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

Why is Medication Reconciliation Important in EMRs?

Consider the following clinical scenario: You are a family physician in an EMR-based practice. One of your patients (a 65-year-old male with Diabetes, borderline renal failure, and Hypertension) presents with atypical chest pain. An initial assessment does not reveal an obvious cardiac cause for the chest pain; however, you decide to refer the patient to a cardiologist for further investigation. The cardiologist identifies early congestive heart failure and decides to increase the dose of one medication, adds a new medication, and stops another medication entirely. (The reason for a lack of specifics regarding the medications is simply to illustrate a point. This scenario could be applied to any situation in which multiple providers share care for patients and modify or add new medications to a treatment regimen.)

You may be saying to yourself, “So what’s the problem here? This situation happens every single day across multiple conditions and specialties!” Well, that is quite true, but herein lies the issue. It is what happens after the consultation that is important. Generally a specialist consult note is dictated and sent back to the referring physician. If the specialist uses an EMR, this may be generated directly from the consultant physician’s system. However, the challenge for the referring physician is how to reconcile the changes to the patient’s treatment profile within their EMR. Without the ability to easily update the medication list (in this case, adjust the dose of one, stop another, and initiate a new medication), it is not likely to happen in real-time and, in many cases, not until the next visit. Because the process is not automated and requires a manual reconciliation of the current medication list with the updated changes, it is time-consuming and difficult to manage. In addition, this is not a task that can safely be delegated to a staff member. As a result, it falls squarely on the shoulders of the referring physician.

The challenge is how to reconcile existing data with updated medication information that is constantly changing. (The Collins World English Dictionary defines reconcile as “to make (two apparently conflicting things) compatible or consistent with each other”.) The ability for an EMR to enable this process potentially exists, but a number of enabling core foundational elements need to be in place. Medication information is managed in multiple locations (including referring physician’s EMRs, consulting physician’s EMRs, pharmacy information systems, and regional or provincial drug information systems). The need to reconcile medication data may be triggered in a number of different ways. For example, the receipt of a consultation report into an EMR. A much higher level of connectivity than currently exists is needed for what comes next. The receiving EMR should be able to incorporate medication information as discrete data from the consultation report. By allowing the physician to view the old medication list alongside the newly updated medication list with the ability to accept the changes that are appropriate directly into the EMR, a reconciliation process is enabled. Similar processes should exist between EMRs and Drug Information Systems (DIS) with the ability for a prescriber to accept information from the DIS directly into the EMR in order to reconcile data between the two systems.

While this type of advanced functionality may still be some way off, limited by existing functionality and interoperability between systems, it does provide a future vision of where we need to go. Clinicians will immediately see value in the ability to easily maintain an accurate list of current medications in a patient’s file.

Do you agree or disagree with these observations? How valuable would this kind of functionality be? Add your thoughts by clicking on the “Comments” link below.

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.

eReferral — Provincial Success Could Mean National Failure

Earlier this week, Manitoba announced a $1 Million investment by Canada Health Infoway to create eReferral, “a tool to help primary-care providers refer their patients to an appropriate specialist and share necessary information through the patient’s electronic medical records”. According to Health Minister Theresa Oswald, “the objective is to roll out the program over the next two years, reaching over 1,000 family doctors, specialists and nurse practitioners who use electronic medical records”.

While the concept of eReferral is sound and necessary (eReferral and eConsultation have long been a critical deficiency in EMR strategies), development of a provincial referral system may solve one problem, but create another larger problem. Canada is made up of many small EMR markets. This creates challenges for vendors who are unable to market their products nationally, in any province, under a single national certification. By requiring vendors to conform to provincial certification requirements, each province adds to the challenge of EMR sustainability. Even small differences between provinces require vendors to maintain multiple versions of their products. The greater the difference, the more costly to maintain... and the differences are not small. Adding a Manitoba version of eReferral may solve one aspect of information exchange at the provincial level; however, it hammers another nail in the coffin of federation and makes standardized data interoperability more difficult to achieve.

Why is there no single eReferral standard for all EMR systems in Canada? Referring a patient in Manitoba is no different to referring a patient in Alberta or Nova Scotia. Why is no consideration being given to creating single national standards for critical processes such as eReferral that can be centrally certified for each EMR vendor... once? Funding negotiations between medical associations and provincial governments are not progressing smoothly. The Alberta POSP is in limbo and other provinces with negotiated EMR programs are having an equally difficult time convincing government that they should continue in present form. As a result, who is going to maintain and enhance certification standards as less and less funding is available for non-clinical purposes?

What are the barriers to simplifying the national and provincial EMR strategies?

• Technology is not the problem — eReferral has been done successfully in many other countries;
• Clinicians are not the problem — they have been asking for capabilities such as eReferral and ePrescribing for years;
• The EMR vendors are not the problem — they have been asking for a single national certification that enables them to sell their products across the country.

The absence of clear policy and a non-existant national roadmap has created an untenable situation. We should not be looking at the short term benefits of provincial solutions at the expense of national sustainability. Clinicians cannot afford it, EMR vendors cannot afford it and the citizens of this country cannot affort it.

What are your thoughts? Do you agree or disagree with this position? What are the potential solutions?

Fiddling while Rome Burns — The Crisis in Health IT in Canada

Nero (37 AD to 68 AD) is notoriously known as the Emperor who “Fiddled while Rome burned”. While this idiom is recognized to be erroneous — the fiddle was only invented in the 16th century — it signifies “doing something trivial and irresponsible in the midst of an emergency”.

As I look over the past 10 years of Health IT (EMR, EHR, Infostructure, etc.) in Canada, my observations are as follows:

• The establishment of Canada Health Infoway in 2001 signalled a decade of investment in modernization of Canada’s health information infrastructure. This was an exciting time. Over a period of 10 years, $2.1 Billion has been provided to Canada Health Infoway to support Health IT investments with various percentages of matched funding from the provinces.
• In the early stages of this investment cycle, a fairy-tale sense of inflated expectations accompanied a great deal of activity in most provinces, with attendance at national eHealth conferences and a feeling that great things were about to be achieved.
• Similarly, EMR programs were in various early stages of development in Ontario, Alberta, and British Columbia and overall EMR adoption by physicians started to increase. Nationally, though, the numbers were still small because of the piecemeal nature of EMR adoption strategies. In comparison to the rest of the developed world, Canada lagged and continues to lag behind other countries (2009 Commonwealth Fund International Health Policy Survey).
• Over this time frame, perception of the EHR and eHealth programs changed. eHealth scandals, criticisms of the Infoway and provincial IT strategies in a number of auditor general’s reports, and a general sense of disillusionment began to creep in.
• Glaring gaps in Canada’s health IT strategies became apparent, including a lack of attention of end-user adoption of technology by clinicians and absent or minimal leadership in relation to EMR-to-EMR interoperability, E-Prescribing and data standards for Electronic Medical Records.
• Attempts to remedy these gaps at the clinician level resulted in development of a Canda Health Infoway EMR certification program in 2011 (see Infoway EMR Certification — Too Little, Too Late?).
• Provincal adoption of EMRs continues to languish (see 2010 National Physician Survey) and a number of established EMR programs are stuck around the 50% mark in terms of adoption of EMRs by physicians.

Last week, the National Health Service (NHS) in the UK announced cancellation of their National Program for IT (NPfIT), which demonstrated some success but was not felt to be deliverable based upon performance to date. $9.9 billion has been spent on this program so far. When a national program of this size fails, one has to ask questions regarding the viability of any national IT strategy. Have the right questions been asked? Are we focusing investment in the most beneficial areas? What are the barriers to successful acceleration of national strategies?

I have not heard a blip about the NHS failure in Canada. How can we be successful with the Health IT agenda without widespread end-user adoption of technology? What is being done to fix the problem of standards for EMRs, vendor viability, and nationally accepted standard messages for E-Prescribing and E-Referral? More importantly, how can we do this without meaningful debate about the national program and strategies to fix the broken components?

The announcement by Canada Health Infoway of the ImagineNation Challenges is a great idea and the organizations who have supported this strategy should all be commended for thinking outside of the box. What I would also like to see is a transition challenge. Once winners are selected, we need strategies to support the conversion of ideas into widespread clinical practice. The innovative idea is easy in comparison to actually deploying a concept and having it widely accepted.

We should not fool ourselves into believing that it is OK to come up with the ideas and then the job is done. In 2005/2006 I participated in a $3 million primary care strategy as a member of a regional team of physicians, clinical architects, IT staff, and project managers. We built clinician engagement strategies, system navigation tools, privacy education programs, and components of the regional EHR viewer. Some survived, but the majority did not. This was a valuable lesson in understanding how difficult it is to transition great ideas from concept to use to widespread adoption.

Some may believe the bulk of work has been done. In reality, it is only beginning.

Do you agree or disagree with my positions and statements? Add your thoughts by clicking on the “Comments” link below.

The Importance of Physician-to-Physician Communication

If you asked the average physician whether it was more important to be able to communicate with hospitals or physicians within the community to whom they refer patients, my guess is that the vast majority would choose physician-to-physician communication. The most recent podcast published on CanadianEMR was a frank discussion with Dr. Mark Dermer entitled Should Physicians be Forced to Adopt EMRs? In this podcast, Dr. Dermer makes the point that physician-to-physician communication has never been part of the national IT strategy. This is evidenced by the fact that EMR-to-EMR interoperability standards have never been clearly defined. This critical limitation is reducing growth of the market and adoption of EMRs.

Why is it so important? Most community-based physicians (where 80% of the care is delivered) spend a significant part of their day referring patients or responding to consultation requests. As a result, even with the best EMRs currently available, these referrals are created digitally and either printed or faxed to the receiving physician's office. There they are printed or received as fax/scanned documents into the EMR (if one is used) and when a report is created, the whole process is repeated as these reports are digitized, printed, and transmitted all over again. What a waste of time and energy.

How could we have missed this fundamental requirement for an EMR? The ability for providers of care to communicate and collaborate with one another!

Some may argue that it is too complex having EMRs communicating with one another directly through point-to-point communication. In this regard, I agree. However, there are many intermediary third-party information exchange providers who specialize in taking data from one system and translating it into a format that can be received by any other system to which it connects. These information exchanges are widely available and in each U.S. state are being deployed to handle exactly these issues.

Physicians communicate with and refer to a wide number of clinicians and ancillary care providers. An information exchange should be able to handle all of these communications needs and options. Perhaps at the beginning, a smaller number of connections are provided, but over time the use of the information exchange needs to become ubiquitous such that sharing of information is not an issue.

We should limit the development of proprietary provincial information exchange capabilities in favour of universal messaging standards that allow vendors of EMRs to build once and use many times. One can only hope that common sense prevails.

To add your thoughts or feedback, click on the “Comments” link below.

Infoway EMR Certification — Too Little, Too Late?

Canada Health Infoway announced their EMR certification program on May 31, 2011. Called “Pre-implementation Certification”, two categories of certification are offered: National or Jurisdication Class.

• National Class Certification — Available for all EMR products that meet the requisite privacy, security, and interoperability assessment criteria. Product vendors may make application to Infoway at any time for national class certification.
• Jurisdiction Class Certification — Available for EMR products that meet the requisite privacy, security, and jurisdiction-specific interoperability assessment criteria. Products eligible for jurisdiction class certification are identified and funded by provincial/territorial physician office system programs.

Forgive my language, but what a crock!

Canada needed guidance with EMR certification 10 years ago to mould national requirements for EMRs, not now. This is a typical example of shutting the stable door after the horse has bolted. With most of Canada’s large EMR programs all well down their path to implementation (Alberta, Ontario, BC, Nova Scotia, Saskatchewan), the claim of a single set of EMR criteria, test cases, and test data for each province does not really reflect the reality. Not establishing national EMR interoperability standards in advance of provincial programs kicking into gear is, in my opinion, a significant policy failure in Canada and one that will have ripple effects for years to come.

We do not have data interoperability at the EMR level in Canada. Our EMR industry has not evolved from a foundation of standards-based interoperability between systems with each sharing a common set of standards. EMRs in Canada have been developed using proprietary platforms and, while standards have been applied in the majority of EMRs to receive lab results and client demographics, we are a long way from drug and clinical report interoperability. Most of the data that is shared with EMRs is sent from source systems (Hospitals, Labs) to EMRs. Interoperability means that the data can be shared in both directions. Most critically, it means that data such as drug information and clinical reports (referrals and consultations) can be shared between EMR systems, amongst clinicians outside of hospitals where 80% of the care is provided.

Here are the challenges as I see them:

• EMR programs are already locked into provincial strategies in three of the four largest EMR markets (Alberta, BC, and Ontario). These programs will have little need or desire to implement another set of standards.
• EMR vendors will be challenged to implement additional standards and requirements if the markets they serve already have set requirements. Most vendors have little capacity to improve and enhance their products to improve usability, something that users are demanding.
• Unless standards are applied universally, they have little value. I do not see how we will get there with our current provincially-driven strategies.

What are your thoughts? Do you see value in the Canada Health Infoway Pre-Implementation Certification for EMRs? Will it have any impact on Canada’s adoption of EMRs?

Add your thoughts by clicking on the “Comments” link.

Data Portability Between EMR Systems

Reported in Technology for Doctors, May 26, 2011, by Rosie Lombardi, OntarioMD has developed data portability requirements for transfer of information between different EMR systems. Eleven EMR vendors in Ontario are certified in Ontario under the version 3 specifications.

However, there are some challenges to transferring data between EMRs that have nothing to do with the technical specifications.

One issue is that doctors often don’t use fields for the purposes they were intended. “They might put in different things in a field designated for lab tests as a workaround. Doctors use EMRs differently. We’ve run into weird problems, like someone cut and paste text from the Web into a comments field, which confuses the system.”

Another issue is that most EMR systems have been set up for text data rather than coded data based on standardized medical terminology such as SNOMED. “We often run into problems when doctors migrate from older EMR versions built on previous specs. The edits on fields were not strong in these legacy systems if doctors didn’t put in the data correctly.”

These are not simple issues to resolve; however, data portability is a critical issue that has to be resolved.

It is also not just about transfer of information between EMR systems for the purposes of migrating from one EMR to another. Patients are mobile and there is always some churn and movement between different practices. Unless there is a mechanism to transfer an electronic patient record from one practice to another, the only options are to print a copy of the electronic chart, which is then sent to the new practice to be scanned or manually entered into the EMR, or to export the record as a .pdf document. The UK dealt with the transfer issue by creating GP2GP, however this is dependent on data being stored in the same standard format.

Earlier this week I had an opportunity to spend some time with a colleague from Denmark. Transfer of clinical information is completely electronic in Denmark, with the ability to send referrals and consultation reports electronically and E-Prescribe directly to the pharmacy. In order to test the structure of the data that is transferred from one EMR system to another, the Danes have set up a test whereby the data is transferred consectively between every certified EMR to confirm that when it reaches the last EMR system, the data is still readable.

What are your thoughts on the importance of data portability between EMR systems? How should we deal with data portability in Canada?

Click on the “Comments” link below.

The Promise of e-Prescribing

One of the most useful functionalities of an EMR is the ability to electronically prescribe medications. True e-Prescribing is more than drug interaction checking at the time of a visit with the generation of a printed prescription. In a fully electronically enabled and interconnected system, there will be the capability to reconcile medications with prescriptions that have been picked up from a pharmacy and taken by a patient. If medications have been adjusted by another physician, there is the ability to have a patient’s medication list automatically updated to reflect the most current medications. Finally, through a formulary, also have access to cost information so that decisions can be made with respect to less expensive treatment options.

While these might seem at this stage to be pipe dreams, the U.S. has made significant progress with their e-Prescribing program that is centrally coordinated through Surescripts. A joint collaboration of multiple agencies and organizations, being compliant with Surescripts data sharing protocols and standards means that drug information is able to be transmitted securely and accurately between many different systems. Despite high levels of complexity in the U.S. healthcare system, this is one strategy that is gaining significant momentum. With the ability to electronically prescribe medications as one criteria for the demonstration of meaningful use and legislative requirements that penalize physicians after 2011 if they do not e-Prescribe, there is a significant momentum building for widespread adoption and use.

For practices that do not yet have an EMR, standalone web-based e-Prescribing applications are available to physicians. Data is stored in a central server/repository and while the data is not fully interoperable with all other aspects of a practice’s information systems, this type of strategy does make sense for certain practices. For example, those that never intend to purchase an EMR.

How important is the ability to electronically prescribe in your practice? If you could choose certain medication management capabilities through your EMR, what would those be?

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

 

Will Canada be Successful Without Standards-Based EMRs?

I was talking with a colleague last week about EMR adoption. He expressed his frustration at the lack of coding and interoperability standards between different EMRs available in Canada. Frequently over the past few years I have written about the importance of structured and coded data for the analysis, management and transfer of health information. The implications are numerous. If data is going to be transferred from one system to another (whether for clinical or administrative purposes) it needs to have the same meaning in both systems. It goes without saying that if I order a laboratory test which is then reported upon, I expect the result to be imported and stored in the correct patient’s file. Similarly, if I transferred a chart from my system to another, I would expect that the data would be transferred in the right format for import into the receiving EMR.

All of this assumes that data is coded using commonly accepted standards and that all EMR vendors use the same reference measures. Makes logical sense, right? The explosion of mobile smart phones in the past 12 months is only possible because of an adherance to standards for software design and data sharing. Imagine if your mobile phone could not speak to another. If you could only text message individuals using the same network or send Gmail only to other Gmail users. It would not be very effective or satisfying.

I would like to point out that this is not the fault of the EMR vendors. While they can be criticized for developing systems that have proprietary databases or data structure that make it difficult to move from one EMR to another, this is not unique to EMRs. The software industry has been built on having closed proprietary systems that provide a unique competitive advantage to a specific vendor. When a vendor becomes dominant (as Microsoft did with the Office suite of products), their document/data format can become the de facto standard for the industry. However that is unusual and although one company becomes highly successful, many others fail as a result.

The bottom line is that there is a delicate balance between maintaining a proprietary advantage in the market and ensuring that data is able to move efficiently between one system and another.

A bit of historical background. EMRs in Canada did not evolve from a need to collect and share data. Early EMRs in Canada grew from billing and scheduling systems with the need to collect basic clinical data and code it using ICD9 codes for billing purposes. There was (and still is) no requirement for a clinical user to code diagnoses accurately. For example, if a patient is seen with an obscure GI diagnosis and the treating physician does not know the exact ICD9 code, a generic code such as 787 — “symptoms involving digestive system” can be used without fear of penalty. Without a stringent requirement for accurate diagnostic coding, the historical diagnostic data might be useful to the individual physician, but completely useless for population analysis or even sorting of patients within a practice for recall purposes. Garbage in ... Garbage out.

There are efforts underway to establish standards for data sharing between different EMR systems for the purposes of sending and receiving referral requests and consultation reports. However, is this sufficient? Should all EMR systems in Canada be migrated to use the same data structure and coding standards (e.g. by 2017)? Or should the focus just be on specific areas such as ePrescribing or Referrals?

Comments are welcome from clinicians as well as the EMR industry. Share your thoughts by clicking on the “Comments” link below.