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

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.

A New Wave of Tablet PCs — Dr. Horii Shares Experiences

The following guest editorial was submitted by Dr. Allan Horii, a Richmond, BC family physician, regular contributor to CanadianEMR, and longtime EMR User.

It seems tablets are in vogue again.

Thanks largely to the success of the iPad, consumers have embraced the “tablet” or “slate” format of computing. What’s often overlooked is that tablet PCs had been available for a number of years prior to the introduction of the iPad. Adopted primarily by vertical markets, such as healthcare, these computers never enjoyed widespread success because they were too heavy, battery life was poor, and the Windows operating system didn’t seem to provide an elegant way to interface with the tablet. The iPad was revolutionary in that it showed that a device could be light, intuitive to use, optimized for touch input, and provide long battery life. We are starting to see the iPad make more in-roads into the health sector, with new medical apps, and physicians and hospitals adopting the device into their workflow. However, many current EMRs still depend on the Windows OS to function.

I’ve been a strong proponent of tablet PCs for use with EMRs. There has been a steady evolution in the technology since I first began using them around seven years ago. Processors are becoming more powerful and energy efficient, battery technology is improving, and weight is decreasing. The greatest quantum leap I’ve seen thus far has been Samsung’s recent offering, the 700T Series 7 Slate. I have to say it’s the most impressive Windows-based tablet device I’ve ever used. The Series 7 slate weighs a mere 0.87 kg (1.91 lb) on my scale. That feels like an immense difference in hand, roughly half the weight of my last two tablets (the Lenovo Thinkpad X201 and the HP Elitebook 2730p). It has a bright 11.6” LCD screen that supports both touch input and a Wacom digitizer pen. Its slim, 1 cm profile holds an Intel Core i5-2467M processor running Windows 7 (64 bit), with 4 GB of RAM and the option of a 64 or 128 GB SSD drive.

This device works well with my EMR. I can navigate screens and menus with either my finger or the digitizer pen. Handwriting recognition thus far has been excellent. Battery life has also been very good: 5+ hours running Wi-Fi. I’ve always enjoyed the fact that a tablet PC allows me to remain engaged with patients while using my EMR; I can access my patient file and still face the patient, just like the old days with my paper chart. The pen also gives me an additional tool to enter information: for example, simple diagrams of physical exam details can be drawn, or pre-generated figures provided by the EMR can be marked up with more precision than a mouse. The tablet has a 3 megapixel rear camera which comes in handy for recording images of skin lesions, etc. A docking station and Bluetooth keyboard are also available if a desktop-like setup is periodically required .

Samsung has indicated that they will be shipping this tablet with Windows 8 loaded on it next year. That promises to be a further improvement, because Windows 8 has been optimized for touch with its Metro interface. In any case, the release of this device bodes well for tablet advocates, like myself. I’m very excited. I hope we will see similar designs and further improvements in the near future.

Allan Horii  MD

Share your experiences by clicking on the “Comments” link below.

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

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

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

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

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

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

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

Use of Social Media by Physicians

How many physicians are using social media for a variety of communication needs? While the number of physicians with Facebook accounts is likely to be significant, I am quite sure that the majority of use is personal. Some interesting questions are begining to surface regarding the ethics of using social media tools in clinical practice. For example, is it appropriate to “friend” a patient on Facebook or accept an invitation to be friended? For most physicians, this would instinctively not pass the sniff test if they were using a personal Facebook page — why would you want a patient to have access to your personal information anyway?

Similarly with social tools such as blogs, Twitter, LinkedIn, Google+, and others, it is important to understand how these tools can and should be used in order to provide value without becoming a burden and potentially placing one professionally in “ethical” hot water. That being said, a properly designed Facebook page specifically for an audience of one’s patients that is well moderated and controlled and provides a venue for appropriate social interaction and education can be a very useful clinical tool.

I have been a long-time advocate of blogging and the CanadianEMR blog goes back to December 2003; however, taking on an editorial role does bring with it a responsibility to manage and update the media (whichever you decide to use) so that the information being publicly presented is accurate, relevant, and up-to-date. Remember, what you do on the web stays on the web.

In the current issue of Future Practice, Social Media is covered extensively, including this year’s Medicine 2.0 conference in Palo Alto, California and an overview of the use of Twitter and blogs by physicians. A very useful section is “Social Media Essentials for Physicians in 2011”, which explains the background behind specific social media tools and provides some information on how they are used by physicians. This issue of Future Practice is highly recommended reading for any physicians who have used social media tools in their practice. Click here to read or download a copy.

Do you use social media in your professional practice? Share your experiences 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?

Highlighter Scanning Trick — Dr. Ian Pun

The following post was submitted by Dr. Ian Pun:

Dr. Brookstone, excellent summary of EMR usage in your podcast.

I like the point about the doctors are working around the EMR rather than in it, doubling your work. Habits are hard to change because of the volume of old charts involved.

Perhaps everyone should have their own personal scanner. I scan the patient chart myself when I’m seeing the patient (so it’s done only once for their first “EMR” visit). It’s really fast with the Scanscap S510 scanner. Feed and press a button. If the chart is really thick, I may just scan the last couple of years. In fact, I’ve scanned probably more than 100,000 pages. I already wore one out (I think I have to replace the feed separator PAd assembly). I still have two scanners left, even a newer S1,500. I stick a highlighter to the scanner so it marks the back of the page, indicating it is scanned. The EMR will work better when all information is in it. My staff then attaches the scanned .pdf into the eChart.

After a year, my documents folder is 2.5GB in size. So, 25,000,000 KB (at 50 KB per page = 500,000 pages.) Wow! But that includes faxes and some pages may use more memory. Probably a more accurate estimate is 250,000 pages. I have 20 x 2m shelves full of charts. That’s 20 x 200 cm = 4,000 cm of paper. 4,000 cm x 500 pages/5 cm = 400,000 pages. I have probably scanned about half my office’s charts this past year. That's just me in my solo office. It should get easier from now.

Let me share with you my highlighter trick to mark the paper as it is being scanned.

New paper reports are scanned into the EMR immediately. This has saved a lot of room and I don’t need to buy more expensive shelves/folders/paper.

Ian Pun MD
GP, Toronto

Share your experiences and tips by sending an email to info@canadianemr.ca

How Mobile Apps Are Changing Healthcare

I began to write this blog post using my newly acquired iPhone 4S, but once I had access to my laptop, I reverted to a more comfortable (and familiar) form factor. Until recently, I was a strong advocate for the Blackberry, which I have used for the last seven years; however, the recent network outage did impact me and resulted in missed calls and communications that needed to be acted upon earlier than received. Until that time, I tolerated some of the Blackberry's limitations, including the small screen that had become less useful in a largely browser-based world. However, after the outage, I made a conscious effort to review my options and decided to switch to either the Android or iPhone platform. What made me choose the iPhone? As an avid Mac user with a household of kids who are Mac converts, an iPhone was the only logical option. My transformation is now complete. I use a Mac, an iPad, and an iPhone. I imagine that my story is not much different to many others. I did not begin down a pathway thinking that I had to convert to a Mac, but I became part of the Apple family. I was just kind of drawn in. My life became a little easier and my productivity improved.

The objective of this post is not to wax poetic about the benefits of the Mac platform, but to talk about mobile applications (or Apps). Approximately 11 years ago, I developed an Internet strategy for a national communications organization and suggested at that time that the fixed web would become an aggregator for content and services. But with the move towards more and more sophisticated mobile applications, the mobile phone would be the area in which to focus 70% of the strategy. In 2000, many of the technologies we now take for granted were not yet available, AOL was still the dominant Internet presence, and mobile phones were used primarily for voice communications. Blackberry had released early versions of their mobile devices; however, while they made email communication easier, the mobile web had not yet begun to develop.

Whether one uses an iPhone or an Android device (or even a BlackBerry), there are now thousands of mobile healthcare applications, many of which are available for free. Yesterday, while searching the App Store on my iPhone, I noticed under the “What’s Hot” section that there was a dedicated area called Apps for Healthcare Professionals. Organized under Reference, Education, EMR & Patient Monitoring, Imaging and Point of Care, I was able to find a number that were relevant to me and quickly had a growing library of free and useful mobile applications including the new IOS5 version of ePocrates and Medscape. In 1997, I launched a website called WorkSmartDoc.com and my Internal Medicine colleague, Dr. Steve Wong, was the first ever to write a review on ePocrates, which at that time was only available for the Palm. (Do you remember them?) ePocrates has grown significantly since that time and offers an incredible number of tools and functions, including an EMR application in the U.S. It is an extremely useful tool (but not unique — there are many others that perform many of the same functions with slightly different nuances), and ePocrates is a leader in this field. I also downloaded the NEJM App as well as an App which is more consumer focused for cancer care developed by the American Society of Clinical Oncology (ASCO).

A particularly interesting section within the Apps for Healthcare section is called “Personal Care Apps” developed by pharma (Novartis, Sanofi-Aventis), sports companies (Nike), Non-profits (National Breast Cancer Foundation), Pharmacies (Shoppers Drug Mart), and more. While I do not see many physicians using these types of applications on their own devices, by grouping them together with other more provider-focused Apps, there is a credibility by association of being a member of an eclectic collection.

The “App World” is becoming richer and is providing more choice to clinicians and patients. A Nov 8, 2011 article in the National Post titled “Paging Dr. Smartphone: How medical apps are changing diagnoses and treatments” highlights the benefits and use of Apps for Type II Diabetes and individuals who have problems with verbal communication. I see a future not far off in which physicians will prescribe mobile Apps for a variety of conditions in addition to more traditional pharmacological treatments and lifestyle advice.

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