS Suite EMR) operated by MD Practice Software LP, a member of the MD Physician Services Group and a subsidiary of the Canadian Medical Association. Closing of the transaction is scheduled for Monday March 4, 2013. (Financial terms of the agreement were not disclosed)

TELUS has invested over $1 billion in healthcare over the past five years in multiple sectors including claims transaction processing through the acquisition of Emergis, pharmacy systems and now EMRs. Over the past year, TELUS has acquired Wolf Medical Systems in Western Canada and KinLogix in Quebec. According to data provided by TELUS, as a result of the acquisition of PS Suite, TELUS Health will provide EMR solutions to 9,000 physicians across Canada. With provincially certified solutions in the four largest provinces, this will provide TELUS with a strong footprint in Alberta, British Columbia, Quebec and Ontario. EMR market consolidation has accelerated over the past three years led initially by QHR Technologies and more recently by TELUS Health. See October 2012 CanadianEMR Article 'Consolidation in the Canadian EMR Market'

What does this mean for the EMR market in Canada and for practices that currently use the TELUS Health EMR products?

I had an opportunity to discuss the acquisition with Dr. Brendan Byrne, VP Physician Solutions for TELUS Physician Solutions. The following is a summary of that conversation.

AB: "With the acquisition of PS Suite EMR, I see one of the challenges being how you will maintain three different EMR products, although they are in three different markets. Do you plan to transition users to one primary EMR system?"

BB: "No, we will be supporting users in each of the markets served by the three products. Our focus is to maintain and focus upon physician relationships. TELUS Physician Solutions has been structured as a single business unit with three products. We have 300 employees across the business unit and over the next 3-5 years we plan to support each of the systems as we analyze the strengths of each platform. Our objective is to develop a next generation world-class solution over that time as the next evolution of our EMR strategy."

AB: "What are your plans in terms of getting all of the product teams working together?"

BB: "We see this in four phases. Phase 1 will be a period of stabilization including taking over the operations of PS Suite. Phase 2 will be focused on discovery in terms of product decision making. During phase 3, we will begin to introduce new collaboration services, such as building connections between EMRs and pharmacy systems and phase 4 is our national platform development. Many parts of these phases will run concurrently."

AB: "You have some unique challenges, for example in Ontario PS Suite is offered both as an ASP and as a local server version of the product. Will you continue to support both versions? In Alberta, with Wolf Medical and PS Suite both being offered as provincially certified EMRs (2 of the 3 certified solutions), how do you plan to manage the products in the same province?"

BB: "In Ontario, approximately 13% of physicians use the ASP (Cloud) based version of PS Suite. The majority of physicians continue to use the Local Server version of the product. We will continue to support both versions. Similarly, in Alberta we will continue to support both PS Suite and Wolf Medical."

AB: "What insights can you provide about the market? As the dominant provider in Canada in terms of market share once the acquisition is complete, what do you see as the next area of focus for EMRs?"

BB: "Up to this point, I believe we have spent too much time focused on regional issues. We need to move beyond regional performance and focus more on patient outcomes rather than EMR products."

AB: "If one looks at the user demographics for the three EMR products within your business unit, your customers are dominantly primary care physicians. Will primary care continue to be your main focus?"

BB: "We see that the next phase of growth in the EMR market in Canada is going to be through the specialties. We are already investing in and building capabilities to support the sub-specialties such as pediatrics and psychiatry. This will be a key strategy for us."

AB: "How do you define success as the TELUS EMR vision evolves?"

BB: "Success will be having more doctors using more of the functionality than what they have today. Too many doctors are not fully realizing the benefits of their EMRs."

With the acquisition of PS Suite from the Canadian Medical Association, two important dynamics will be unleashed. Canada's EMR market is beginning to mature and what we see is the emergence of a small number of dominant EMR vendors. At the same time, with the sale of the EMR business division, the Canadian Medical Association will be free to return to its role as a powerful independent advocate on behalf of Canadian physicians. Both, in my opinion, represent a movement in the right direction for Canadians.

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