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

What's New with Printers and Scanners?

Despite the effort to create paper “light” medical offices, the likelihood (in the forseeeable future) that all data is going to flow electronically is extremely low. In fact, some would argue that we manage more paper now than in the past, with the exception of lab results. The reality is that medical practices manage an enormous number of paper documents in the office in the form of referral requests, consultation reports, historical patient data, diagnostic reports, and reports from third parties. All of this information has to make its way efficiently into the EMR and documents generated by the EMR (such as prescriptions and handouts) have to be provided to patients, medical colleagues, and a multitude of additional individuals.

Thus, the need to have good printers and scanners at one’s disposal to manage these documents is extremely important.

When thinking about document scanning management needs, I would suggest dividing documents into two distinct categories:

• Documents that need to be stored and archived for historical purposes. For example, old charts for which a summary may have been entered into one’s EMR, but the original documents have been stored based upon the provincial record storage guidelines.
• Documents generated on a day-to-day basis in the management of patient care.

Each of these document categories has different scanning requirements. It is impractical to use a small office-based scanner to enter and archive thousands of historical paper charts. In this instance, I would recommend using a commercial organization that has the equipment to scan these documents quickly and efficiently, can guarantee the media that are used to store the digital files will not degrade, and can securely dispose of the paper documents after scanning, if that is desirable. While this is more costly than having a family member or student scan the documents one page at a time, the accuracy and quick turnaround are worth the effort, plus you will no longer have to pay for storage. This is an important consideration if you are closing your practice and would like to be able to transfer patients to a colleague. Receiving a digital copy of a patient’s record is more desirable than a thick paper chart.

For day-to-day scanning of documents, there are a number of excellent small footprint scanners made by Fujitsu (ScanSnap series) and a wide range of scanners from Hewlett Packard. While it may be tempting to purchase a $100 scanner from your local Best Buy, the likelihood that this will meet your office needs in terms of volume and output format are small. Spend the extra money and make sure you have an industrial strength scanner that is going to provide years of service. Your staff will also be appreciative.

What is new in printer technology? Greater print efficiency and wireless capability are some of the most important considerations. Small footprint printers that can easily be installed in an examination room are desirable if you would like to print and hand information to a patient without disrupting the clinical encounter. If you have to walk out of the exam room to collect every document that is printed, it can be very disruptive to patient care. If you elect to install inkjet printers, expect the ongoing maintenance costs to be higher than an equivalent laser printer. It may be cost-effective to install a number of multifunction printer/scanners in your medical practice wirelessly connected to a network. For example, in the doctor’s common work area or as an additional scanner/printer should the primary scanner be in use. Brother makes an excellent series of wireless multifunction printers. Remember that if your office is dependent on a single multifunction printer/scanner and the device fails, you lose all of your devices at the same time. It is best to keep a spare in reserve in case of emergencies.

Have you had any experiences with printers or scanners that you would like to share? Click on the “Comments” link below to add your thoughts.

Integrating Computers for Maximum Patient Benefit

When upgrading an existing medical practice, small examination rooms can be difficult to reconfigure without losing seating space for patients, or critical counter space if the room is too small to accommodate a desk. So, what are your options when integrating computers into an existing medical office? Each clinic may differ to some degree and, rather than providing specific examples, here are some suggestions to consider:

• Do you need a local network to run your EMR? If you install an EMR system that has a server locally in your office, you may need to install a network to connect to workstations in the examination rooms, scanning areas, front office, hallways, etc. If your office is located in an old building, this may incur significant cost as it may not be simple to run the wires through the ceiling and walls. Check with your landlord and consider this when you are selecting your EMR and intended hardware.
• With the growing prevalence of high-speed wireless access points and networks, it may be much more cost-effective to run a wireless network for your examination room computers. However, make sure that you choose the fastest wireless network router and that you have an office survey completed to check the wireless signal strength throughout critical care areas. There is nothing more frustrating than having a great EMR and computers that continuously drop the network signal necessitating restarting the router or the computer. Also make sure that your wireless security settings are correctly configured.
• Make sure not to place the computer between you and your patient. The computer can act as a barrier and it can be disconcerting for patients to be looking at the back of a computer monitor wondering what it is that you are writing.
• Consider an L-shaped desk configuration enabling your patient to view the screen during the encounter. It is much more effective as a mechanism to engage patients in their own care; plus they will often identify errors or outdated information during the encounter allowing you to make the necessary corrections immediately.
• If you use a tablet to access your EMR, make sure that you have somewhere to “dock” the tablet while examining your patient so that the device is not left lying on a countertop or at the foot of the bed. This will protect your investment with the added benefit of charging the device during the encounter so that your battery is able to last for a full clinic shift.
• Some clinicians may opt for a second monitor screen specifically for the patient to view during the encounter that can be wall mounted for patient convenience. This is a reasonable option if the layout of the examination room requires a contortionist to share the computer screen while documenting clinical notes.

For examples of medical office configurations, click here.

Privacy and Security in an EMR Based Practice

Anyone who has implemented and used an EMR is aware of the terms Privacy and Security. However, what do they mean and how does one apply the concepts to the protection of personal patient data in the EMR-based practice? Privacy experts will describe privacy principles as enablers in the development of the right technology processes and software. While this is true if understood and applied in advance, privacy can also be a barrier to adoption, particularly if software was never designed with today’s privacy requirements in mind.

In 2005/2006, I was a member of a team of primary care physicians and specialists working on a primary care strategy for Vancouver Coastal Health. One of the strategies was the development of a Privacy Toolkit for the medical practice. Nigel Brown, Managing Consultant of the Security, Identity and Privacy Practice, IBM Global Technology Services, led the development of the toolkit and described privacy in the following ways:

Historical Definition — Physical Privacy: “the right to be left alone”
Modern Context — Information Privacy: “the right to have knowledge and control over information about you”

Information Privacy — Identifiable Information about an individual, including the following:

• Factual information such as contact, health, financial, affiliations, etc.
• Biological information: biometrics, blood type, DNA
• Derived information: credit scores, etc.
• Opinions: performance evaluations, etc.
• Observations: shopping habits, etc.

Security is the ability to protect the confidentiality and integrity of information and computer resources using the acronym CIA:

• Confidentiality: Allowing access only by authorized individuals.
• Integrity: Ensuring that information is not altered or tampered with by unauthorized individuals.
• Availability: Ensuring that information is available when needed.

Confidentiality is the process of ensuring that information is accessible only to authorized individuals.

A failure in either security or confidentiality can compromise privacy. However, privacy can also be compromised through the use or misuse of information by authorized individuals.

What can you do within your office to protect privacy? The following are a number of suggestions that apply to both paper-based and EHR-based practices:

• Position computers in administrative areas so that staff conversations cannot be overheard from public areas.
• Place computers, printers, and other devices in non-public areas and rooms that can be locked.
• Limit the display of personal information in areas where patients wait or walk to examination rooms.
• Establish policies that encourage discretion when discussing patient information, particularly if there is a possibility of being overheard by other patients, for example in check-in areas.

The issues of Privacy and Security are complex and require a common sense approach to correctly apply the right principles to specific situations. To assist you further, the BC Medical Association provides a very useful resource on privacy issues.

Converting from Paper to an EMR

The conversion of existing paper charts during EMR implementation is routinely seen as one of the greatest barriers to conversion of a practice to EMR. Chart conversion is a time-consuming and resource-intensive task that many physicians view as a hellish purgatory. In addition, ineffective and expensive chart conversion is one of the most frequently cited reasons for the failure of EMR implementations. However, there are several things your practice can do to help shorten and reduce the pain of chart conversion.

Develop a plan that both identifies the process you will use to capture the information from your paper charts, and establishes realistic time frames within which to complete the process. You should take into consideration the data that is most frequently going to be clinically relevant in the treatment of your patients. One of the most common mistakes is to attempt to input the entire patient chart into a new system. This is an understandable instinct given the effort most clinicians put into maintaining their patient charts, but tends to be extremely expensive and is generally not necessary.

Data you will most frequently need include the following: allergies, current problems, current medications (episodic and long-term meds), past medical and surgical history, important diagnostic results (e.g. lab results, pathology, or most recent EKG), immunizations, screening test dates/results, and advance directives.

Here are some tips for chart conversion:

• Review and update your paper charts prior to implementing your EMR. Irrespective of which EMR you choose, you will need to get your charts prepared for data input. Organizing the updated clinical data using a standardized face sheet will streamline your data entry process when you populate your EMR.
• Identify patients who are seen regularly in your practice with chronic medical conditions or complex care problems. Getting these paper charts organized and entered into your EMR will allow you to focus on the clinical encounter when you see that patient. It is much easier to pre-enter all the complex patient data, which will allow you or your staff to enter less complex patients on the day they are seen or during the clinical encounter.
• If you choose to scan all of your old patient records, you will then be able to move any remaining paper charts off-site and will be able to reclaim space used for chart storage and utilize that space for other purposes such as additional examination rooms. If scanned into a compatible format (e.g. PDF), a copy of each scanned patient record can be attached in your EMR allowing for quick review of the paper medical chart if needed.
• Establish a definitive goal to keep everyone in the practice motivated. One of the most effective strategies is the “three time rule” where the physician is allowed to use the patient’s paper chart only three times (three visits) before the paper chart is retired. After that point, the chart is still accessible, but — as a deterrent — some practices charge each physician a small fee per chart.

Have you converted from paper charts to an EMR? Share your experiences by clicking on the “Comments” link below.

EMRs and Medical Devices — How Do they Integrate?

Walk into any emergency room and you will see a plethora of connected devices attached to patients, beeping and displaying blood pressure and other vital signs on a continuous basis. Similarly, in the operating room, an anaesthesiologist has a completely integrated suite of equipment that collects, stores, and displays vital information for immediate action if needed.

This is the promise for EMRs — the ability to have the mundane and repetitive tasks of measuring vital signs collected and immediately integrated into the EMR. All without any further effort other than connecting the cuff or monitor to the patient. Now, that would be a real time saver, and would also reduce inaccuracies related to entering data into the EMR. While this seems to be a logical next step for EMRs, there are some challenges and points to consider with regard to connected medical devices.

• Integrating devices into an EMR is a costly and time-intensive process. While there are standards that have been developed, each EMR has a proprietary database and structure. As a result, building and maintaining the EMR interface requires ongoing commitment by the vendor, particularly as new versions of the EMR software are released.
• Not all integrated devices are the same. The integrated devices market varies country by country. In the United States and Canada, the market is dominated by Philips, Welch Allyn, and GE with the majority of devices more focused towards the hospital setting. In addition, the amount of interface development with a specific EMR system can result in significant differences in the way the data is presented in the EMR.
• An important first step is to do a careful workflow analysis in your practice to determine what you need. For example, if your computers are fixed in each exam room and you can plug each device into a computer, you may not need wireless connected medical devices. This can significantly reduce the cost of connecting devices to your EMR.
• What kind of connected devices are available? The majority of devices for the EMR tend to be for vital signs monitoring (BP, Pulse, Temp, SpO2). A wider range of devices are available for cardiologists; however, beyond that a very limited selection is available.

Even if your EMR vendor does not yet offer integration with connected diagnostic devices, share your needs and desires. As with the tablet market, it took Apple getting the iPad right before we saw a widespread availability of tablets. I expect the same to happen once we have some exceptional connected devices.

Do you use any connected devices with your EMR? Click on the “Comments” link to share your experiences.

Advantages of Remote Access to Your EMR

Do you access your EMR from home, a second office, or the hospital? If so, you are taking advantage of one of the most useful features of an EMR system. There is nothing worse than being on call for your practice and having to physically get into your car and drive to the office so that you can review important medical information. As the access to data becomes more pervasive through the Internet and multiple devices, it is becoming almost expected that you should be able to access information anywhere and anytime. However, there are some important considerations with respect to remote access.

• Access from the hospital can be challenging for some clinicians. Many hospitals set a much higher bar from a security perspective and limit access to the Internet from hospital-based computers that are connected to the hospital network. If you are using remote access software to login to your EMR, particularly VPN software that requires its own security protocols, you may be blocked from accessing your EMR when you are in the hospital. If a particular EMR product is heavily used in a specific community, or if your vendor has a good working relationship with the hospital, workarounds can be developed. One solution is to have a number of computer stations connected to the Internet, but not connected to the hospital network. These computers can then be used without putting the hospital network at risk.
• If you are accessing your EMR from an international destination, confirm that there are no international restrictions to accessing your data remotely before you leave. Particularly in situations where your EMR may be an extension of a hospital system.
• Manage your passwords carefully. If your EMR allows access directly via the Internet using an ID and a password, be very cautious with public computers such as in an Internet cafe. Keystroke trackers and other dubious software can be loaded on those machines designed to collect usernames and passwords from unsuspecting users. Change your password according to a regular schedule.
• Finally, if you access your EMR from your mobile phone, make sure that you protect your device. Switch off the save password feature for your EMR and enter the username and password each time you remotely access the system. This does take more time; however, if your device is stolen or lost, you have the confidence of knowing that your patient information is secure.

What are your experiences using remote access? Click on the “Comments” link below to share your thoughts.

Update on Provincial EMR Funding Programs

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

What have the provincial programs done well?

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

How could the provincial programs improve?

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

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

Important Announcement — CanadianEMR Product Ratings

An important part of the mandate of CanadianEMR is to collect EMR satisfaction ratings from a wide range of physician users of EMR systems that are commonly used in the Canadian market. Ensuring the validity and currency of the rating data is of primary importance. To that end, we regularly send requests to verified users of EMR products asking them to keep their ratings current by logging in to CanadianEMR and checking and updating their rating.

In addition, as part of our due diligence, EMR product ratings are reviewed on a regular basis to ensure that rated products are actively being sold and supported in the market. The dynamic nature of the market results in certain products being phased out as new products are introduced, as well as consolidation through EMR companies being acquired by other companies or simply ceasing business. All of these situations have occurred in the past 12 months.

Two updates will take place:

• All verified raters of an EMR product who have not updated their ratings within the last 12 months will receive a reminder request to update their ratings or to let us know whether they have stopped using that EMR product. If that user has changed to another product, they will be given the option to submit a new rating for their current EMR. If any product no longer has a minimum of 5 current EMR ratings by May 31 (5 ratings submitted by verified users within the previous 12 months), that product will not have ratings displayed until at least 5 current ratings have once again been submitted. A notice of this update will also be sent to all EMR vendors.
• EMR products that ceased to be actively sold in the Canadian market from July 2011 onwards will be retired and their ratings will discontinued on CanadianEMR. This update will take effect within the next week.

Please direct questions about any of these changes or updates to info@canadianemr.ca.

Explanation of mechanisms used to validate EMR User Ratings:

• In conjunction with EMR vendors that participate on CanadianEMR: These vendors are provided with a mechanism to verify that an individual who has submitted a rating is a legitimate user of their product. Vendors are only provided with sufficient information to verify a user, but never see the actual rating information that is provided by that user. A number of mechanisms have been built into the rater verification process to ensure that submitters are not rejected because they are known to the vendor as an unhappy customer. If a vendor rejects a rating, an email is sent to both the rejected rater as well as CanadianEMR, and we review each rejection to ensure it is legitimate. If a vendor has a legitimate reason not to approve a rating (for example, if in a legal dispute with a user or if the individual has not been using the EMR for at least three months), there is a mechanism to challenge any submitted rating. Once a submitter has been verified as a physician user of that product, they may return at any time to update their rating, which supersedes any previously submitted rating.
• Directly by CanadianEMR: If a rating has been submitted and is not verified by an EMR vendor within two weeks of submission, we reserve the right to manually verify that user by other means, usually by direct confirmation with the user of that product. If a rating is submitted by a user of an EMR product from a non-participating vendor, we will make every effort to verify the user of that product directly.

The Importance of Performance Reporting and Scorecards

In the past, I have written extensively about the value of performance reporting and scorecards. Nowhere does this principle hold truer than in the development of new programs and processes for which there is little prior experience or knowledge.

Successful adoption and use of information is the result of the successful integration of three primary components — People, Process, and Technology. Because each implementation of information technology varies based upon the relative proportion of each of these components, it is extremely difficult to separate the relative importance of each in the context of a successful program. There are so many moving parts in any healthcare project, that a small part of any component could be the determinant of success or failure.

What is needed is a concerted effort to collect and report on a wide range of metrics to which decisions can be applied in a quantitative manner in order to derive best practices. In addition, this will create a competitive environment keeping important issues front and centre.

In the U.S., the Open Government approach is one in which “transparency, participation, and collaboration come together to create shared ownership and accountability for public goals.” As part of Open Government, the Office of the National Coordinator for Health IT has created a Health IT Dashboard that allows one to review summary information about all ONC HITECH grant programs, and detailed data from the Regional Extension Center, and Community College Consortia to Educate Health IT Professionals programs. Click on the Image below to view more.

What are your thoughts? Could we facilitate the adoption and use of health IT in Canada with similar types of dashboards? Add your thoughts by clicking on the “Comments” link below.

Mike Martineau's Rant on eHealth and mHealth

Mike Martineau — in his regular feature article in Technology for Doctors — makes a plea for simplification of the artificial stratification that is taking place with health information technology. The article is well worth reading.

There is actually a very good analogy in healthcare. The levels within the healthcare system tend to be divided along the following lines: Acute, Community, and Primary care. What these divisions define are the budgeting and policy decisions that have to be made when managing each of these very large sectors. From an administrator’s perspective, this makes perfect sense; however, from a patient centric view of the system, it makes no sense at all.

As a patient, I go to see my family doctor, I am referred to the hospital for investigation or treatment and perhaps admitted. If necessary, I am transferred to community care for home care services or long-term care needs. If I am discharged, I am sent back to the care of my family doctor. From a care perspective the system appears to be seamless (in some cases) and is often highly disjointed because of the stratifications. This is a good point to keep in mind as we create increasingly finer definitions for different types of healthcare delivery using technology.

In his article, Mike states:

“OK, I’ve had enough. I have grappled with understanding and explaining the difference between an EMR (electronic medical record), an EHR (electronic health record), and an EPR (electronic patient record). I have struggled to distinguish how a PHR (personal health record) tethered to an EMR is different from a patient portal. I have even wrapped my head around how telehealth, telemedicine, and eHealth might in fact refer to somewhat different concepts. I draw the line, however, at mHealth! As Howard Beale said in the 1976 movie Network, ‘I’m mad as hell, and I’m not going to take this anymore!’”

Click here to read Mike's article or to comment on his blog.