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The Social Fragementation of Information in Primary Care

For the past 2 years I have worked in a number of walk-in clinics in Vancouver in order to remain connected with clinical care, keep up my competencies and better understand the challenges experienced by front-line clinicians who are using EMRs to manage their patients.

I would like to share my observations and also encourage some discussion on this topic. My perception is the following:

1. There are fundamental problems in the structure of primary care delivery that are not being addressed despite the attempts to develop primary care networks and team-based models to manage the more complex patients with chronic disease;
2. Simply adding technology in the form of EMRs, EHRs, Personal health records and Patient Portals is not going to achieve improved outcomes and efficiencies without significant change in policy and workflow;
3. We function within an unbalanced framework of accountability. This is driven by policy (or a lack thereof) that enables behavior to persist unchecked.

This is a bit cryptic, but bear with me as I explain:

• Supply: Despite the fact that Canada is graduating more doctors year-after-year, there remains a critical shortage of family physicians. By recent estimates 5 million Canadians still do not have a family doctor. In addition, new graduates are completing residency training with record levels of debt. Few new graduates are establishing family practices — expectations regarding lifestyle and work result in the majority of these new graduates seeking work in hospitals as hospitalists or other salaried positions, walk-in clinics (where there is unlimited demand for their services) and a small number may join existing practices. Establishing a new practice from scratch including an EMR - new graduates do not want to work in paper chart based practices - is a very expensive undertaking, in a setting where it is easier and more profitable to join a busy walk-in clinic without any risk.
• Demand: There is an unlimited demand for healthcare services. We see this in crowded emergency departments, lengthy waitlists for surgery and packed walk-in clinics which are used by a large segment of the population including those who do have a family doctor, but choose to attend the nearest walk-in clinic. Convenience wins over quality 9 times out of 10! In fact, it is my understanding that the average British Columbian sees approximately 6-8 different primary care providers each year including the individual who is designated as their family doctor. Walk-in clinics have become part of the fabric of care delivery, but many are not EMR-based (for a variety of reasons that I will not address in this article) and are seen by many Canadians as a quick fix for any acute problem that needs attention.
• The biggest issue that we face is a lack of accountability on behalf of the public that we serve. On numerous occasions I have seen patients in the walk-in clinic who have attended a different walk-in clinic for some investigations and because the waiting time was shorter, arrived at the clinic in which I was working to ask for their results. In addition, on numerous occasions I have seen individuals who have gone from clinic to clinic (on the same day) looking for an answer that they were satisfied with, requesting referrals or investigations or shopping for medications. I estimate that 20-30% of the encounters in the walk-in clinic are unnecessary, minor issues that should not need to be seen by a physician. Simply a waste of money and resources.

This zero accountability framework associated with a convenience driven 'access to care' philosophy has created a major challenge for EMRs and attendant technologies in primary care. If the average British Columbian patient has healthcare information sitting in 6-8 walk-in clinics as well as some information in their designated family doctor's office (if they have one), we have a big problem. Information is completely fragmented across primary care. Based on conversations I have had, I suspect that other provinces face similar problems.

If we want EMRs to work properly in primary care, in addition to providing complete solutions with high levels of usability at reasonable cost, policies must be put into place to resolve the accountability issue. The alternative is applying technology to a broken system that is not designed to deliver high quality care. Instead, it encourages unfettered access to primary care services whenever and wherever desired with a resultant fragmentation of clinical information and a social framework that has limited accountability.

Do you agree or disagree? What are solutions to this problem? Add your thoughts by clicking on the 'Comments' link below.

2062 - The Good Old Days of Social Media

A futuristic look at Social Media - Very funny!

Building an EMR from Scratch - A Saskatchewan Success Story

The Medical Post January 31, 2012 by Deana Driver (Republished with permission)

(This article is one of a series titled 'The Innovators' - EMR success story: Sustainable rural care built from the ground up)

Dr. Werner Oberholzer can barely contain his enthusiasm as he shows a visitor the electronic medical records system that he and his colleagues created as a key component of their region-wide primary-care team, here in rural southern Saskatchewan. Thanks to the EMR, which Dr. Oberholzer and his colleagues built essentially from scratch, their Rural West Primary Health Care Team is an admirably smooth operation, despite consisting of more than 17 practitioners—including two doctors—working at three separate facilities. It’s also admirable because of the challenge of serving more than 7,000 patients spread over 14,000 square kilometres, an area more than twice the size of Prince Edward Island.

As soon as information is entered into a patient’s file on the EMR, Dr. Oberholzer or his wife and colleague, Dr. Nelly Helms, can read it online and determine what they wish to do for that patient. “I can pick a name of any member of my primary-care team and send instructions to them,” says Dr. Oberholzer, who is also on Saskatchewan’s provincial e-health committee. “We spent hundreds of hours to make these forms and templates. We changed them with the designers to suit our function. I scanned all these forms in for different reconciliation forms, the medication, dosages.”

Accessible information

He gives a patient with diabetes as an example. The nurse doing a home visit can hover her computer’s cursor over an information field—related to BMI or blood pressure, for instance—and a screen pops up to tell the nurse what information Dr. Oberholzer wants. If the patient needs to see a specialist, the team can easily print out a summary to send to that doctor. And with a few simple clicks, a summary of the patient’s medications, immunizations and other info can be sent to a pharmacist’s iPad.

The doctors maintain control over every patient’s record, and can block or narrow what other caregivers can see in the EMR. “My pharmacist can put the medications in,” says Dr. Oberholzer. “I can say, ‘I agree with that.’ ” As well, they can use the EMR to generate reports on any topic - for instance, their 20 most common diagnoses or tests, or the top drug allergies. In terms of the EMR system’s impact on the care he provides, Dr. Oberholzer says: “If you can’t measure it, you can’t manage it. If I don’t have a target goal to start off with, then I don’t know where I’m going.” Moreover, since each physician needs to sign off on the chart of every patient seen that day, “if I have a task yet to do for the day, it lets me know.”

Building care

In 1998, Drs. Oberholzer and Helms joined many other South African doctors and left their homeland to take up practice in rural Saskatchewan. They settled in Radville, where their health-care team has its main base. It’s in prime grain-growing country, about 90 minutes south of Regina, that abounds in unobstructed views of rolling hills and roads stretching for miles in all directions.

When they arrived, there was no other doctor in town. Almost immediately, Dr. Oberholzer began thinking about ways to improve health services for their patients. He began lobbying the province to build a new health centre, since the existing one was cramped and “literally falling apart.” (After 10 years, lobbying and fund-raising have paid off, as a recent groundbreaking ceremony kicked off what is expected to be “a one-stop shop” in a $12-million facility scheduled to open by the end of the year.)

As the doctors in the neighbouring towns of Pangman, Bengough and Coronach left their practices in recent years, the workload for Drs. Oberholzer and Helms continued to increase. Today, they each see from 45 to 75 patients a day and they have come to rely on allied health professionals for solutions. A few years ago, pharmacist Kim Borschowa and Dr. Oberholzer attended a chronic disease management workshop on clinical practice redesign that the Saskatchewan’s Health Quality Council hosted. Almost immediately they began collaborating on the care of their diabetic patients along with Leila McLurty, an experienced community health services manager who splits her time between Pangman and Bengough, who was also interested in providing better care. They all recognized that they needed to find a way to provide care to an ever expanding patient population (due to the physician exodus), spread over a large geographical area. Community meetings were soon held to determine which services were needed most.

A properly designed EMR would be crucial. In May 2010, the Rural West Primary Health Care Team officially launched. It consists of more than 17 practitioners including the two doctors, a dietitian, two pharmacists, a nurse practitioner, home-care and diabetes nurses, plus administrative staff. The team also teaches nursing, pharmacy and first-year family medicine students from the University of Saskatchewan who come for two to six weeks to experience rural remote medicine.

Going the distance

An unavoidable part of caring for so many patients over such a large area is the need to get behind the wheel. So, one day a week, Dr. Oberholzer drives several hundred kilometre to see patients—to Bengough then to Pangman, then back to Radville—often arriving home around 10:30 at night. Typically, Dawn Geiger, a team assistant who travels with Dr. Oberholzer to the communities, types patient complaints and information into the EMR after meeting with the nurses in the health-care centres and nursing homes. From its base in Radville, the team also provides 24-hour emergency care for the region.

The EMR is key to the team’s success, but so are the face-to-face meetings that build trust and knock down the walls of professional territorialism. “The EMR makes a big difference because, say I get a patient coming in and they don’t remember what they discussed with the doctor,” says Borschowa. “I can look it up and see that, yes, they discussed this.”

Dr. Oberholzer spoke at length about his team’s strengths at the recent Saskatchewan Medical Association meeting. Dr. Phillip Fourie, the SMA president, says Dr. Oberholzer “is well ahead of the curve. He’s where we want to go with primary health care,” adding the province lacks a province wide EMR system. Not that everything was easy with the team’s setup, far from it. The transition to the new EMR “was absolutely horrible because there was no one to tell us how to use this thing. The whole office was in an uproar,” recalls Dr. Oberholzer. But after six months of fine- tuning, all agreed the EMR and instant access to each other as caregivers is invaluable. “Now that the team is in place, we’ve brought access and health care to areas where they thought it was not possible or sustainable,” says Dr. Oberholzer. “And we’ve empowered the health-care providers within the team to perform to the best of their abilities to promote higher quality medicine. We can now design the care around what the patient needs instead of forcing the patient into a model that’s not suitable to him or her.”

To sum up his approach, he says, “Anything that doesn’t change goes stagnant. You either make it better or you leave it.”

Deana Driver is a freelance writer in Regina.

Innovation in Primary Care — Medication Reconciliation

Dr. Christopher Clarke, a family doctor in Puslinch, Ontario, is no stranger to innovation. In 2011 he won a $10,000 award for first place in the ImagineNation Ideas Challenge, a competition run by Canada Health Infoway. His winning idea was a web-based system to record and schedule immunizations, based on the latest recommendations from the Canadian Immunization Guide.

Dr. Clarke has not stopped innovating or thinking about system deficiencies that can be solved using technology. His latest concept is a medication reconciliation process using a database-driven web-based system to send prescriptions electronically to a pharmacy. He speaks passionately about a real-world problem that can be solved by changing the processes through which medication can be prescribed and dispensed.

In the real world of healthcare, nothing is simple. Barriers include current provincial policies, existing regional and provincial systems, privacy and security issues, standards, information exchange, and many more factors. All of these bundled together create real or perceived reasons why such a solution should not succeed.

However, the real value of what Dr. Clark has done is clearly identify and articulate a problem that, if solved, could improve safety, healthcare system efficiency, and quality of care. He has hit the nail right on the head!

Asked what happened to his $10,000 prize winning idea, Chris states he has heard nothing further since receiving the award. While gratifying to have innovation recognized, unless there is a mechanism to incubate and then translate ideas into practical solutions, this is very much an academic exercise.

Have you tried to innovate locally or on a larger scale? Has your idea lived out the test of time or been relegated to a dark corner? Share your thoughts by clicking on the “Comments” link below.

TELUS Health Solutions Purchases Wolf Medical Systems

Vancouver, B.C. – TELUS Health Solutions today announced the acquisition of Wolf Medical Systems. This acquisition will create a new line of business within TELUS Health Solutions called TELUS Physician Solutions. Financial terms of the agreement were not disclosed.

For further details regarding the acquisition and to read the press release, click here.

How Safe is Your Patient Data? The Password Conundrum

When using computers in healthcare, there is not much that seems more mundane (and irritating) than having to change your password on a regular basis. Government organizations and hospitals excel at requiring users to change their password every 42 days. Not sure why this particular number of days was selected — perhaps there is evidence that this is the safest timeframe. However, when one has to access multiple systems (EMR, Hospital system, Provincial EHR, Diagnostic systems) each with their own password renewal cycle, it can become a full-time job managing passwords. Add to that the need to never use the same password twice, plus the requirement for passwords to be of differing lengths and contain specific characters, and you have a formula for password perdition. Click here to read a very amusing (and unfortunately accurate) summary of the challenges of password management.

A number of years ago, I had the opportunity to work in a regional health authority as a member of the IMIT team. I met and spent time with a number of security and identity management specialists and was astounded at the complexity of identity management and how many different options exist to identify and authenticate users of computer systems. As a general rule of thumb, the more stringent the control, the more complex to use. The ideal option is to have high security with maximum ease of use. Unfortunately identity management often gets in the way of easy access to clinical data, particularly when there are multiple individuals using the same computer terminal.

In a medical practice, it is not uncommon to find a list of passwords on a sticky note attached to a computer for easy access by staff, particularly if needed to access clinical applications on the physician's behalf. The medical office is designed for maximum efficiency using whatever workarounds necessary to focus on the job at hand — namely, caring for patients.

Implementing a robust identity management program is a challenging change management exercise and one that is likely to be resisted for all the reasons provided above.

So, are there viable alternative options to passwords that are just as secure and do not require the dreaded 42-day password renewal? One option is to use a proximity card. This is an electronic wireless card that automatically athenticates a user when you are within a certain distance of a computer terminal. To read an earlier blog post on proximity cards, click here. However, proximity cards are not a perfect solution. They are costly and also are difficult to use if there are multiple proximity cards used within a practice. For a new user to login to a computer, the existing user has to move out of the critical proximity of the terminal to “log out” and the new user then can move into that zone to login. Efficiency is degraded because of the time lags in logging in and out. Another option is to use a thin client (such as an Oracle Sun Ray terminal). If the EMR is run on a remote server, the software can be accessed using a process called virtualization on these terminals. This probably does not mean much to readers, but how it works is that each user has a unique card. Upon entering the exam room, the card is plugged into the terminal and the same software session is immediately displayed as when removing the card from the previous terminal. This is fast and does not require multiple passwords or other factors to login or out. Not all EMRs can operate using Sun Rays; however, it is certainly a viable option. If you have an opportunity to see a Sun Ray based practice in action, I highly recommend you do so.

What are your experiences with passwords? Do you suffer from password fatigue. Do you have any suggestions for readers of this blog to help them with their identity and password management strategies? Add your thoughts by clicking on the “Comments” link below.

The Real Advantage of Using an EMR

The following was submitted by Dr. Ian Pun and is published on his behalf:

Recently Novartis issued an advisory about stopping the combination Rasilez (renin inhibitor) + ARB or ACEI  in diabetics.

Using my EMR, I quickly searched my patient database for “Rasilez”. Although, I’ve never started this combination myself personally, I found one of my patients where a specialist had started Rasilez and I had already put him on Cozaar. The other six results were patients of other family physicians that I had seen. Immediately the patients were contacted via phone or email.

Good for the EMR. The more (correct) data that is in an EMR, the more useful it becomes. There is no way you could search this using paper charts — unless you went individually through a ton of charts! If done manually and browsing one paper chart per minute, for 3,000 charts it would take you 3,000 minutes or 50 hours. The computer does it in five seconds.
 
This is a true-to-life example of how an EMR should serve you.

Dr. Ian Pun, Family Physician, Scarborough, Ontario
(Dr. Pun uses OSCAR EMR)

Add your experiences using an EMR by clicking on the “Comments” link below.

Have Your Scanning Requirements Decreased as You Use Your EMR?

It would seem logical that as physicians progressively automate their practices, implement EMR systems and over time become more effective users of those systems, that the administrative load on medical office staff should decrease. After all, more information is being communicated to those practices electronically in the form of bits and bytes. Instead of paper, lab results are delivered electronically into EMRs. The increased use of fax servers by hospitals, physician offices and diagnostic facilities allows faxes that were previously received as paper to be saved electronically, digitally renamed and attached to patient records. In addition, as more practices transition to EMRs, should there not be less demand overall for paper as the critical mass of users increase and become automated?

We are either getting closer to Nirvana with near paperless offices or creating (and maintaining) scanning sweatshops (see earlier article) in the medical office.

I hope that we are transitioning closer to becoming “paper-light” medical practices; however, I believe that there is still a significant amount of scanning and re-digitization that takes place in the majority of medical offices for the following three reasons:

1. There is still a significant inflow of paper documentation including diagnostic and consultation reports, ancillary reports from physiotherapists and other care providers, legal documents, motor vehicle requests, WCB, insurance reports, hospital discharge summaries, and so on. These documents are nowhere close to being delivered in digital format in the forseeable future.
2. Workflow and business practices in many medical offices that have adopted EMRs have not sigificantly changed since initial implementation in order to more effectively use the EMR to reduce paper generation. Workflow optimization is time consuming and hard work. It is difficult to change behaviours and apply consistent policies across small practices.
3. The inability to transmit and receive referral requests and consultation reports electronically from medical office to medical office or transfer electronic copies of a patient record places medical practices in an untenable position. This virtually guarantees a large proportion of paper management in medical offices.

I may be wrong in this assumption, but I would like to invite your feedback. If you have been using an EMR in your practice, has the amount of scanning reduced since implementing your system, remained static, or actually increased? What is the most important change needed in order to decrease scanning in medical offices?

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.

TED — Paddy Ashdown: The Global Power Shift

I try, whenever possible, to listen to the TED talks as I find them a fascinating and eclectic mix of ideas and concepts with broad application. Paddy Ashdown is a British politician and diplomat who served with the United Nations and as a negotiator on behalf of the UN in Afghanistan. He states, “Everything is connected to everything” (12:58 of the presentation). “The paradigm structure of our time is the Network... the most important thing about what you can do, is what you can do with others... resulting in a shared destiny.” These are lessons that can be applied to the healthcare system.

So, what does this have to do with healthcare and, more specifically, health IT? In a traditional model, acute, community, and primary care function independently with loose connections between the sectors. Each has its own oversight, budget, and governance. Sometimes the sectors communicate with one another, but frequently they do not, resulting in duplication of services (e.g. lab results and diagnostics), ineffective hand-offs (hospital or ER discharges), and poor coordination of care (particularly in primary care).

The reality is that in a healthcare system struggling to sustain itself with unlimited demand for services, we can no longer afford silos. In the words of Paddy Ashdown, as patients we “share a common destiny”. The barriers are artificial — created by historical structures, processes, and policies.

In order to “fix” the healthcare system, we have to turn many of these accepted norms upside down and place the patient at the centre of the re-engineering process.

What are your thoughts? Click on the “Comments” link below. 

Making the Case for E-Prescribing in Canada

Would you buy a mobile phone that could only receive incoming calls, or a car without the ability to drive in reverse? Of course not! There would be limited value in having semi-functional products. However, that is exactly the issue we face with EMRs (recognizably not as extreme as the examples provided).

Doctors have to be able to prescribe efficiently using their EMRs. Not prescribe, print, and hand the prescription to the patient, but true E-Prescribing with direct-to-pharmacy transmission of prescriptions plus ultimately the ability to reconcile, query, and update medication lists automatically through the EMR based upon changes to the patient’s medication profile. This is not pie-in-the-sky thinking. It has been done in many countries — including the United States, which has a much larger and more fragmented healthcare system than Canada.

In November 2011, the Commonwealth Fund published results of a Multinational Comparison of Health Systems Data.

In 2010, the U.S. spent $2.6 Trillion on healthcare, more than the gross domestic product of France, the fifth largest economy in the world. Spending on healthcare is forecast to reach 11.6% of Canada’s gross domestic product (GDP) in 2011 for a total $200.5 billion. (CIHI) Total drug expenditure in 2010 reached $31.1 billion, representing 16.3% of total healthcare spending.

According to CIHI data, “after hospitals, physicians represent the second-largest category of public-sector health care spending (20% in 2011) and drugs, the third-largest. However, the price of doctors’ services was the most important cost driver of spending in this category, with compensation for doctors’ services growing by 3.6% a year.”

In December 2011, the federal government announced that Ottawa could begin cutting back on Federal transfer payments starting in 2017, reducing the payments from the current 6% rate of increase to approximately 4% (the rate of economic growth including inflation). Bottom line: neither the federal nor provincial/territorial governments can afford unchecked increases in healthcare spending.

Canada Health Infoway estimated that in 2010, Canada’s investments in drug information systems (DIS) generated $436 million in cost savings and efficiencies. This number (if correct) does not include any potential benefits that could be accrued if physicians (the gatekeeper for the majority of prescribed medications in Canada) had the ability to E-Prescribe. Even with a conservative cost savings estimate of 5% (if all physicians could E-Prescribe) through reduction in duplication, more effective use of generics, improved compliance, and reduced medication abuse, the numbers are significant. A 5% cost savings on expenditures of $31.1 billion = $1.55 billion per year. There is no doubt that the business case exists to implement widespread E-Prescibing. In fact, I would argue that this is one area in which cost saving is not just needed, it is possible with the right tools and processes.

If Canada could bring pharmaceutical spending inline with the OECD Median spending of $518 per capita, vs. $744 per capita, the cost savings would be in the range of 30% per annum. A staggering amount: $9.3 billion per year. It is interesting to note that in every country with pharmaceutical spending per capita below the OECD Median, E-Prescribing is used by almost 100% of primary care physicians and most specialists.

There is likely some additional cost savings that could be driven from policy changes and negotiation to bring drug costs down for both brand-name and generic medications. This useful comparison chart, from the Commonwealth Fund report, benchmarks drug costs against the U.S.

What do you think? Is there a business case to be made for investing in widespread E-Prescribing? If you are a physician user of an EMR, how much additional value would E-Prescribing bring you? If you are not yet using an EMR, would the ability to efficiently E-Prescribe provide the tipping point value that would make you adopt an EMR? Add your thoughts by clicking on the “Comments” link.

Health IT Predictions for 2012

With 2011 behind us, it is time to begin thinking about 2012. What can we expect in the next 12 months? Will EMR adoption accelerate? What are the new technologies that will be adopted by clinicians?

Here are my predictions for 2012:

1. EMR adoption will continue to increase, particularly with the announcement of an EMR funding program in Quebec, which has not had a formal EMR adoption program. However, due to deficiencies in universal core fundamental requirements such as the ability to send e-Prescriptions or e-Referrals, it will remain difficult to encourage adoption by the large middle and late majority who are waiting for a greater value proposition before implementing an EMR.
2. Certain provinces will come close to reaching a critical mass of users (Alberta, BC, Ontario, and Saskatchewan), but will not yet reach a tipping point at which it will make sense for widespread adoption.
3. Growth in EMR adoption in the United States will significantly outstrip Canada due to a clear national EMR strategy, state level health information exchanges, and the Meaningful Use incentive program.
4. Tablets will become more prevalent in hospitals and will begin to be more actively used for administrative purposes such as patient registration in medical practices.
5. The number and variety of mobile health Apps will increase significantly as the transition to smart phones accelerates. Expect to see mobile Apps that are extensions of EMRs as well as standalone personal health records.
6. Data stewardship and privacy concerns increase as more data becomes accessible for analysis and research through collaborative programs linked to EMRs.

What are your predictions for 2012? Add your thoughts below.

Out with the Old... In with the ?

I had an opportunity to spend some time wandering around Vancouver last weekend and the one store that caught my eye was HMV at the corner of Burrard and Robson. Initially a flagship store for this retailer in Vancouver, HMV has tried to reinvent itself adding electronics and a variety of other mechandise to stave off the hemorrhaging from loss of sales of its traditional business — music. For that it can thank the revolution started by Napster with the final nail in the coffin being the launch of Apple’s iTunes store and a new model for purchasing music in which users were able to personalize their selection and disaggregate the individual tracks from the album.

Two disruptive technologies that changed the course of business for the entire music industry: music sharing (much of it illegal), and new sales models such as iTunes.

When one applies these lessons to health IT and EMRs, there are similarities and some differences. It is not yet clear which will be the truly disruptive technologies for the sharing of healthcare information. There are some frontrunners: mobile applications, personal health records, and cloud-based storage of healthcare information. However there is no clear winner.

Comparing EMRs, EHRs, and health information technology to the music industry is not an apples to apples comparison. Beyond the obvious, a major difference is maturity. The music industry was mature when the disruptive technologies took hold. The business models regarding creators, distribution models, and consumers were rigidly maintained. The Internet changed that at a speed that was difficult for established players to respond to.

However, we are seeing similar signs in healthcare. Traditional family doctors are slowly disappearing, replaced by walk-in clinics that respond to the just-in-time need for care, albeit without the same level of consistency as someone who has known you from early years. Individuals are consuming services differently — making use of disease support forums and social online communities, mobile health applications, and other care providers such as nurse-practitioners vs. physicians. At the same time that healthcare is becoming more personal and granular, it is also becoming more fragemented. Information no longer lives primarily in your family doctor’s medical chart. It can exist in a multitude of walk-in clinics, hospitals, diagnostic systems, repositories, and ancillary care provider offices.

In the same way that music sharing changed a business and turned it upside down, disruptive technologies are also going to change healthcare as we know it today. We just don’t know what and when.

The physician has not just been the holder of the knowledge; he/she has also been the translator of that information and had the skills to sort through the relevant vs. irrelevant in order to make a diagnosis and suggest a treatment plan.

However in a fast-paced world, the desire for the right information at the right time in the right format is not just a priority for providers of care. As the power shifts from caregiver to consumer, expect to see dramatic changes in care delivery and the roles and functions of care providers in the future.

What do you think? How do you see healthcare changing? Which are most important “disruptive technologies”? Click on the “Comments” link below to share your thoughts.