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

Is Data Exchange Being Held Back by Paper?

Fax technology slotted in perfectly with paper processes and quickly revolutionized the way that information was communicated. Within a few years of introduction, fax machines were cheap, good quality, and virtually ubiquitous. However, because they were so successfully adopted, faxes also created dependencies in terms of the way that organizations shared information between one another.

In a report by Healthcare IT News, a new study by HIMSS Analytics examined the current state of information exchange among U.S. hospitals and found that if a hospital was not participating in a health information exchange (HIO), 64% of data sharing was conducted via fax. In addition, 63% of the same HIOs processed faxed information into an electronic format via scanning. This is a common phenomenon in physician offices. Reports and related information are transmitted between practices by fax. In those practices, running EMRs, if the faxes are not received electronically using a fax modem, they are scanned into the EMR setting up a repetitive cycle of printing and digitization.

Achieving widespread information exchange means getting beyond the “if it ain’t broke, don’t fix it” thinking that is also prevalent. The first prerequisite is that a viable information exchange option exists; the second, that one is willing to give up existing dependable processes that are an integral part of workflow. Despite producing a lot of paper, fax technology is very efficient and dependable; however, there are ways to integrate faxing effectively into an electronic workflow. If you are not yet using a fax server with your EMR software, or even standalone, this should be seriously considered. In a 2012 article on CanadianEMR, “Do You Need a Fax Server for Your Practice?” this topic was covered in some detail and is well worth reading.

Bottom line: Because we do not yet have widespread data interoperability between different EMRs and between multiple providers and sites within the healthcare system, faxing will likely be around for some time. The best strategy is to optimize your existing setting, integrate electronic faxing into your workflow process, and be prepared to transition tasks that currently require fax technology once other sites are set up for different forms of data exchange.

Best Practices — Converting from Paper to EMR

Converting paper charts during EMR implementation is generally seen as one of the greatest barriers to switching over a practice. Chart conversion is a time-consuming and resource-intensive task; however, there are several things your practice can do to help shorten and reduce the pain of chart conversion. In order to maximize the benefits of your EMR, you will need to pre-populate the record with important clinical and demographic information. The following simple steps will improve your successful transition from paper charts to an EMR.

Develop a plan that both indentifies the process you will use to capture the information from your paper charts and establishes realistic timeframes within which to complete the process. Consider the data that is most frequently going to be clinically relevant in the treatment of your patients. One of the most common mistakes is to attempt to input the entire patient chart into a new system. Not only is this expensive, but also it can end up corrupting the data in the new system.

Data you will most frequently need include the following: allergies, current problems, current medications (episodic and long-term meds), past medical and surgical history, important diagnostic results (e.g. lab results, pathology, or most recent EKG), consult letters, immunizations, screening test dates/results, and advance directives.

Here are some tips and best practices for chart conversion:

• Review and update your paper charts prior to implementing your EMR. Irrespective of which EMR you choose, you will need to get your charts prepared for data input. Organizing the updated clinical data using a standardized face sheet will streamline your data entry process when you populate your EMR.
• If you have more than one physician in your practice, it is important to agree upon a single standard paper template to collect this information. This will allow you and your staff to pre-populate summary information and makes the data you may want to transfer to your EMR more readily accessible and faster to input into your EMR. It also gets you and your practice used to documenting your patient visits in a structured manner that will likely be similar to most EMR systems.
• Identify patients who are seen regularly in your practice with chronic medical conditions or complex care problems. Getting these paper charts organized and entered into your EMR will allow you to focus on the clinical encounter when you see that patient. It is much easier to pre-enter all the complex patient data, which will allow you or your staff to enter less complex patients on the day they are seen or during the clinical encounter.
• When choosing how to enter the data, remember that discrete information such as immunizations or labs, if entered as a .pdf or TIFF file will not populate any of the data fields in your EMR. As a result, any alerts in your system will not be reflected in this data.
• If you choose to scan all of your old patient records, you will then be able to move any remaining paper charts off-site and will be able to reclaim space used for chart storage and utilize that space for other purposes such as additional examination rooms. If scanned into a compatible format (e.g. PDF), a copy of each scanned patient record can be attached in your EMR allowing for quick review of the paper medical chart if needed.
• Establish a clear goal to keep everyone in the practice motivated. One of the most effective strategies is the “three time rule” where the physician is allowed to use the patient’s paper chart only three times (three visits) before the paper chart is retired. After that point, the chart is still accessible, but — as a deterrent — some practices charge each physician a small fee per chart.

Have you converted from paper charts to an EMR? Share your experiences by clicking on the “Comments” link below.

Tips to Selecting the Right EMR for Your Practice

Selecting the right EMR for your practice is one of the most important business and clinical decisions you can make. With a range of potential EMRs available in each province, how should you choose the right system for your specialty and practice size?

In addition to viewing EMR information and rating data on CanadianEMR, the following tips are provided to assist you with EMR selection:

1. Are you ready for an EMR?
2. Is the EMR appropriate for your specialty?
3. Is the EMR appropriate for your practice size?
4. Ensure you receive sufficient training.
5. Post implementation support.

Are you ready for an EMR? Assess your practice’s readiness to adopt an EMR system and develop a list of requirements for your practice. Evaluate both your own and your staff members’ readiness from a computer use and commitment perspective, and ensure that all members of the practice have reasonable expectations about what the EMR will do. If a provincial EMR program is available in your province, you may qualify for funding support either as a GP or specialist. The better prepared your practice is, the more likely you will be successful with your EHR implementation.

Is the EMR appropriate for your specialty? Not all EMR systems are designed to work well for every specialty. For example, ophthalmology-specific systems provide highly specialized functionality that is not appropriate or necessary in a primary care setting. There are a number of important considerations when selecting a specialty specific system, including:

• Templates that are designed to capture information specific to that specialty in a format and according to a workflow that is appropriate. Templates should be easily customizable by the clinician or practice.
• The ability to connect diagnostic devices directly to the EHR so that data from the devices can be automatically imported into a patient’s record, e.g. spirometry readings for respirologists or EKGs for cardiologists.
• For surgeons, schedule synchronization between the EMR and the hospital OR booking system. This is usually conducted through a third-party software; however, it is worthwhile checking with EMR vendors whether they offer this capability.
• Quality of consultation reports — review what a typical consultation report looks like to ensure that you are comfortable with the output and the format.

Is the EMR appropriate for your practice size? EMRs are generally designed for certain practice sizes. Systems that work well in practices of 1–3 physicians are not necessarily the right type of EMR for a larger multi-specialty practice of 25 or more. EMRs for large practices have to be able to support larger numbers of clinicians and staff working on the system (and sometimes the same patient record) simultaneously. More complex EMRs frequently are a higher cost as the hardware to support the system needs to be higher performance. Ask EMR vendors for information on the size of practice in which their software is typically used.

Ensure you receive sufficient training — Make sure that training is a key factor in your selection process. Some vendors skimp on training in order to reduce the purchase price of their software, but this can be a big mistake that will ultimately cost more in the long run. When you do your reference checks and site visits (with existing users of the EMR you are considering), ask physicians and staff how much training they received and what they would recommend as ideal for that product. Onsite training is preferable initially rather than online training, as you will have the opportunity to test and learn the software in the exact setting in which it will be used. However, even with comprehensive initial training, it is not possible to learn everything you need to know about your EMR. As a result, you should include follow-up training in your budget to learn how to use the more advanced functionality. Even with adequate training, getting the most out of an EHR means that you will need to practice as much as possible so that the commonly-used features become second nature.

Post implementation support — It is critical that you understand what is included in your contract in terms of post-implementation support and maintenance. You will need to know support levels offered by your EMR vendor and which level of support you need to ensure the ongoing operation of your practice. These are frequently spelled out for you through the provincial EMR programs such as PITO and OntarioMD. Confirm how frequently updates are typically released and your role in terms of installing them — this is not an issue if you purchase a cloud-based EMR system, as the updates are managed centrally by the vendor. Ask current users what their experience has been in relation to vendor availability and responsiveness to support requests as well their responsiveness to concerns and requests for enhancements.

Do you have any other feedback or suggestions? Click on the “Comments” link below.

Tips, Tricks, and Best Practices to Maximize Use of Your EMR

Implementation of electronic medical records does not necessarily mean that the systems are being used effectively. Using EMRs optimally requires extensive optimization. This presentation provides a number of useful tips trick and best practices to assist practices with the optimal use of their EMR systems.
 

 
This presentation took place at the 2013 Technology in Clinical Practice Cruise Conference.

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

Surviving as a Solo Practitioner

Over the past 5–10 years, I have read a number of articles that describe solo practitioners as a dying breed. In primary care, the transition to shared care by teams of providers (including physicians) and the development of primary care networks have accelerated this change. I have not come across any new family medicine graduates in the last few years who plan to enter solo practice. The concept of setting up and running a practice is too daunting, particularly if that physician wants to start off their practice with an EMR. This is not the case with specialists. Even though many may wish to work in either a single specialty group setting or multi-specialty practice, there are a number of specialists who continue to work in solo practices.

The benefits of solo practice are well recognized. These include the ability to:

• Make your own policy and financial decisions about how you want to run your practice
• Spend as much time as you feel is appropriate with your patients
• Create stronger, more personal bonds with patients
• Employ the staff of your choosing and control your own schedule

In 2013, in the face of financial, administrative, and oversight pressures, can a solo practitioner survive? If so, what strategies should be considered in order to do so? The answer is yes, but physicians wanting to retain their independence and continue to practice solo need to be creative in order for their practices to remain viable. It is important to keep your overhead costs down and to run as efficient a practice as possible.

Some suggested strategies include the following:

• Take advantage of provincial EMR incentive programs and implement an EMR that is appropriate for your practice setting. In small practices, ASP- or cloud-based EMRs are a good choice because they do not require a local server or expensive hardware. Frequently these EMRs will run on low cost desktops or tablets, as most of the intensive computing takes place in the cloud. Backups are also handled centrally by the vendor, reducing the need to keep local copies of data in case a server fails. However, do your research, conduct site visits, and speak to colleagues before selecting a system.
• At the present time, EMRs in most settings have yet to achieve true interoperability with other systems. The advantage of the Electronic Medical Record is the ability to share information efficiently electronically with other clinicians and ancillary care providers. Once we have widespread interoperability between systems, the ability to practice in a solo setting but still function as part of a virtual group will become a strong facilitator for those who want to work solo. I am often asked by colleagues whether they should wait for interoperability before implementing an EMR. My advice is to choose a system that will best match their needs and get on with adoption. Over time, once a critical mass of EMR users exists, the interoperability will take place more quickly.
• A concierge practice is another viable option. Patients are charged an annual fee to belong to the practice. As a result, a physician can care for a smaller number of patients and provide a concierge level of care with the annual fee offsetting associated reductions in revenue. For example, a concierge practice of 500 patients in which each patient pays an annual fee of $300 generates a baseline revenue of $150,000/yr. Some physicians are integrating remote consultations, tele-consults, and using other tools such as text messaging to provide a level of care that differentiates them from a more traditional family practice. It is important to ensure that any practice following this model does not contravene the Canada Health Act and that patients are not charged for services covered under their provincial payment system. It may be necessary to completely opt-out of the provincial payment program. In addition, a number of provincial licensing bodies publish guidelines on the use of Annual Fees.

Are you in solo practice? Do you intend to join a larger group or have you found a way to maintain your independence? Share your experiences by clicking on the “Comments” link below.

Are You Finally Ready for an EMR?

Are you one of the approximately 35% of Canadian primary care physicians who have not yet adopted an EMR? If so, now is a good time to begin thinking about the next 5–10 years in your practice and what it will mean if you do not have an EMR system. When I began talking and writing about EMRs over a decade ago, using electronic medical records was the exception rather than the rule. At that time, although EMRs were already widely adopted by primary care doctors in many other countries, Canada was still an outlier. This has changed. Canada is still behind most other developed countries in the adoption of EMR, but we are quickly catching up and those who continue to avoid implementing a system will have different challenges they will face by retaining paper charts in an increasingly electronic healthcare system.

I regularly talk with physicians at educational sessions and the major change that I have noticed has been a growing sense of inevitability that EMR is the future of medical practice. I have not met a single physician in the last couple of years who does not believe that the healthcare system of the future will be technology driven and supported. The remaining physicians who have not yet adopted an EMR fall into the late adopter category. Unlike early adopters who are excited by technology and would implement EMRs irrespective of whether financial incentives were available or not, the late adopters need clear evidence that the EMR will provide greater benefit than their existing processes and are not particularly interested in the technology alone.

You may fall into one of the following categories of physicians who are still undecided. A list of potential benefits are provided to help support your decision to adopt an EMR:

• I am too close to retirement: This is often quoted by physicians as a reason not to adopt an EMR. They do not want to go through the implementation process and see themselves completing their careers without the necessity to make this change. While there may be a benefit to retiring and placing one’s paper records in storage, there are responsibilities post-retirement in terms of custodianship of paper records. Although licensing bodies may vary slightly with respect to the storage of records, prepare yourself to be searching boxes of paper charts and sending those records via courier to new physicians (if your patients are lucky enough to find a new family doctor). Alternately you can take advantage of a number of services that offer chart storage services for practices and charge patients a fee to have their records scanned or sent to other physicians. There is another very good reason to consider implementing an EMR prior to retirement. The likelihood of being able to attract a physician to take over your practice and patients without an EMR is very small. There are very few physicians (particularly new graduates) who would want to join a paper-based medical practice in 2012.
• It is too expensive to implement an EMR: Currently funding is still available in a number of provinces to support physicians in their purchase of an EMR. The funding does not cover all of the costs of hardware and software, but does underwrite a significant part of the adoption expense. This funding is not going to be available indefinitely. As a result, you should consider taking advantage while it is still accessible. There are many benefits to implementing an EMR, particularly with respect to the management of patients with chronic disease. As provincial payments to physicians are increasingly directed towards improving outcomes and measuring quality of care, EMRs make this easier through automated recalls and reminders and the ability to generate chronic disease management templates that make the entire process easier and more efficient. Incentives to provide care for chronic disease patients can amply compensate for the ongoing cost of operating and maintaining an EMR.
• I am happy with my practice the way it is: Nothing stays the same forever. You may have refined your work processes so that your practice runs like a well-oiled machine and with minimal dependence on technology. However, the world around your practice is changing. As more information is transmitted and shared between physicians and other providers through electronic referrals and consultations or E-Prescribing, you will not be able to maintain your existing processes and will be forced at some point to make the change to EMR. Rather than this being forced upon you, it is better to plan the transition and ensure that it is least disruptive.

There are many other reasons why you should consider adopting an EMR and I will cover more of these in future articles. However, if you have recently been through EMR implementation and would like to share your experiences and what drove your decision making, please click on the “Comments” link below.

Taking Control of Forms in Your Practice

Even if one uses an EMR for the majority of patient management, it is highly likely that there are drawers full of preprinted forms that are used every day by physicians as well as administrative staff. These include new patient registration forms; requisitions for a wide range of services including radiology, laboratory, and pathology; and referral forms for physiotherapy, specialty clinics, auditory assessments, and orthotics — to name a few. Each form is unique, despite requiring all of the same demographic information when completed. And due to the need in some cases to only use the most up-to-date version, scanning a form for later retrieval and printing can become problematic because of a need to manage different versions.

Forms are an area about which there has been very little discussion in the private medical practice setting and yet could provide significant improvements in efficiency if they could be better managed. Not only is there an environmental aspect to reducing paper usage, the need to reduplicate information could be significantly reduced. Many practices have dealt with this problem using demographic labels printed in sheets or at the time of an encounter. Some continue to fill out the forms manually and for the most commonly used forms, others use scanned forms with overlaid demographic fields, which can be populated from the EMR or patient registration system at the time that a form is needed. This still requires manual entry of some information such as main complaint or reason for referral plus history; however, it does improve efficiency as the need for separate labels can be reduced.

Solving the “form problem” is no simple matter. Forms are a primary source of communication between organizations and providers. The format of these documents is meticulously managed in many settings and are usually developed through a consensus process. Because of the “management by committee” approach to the development of forms, individuals as well as organizations are very protective of their forms. Changing forms is frustrating to busy care providers and the layout is often designed to capture highly specific information in a way that is most useful to the receiving entity. I recall an orthopaedic specialty group that would not accept a referral unless it was written on one of their most recent forms. Multiply this by dozens of consultants and one has a major challenge standardizing forms. Incomplete forms require phone calls to fill in the missing information and, in some cases, the investigations or referrals are not booked due to this lack of information.

What can be done to take better control over forms in a medical practice? The following strategies can help:

• Do an inventory of all the forms used in your practice. This should be repeated on a scheduled basis, e.g. twice yearly to ensure that forms are the most recent versions. One administrative staff member should be designated with the task of managing the form inventory. If a new form is added, such as a consultant referral or for a diagnostic facility, this should be tracked as part of forms management.
• Next divide the forms into categories such as frequently used, infrequently used, or original required. The “original required” group of forms are those that have to be submitted using the original form. These can include forms that have duplicate copies attached, provincial requisitions, or mandatory reporting forms for infectious diseases.
• Designate a single location to store scanned versions of those that do not require the original to be used and ensure that everyone in the practice knows how to access the forms. If it is the policy of the practice to print certain forms, e.g. less commonly used referrals, make sure that it is easy for the physician to print the form and complete it without having to leave the consultation room. This means printers at convenient locations and ideally in the exam rooms.
• The hard work is trying to get consensus within one’s community or referral catchment area regarding a standard referral form for as many of the specialties as possible. This is extremely challenging if there are distinct differences between the types of information that one specialist requires in comparison to another.
• Ideally, one should be able to configure these nuances into an EMR that is able to send referrals electronically (referrals being just one of many forms that a practice needs to be able to complete). The EMR should be able to pre-populate the referral form with the needed clinical information and append the appropriate attachments that can be electronically submitted to the consulting physician for review and acceptance.

These are just a few tips and suggestions for a very complex challenge. Have you had any experience with forms in your EMR that you can share? How have you dealt with these problems in your practice? Click on the “Comments” link below to add your thoughts.

Pros and Cons of Wireless and Local Networks

Physicians are mobile workers. Some may work in more than one practice location; others may use multiple examination rooms in a single clinical setting. However, one feature common to all physicians is that they move around during a clinical examination. Unless a physician has an administrative job, they are usually not restricted to a desk and a single computer. This creates certain challenges when it comes to hardware in the examination room and throughout a medical practice. A good needs analysis is necessary to determine whether one should have a wireless or wired local network, or a combination of both.

With the growth in availability of smaller, faster, and lighter wireless tablets from a wide range of manufacturers such as Apple and Samsung, and mobile phones with larger screens (the new Samsung Galaxy S3 has a 4.8 inch HD screen), physicians now have more choice than ever regarding tools that fit the mobile form factor. Wireless networks and access points have matured significantly over the past five years and bandwidth is generally no longer an issue unless one is accessing extremely large files, such as radiology images. The new Apple iPad with retina display is being used increasingly in hospitals to view images due to the high resolution screen and there have been regular reports of a soon to be released Apple iPad with a 7–8 inch screen. Sure to be a hit for physicians who do a lot of prescribing.

However, there are some important steps that you should follow if you plan to install a wireless network in your medical practice:

• Talk to your existing (on intended) EMR vendor to ensure that their EMR product works well on wireless networks and what the minimum bandwidth requirements might be. This may be your primary determinant as to whether you go with a wireless or wired network implementation.
• Wireless may be your network of choice if you are using an ASP- or cloud-based EMR. In these types of systems, the EMR is hosted outside of your practice at a remote location and is accessed through the Internet or a secure network connection.
• Unless you have a very small office space that requires a single wireless access point and you are comfortable installing it and setting up the wireless security, bring in an expert to do the installation. They will ensure that you have sufficient wireless coverage throughout the practice, install signal amplifiers (if needed), and will set up your wireless security for the maximum level of protection.
• Do not install an unsecured wireless access point in your practice that is connected to your office computer(s). Using sniffer software, it is possible for hackers to easily gain access to your system and anyone else who connects to the network within your practice.

Wired networks:

If you are running a server in your practice, you certainly can install a wireless router, but this is something that will require consultation and advice from your vendor. Wired networks have some distinct benefits. They are fast, stable, and have high availability. They are also secure in that your practice can function as a closed environment if you are not connected to the Internet or an external network. If you are connected to the Internet, you will need to install a firewall (as you would with any wireless network). Wired networks also tend to be more costly to install initially and do require maintenance and some ongoing cost.

Have you had any experience using wireless access points in your practice? Share your thoughts by clicking on the “Comments” link below.

Managing Paper Documents in Your EMR — Scan and Fax

The paperless office is a misnomer! There is a constant flow of paper into every medical practice from multiple sources including hospitals, consultants, and other non-automated service providers. In many cases, clinical information is digitized in the form of Word documents and other digital formats printed and re-digitized by scanning the documents into the EMR. In the distant future, medical practices may become completely paperless when all data and documents are delivered electronically into EMRs or are transmitted from EMRs through information exchanges to other parts of the healthcare system. In the present state, we could aim for paper-light offices at best, by methodically reducing the amount of paper we receive and generate.

One of the greatest sources of paper is the volume of historical paper charts that exist in medical offices and storage facilities. As practices migrate from paper records to EMRs, many of the paper charts need to be partially or completely digitized and archived or incorporated into EMRs. What are the principles and guidelines that practices should follow in terms of scanning and archiving these records?

The advantage of the EMR is that once a practice has fully transitioned, there is limited need to access paper charts. They can then be moved off site, freeing up expensive storage space. However, records may need to be retained for legal purposes or based upon organizational/practice policies.

Some key questions arise regarding document scanning and retention:

1. What is the best format in which to scan a document for inclusion in an EMR?
2. Is there a required minimum resolution?
3. What are the most commonly used formats?
4. Is the size of the document (in Megabytes) an issue?
5. Are there any existing legal requirements or precedents governing these guidelines?

As a basic principle, a scanned record needs to be non-editable. In other words, once it has been scanned, it must not be possible to modify the record or document in any way. In addition, the document must be readable. This is where the question of resolution comes in. The higher the resolution of the scan, the larger the file. So there is a trade-off between document size and resolution. But is there a minimum that is acceptable?

In order to optimize integration of documents from external sources into EMRs received via fax, if you are not currently using a fax server, this should be a top priority. Click here for more information about fax servers.

In terms of scanning, Adobe Acrobat (.pdf) and Tagged Image Formet (.TIF) seem to be the most common formats that are easily readable. Are there any other formats that practices or EMR systems are using for scanned documents?

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