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

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.

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

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

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

The report specifically highlights primary care and electronic health records:

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

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

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

Sometimes, Not Knowing is Better!

Call me a cynic, but earlier today when I reviewed the Canada Health Infoway “Knowing is Better” toolkit and associated materials to encourage clinicians to adopt technology in their practices, I had the distinct feeling that the objective was more about catering to the needs of Infoway than helping physicians improve patient care. 

According to a November 22 article in CMAJ “Clinician, upgrade thyself”, Dr. Karim Keshavjee, an Ontario family physician, CEO of InfoClin and an advisor to CanadianEMR  argued that “there’s no legitimate explanation for the duration of time that it has taken Infoway to focus its attention on clinical use of EMRs, and that a clinical education campaign is hardly an indicator that Infoway has abandoned its fondness for ‘big projects’ in favour of measures that integrate EMRs with the electronic systems of hospitals, labs, pharmacies and other elements of the health system.”

The Knowing is Better than not Knowing toolkit is described as being designed for “clinical champions” and comprises of a downloadable PDF orientation guide with links to a number of videos, a PowerPoint template containing user modifiable content that can be presented to an audience, and a list of FAQs. There is a kindergarten-level animated video described as providing “an overview of the Canada-wide initiative and progress for a network of interconnected point-of-care and electronic health record systems”. Watching the video, I cannot imagine why my clinician counterparts would be interested in presenting this content to a group of colleagues. In fact, in my mind’s eye I can see the quizzical looks on the audiences’ faces as they view this vidoe. And, what are “Point-of-Care systems”? This terminology has no relevance to physicians or allied health professionals. Call them EMRs.

Clicking on the TImely Access to Information video through the orientation guide generates the following message:

Note: This document was released on September 20, 2012.

Upon reviewing the PowerPoint deck, the entire presentation is geared towards selling the Infoway Kool-Aid. A word of advice: physicians do not care about progress with implementation of provincial data repositories across the country!

Over 60% of doctors already have EMRs and are struggling to optimize their systems and use them effectively. This is where the energy should be directed. For example, how does one manage medications most effectively through an EMR? Is there any liability for physicians if they view information through a provincial EHR and do not place a note in their EMR? What are the best practices for managing shared clinical information in a family care network? These are the types of questions for which help and guidance is needed.

One bright light: there are a couple of good videos, particularly interviews with clinicians who discuss how EMRs are helping deliver better care.

Perhaps the Knowing is Better than not Knowing campaign would have been relevant in 2003 before most of the EMR work in Canada began.

However, based upon what is presented now, I think that Not Knowing is better!

EMR in Canada Part III — A Developer’s Perspective

Part 3 of a three-part series of articles written by a veteran software developer who has worked extensively in the EMR industry. The article series is published on his behalf. His comments are directed broadly at the industry. Read Part 1 Read Part 2

How We Got Here

EMR systems arose out of a cottage industry. The first systems were written by a doctor who had learned some programming, or a university student working on a side project. Most of these started out as simple systems used in a single practice or by a specific specialty then grew in complexity to encompass new needs. This frequently happens with first generation software in any industry. People see a need and create programs to fill that need. Eventually, as the market matures, the better software gains market share and others drop by the wayside. The winners eventually bring in professional developers or are bought out by software companies. Usually the founders move on or are given advisory roles. As the organization becomes more professional, the software does too. This leads to a second generation of software, much improved over the first generation and which continues to evolve as companies fight for market share. Most software companies make money from new sales and from upgrading existing customers to new versions.
 
This did not happen in the Canadian EMR sector. Initially it was because demand was low. Purchasing an EMR system was an overhead cost to the practice that did not pay off in increased profit. Then, in order to get doctors to start using EMR systems, the provinces started funding the purchase of EMR software. While well intentioned, this has had a negative effect on EMR software development and prevented the industry from maturing.
 
It is my belief that as doctors are not paying directly for the software, there is no incentive for them to make sure they are getting value for the money. Timelines on qualifying for funding only make this worse. If someone else is paying the bill and you have a limited time to buy, you are not going to be as diligent in your evaluation and you are not going to wait for something better to come along. This is a sales person’s dream, selling a product that people need to buy according to a deadline and for which someone else is footing the bill.
 
In order to qualify for funding, EMR software has to meet a set of requirements and pass certification. Not only does each province has its own requirements and certification process, when the requirements are updated the software must be updated to meet the new requirements and then be re-certified. In Ontario, new specifications have been released every two years. I was involved with meeting one of the re-certifications which took nine months of planning and work to make the changes. This was for a single province. As a result, EMR companies are forced into cycles of software upgrades in order to meet the next round of requirements. In between these rounds, they have releases to fix bugs and add features requested by users.
 
The funding structure discourages companies from developing new versions and does not encourage them to make better software. For example, Ontario pays doctors $600 a month for support costs, spread over three years. This encourages EMR companies to lock clinics into three year support contracts. Unlike other software companies, EMR companies do not have to come up with new versions of the software to generate new revenue. They receive income from the support contracts. This method of funding also reduces the incentive for EMR companies to develop software that does not require much support. While software support is a cost to the vendor, support fees are a major source of income and are budgeted into their business plan, so generally they continue to release new versions of the existing product.

The Path Forward

The Canadian medical system is an odd hybrid. Doctor’s clinics are businesses, but they receive almost all their income from provincial medical programs on a fee per service basis. As fees are fixed, clinics generate profit by keeping costs down. For a clinic to purchase an EMR system, they have to justify the investment in terms of cost saving. I know there are arguments that EMR systems make for better medicine and I agree, but a clinic has to make a profit or risks shutting down.
 
The Single EMR Solution

A single, standard EMR system that could be used in every clinic across the country would have a number of benefits. Doctors and other personnel moving from clinic to clinic would not have to learn a new EMR, provinces would not have to test and certify multiple EMR systems, etc. The question is how could we achieve this?

The Government Program Option

Having government pay a company to develop and support a single Canadian EMR system would seem to be a good solution. Ultimately our taxes are paying for EMR companies to develop and support EMR systems, so why not simplify things and pay a company directly? Unfortunately it is a very dangerous approach. There are a number of scandals related to government funded software projects. It would be naive to expect that one could be avoided when creating a Canadian EMR system. I would not get involved with such a project and I would not recommend anyone else to do so for this reason.
 
The Open Source Option

I am a big fan of open source applications. I use them in my work every day, and I am a contributor to a couple. I would love to see an open source EMR system that could be used in every clinic across the country. Open source would allow better integration with external systems; however, successful Open Source projects are those used by the very people who contribute to them. This is why the best Open source projects are tools for software developers — they have an interest in making their tools better. However, I believe that doctors should not try to be programmers just as programmers should not try to be doctors. This can prevent good programmers from contributing to an Open Source EMR.
 
Changing the current system

I can only see two things that can be done to improve the current system — common standards and changes in the funding formula.

Provinces need to coordinate not only their standards for EMR software, but the timing of new standards. EMR companies should be able to submit the same version for approval in each province and not have to modify a system that is approved in one province in order to receive approval in another. If the standards were consistent across provinces, approval in one province would automatically mean approval in the other province. This would help break the cycle of releases that EMR companies are trapped in. In addition, improvements in EMR systems need to be implementable without impacting the certification status of that system. For example, if an improvement is made to a screen design or workflow, it should not be considered a functional change that results in the EMR no longer being in compliance with certification. This discourages vendors from improving their products.
 
If funding for support is reduced or canceled altogether, EMR companies would need to include support in the initial cost of the system. This would make support a cost to the vendor, not the customer. EMR vendors would then have to develop better software in order to reduce costs.
 
Conclusion

These two reforms to provincial funding will help, but to be truthful I can’t see anything that will radically change the landscape. I think we are stuck with the systems we have available until a new company arrives on the scene and takes over the market.

EMR in Canada Part II — A Developer’s Perspective

Part 2 of a three-part series of articles written by a veteran software developer who has worked extensively in the EMR industry. The article series is published on his behalf. His comments are directed broadly at the industry. Read Part 1 Read Part 3

Where We Are

There are three key areas that I see as the most problematic:

• Poor User Interface (UI) Design
• Lack of Quality Assurance
• New Technologies

Poor User Interface (UI) Design

The development of our current EMR systems usually started with selection of an SQL database, creation of the tables and links between the tables, then development of the client system. This resulted in clients with user interfaces that were heavily influenced by the database schema, not by how the user would want to see the data. (Define the Client)

One can see the result of this development approach in the most vital part of an EMR — the patient chart. In clinics that are still paper based, a patient’s chart is a collection of documents, lab reports, clinical notes, etc. that are usually sorted chronologically. The doctor can quickly flip through the pages to gain an understanding the patient’s history and current conditions. In EMR systems the client chart is often a jumble of data grids in separate tabs or windows. This results in lab results on one page, procedures on another, consults on a third, etc. Even in EMR systems with a Cumulative Patient Profile (CPP) the CPP tends to look like a bunch of grids cut and pasted together. The data is organized the way a programmer would organize it, not the way a doctor would.

In designing user interfaces I use a technique call Task Analysis. With this method you break down each task a user would perform into individual steps, and then mock-up the steps one window at time. For this I like to use old fashioned pen and paper. I draw each window on a page of paper and walk through a task one page at a time. Drawing the windows by hand is a good way to judge the complexity of the information the user is looking at. If it takes more than a few seconds to draw the window, then it is too complex and you probably have items in the window that are irrelevant to the task being performed. If you find there are too many windows, they may need to be combined into one so they can be executed in a single step. I repeat this for each task that has been identified. Once completed, I take the stack of pages to a user and have them walk through each of the tasks one page at a time. This technique is also a good way to analyze an existing user interface, drawing the pages and walking through the steps. Simplicity is key. However, most EMR systems I have looked at fail in this regard.
 
Years ago, when designing software for Win 95 and XP and 640×480 screens, data density was a big deal. We used to calculate data density by measuring the area taken up by data compared to the entire screen. Having multiple windows open at the same time was a problem with Win 95 and XP, so you tried to fit as much data as possible into small screens. These days the opposite is true. With Windows 7 and large wide monitors, good UI design means an uncluttered display and sparse data. This makes it easy for a user to comprehend at a glance what is on the screen. There are many ways to display more information; most current EMRs still have densely populated windows. This is the result of designing around database tables.

Lack of Quality Assurance

Over 10 years ago the term “Test Driven Development” was coined. This referred to the concept of writing tests to check the functionality of each section of code as you developed it. This forced developers to separate code into small, testable chunks or Units and the tests were called Unit tests. Frameworks were developed to create and run Unit Tests for almost every programming language. It was a huge leap forward in improving both the quality of code and the pace of development. Test Driven development and Unit testing quickly became standard practice, or so I thought until I started working for EMR companies. The companies I worked for did some Unit testing; however, it was not standard practice and the amount of code tested was limited.

Unit testing has its limits, programmers only write tests to make sure their code does what it is supposed to do. By inserting X, one tests in order to produce Y. This is called Positive testing. An equally useful form is Negative testing. If one inserts Z, or anything other than X, what is produced? Programmers regularly perform Positive Unit tests, but rarely Negative tests.

Another way of testing applications is running automated test scripts on the actual application as a whole. This is called QA testing. It predates Unit testing and requires special tools. It also requires a different type of programmer. QA testing needs to include both Positive and Negative testing. In the latter case the QA person creates tests to see what happens if the user does something unexpected or that they should not be allowed to do. QA tests also make sure that the application meets design specifications. More importantly for EMR systems the QA tests check that data entered in one part of the system appears correctly in another. This is important to ensure that updated patient health data appears correctly in other areas of the EMR.

A robust system cannot be developed without strong quality assurance and good QA is as intensive as programing the system being tested. Mature software companies have requirements for the size of the QA team. Microsoft has a ratio of 1:1 in that there is one QA position for every programer in the development team. Other companies have different ratios, but the important thing is that these ratios are maintained. As the development team grows, the QA team should also grow.

None of the EMR companies I worked for had set requirements for the size of the QA team. The QA teams were small and with each release, they found themselves scrambling to adjust their test suite for all the changes the developers had made. This left gaps in the test coverage and releases often went out without the QA process completed. The quality of the product is directly related to the amount of QA that is performed prior to release. This is important in critical healthcare applications such as EMRs.

New Technologies

Some will argue that EMR systems should stick with established technologies and that the risk of using new technologies is too high. The difference between “New” and “Established” in the high tech industry has been shrinking for years and now is almost nonexistent. As one well regarded development manager told his team designing a new system: “Use things that are going to work great in two years.” Canadian EMR companies tend to use older technologies.
 
NoSQL Databases

About 12 years ago, the industry started to realize that SQL databases had their limitations and alternate database systems were re-introduced and new database systems developed. This was dubbed the NoSQL movement and today NoSQL databases are behind many of the websites you use every day. It is not unusual for a site to use more than one type of database.
 
NoSQL databases store data in a number of different formats, each suited to a different type of data. One category of NoSQL database is the document database. These databases do not have a fixed schema like an SQL database, but are dynamic with the schema being generated as documents are added to the database.
 
The SQL database model is well developed and understood, but EMR systems deal with a number of different types of data. Managing client lists, scheduling appointments and billing operations are things that SQL database are well suited for, but this is just a small component of an EMR system. The client chart is made up of completely different types of data. Most of this data comes in via EDT interfaces as HL7 files. EMR companies often have teams working on just the EDT code in order to shoehorn this data into a SQL database. Document databases are well suited to EMR chart data as most digital data is in HL7 format, which at its heart is a document format. However, I don’t know of a single EMR system that uses anything other than a SQL database.

Tablets

There is almost a daily growth in the number of tablets computers. The next generation of doctors will have gone through training with tablets in their lab coats and will be expecting to use them in clinical practice settings. While some EMR vendors do have “tablet” applications, I was unable to get much information about them and I am skeptical of how useful they really are. The tasks you would want to manage on a tablet are not the same tasks you would on a desktop. Even when completing the same task on a tablet, the user interface for a tablet needs to be completely different. Tablets come with built in cameras for still images, video and audio recording, which opens up many new ways of capturing data during an encounter. A good EMR client on a tablet should be designed and developed separately from the desktop or web app version. There are also security considerations that need to be considered with tablet applications. Tablets are easily lost or stolen. Can you remotely wipe all data from your tablet that has gone missing? There are security systems that provide this function as well as other security functions needed on tablets with access to sensitive data, but I am unaware of EMR vendors that have made use of them and I would not use one that was not secured by one of these systems.

The next article will focus on the evolution of the EMR market in Canada and a vision of the path forward for EMRs from a developer’s perspective.

EMR in Canada Part I — A Developer’s Perspective

Part 1 of a three-part series of articles written by a veteran software developer who has worked extensively in the EMR industry. The article series is published on his behalf. His comments are directed broadly at the industry. Read Part 2

I have been a software developer for over 25 years and have worked in a number of industries, making use of new technology to create leading edge software systems. I started off in university headed to Med School, but switched to Computer Science when I found I could get much higher marks, with much less work, in programming courses. So a few years ago when I started working at an EMR company, I felt that I could really contribute to enhancing the software. I have worked for a number of EMR companies throughout my career and these are my observations and recommendations. What I have observed in the EMR software industry is a wide range of weaknesses and deficiencies.

Areas of deficiency include:

• Software design
• User interface design
• Quality assurance, and
• Design principles that do not encourage safety

In doing research on EMR use, I found that some clinics had switched EMR systems two or three times and some had even gone back to paper systems. There is no better indicator of the state of EMR software. One EMR company was averaging more than one support call a day for every three installed sites. This is an extremely high ratio and would not be sustainable in any other sector.

There are over 350 EMR companies in the U.S., but only a handful in Canada. Some of the U.S. companies offer very sophisticated software. It is my belief that it won’t be long before the U.S. companies realize the weaknesses in the Canadian EMR landscape and make a move into the market.

The Anatomy of an EMR System

There are three or four components to an EMR system: the database, the client, the EDT interface, and, in the case of web-based EMR systems, the Web Server.

The Database

A database is simply where you store data. The standard database used is the Entity Relationship (ER) model. In these databases data is stored tables (Entity) with links between tables (Relations). SQL is the language used to retrieve data from tables and update the data in the tables. These databases are now generally referred to as SQL databases. The structure of the database, the tables, and relationships between tables is called the Schema.

The Client

The Client is what the user interacts with; this could be a desktop application or a web application (a website viewed in a web browser). Some people refer to the desktop application as a thick client and the web application as a thin client. Usually a desktop application is more interactive than a web application. However, with the capabilities of today’s web browsers, that difference is becoming less. The only real difference is that a desktop application has to be installed on each system, whereas a web application need only to have a single install on a web server.

The Electronic Data Transmission (EDT) Interface

The EDT interface is where the EMR system exchanges data with remote systems as well as other applications, medical devices, and local systems. Most of this data is in HL7 format, but there are also XML files, text files, binary files, and custom formats. How the EMR talks to other systems varies considerably. Each interface seems to have its own standard, and there are device interfaces, laboratory interfaces, hospital interfaces, local and regional interfaces, and provincial interfaces. Even when the data is in HL7 format, there are many different versions. In some cases, custom code has to be written to parse HL7 files from different sources. EMR companies frequently have a team that does nothing but write and update the EDT code to handle new and changing interfaces.

The second article will focus on the current state of EMRs from a developer’s perspective. Read Part 2

Do You Intend to Change Your EMR?

Are you satisfied with your EMR or do you intend to change to another system? This may be more significant an issue in the United States than in Canada, although there is always a certain churn rate with any product or service. (Churn rate, when applied to a customer base, refers to the proportion of contractual customers or subscribers who leave a supplier during a given time period – Wikipedia.)

The rapid rate of change in the U.S. EMR market in association with a number of additional drivers — incentives and subsequent penalties (beginning 2015) linked to Meaningful Use, incentives and penalties related to E-Prescribing, and increased focus on performance and quality of care measures at the practice and hospital level — that are driving significant numbers of physicians to change their EMRs.Two recent reports in the U.S., one by research group KLAS and the other by Medscape, indicate a high level of dissatisfaction with current EMR systems.

Medscape surveyed 21,000 physicians across 25 different specialties and found that, “More than one third (38%) are dissatisfied. Roughly a third of those unhappy users plan to shop for a new system, while others said that they're stuck with their current system because they’ve already invested too much. Still others noted that they do not have the authority in their practice to make a switch.” KLAS surveyed 300 prospective ambulatory EMR buyers with their results suggesting that in this particular group, replacements are up this year from 30 percent to 50 percent, another indication of dissatisfaction, particularly in relation to support or product development issues.

With this as background, what is the experience with EMR systems in Canada? Due to provincially funded EMR certification programs, my impression is that a lower percentage of physicians intend to change their EMRs in Canada vs. the United States. A more common reason to change is a vendor that has been acquired or has gone out of business. Examples include Clinicare, Healthscreen, and EMIS — EMR vendors that are no longer commercially sold or supported in Canada. However, anecdotally I have met and talked with many physicians who are on their third or even fourth EMR system.

Why do physicians change EMRs? Have you changed your EMR and if so, what were the reasons driving your decision? Click on the “Comments” link below to share your experiences.

The Demise of Small and Solo Practice

What does the future hold for small and solo GP and specialist practices in Canada? Are solo practices slowly moving towards extinction or is there a future for this traditional form of care? Programs designed to bring together primary care practitioners in groups through primary care care networks have been developed in multiple Canadian provinces, supported by a technology infrastructure. In many cases, the EMR has been the glue that has allowed for cost and resource sharing amongst practices while still maintaining the independence of one’s own office. The networks, in combination with provincial funding support to adopt an Electronic Medical Record have allowed GPs as well as some specialists to maintain their solo practices for the near term. However, the shift towards accountable and measureable care as well as cost pressures on health systems that are being filtered down to doctors is making it more difficult to sustain a practice without the ability to pass on the increasing overhead as well as maintain increasingly stringent reporting requirements.

Although the U.S. healthcare system is structured differently, perhaps we should take a look south of the border to see what is happening in small practices, as there may be some indication of what we could expect to see in Canada. In an article in TechTarget, titled, “Small practices, solo docs air EHR implementation, meaningful use woes” at a recent U.S. House of Representatives Subcommittee on Investigations, Oversight and Regulations’ hearing, the message came through loud and clear.

“If declining reimbursements don’t kill them, electronic health record (EHR) implementation and meaningful use compliance will finish the job.”

Small and solo practices are under great pressure due to increased regulation, declining Medicare reimbursement, and increasingly more stringent reporting requirements. Add to this penalty programs associated with adoption of ePrescribing and EMR (initially supported by incentives) and the need to make the upfront investment before being able to claim the incentives and practices are struggling to survive. This is not just in primary care — typically more well-off specialties, such as cardiology, are having a similar challenge. The result of all of these factors is a trend towards joining larger groups or hospitals that have additional resources to manage reimbursement, reporting, and compliance.

What has been astounding in the U.S. is the speed with which these national programs are being applied. EMR adoption is growing rapidly and certain specialties (such as family practice) are reporting that over 65% of their members have now adopted EMRs. The next phase is optimizing the EMR to work more effectively.

Provinces are evaluating the application of Meaningful Use measures in order to track and report on patients with Chronic Disease as well as preventive care measures. Although the Accountable Care Organization (ACO) structure does not exist in the same format in Canada, we are moving towards care that can be tracked and measured as governments strive to extract value from scarce healthcare funds.

What has been your experience? Are you in solo or a small physician practice? Do you believe your practice structure is sustainable? Share your thoughts by clicking on the “Comments” link below.

How Do Patients Use the Primary Care System? A Lesson for Health IT

Over the last year I have been working one day per week in a busy walk-in clinic in which all physicians and staff use an EMR. As with any EMR-based practice, there are ongoing challenges associated with using technology effectively in a clinical setting. Some features of the EMR work well and others are mediocre. Working in the clinic serves a number of purposes. It allows me to keep up with current clinical practices and maintain my skills. It is also a useful reality check in terms of care delivery in an urban primary care centre irrespective of technology.

The intent of this article is not to examine the use of the EMR system in the clinic, but rather to provide my observations regarding use of the primary healthcare system by patients:

• There are a lot of patients who cannot find a family doctor. During every clinic shift I am asked by at least five patients whether I am accepting new patients. Working a single shift per week, I am not able to provide the type of comprehensive primary care and continuity this demands, so I decline. It is nationally estimated that five million Canadians cannot find a family doctor. This number feels realistic.
• Availability wins over quality 9 times out of 10. The number of patients who attend a multitude of walk-in clinics for their day-to-day care is astounding and has serious negative implications for the healthcare system. Even though many BC patients may identify one individual as their “family doctor”, they often see many other physicians in walk-in clinics for a variety of clinical problems including medication renewals, minor medical conditions, sensitive issues such as sexually transmitted infections, and — in some cases — for all of their medical care. Thus, the “family doctor” becomes the repository for reports, lab results, and specialist consults they had not ordered but are cc’d. This situation creates an increasing disjointed way to provide care. In a world of EMRs, it is not possible to provide a comprehensive summary of a patient’s medical care, as the information exists in multiple charts across multiple practices. Without the ability to link patients to providers (through accurate patient and provider registries), it is not possible to create the one-to-one relationship needed for successful use of patient portals and personal health records. The core information is generally incomplete.
• There is no accountability on the side of patients for over-use of the healthcare system. On numerous occasions, I have seen patients during my clinic shifts who have seen one or more primary care physicians for the same problem on the same day because they ‘did not like/trust’ the recommedations of the other physician(s). Not only is this a terrible waste of scarce healthcare resources, it also creates an administrative challenge for the practices. The first practice to submit a claim for the visit to the provincial payment agency (MSP) gets paid and the other claims submitted are rejected. While it is possible to request payment in situations that a patient has been doctor shopping, the process takes place after the fact and requires additional effort and explanation in order to get paid for providing a requested service.
• Some very sick people are receiving their primary care at walk-in clinics. I also find the severity of illness surprising for a number of patients. I have diagnosed patients with spontaneous pnemothorax, pulmonary emboli, and muscular dystrophy to mention a few conditions that I can recently recall. These individuals should be receiving their care in a setting that provides greater continuity. They are also difficult diagnoses to make, particularly in settings where the physician may be seeing a patient for the first time. An EMR helps if a historical record exists for that patient.

Bottom line — we can implement EMRs and a wide range of information technologies in medical practices, but there are policy, utilization, and access issues that are fundamental in an efficiently functioning healthcare system. These issues (and I have listed just a small number) are barriers to effective use of health IT. While it may not be possible to “fix” the broken system, there appears to be a lack of recognition that these problems exist. We have to do a deep dive into the problems, optimize the delivery of care, and then apply technology to these improved business processes.

The alternative, as Bill Gates once stated, is as follows:

“The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.”

Canada 2010 National Physician Survey Results — 16.1% of Physicians Use EMR Alone

The 2010 National Physician Survey Results are now available online. The numbers tell an interesting story regarding the adoption and use of EMRs.

There are a few provisos to keep in mind:

• The 2010 data is already over six months old, so numbers are likely a little higher than reported.
• The adoption rates refer to all physicians (GPs and Specialists) and do not separate out eligible providers based upon role, e.g. exclusion of ER physicians or Radiologists.

A total of 16.1% of physicians report using Electronic Medical Records instead of paper charts. This compares to 9.8% in 2007 (21.5% of GPs and 10.1% of specialists in 2010 vs. 12.3% and 7% respectively in 2007).

The major change was in the number of physicians reporting the use of paper charts alone (37.6% in 2010 vs. 57.9% in 2007).

A total of 34.1% of physicians reported using a combination of paper charts and EMR in 2010 vs. 26.1% in 2007. With the reduction in numbers of physicians using paper charts alone, this clearly indicates that physicians are on the move in terms of their transition to EMR. But the rate of change is still disappointing and is in part reflected by a lack of coordination of national strategy with regard to encouraging EMR adoption. Some provinces have had programs to encourage adoption for 10 years and others have yet to begin.

The numbers by province also tell a tale regarding provincial effort. Alberta is the leader in terms of physician use of EMR alone at 27.7% followed by:

Ontario — 19.8%,
BC — 18.8%,
Saskatchewan — 17.8%, and
Manitoba and Nova Scotia — 17.6%.

Only 4.2% of physicians in Quebec report using EMR alone.

I am sure there will be much analysis and report on the NPS 2010 data; however, it is clear that after 10 years of effort across a select number of provinces, we are still far from a critical mass of users.

Much more work needs to be done to collect information and report on adoption of EMRs and to encourage meaningful use of information technology and EMRs.

What do you think of these numbers? Add your thoughts by clicking on the “Comments” link below.