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

Consolidation in the Canadian EMR Market

The recent announcement by TELUS regarding their acquisition of KinLogix, a cloud-based provider of EMR systems in Quebec, further consolidates the EMR market in Canada. Quebec has tended to function as an independent market for EMR systems. Four additional EMRs are commonly used in Quebec, namely Info-Data, Soft Informatique, Purkinje, and Omnimed. Other than Purkinje, which has a contract with the Canadian Armed Forces to provide Electronic Medical Records, none of the other EMRs are sold outside of Quebec.

As a result, TELUS’ strategy makes perfect sense in that it adds a new market for EMR systems to the TELUS Health family of products that is complementary to Wolf Medical, a product that TELUS acquired in February 2012. Additionally, both divisions (Wolf Medical and Kinlogix) are led by physicians, namely Dr. Brendan Byrne and Dr. Michel Hébert. The only gap for TELUS at this time is an EMR presence in Ontario and, with the acquisition of two cloud-based EMR systems to date, I would not be surprised to learn of the acquisition of a third cloud-based EMR system in Ontario at a future date. This would provide TELUS Health with virtually coast-to-coast EMR presence and the ability to link EMR systems through the cloud, plus the ability to offer a French or English version of their product in markets such as New Brunswick and Manitoba, each of which have pockets of dominantly French-speaking populations.

The other consolidation story playing itself out in the Canadian market is that of QHR Technologies, a company led by Al Hildebrandt, President and CEO. In rapid succession, QHR Technologies acquired EMIS Inc.’s assets in Canada in August 2011, followed by Healthscreen Solutions Inc. in October 2011. Two years prior, in November 2009, QHR Technologies acquired Clinicare Corporation, a Calgary-based company that developed one of Canada’s first comprehensive EMR systems. The QHR family of EMR products provides solutions for family practictioners as well as specialists with the Accuro EMR solution used by a wide range of specialties across English speaking Canada. What QHR currently lacks is an EMR product for the French-speaking market.

This story is one of a maturing marketplace for EMRs. Smaller EMR companies that do not have the resources or expertise to compete are being bought out by larger, more established companies with deeper pockets and a broader market presence.

Is this good for the EMR market in Canada? Yes, I believe so. Most mature EMR markets (UK, New Zealand) have a small number of dominant EMR products and a number of smaller companies that serve specialty niches or markets. This provides needed choice in the market and competition amongst vendors, which encourages improvements in the products over time. As with any growth-by-acquisition strategy, the biggest challenge that any company faces is retaining and supporting existing customers and simplifying the management of one’s products, particularly if there are multiple different versions in the marketplace. With cloud-based systems, this is easier, as there is one central version of the EMR that is updated centrally as new changes and enhancements are applied. It is certainly more challenging with local servers in individual physician offices.

The EMR consolidation story in Canada is just in the process of being written. Watch for future updates on CanadianEMR as the market continues to mature.

If you have thoughts or comments, click on the “Comments” link below

EMRs and Crowdfunding — The Policy Connection

Those who read this blog will be aware of previous articles I have written about the EMR market in Canada — most recently an update on provincial EMR funding programs in Canada. First, let me clearly state that provincial EMR programs have played a critical role in advancing adoption of EMRs in Canada. However, the programs are governed by provincial legislation and policies; as such, it is their mandate to operate successful provincial programs — not look out for the health of the EMR industry as a whole. And therein lies the conundrum.

A healthy Canadian EMR industry needs competition, innovation, revenue, and growth opportunities for vendors and the ability for EMR vendors to sell their products unhindered across Canada. This is particularly important for the smaller provinces that do not individually offer sufficient market opportunity for some vendors to sell their products without taking significant risk. This is further compounded by dual language requirements if a product needs to be available in both English and French. Current provincial strategies require EMR vendors to develop and maintain provincial versions of their EMR systems. Even if differences between provincial versions are small, vendors must still maintain multiple code sets in order to ensure the quality of their products in each market. The drivers are perfectly logical. Each province requires EMR systems that are designed to meet their needs under provincial mandates and policies. However as discussed above, what is good for a province is not necessarily good for an industry.

So, where does Crowdfunding come into the picture, and how is it applicable to the discussion on EMRs? A May 2, 2012, article in the Globe and Mail titled Crowdfunding: Why Canada is far behind the U.S. describes a situation eerily similar to the challenges faced by the EMR industry.

According to the article:

Crowdfunding relies on social media platforms to bring entrepreneurs and companies together, not unlike an online brokerage firm. Among the companies developing an internet-based exchange is Durham, North Carolina-based Motaavi. One of the company’s co-founders is Nick Bhargava, who is originally from Edmonton. He has no intention of setting up shop back home in Canada.

Mr. Bhargava and his associates spent months lobbying Congress to make crowdfunding legal. That was no easy thing, but at least they could focus their efforts on one government: federal securities law trumps state regulations.

In Canada, Mr. Bhargava would have to seek rule changes in each of the 13 provinces and territories. He reckons that’s more trouble than it’s worth.

Sound familiar? According to the author, what makes Canada unattractive to entrepeneurs like Mr. Bhargava is that he would need unencumbered access to the entire country to turn a profit.

The value of the central regulator cannot be underestimated. While this role has existed for acute care and large provincial health IT systems under the auspices of Canada Health Infoway, provinces have developed much more provincially focused strategies for EMR programs, in many cases linked to provincial fee negotiations.

I would like to see a future with strong national EMR vendors competing vigorously for clients and innovating aggressively to enhance product features in order to deliver more efficient and higher quality care. Under the current systems and processes, I cannot see this happening without some fundamental changes in the way EMR systems are certified and sold. The alternative is less attractive. Canada will lag behind the U.S. in adoption and use of EMRs. Why? Because just as in the Crowdfunding business, the U.S. has a national regulator and strategies to encourage competition and sales of EMR systems across the entire market. Canada is just not ready to take that kind of leap of faith.

What is necessary to create a healthy competitive EMR market in Canada? Share your thoughts by clicking on the “Comments” link below.

Update on Provincial EMR Funding Programs

Many of Canada’s provinces now operate EMR funding programs to support the purchase of EMR products by physicians. Some of the programs have already been established for some time and have been through multiple iterations (Alberta, Ontario). Others are much earlier in their evolution (Manitoba and, recently, Quebec). In the short space of this article, it is not possible to do a detailed review of a single program, let alone multiple provincial approaches to EMR funding. As a result, what I would like to do is offer selected observations of the programs — what they have done well, and what I believe they could do to make themselves more successful. For individuals who are considering a funding application, please contact your individual program directly.

What have the provincial programs done well?

• By raising the visibility of EMR as an important component of care transformation and facilitating the adoption of individual EMR systems by implementing certification programs, the provincial EMR programs have raised the bar significantly in meeting the needs of early users.
• Funding provided by the provinces, in addition to funding provided by Canada Health Infoway, has created valuable peer support networks that have been critical in advancing adoption and use of EMRs through collaboration and education. It is not possible to improve practice performance without this type of collaborative network.
• The implementation of EMRs has forced discussion by many of the provincial colleges and licencing authorities to better understand issues relating to privacy and the sharing of clinical information using electronic systems. Certain provincial colleges (BC, Alberta) have developed data stewardship policies outlining the physician’s responsibilities in terms of information management in an electronic setting.

How could the provincial programs improve?

• Each of the provincial EMR programs has invested significant funds and resources to develop implementation and support strategies as well as educational programs and each has valuable lessons learned from their program. Through my work in different provinces, it is evident that there is limited sharing of the knowledge, resources, and expertise to reduce duplication of effort and reduce mistakes already well learned through the more mature programs.
• By moving away from certification programs focused on functional requirements to certification of the messages transmitted by the EMRs with a focus on achieving clinical and operational outcomes (Meaningful Use of EMRs), it will be possible to future-proof certification to a greater degree by facilitating information exchange rather than EMR functionality.
• Wherever possible, standardize the messages for information exchange across all of the provinces. It is not sustainable for EMR vendors to support different messaging requirements for referral/consultation, chart transfer, or ePrescribing in each of the provinces in addition to supporting other functional requirements for each provincial program. This will reduce the cost for vendors, allowing more resources to be applied to important usability improvements that need to be made to each of their systems.

If you have any additional observations on the provincial EMR programs that you would like to share, click on the “Comments” link below to add your thoughts.

So, You Want to Start an EMR Company?

You may be a physician, software developer, or may just see a business opportunity. Millions of dollars are being invested in health IT and electronic health records. Healthcare costs continue to climb and the only logical solution appears to be process automation — as has happened in other industries such as travel and banking. EMR adoption has stalled in a number of provinces. There must be an opportunity for a new EMR system. Right?

This thought process seems to make logical sense. However, there is a lot more to the development of a successful EMR than building software. Even though there is always opportunity in any marketplace for a “better mousetrap”, the EMR market is challenging largely due to national and provincial policies, but also due to the variety and complexity of medical practice.

What should potential EMR developers consider? The following list provides some guidance:

Provincial Policy

• Canada is not one single EMR market; rather, it is multiple smaller markets ranging in size from Prince Edward Island to Ontario. Quebec is a completely separate market with vendors that specialize in the French market and little overlap with the other provinces. In addition, the dual language requirements of Quebec and New Brunswick create additional challenges for EMR vendors.
• There is no national EMR certification program in Canada. Most provinces operate their own certification program (Alberta — POSP; British Columbia — PITO; OntarioMD; Saskatchewan EMR Program; Manitoba eHealth; and Nova Scotia — PHIM). For more information on provincial programs, click here.
• In order to qualify for reimbursement funding from the provincial programs, vendors must meet provincial certification requirements. However, in some provinces vendor certification has been limited to a set number of certified vendors (BC, Alberta, Saskatchewan, and Manitoba). Unless there is a change in policy, it is not possible for new products to be certified under provincial funding programs.
• Recommendation: Choose your province carefully.

Market Maturity

• Early adopters and early majority physicians have already implemented their first, second and sometimes, third EMR in provinces that have offered funding programs for some time such as Ontario, Alberta, British Columbia.
• In these markets, the group that are now adopting EMRs are the middle and late majority. This group of potential clients is much more difficult to convince regarding the value of EMRs. They are not interested in technology, simply want to practice medicine and need to clearly understand the value proposition of the EMR in their practice. In addition, they often require more training and support in comparison to the more tech-savvy early adopters.
• Recommendation: Unless you can offer a product that is incrementally better than other EMRs available, you will have a challenge selling into a market that has already made the early sales.

Market Size

• The potential market is smaller than you may think. Based upon the 2010 National Physician Survey data - National Demographic Data, Canada's 66,906 physicians comprised 34,810 Family Physicians and 32,096 Specialists.
• If Quebec is not your intended market, subtract 16,457 physicians from the total number. This leaves a total of 50,449 with 26,450 Family Physicians and 23,999 Specialists.
• Not all physicians are a potential client:
  • A larger percentage of Family Physicians overall will adopt EMRs. However one should make exclusions for those in academic medicine, hospital based primary care physicians (employed by hospitals or regional health authorities including hospitalists and emergency room physicians), those in administrative medicine, practicing alternative specialties such as cosmetics, retiring physicians, locums and a small group who simply refuse to adopt an EMR.
  • Specialists who are unlikely to purchase EMRs include those that are in academia or administrative positions, anesthesiologists, radiologists, interventional cardiologists, laboratory medicine and pathology or other specialists who are hospital based and those that have highly specific requirements such as ophthalmologists.
  • Because of these limitations, I estimate that the potential market ranges from 60% of overall numbers for Specialists to 80% of Family Physicians.
  • These percentages translate into 18,515 Family Physicians and 14,394 Specialists in provinces and territories excluding Quebec
• While this may be sufficient to support a healthy EMR market, remember that provincial policy has dictated that each province functions independently in terms of EMR certification.
• Recommendation: Choose your initial province carefully and keep these numbers in mind as you consider entering other provinces.

Infostructure Limitations

• For regular readers of this blog, you will be aware of my concerns regarding the core infrastructure needed for medical practices to effectively implement and use an EMR. Unless physicians can refer patients and receive consultations electronically, E-Prescribe or transfer patient records (even a core set of data such as the UK GP2GP transfer system), every medical practice that implements an EMR is a hybrid of electronic and paper processes.
• Without this core capabilitiy, it is not possible to become an advanced EMR practice.
• In our current state without any of this advanced capability, we do not have advanced EMR practices in Canada - this is not a limitation of EMR vendors, but a limitation of the development, implementation and support of standards and policies that allow these capabilities to evolve.
• Recommendation: There are issues that are out of your control that you will need to consider

This is not a comprehensive list, however I hope it is useful guidance to individuals who are implementing new EMRs, considering the development of an EMR or existing vendors who are looking into expansion into new markets.

Do you agree or disagree? Add your thoughts by clicking on the 'Comments' link below.

Webinar June 23: How to Finance the Cost of an EMR.

What are the options available when purchasing an EMR? In 2001, Alberta was the first province to establish a funding program to encourage physicians to adopt an EMR. The Physician Office System Program or POSP. The program established a formula that has been duplicated in other provinces whereby government would shoulder 70% of the cost of the EMR system and physicians the additional 30%. However, EMR systems have been available in Canada since the 1980s. How did physicians finance their EMR systems before provincial programs? How can one build a value proposition that supports the purchase of an EMR system in the absence of provincial funding? Are there any other options?

Date and Time: Thursday, June 23, 2011 6:00 pm (Eastern Time) 3:00 pm (Pacific Time)

Moderator and Co-Panelist: Dr. Alan Brookstone, Founder, CanadianEMR

Guest Panelist: Mark Dermer is a community-based family physician who is the founder and managing associate of an 11-doctor, 4-nurse primary care practice that uses a full electronic medical record and which is recognized as a Canadian leader in innovative, high quality interdisciplinary care. Mark also provides consulting expertise to regional, provincial, and federal organizations and to the private sector in the areas of information management, primary care, health system reform, and medical economics.

Sponsorship funding for this webinar has been provided by Hewlett Packard (Canada) 

A Recording of this Webinar will be published on the CanadianEMR site shortly after the event.

Do you have any questions or comments on this topic? Click on the “Comments” link below.

Future Practice — Why I Love My EMR

Published in a web-only format, Future Practice is a Canadian Medical Association publication that provides feedback from users of EMR systems and an update on the adoption and use of EMRs in provinces across Canada. In an editorial, Dr. Jeffrey Turbull, President of the Canadian Medical Association, highlights the need to focus on solving clinical problems through a “bottom-up approach that is needed to accelerate the adoption of electronic health records — one that focuses on the needs of physicians and others delivering front-line services.”

Topics in this issue:

• Why I LOVE my EMR
  
  • Physicians from across Canada weigh in on the benefits of EMR systems.
• EMR funding in Canada: current status
  • This summary covers EMR programs in 5 provinces: Alberta, BC, Ontario, Manitoba, and Saskatachewan.
• E-prescribing (whatever its form) remains elusive in Canada
  • E-prescribing is one of the high value capabilities of EMR systems that significantly improve the speed and benefits of automated medication management.
• Life on an electronic island
  • Dr. Steve Pelletier narrates his experiences and frustrations using an EMR system that is not connected to healthcare system at large.

Download a .pdf copy of Future Practice

Health IT and EMR Predictions for 2015

In 2000, it appeared that EMRs were poised for rapid adoption in Canada. Countries such as the UK, Denmark and New Zealand had already solved many of the challenges associated with computing in primary care with EMRs widely adopted and used by general practitioners. Over the past 10 years, this number has grown progressively reaching close to 100% in all of these countries. With a great deal of international experience to draw from and committed national and provincial funding EMRs should have been widely adopted. But this has not been the case.

Without a national approach to data communication standards for EMRs, ePrescribing and referrals and consultations, big gaps have remained that hinder the adoption and use of EMRs. Complicated by provincial certification requirements, specialist needs with respect to EMRs, the geographic diversity of Canada and a lack of widespread reliable high-speed connectivity to support ASP-based EMR systems, we have continued to see adoption in fits and starts. A growing number of practices and networks have begun to derive significant value from their EMRs, an example of which is the Associate Medical Centre in Taber, Alberta (Listen to the Podcast with Mike Brand and Audrey Wiebe).

I would like to make 5 predictions for the period 2011 - 2015. Please feel free to add your thoughts or comments to this blog whether you agree or disagree, or perhaps would like to add a prediction of your own.

Prediction 1: Canada will solve the problems associated with referral and consultation between EMRs. There are sufficient users of EMRs to justify a concerted national effort to establish national approaches and standards in order for information to begin flowing between GPs and Specialists and also between EMRs and other clinical sites. Success will depend on a national strategy that is supported by all provinces such that EMR vendors do not have to develop different referral protocols for each province

Prediction 2: We will continue to struggle with ePrescribing through EMRs. The lack of national acceptance of electronic signatures coupled with the absence of a national body overseeing ePrescribing (such as Surescripts in the US) will continue to hamper the widespread adoption and use of ePrescribing and medication reconciliation information. Provincial programs will continue to fragment the use of ePrescribing as systems are designed to meet the requirements of provincial systems vs. all systems meeting a single national ePrescribing standard.

Prediction 3: Use of tablet computers and smart phones to access and interact with EMRs will become widespread. The development of special apps to access specific components of EMRs (e.g. lab results, patient contact information) will make the smart phone a standard tools in the physician's use of EMRs and will significantly increase the value proposition of EMRs.

Prediction 4: Physicians will struggle with the growing prevalence of social networks and the challenge associated with maintaining personal and professional boundaries as Facebook and other social networking tools become the preferred mechanism for communication by many patients. Widespread use of social networking tools will require provincial licensing bodies to develop new policies and guidelines regarding the appropriate use of these tools.

Prediction 5: Without widespread and transparent quantitative satisfation data on the adoption and use of EMRs, selection and optimization of EMRs will remain difficult for physicians and their practice teams. The need to benchmark and measure one's progress against that of peers will either limit adoption and use (if these data are absent) or will significantly enhance the ability to guide EMR adoption and use.

Please feel free to agree or disagree with anything that I have said. Add your thoughts by clicking on the 'Comments' link below.

CMAJ: National electronic health information strategy needs to be refocused, critics say

November 30, 2010 - In the 12th in a series of articles on Electronic Health Records, author Paul Webster has gathered a range of opinions from across Canada regarding the focus on the current investment strategies and where effort should be focused to achieve successful adoption and use of health information technology (EMRs and EHRs).

"Canada’s health information strategy is overly focused on the development of a national infostructure and underserves the needs of physicians and patients, provincial administrators say following release of a major new study of electronic medical records (EMRs) in Ontario.

In focusing it efforts on electronic architecture, Canada Health Infoway, the federal agency working with the provinces on designing and financing the national health infostructure, hasn’t given physicians the tools they need to adopt and use EMR, says Brian Forster, chief executive officer of OntarioMD, a subsidiary of the Ontario Medical Association which manages the provincial government’s $386 million EMR Adoption Program. “If you look at Infoway’s blueprint, not much of it is available to physicians.”

David Ludwick, manager of the Sherwood Park Primary Care Network in Alberta adds that “there’s been a lot of time and money invested in a national infostructure.” But given that the bulk of patient demand is local in nature, the time has come to refocus on investing in delivering ehealth solutions “that help patients equip themselves,” he says...."

Click here to read the full article

Share your thoughts. Do you think that Canada needs to refocus in terms of national and/provincial strategies with respect to EMR adoption and use by frontline clinicians?

Add your thoughts by clicking on the 'Comments' link below

Manitoba Announces Funding Program for EMRs

Manitoba has announced a funding program for EMRs. Until this announcement, provincially certified EMRs were available in the province of Manitoba, however no funding had been made available to support physician adoption of EMR systems.

Winnipeg Free Press - October 27, 2010 - Health Minister Theresa Oswald said Tuesday the province will spend $16 million over the next few years to get doctors working in small community clinics linked into the province's expanding electronic medical records system. The money will be used to pay up to 70 per cent of implementation costs to help doctors' offices switch over from paper to electronic records and pay operating costs up to a maximum of $20,000 for the first two years.

The incentive is being offered through the $30-million federal Canada Health Infoway, a national program to accelerate the development of electronic health record projects in Canada. "The ultimate goal is a more connected Manitoba," she said. "We look forward to many doctors coming on board now.

Read the full article - Manitoba pushes clinics to switch to electronic records

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

CMA Paper - Shift EMR focus to front-line patient care

With Canada's EMR strategy significantly lagging other developed and OECD countries, the CMA has released an investment strategy that it hopes will shift investment focus to frontline patient care.

The CMA document points out that there has been too much of a focus on top-down strategies with too little focus on EMR adoption adoption by physicians and other frontline workers.

Based upon 2005 Ontario Ministry of Health data, 78% of patient visits per day take place in family physician and specialist offices vs. 1% of patient visits in hospital and 5% in Emergency Rooms. Current investment focus in Canada has resulted in the majority of funding being spent in the acute sector.

Given the uneven success in HIT implementation across Canada - specifically in terms of front-line patient care - the CMA considers the new five-year investment strategy an integral component of its effort to transform Canada's health care system so that it is patient-centred.

The CMA's new strategy targets five key clinical and system priority areas for investment over the next five years:

• chronic disease management
• prevention and health promotion
• continuity of care
• patient involvement
• public health reporting

The paper sets three interim goals: the significant adoption of EMRs in ambulatory settings, accelerated exchange of health information and more effective use of EMRs and related solutions.

It also spells out a $923-million investment program to accelerate adoption of EMR systems.

Shift EMR focus to front-line patient care, CMA says

Do you agree with this approach? Should more funding and support be provided to encourage and measure adoption and use of EMRs by frontline clinicians?

Add your thoughts by clicking on the 'Comments' link below.