CanadianEMR: EMR Comparisons, Ratings and Expert Discussions

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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Sophisticated 10-12 Physician Practice Established in Ontario

The following has been submitted by a colleague in Ontario and describes the layout and configuration of a new practice that has been established to bring a number of smaller groups of physicians together in a shared care setting.

"The practice is designed to be a very open space with shared work "pods" where the physicians and nurses spend most of their day. The pods have 8 workstations that are used by physicians, nurses, our usher who moves patients around and residents when they are there. There is never more than 4 docs for the 12 rooms on one pod and we have 2 identical pods on each side of the building. Our offices are shared between 2 physicians since we end out spending very little time there. The physicians never have less than 3 examination rooms to work with at any time, so this makes for good throughput of patients - very efficient and quick. Our wait time is under 10 minutes for patients as a result of this (in fact we are usually ahead of schedule during the day) We have 90 workstations and about 60 printers so no one waits for a workstation or walks to get what they printed.

 

There are 24 identical examination rooms (12 per pod), 2 large treatment/emergency rooms, 2 nursing areas that can allow 3 nurses to work at once per pod We have about 10 offices for allied health professional and are starting to hire. We have just brought on a PHD in kinesiology as a health educator for our patients and as well to start our cardiovascular risk management program and do our research. We have our own ambulatory BP monitors and will be getting Holter monitors exclusively for our patients. EKG, PFT, and ambulatory BP are all integrated into our EMR.

We have a total of 14,850 square feet and occupy 55% of the whole building. Overall we are happy and have been able to let in 500 new patients since we moved (December 20, 2007) without adding any physicians or any additional hours of work. We are actually allowing people to call in every 6 weeks or so to get a spot on a first call basis and close the lines at 250. Once these patients are signed up and appointments are given we assess our capacity to take on new patients.

On a good day we see just under 400 patients and at most we have had about a dozen patients at any one time in the waiting room with 8 docs and 5 nurses working. Although I suspected that space was a big limiting factor in the whole improvement process, I never realized exactly how important it was. We are using the same EMR in the same way as we did for the last 2 years and in the past we often had one hour wait times in the waiting room and could not even dream of taking on new patients.

My final conclusion is that EMR's alone are not enough to make a difference and as much effort and investment needs to be made into the space to make real differences!"

This is an example of an efficient practice redesign. The evidence can be seen in the new practice layout and the ability to open capacity and reduce wait times while increasing physician satisfaction.

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The Growing Role of Information Technology in Healthcare

The following article (from Medscape) was suggested by regular reader and contributor, Dr. Scot Mountain. The author, Dr. Blake Lesselroth, makes some very powerful arguments in terms of the role of technology in healthcare. Earlier today, I had an opportunity to speak at the 43rd Annual Post Graduate Review in Family Medicine Conference in Vancouver. I presented on the role of information technology and how physicians fit into the bigger picture of eHealth. The discussion led to a very interesting and wide range of topics. What is evident when speaking with physicians in 2008 vs. 1998 is the inevitability of EMR/EHR in healthcare and degree to which it is now accepted as a part of medical practice for some and soon for many.

"I believe individual physicians must intervene to catalyze the national adoption of electronic health records, or EHRs.

Research has shown that EHRs are slow to penetrate our healthcare landscape despite the potential benefits, including better quality, error reduction, and $80 billion annually in cost savings.[1-4] Although the federal government has begun investing in EHRs, widespread diffusion has been thwarted by misaligned financial incentives and a fragmented healthcare infrastructure.[5,6] More importantly, there has been cultural resistance among physicians citing issues of poor usability and awkward workflow design.[2,7-9]

Virtually every other industry has exploited technology and, in turn, captured a market premium. Apple changed multimedia; Amazon revolutionized retail; and Google democratized access to knowledge.[10] By contrast, EHR interfaces tend to be faithful representations of paper records. We must therefore ask how we can do better than paper if we are to capture the clinician's imagination. Three things must happen. First, the record must include tools, such as information filters, and preappraised resources to address pressures of a busy practice.[7] Second, we need context-dependent decision aids to support problem solving.[11] And third, we should borrow innovative ideas from other industries.

What if clinical histories were depicted using multimedia, and therapeutic interventions were represented using graphics? What if patients updated their data using automated kiosks like patrons at an airport? Technology has leveled the playing field, empowering individuals to develop and distribute new innovations. Now every provider is positioned to be a visionary and reimagine the EHR. This can be done several ways. Health policy advocates and federal administrators can finance and support open source development communities.[12] Clinical educators can include bioinformatics in their curriculum.[13] And frontline clinicians can avail themselves of the IT literature to inform product design and pilot new technology. The provider working at the intersection between technology and medicine is destined to reinvent the health record and drive adoption.

That's my opinion. I'm Dr. Blake Lesselroth, Portland Oregon VA Medical Center."

http://www.medscape.com/viewarticle/570116?src=mp (requires a Medscape Account)

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Unanticipated Costs: The Need for a Project Manager when Implementing a EMR

Ask just about anyone who has implemented an EMR and they will tell you there were unanticipated costs that were incurred through the process over and above what was initially projected. The additional wall mounts for laptops, uninterrupted power supplies and extra network drop points that needed to be installed in the office are just some small examples.

When selecting and implementing an EMR, physicians are faced with a multitude of questions. The obvious ones relate to the selection of the system that will be right for that specific practice and physician mix, however there are other fundamental questions that are brought up through this process. How long is the current office lease? Is this a time to move into a group practice and share costs and overhead with a group of physicians? Is it possible to use existing space and exam rooms and repurpose physical rooms to accomodate an EMR system?

The importance of a physician champion in a practice to lead this process can not be underestimated. In fact, this is probably the single most important requirement when implementing. However this individual takes on a great deal of responsibility and commits time and energy in the process.

Recently I have become more aware of physicians that are coming together in groups of 8-12 to set up new practices that accomodate other care providers such as dieticians, nurse practictioners and pharmacists. Financial incentives coupled with the ability to provide shared care supported by an EMR are a catalyst to move in this direction. Planning and management of this implementation can be a multi-year process and is not a simple task to undertake. The most valuable commodity that a physician has is his/her time and if not seeing patients, that physician is not generating income. So, the question of additional needed resources comes to mind.

I was talking with a physician colleague recently who established a 10 physician clinic. The process from planning to design to occupation of the premises took nearly 2 years and included bringing multiple physicians together who had worked in smaller practices geographically separated from one another. The only way that this could be managed efficiently was to employ a full time project manager for approximately 1 year. The cost was in the range of $10-$15,000 per physician. His comment was that it would not have been possible to manage the project without this additional set of hands (and come out sane at the other side).

Questions to readers of this blog who have made a transition to a group practice:

• Did you use a project manager to assist you in the process and what were your experiences?
• If you did not use a project manager, if you had to do it again, would you employ a project manager to assist your group?

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CMA Journal: Getting to the Electronic Medical Record

Ken Flegel, MDCM MSc Senior Associate Editor, CMAJ has written a very thougtful editorial on the Electronic Medical Record in terms of patient safety and the ownership and stewardship of the clinical data.

"By custom, the medical record has been stored as a paper file in the physician's office. The keeper of the record has been the physician — a banality in which lie 2 deeper concepts: one of ownership and one of access. Lately, it has come to be understood that the physician and the patient own the information in the record jointly and that each is entitled to control the access by third parties, though normally for different reasons. But now, driven by need and abetted by technology, much about the medical record is changing, raising new questions about how ownership and access are affected.

Obviously, the only way to restore coherence is by moving from the paper record to electronic storage and linkage. The essential quality of the electronic record is that it can allow all significant information to be accessible in one place at the same time. It can be searchable. It can possess a kind of algorithmic intelligence. If well designed and efficient, it can be organized and user-friendly.

There is a clinical need — one might say imperative — to proceed. Patient safety is the principal reason. For example, an electronic record could inform a physician not to prescribe a drug that is contraindicated by the patient's history. Emergency visits are another standout circumstance where access to the complete record will avoid harm, to say nothing of time and money. The question, then, is who shall keep the records and who shall own them? Although the keeper is likely to change to encompass a virtual network of health care providers, ownership should remain with the patient.1 But ownership here means the ability to grant privilege to others to contribute to or gain access to the information. It does not mean the patient can change the record (although there could be a place for him or her to add comments).

Who will have the ability to make or alter an entry? Are we each about to become holders of our own somatic Wikipedia?

Click here to read the full article: Getting to the electronic medical record -- Flegel 178 (5): 531 -- Canadian Medical Association Journal

What I read into this is a growing acceptance of the need for a transition from the old ways to the new and a change of thinking in terms of how we share information in a much more fractured environment. Technology and EMRs are some of the important keys to this puzzle.

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Standardization in a Multi-Physician Clinic - Office Layout

Working together in groups has never been more attractive than right now for physicians. The ability to share costs and overhead, cover one-another for on-call and pay-for-performance programs for Chronic Disease Management (such as the Complex Care program in British Columbia) make the multi-physician clinic a very cost-effective way to practice. Adding an EMR into this environment provides additional capability to do pro-active recall, prescribe electronically and automate repetitive functions.

The following series of images was submitted by a colleague who has recently established a group practice.

What I particularly like about this set up is the very effective use of wall mounted monitors in order to maximize examination room and desk space for clinical use. Using space effectively (and cost-effectively) is one of the key challenges when designing a medical practice, particularly if you have a limited room size.

With the shift in patterns of practice from solo to group and with physicians making a significant investment in the infrastructure (EMRs, telephone systems, office equipment etc.) there are many more physicians who are re-thinking their work environment. I have always been struck by the difference between dental offices and medical offices in terms of the investment in furnishings and equipment that make a practice environment comfortable for staff and patients.

With practices such as this being developed, physicians are making a quantum leap forwards. Welcome to the medical office of the future.

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Are GP Oriented EMRs Appropriate for Specialists?

This is the first posting in a new section that I have created on CanadianEMR focused specifically on specialist needs for EMR. The focus in Canada to date has been to identify EMR systems that meet the needs of GPs, the largest single group of physicians. This has also occurred at a time that primary care has begun a significant transition process. Ontario has limited funding for EMRs to primary care physicians who are willing to change their practice structure to a shared model of care through FHTs, FHNs, FHGs. Alberta recognized the needs of specialists and through their funding program, provided support for specialists to adopt EMR systems. British Columbia, through the PITO program has also designated funding for both specialists and GPs, however with different limitations to Alberta.

Requirements for EMRs as a result of RFPs, selection and conformance testing processes across Canada have tended to select out EMR systems that are designed to meet the needs of GPs rather than specialists. However, is this statement really true? Can these systems be used efectively by specialists? Are there differences between specialties that require specific EMR solutions in order to meet these needs? Are there some basic requirements for all EMR systems that should be able to meet the needs of GPs and specialists equally? The purpose of this posting is to begin to flush out these thoughts and ideas.

Canada is at a critical juncture as we begin to deploy EMR systems more widely. 50% of physicians in Canada are specialists and the critical business need in a functional health care system is for GPs and speciliasts to be able to communicate effectively with one another (as occurs in the paper world). Your thoughts, comments and feedback will help to inform this critical issue.

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NHS: Doctors have no confidence in NHS database, says BMA News

The move towards centralized storage of patient information has not been without its challenges. In a British Medical Association survey, 90% of doctors who were surveyed lacked confidence in the government's ability to protect patient data:

"Nine out of ten doctors have no confidence in the government’s ability to safeguard patient data online, a poll conducted by BMA News has revealed. More than 90 per cent of respondents (93 per cent) to the survey said they were not confident patient data on the proposed NHS centralised database would be secure. A series of recent high-profile data losses, such as the HM Revenue and Customs computer discs containing the details of 25 million child benefit claimants and security breaches during last year’s online training recruitment fiasco for junior doctors, have left doctors sceptical about safety. Nine out of ten of the 219 doctors who responded to the Doctors Decide poll said they did not feel they were in a position to assure patients that their data would be safe. More than eight out of ten (81 per cent) said they would not want their surgery data stored on the national NHS ‘spine’.

To read the full article: Newswire Article: BMA News Press Release: Doctors have no confidence in NHS database, says BMA News poll 02/01/2008

As a Canadian physician, what is your opinion of these findings? What is your level of confidence that the privacy of data stored in centralized databases can be protected? How does the system ensure that data is protected?

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Using EMR in Clinical Practice - Video Presentations

How do Electronic Medical Records affect lives. In a special report from Canada Health Infoway, a number of scenarios are highlighted through video. Click here to view this page

On November 24th, 2006, OntarioMD hosted two breakout sessions at the Primary Healthcare Update Conference. One of the most informative presentations was entitled "Assessing and Integrating EMR into your Practice". The presenter is Dr. Stephen McLaren - Markham Family Physicians. Click on the following links to view the presentation.  Windows Media  Quicktime

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