CanadianEMR: EMR Comparisons, Ratings and Expert Discussions

Norway - Effects of the use of an EMR in Primary Care

Certain countries have had a lengthier experience with EMRs than others. Norwegian GPs began to adopt EMRs in the early 1980’s. Over 95% of Norwegian GPs have been using an EMR for the past 10 years. A study of GPs use of EMRs conducted in Norway and reported in BMC Medical Informatics and Decision Making seeks to understand the actual benefits and effects of the use of EMRs in a system in which a high uptake of EMRs tends to be looked upon as a proof of their value.

Abstract - Background:

In spite of successful adoption of electronic patient records (EPR) by Norwegian GPs, what constitutes the actual benefits and effects of the use of EPRs in the perspective of the GPs and patients has not been fully characterized. We wanted to study primary care physicians' use of EPR systems in terms of use of different EPR functions and the time spent on using the records, as well as the potential effects of EPR systems on the clinician-patient relationship.

Methods:

A combined qualitative and quantitative study that use data collected from focus groups, observations of primary care encounters and a questionnaire survey of a random sample of general practitioners to describe their use of EPR in primary care.

Results:

The overall availability of individual patient records had improved, but the availability of the information within each EPR was not satisfactory. GPs' use of EPRs were efficient and comprehensive, but have resulted in transfer of administrative work from secretaries to physicians. We found no indications of disturbance of the clinician-patient relationship by use of computers in this study.

Conclusions:

Although GPs are generally satisfied with their EPRs systems, there are still unmet needs and functionality to be covered. It is urgent to find methods that can make a better representation of information in large patient records as well as prevent that use of EPR systems contribute to increased administrative workload for physicians.

Link: BioMed Central | Abstract | 1472-6947-8-12 | Instant availability of patient records, but diminished availability of information: a multi-method study of GPs use of electronic patient records.

My sense is that in order to achieve efficiencies with technology and EMRs, one needs to examine the process of care delivery at a very granular level. Once the adoption phase is over, using the EMR effectively depends on defining a specific outcome that one wants to achieve and then re-engineering the process.

Have you had experience with this process? Do you agree with the findings in this study? Does the EMR in your practice provide definite efficiencies? If so, how did you achieve those efficiencies?

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Dr. Martin Dawes - Winner of the first CanadianEMR Survey on Non-EMR Products and Services

Dr. Martin Dawes of Montreal, Quebec is the winner of the first CanadianEMR survey on Non-EMR products and services which attracted 166 responses from 454 registered physicians and practice managers on CanadianEMR.ca (36% response). Dr. Dawes and his group are just in the process of implementing an EMR in their practice. He wins a Hewlett Packard Officejet J6480 All-in-One printer, copier, scanner and fax for his practice. The high response indicates the significant interest amongst physicians regarding the products and services that surround and support an EMR-based practice.

CanadianEMR has always been interested in understanding the complex ecosystem surrounding the use of Electronic Medical Record systems within the Canadian healthcare environment. Physicians require a variety of software, hardware and services to gain maximum return on investment when implementing or using EMR systems. To better understand this EMR ecosystem, we asked our users for guidance.

The results from the 166 responses are broken down into three main categories, Physicians considering an EMR (33% of respondents), Physicians currently using an EMR (62% of respondents) and Practice Managers (5% of respondents).

• All respondents to the survey showed a strong interest in a variety of hardware categories, ranging from Monitors at 74% to Computers, Laptops and Tablets at 81%. Other categories of interest include Network Installation (73%), Internet Access (72%), Services surrounding medical charts (69%), Support for home access to EMR systems (67%) and Dictation and Transcription software/services (63%);
• Physicians considering an EMR had a greater than average interest all of the hardware categories (on average 10 percentage points higher), but a lower interest in services surrounding management of paper charts (58%). These results indicate that first time EMR buyers have not yet been exposed to the challenges of management, storage and destruction of paper medical records which are seen as a significant burden by physicians who have already adopted an EMR;
• Physicians currently using an EMR had the most interest in services surrounding paper medical records (77%), followed closely by a number of hardware categories;
• Practice Managers had similar category interests to the Physicians considering an EMR, however 100% wanted more information on computer hardware, laptops and tablet PCs and 71% wanted more information and services to assist with the installation and support of Networks in a physician office.

More detailed information about this survey will be published on the CanadianEMR blog in the near future.

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What is the Physician's Responsibility with regard to the Paper Chart in an EMR-based Practice?

I received this question from a practice manager regarding the responsibility of a group of physicians with respect to stored paper charts when some of the physicians leave a practice that has implemented an EMR system. It poses a challenging issue.

"Please can we have your advice on the following situation:

If associate doctors in a clinic which computerised their records decide to separate and move into a new office location in the same city approximately 18 months later, is it reasonable for them to ask for copies of ALL paper charts? Who is responsible for payment of these copies? Surely all the relevant and pertinent data should have been incorporated into the EMR prior to their departure rather than putting the onus on the remaining physician(s)?

Is there a recommended time frame for computerising EMR?

I would greatly appreciate your feedback."

The practice that retains the paper charts has a responsibility as the steward of that chart until the record requirements of the College of Physicians and Surgeons in that particular province have been met. For example in British Columbia, the requirements are the Age of Majority (18 yrs) plus 7 years for patients that have left that practice. However for patients who are still active, it is necessary for physicians to retain the paper chart indefinitely or until the patient passes away.

If part of the chart has been entered into an EMR (set a start date, enter important information and go forward from a point in time using the EMR), then it is necessary to keep the old paper record in storage, either at the practice or off site in a secure storage facility. The old paper chart still remains part of the legal record even if the patient record has been partially digitized on a go-forward basis in the EMR.

The physicians in this situation are in a difficult situation. They are required to retain the original paper record even though there is sufficient data in the EMR to manage the patient going forward. However they are required to send a copy of the patient record to the requesting physician according to College guidelines. Who bears the cost? Is it the requesting physician? Is it the patient?

What are your thoughts? To add your comments, click on the 'Comments' link below

NHS - Does Lorenzo mean the end of GP electronic patient records?

This article in E-Health Insider discusses an ASP based EMR application called Lorenzo. iSoft, the company that developed Lorenzo has won major contracts with the National Program for IT in the UK (NPfIT). The UK arguably has the most advanced GP computing community in the world with many practices who have been using Electronic Medical Records for 20 years.

"Does Lorenzo mean the end of GP electronic patient records? 15 Apr 2008 GP computing has been one of the great success stories in patient care and the use of IT in the NHS. Since its earnest start in the early 1980s, GP records have gone from paper based narratives held in A5 Lloyd George envelopes to fully interactive records, capable of handling the complexities of modern patient care, including the Quality and Outcome Framework (QoF) used for performance related pay and its central reporting mechanism, Quality Management and Analysis System (QMAS). Without the universal use of electronic GP records throughout the UK, neither the targets introduced in 1990, nor the 2003 new General Medical Services contract, would have been achievable.

Link: Does Lorenzo mean the end of GP electronic patient records?

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What Is the Biggest Benefit to Physicians Who Use E-Prescribing?

In an interesting article in iHealthBeat from the California Healthcare Foundation, a group of healthcare professionals were asked to describe the biggest benefit of electronic prescribing.

"Sixty-five percent of health IT professionals said that reducing the risk of medication errors is the biggest benefit to providers who use electronic prescribing, according to a survey by the Healthcare Information and Management Systems Society. Twenty-one percent of respondents said gaining access to patients' medication histories was the biggest benefit of e-prescribing to providers, while 7% said reducing potential for fraud and tampering was the biggest benefit. Meanwhile, half of respondents said the elimination of the need to mail, fax or drop off prescriptions at the pharmacy is the biggest benefit of e-prescribing to consumers. Twenty-six percent of respondents said the biggest benefit to consumers is the reduced wait time for prescriptions, while 18% said the biggest benefit of e-prescribing to consumers is that there is no handwriting to interpret. Results are based on a March survey of 309 health IT professionals."

Source: HIMSS Link: What Is the Biggest Benefit to Providers Who Use E-Prescribing? - iHealthBeat.

Do you prescribe medications electronically using an EMR. Do these numbers match your experience? Are there additional benefits (or drawbacks) of e-Prescribing based on your experience? (For the purposes of answering this question, e-Prescribing does not require that you have to send your prescription to the pharmacy electronically. Using the EMR to prescribe and printing or faxing the prescription to the pharmacy is within the scope of this discussion. Click on the 'Comments' link to add your thoughts.

UK: Choose and Book breaks 25K a day

One of the big challenges that we currently face in Canada relates to the 'mapping' of healthcare information technology to the workflow process (clinical and business). What I mean by this is that we have not yet done a good enough job at describing the clinical and workflow needs of healthcare, understanding the current system and determining where and how EMRs/EHRs can be applied to enhance the process. We have tended to focus on the IT rather than focus on the underlying system, ensuring that the way that we currently work is the most efficient way to deliver care and then determining how we apply technology in the most effective manner.

If we have poor business processes relating to delivery of care (e.g. duplication of effort in schedule management, dual systems to manage the same data and complex referral systems) and we do not first fix the underlying problems, we simply enable inefficient processes with IT..... not an ideal solution.

The 'Choose and Book' system in the UK is gaining support and becoming more of the norm in terms of how patients are referred in the NHS. This short article in eHealth Insider, describes the progress that is being made.

"Choose and Book has been used for more than 25,000 bookings in a single day for the first time. The e-booking system recorded more than 25,000 referrals one day last week, according to Choose and Book medical director Dr Stephen Miller. Dr Miller told EHI Primary Care: “That is our highest ever bookings day in a single day.” Dr Miller said that despite the increase in bookings usage of Choose and Book remains around the 50% mark with around 85% of all GP practices using the system to make referrals in the last week. Dr Miller said the 50% figure was good news but there remained another 50% of bookings which were not made using the system. Link: E-Health Insider Primary Care :: Choose and Book breaks 25K a day.

Should we be developing similar systems in Canada? By adopting this type of approach, do you think we would force more attention on the detailed processes of care delivery?

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

Future Practice - Communication, Implementation, Collaboration. Are we getting IT right?

In a very interesting issue of Future Practice (published by the Canadian Medical Association), a number of important issues are discussed that provide insight in the world of EMR and IT adoption and use in clinical practice settings.

Articles include a discussion on EMR implementation by Dr. Nikki Shaw who undertook a research study — the Informatics: Enhancing the Clinical Experience? (ICE)* study — in 30 British Columbia primary care clinics to find out what effect the use of an EMR has on patient care and which of the benefits accredited to EMR use are real and which are myths. An introductory editorial by Dr. Brian Day, President of the CMA and interesting interpretations of the National Physician survey data as applied to the use of EMR exclusively in the main patient setting.

• Editorial: Communicating in the modern world
• EMR implementation and use: the physician perspective
• The benefits of using EMRs
• Are we at the tipping point? NPS survey results on physician uptake of IT
• Doing it right: CMA principles for EMR adoption
• Leading adoption in Sault Ste. Marie
• Collaboration in a small town: a community EHR
• Telemedicine: a push for national consensus
• Looking in on an international e-health conference
• Influenza on the electronic island

To view the articles (.pdf format) and read more, go to Future Practice April 2008

BCMJ: How I learned to stop worrying and love the computer

This very humerous overview of EMR selection and implementation was published in the April edition of the BCMJ. While tongue-in-cheek, the article highlights some very real issues that physicians face when implementing an EMR.

"Like many of you I had been wondering if it was time to modernize and consider an electronic medical record, or EMR for short. I was growing tired of using an archaic implement to scratch barely legible words across our pulped forests. I was constantly impressed by my forward-thinking colleagues who had already adapted to this brave new world and spoke confidently, throwing around terms like gigabyte, megahertz, and snack bites. How difficult could this be? I am a man of the 2000s. I am adaptable and rapidly yet seamlessly adopt new technologies. Well, there could be a first time.

My colleagues and I carefully researched all the available medical software packages, and after an ex­hausting review chose the one that appeared to fulfill our needs most closely. “Carefully researched” is really a loose term which means we chose the first one we were presented with. In our minds we were now ready to proceed.

Oh right, you need computers to run the software and apparently you need more than one. We contacted a computer company who came into the office and, after assessing our needs, produced a quote. Who knew that you also need printers, scanners, cords, and software to run the medical software you have just paid thousands for? I was assured that the quote wasn’t for gold- and diamond-plated hardware despite the number of zeros along the bottom. Oh well, we reasoned, sometimes you have to spend money to leave the old days behind.

We were ready to begin. “Who is going to network the cable throughout your office?” the hardware guys asked out of the blue. “What networking?” I asked. “Don’t you guys do that?” “No, we only set up the machines in the offices and make sure they work. Someone else has to run the cable through the office.” Read the full article>> BC Medical Journal - BCMJ.

Have you had experiences with EMR implementation that mirror those of Dr. Richardson? To add your thoughts or comments, click on the 'Comments' link.

New Release: Human, Social, and Organizational Aspects of Health Information Systems

A new reference text has been published by Andre W. Kushniruk - associate professor and director of the School of Health Information Science at the University of Victoria and Elizabeth M. Borycki who teaches health information science at the School of Health Information Science at the University of Victoria.

Human, Social, and Organizational Aspects of Health Information Systems offers an evidence-based management approach to issues associated with the human and social aspects of designing, developing, implementing, and maintaining health information systems across a healthcare organization—specific to an individual, team, organizational, system, and international perspective. Integrating knowledge from multiple levels, this book will benefit scholars and practitioners from the medical information, health service management, and information technology arenas.

“In this book we gather multiple perspectives on human and social aspects of healthcare information technology. The contributors to this book describe a variety of models, frameworks and empirical approaches to considering human and social aspects of health information systems.” -A.W. Kushniruk, University of Victoria.

Download and order Kushniruk_Reference_IT_Feb_2008.pdf (480.4K)

Advanced Communications - Overview and Potential Uses

On March 29, 2008 I was invited to present some ideas and concepts for discussion at the EMIS National User Group conference in Banff, Alberta on the potential uses of Advanced Communication Technologies to support physicians and their staff in practice settings.

CanadianEMR is committed to supporting the adoption and use of Electronic Medical Records and the development of best practices and educational programs to assist in the optimal use of electronic tools in clinical practice settings. Based on availability and as a service to support physicians and the vendor community, Dr. Brookstone is available to speak at vendor user group meetings. For further details, send an e-mail to CanadianEMR.

If you would like to comment on this presentation, please click on the 'Comments' link below

March 24, 2008: EMR Request for Proposal - Released in Saskatchewan

The Electronic Medical Record (EMR) Program Request for Proposal (RFP) has been released in Saskatchewan effective March 24th, 2008.

The Saskatchewan Medical Association (SMA) intends to identify a selected group of vendors to offer EMR solutions to physicians within the province. At the same time, Saskatchewan's Ministry of Health has identified a need for a Primary Health Care (PHC) software application to facilitate the advancement of Primary Health Care within the province of Saskatchewan. As most of the functionality required by these two initiatives overlaps, a joint Request for Proposal (RFP) process has been employed. The SMA intends to identify four separate EMR vendor solutions. Once identified and approved, physicians within the province wishing to participate in the SMA EMR program can select one of these EMR solutions to implement in their clinics.

Funding from the SMA and Saskatchewan Health will help offset the cost of the EMR for the physicians. As well, a Change Management Program is being developed to further assist the physicians in the transition to an EMR. The Health Information Solutions Centre (HISC) is responsible for identifying a single Primary Health Care Solution (PHCS). The PHC intent is to procure a solution, which can operate as a single hosted instance and supply functionality to the primary health care providers throughout the province. The physician EMR solutions and the PHC solution will be important components of the Electronic Health Record in Saskatchewan, including interoperability with labs, pharmacy, RIS/PACS and the shared health record.

The RFP has been posted on the Saskatchewan Ministry of Government Services website - Competition Number 2462. The RFP closes May 30th, 2008 at which time the process to select the successful vendors will begin. This process will be completed by the fall at which time the SMA plans to begin the physician EMR program while HISC intends to begin planning for the first pilot installation of the PHC solution.

NHS: Setting up a Local, Shared, Computerised Diabetes Health Record

In an article from the UK by Dr. Neil Paul, he discusses the desire to develop a shared computerized diabetes record for access in both primary care and secondary (hospital) settings. The desire to develop inter-operable solutions is an international phenomenon and is more difficult to accomplish when one has many different EMR/EHR/Hospital systems. In Vancouver Coastal Health, we have been working to develop a shared care record for patients with chronic disease including diabetes, COPD and chronic kidney disease. What becomes clear is that this is less about the technology and more about the people, process and workflow issues that are identified. However I believe this is where we should be heading. Once we begin to focus on the clinical and business process issues, the technology becomes more transparent and becomes correctly positioned, not as the solution, but as the sharper pencil.

"There has been local talk of a shared, computerised diabetes record for about eight years, but it has never seemed as likely to happen as it does now. The idea was previously hindered by a lack of understanding about what would be gained from having a record. Indeed, there was some feeling that secondary care just wanted primary care’s data for its own purposes, so all the information would go one way. " “No one wants pain without gain. We want each user to only have to input information once into a system that is designed for them.” Now, we have two new consultants who are IT literate and are championing the cause. They want to record their own consultations electronically and share information in the most efficient manner. They have made it clear that they see this as a two-way process. They are keen for their information to come to our records and would like access to the relevant bits of ours. The fact they can see the benefits and are willing to be open and to share is driving the process, which has built up real momentum."

To read more, click here

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