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

Highlight - QHR Technologies

Congratulations to Kelowna-based QHR Technologies, developer of the Accuro EMR, which has just been named one of only 50 employers on the Canada Top Small & Medium Employers for 2014 list.

Canada’s Small & Medium Employers is organized by the editorial team at Canada’s Top 100 Employers. This project recognizes small and medium enterprises across Canada leading the nation in creating exceptional workplaces with forward-thinking human resources policies. Employers are evaluated on eight criteria: (1) Physical Workplace; (2) Work Atmosphere & Social; (3) Health, Financial & Family Benefits; (4) Vacation & Time Off; (5) Employee Communications; (6) Performance Management; (7) Training & Skills Development; and (8) Community Involvement.

Some of the reasons why QHR Technologies was selected as one of Canada's Top Small & Medium Employers (2014):

• cultivates an ownership culture through a share purchase plan that is available to all employees
• and offers additional financial benefits including signing and year-end bonuses for some, referral bonuses and matching RSP contributions (to 3% of salary)
• provides maternity and parental leave top-up payments to employees who are new mothers (to 75% of salary for 20 weeks) and offers a generous subsidy for in vitro fertilization (IVF) when needed (to $15,000)
• encourages ongoing employee education with tuition subsidies for courses taken at outside institutions (to $1,500)

In a related, but separate news item, Logibec Groupe Informatique Ltée (Logibec) announced December 9, 2013 that it has entered into a definitive agreement to acquire the Enterprise Management Solutions (“EMS”) division of QHR Technologies for a transaction price of CAD$20M, less working capital adjustments. The business unit will operate under the name of Quadrant upon closing of the transaction. All employees of the EMS division will be offered employment by Logibec. The transaction is expected to close in December 2013, subject to satisfaction of closing conditions. For more information on this announcement, click here.

Re-Designing Your Medical Office

It is now a couple of years since you have implemented your EMR. Your needs have evolved as you've become more proficient using the technology in your practice. In addition, your lease is up for renewal and you have important decisions to make. Do you renew your lease or move to a new practice location? Either may involve a refresh of the physical space with or without the financial support of your landlord. There are pros and cons either way, however staying in the same location and simply using the space more effectively reduces the needs for many of the administrative issues you may face. A major concern is disruption. How quickly can your office be refreshed? Is this turnkey or does the process continue piecemeal for days or weeks?

I had an opportunity recently to discuss these questions with a specialist in the office redesign market, Ruth Jankelowitz from the Janks Design Group.

AB: Ruth, as a design specialist, how do you respond to concerns about disruption to practice operations?

RJ: If you have a medical office that is tired or run down or are taking over an existing practice, scheduling and and tight timelines are critical. What we have done is develop a Five Day Makeover (FDM) that is best suited for renovations of existing offices/clinics. This renovation program incorporates weekend days resulting in only a 2 business day loss on the part of the clinic.

How does it work?

• If planned well in advance, we recommend scheduling “On Call” duty for those days or maybe even a weekend away with the family;
• We design and prepare all plans well ahead of implementation. We select all finishes, lighting, colours and ensure all ordering takes place well in advance to ensure every item is ready once we begin. In addition, detailed millwork plans are 100 % complete before raising a hammer;
• Once everything is ready, the transformation begins...
• A highly experienced construction team arrives on a late Thursday afternoon and removes all files and items to be stored/reused. The next step is to rip and strip (flooring, walls, furniture & lighting);
• Friday - clean up, repair, paint and install lighting;
• Saturday - second coat of paint plus install new flooring;
• Sunday - install millwork and hook up plumbing;
• Monday morning - finishing installation, touch ups and reworking of all Tel/Data;
• Monday afternoon - bring back files and items from storage.
• Tuesday morning - back at work... completely rejuvenated!

AB: Any suggestions when designing a new medical office?

RJ: It is important that your design/implementation contractor understands your philosophy, demographics, tastes, target patient base and your budget. Our approach is to develop a conceptual design that best suits your needs and present it to you in 3D model so that you can virtually walk through the space and approve, before spending a penny on construction.

Once a conceptual design is in place, we prepare detailed permit & construction plans, handle permit process, issue detailed millwork and finishes plans for construction and assist through the entire construction process. Occasionally we also conduct tender processes and provide full project management services to some clients. Many of our clients, who are busy providing care to patients, want the project to be completely 'Turn Key' without any hassle or stress, so we manage the constraction as a project project.

AB: How can you be contacted if someone is interested in assistance or a quotation?

RJ: Visit our website or contact us via email for more information.

AB: Thanks Ruth - I have included some of your medical office design images below.

A Complication of Paper Faxes?

Received any recent faxed consultation reports from a colleague or diagnostic imaging reports from your local hospital? Most of these are accompanied by a cover sheet. Great in the paper world, however a real challenge when using an EMR. Cover sheets are very useful at separating one fax from another when multiple faxes are received on a single fax machine. They ensure that critical reports are not mistakenly mixed with other faxed information and make the sorting of these reports more efficient and more accurate. Once the fax is correctly sorted and ready for filing in the paper record, the cover sheet can be discarded, leaving just the important information in the patient chart.

However, this is not as simple a process in an EMR. Many EMRs now used fax modems to send and receive patient information. In the majority of cases, the faxed reports are electronically converted into PDF files which can then be tagged and attached in a patient record in the appropriate section or file folder within the EMR. Electronic snapshots of PDFs can also increase the speed with which one can review multiple documents. A miniature image of a PDF can make it easy to differentiate between the type of document you are seeking without actually needing to open the file. For example, EKG vs. Diagnostic Imaging report vs. specialist consultation. If a PDF has a coversheet (which generally is page 1 of the file), all documents look the same in snapshot view as the coversheet is the first to be presented. Removing the coversheet is not a simple process. Using a PDF document editing program (such as Adobe Acrobat), one needs to open the file and delete the cover page, resave the file and then attach it in the patient record. This is an unnecessary extra step that takes time and requires software and expertise.

As the majority of practices begin to use EMRs, could we dispense with cover sheets entirely as a relic of the paper chart? This will make attaching and viewing PDF files a much simpler and clinically more efficient process in the EMR.

This may seem a logical and easy step, however it will need a methodical action plan, contacting all providers and organizations that send faxes to electronic systems. Then convincing them that the cover sheet is no longer necessary and making the changes to the transmission software to ensure that the cover sheets are removed.

What worked well in paper does not necessarily translate effectively into an EMR-based world of clinical practice.

What do you think? Have you had similar problems with cover sheets? Do they get in the way or can you live with the current format in which faxes are sent and received? Add your thoughts by clicking on the 'Comments' link below.

Too Many Doctors in Canada?

Recently there has been a great deal of coverage in the media regarding the surplus of doctors in Canada. An article in the November 5th Medical Post by Steven Lewis, health policy and research consultant based in Saskatoon and an adjunct professor of health policy at Simon Fraser University, highlights some of these issues. Titled, 'The dawn of the era of a superabundance of doctors', Lewis hypothesizes that provinces could have worked more collaboratively to identify root causes to access problems to care as well as health human resource numbers rather than focus on just numbers of physicians in isolation. Although I have not been a supporter of many of Lewis' views in the past, I do agree with him here. It is in many respects a perfect storm, which includes the changing population demographics and expectations, a shift from acute care to community-based services and rapid outpatient procedures, the growing impact of information technology use by both doctors and patients and the impact of multiple chronic diseases.

Many of these changes have been insidious over a number of years, however the Royal College of Physicians and Surgeons reported recently that 16% (more than 1 in 6) of the country's new specialists and subspecialists cannot find work, while another 31% are pursuing further training in an attempt to become more employable. That's a hard pill to swallow after 12-15 years or more of graduate and post-graduate study. Gone are the days that specializing would guarantee a busy career with guaranteed healthy income from day 1 of clinical practice.

The shift towards collaborative and team-based care has also had a significant impact on the demand for clinical services and the need for specific types of physician and supportive care resources. This has further changed the pattern of practice of many clinicians and the way that communities have planned their physician resource needs. Economists Barer and Stoddard (authors of the infamous 1991 BS report - Toward Integrated Medical Resource Policies for Canada) have also weighed in to the debate.

There is no doubt that we are experiencing a sea change in terms of the way that care is delivered and the resultant mix of medical services needed to meet the needs of the population. Facilitated now by technology in almost every setting, EMRs, EHRs, telehealth, mobile tools, portals (and more), the one missing ingredient that still has to be addressed is patient (or consumer) accountability. The system is changing and the tools and processes are being put into place to facilitate this change, however the weak link is that patients can still utilize an unlimited number of medical services without any need to be accountable for their demands on the system. For Joe Public, the healthcare system is still 'free'. After more than 30 years in clinical practice, I strongly believe that convenience still trumps quality 9 times out of 10. Simply changing the supply side of the equation is not enough. We need a healthcare system in which patients take increasingly greater responsiblity for their health and do so in a way that treats the healthcare system as a precious resource. Is this the impossible dream?

Use of Digital Cameras in Clinical Settings

The widespread availability of digital cameras (standalone, computer-based, in mobile phones) has made images broadly available for entertainment as well as for clinical teaching purposes. However, there are ethical and privacy issues that need to be carefully considered before whipping out the digital camera (or mobile phone) and taking a photo of an interesting skin lesion or post-operative result.

An article on the use of photography in clinical settings was recently highlighted by the CMPA and although the article was written in 2011, the points that are made are even more relevant in 2013 and should be reviewed by any physician who documents patient information using a digital camera.

• Always obtain express consent before taking photographs of patients for clinical or promotional purposes and clearly explain to patients how the images will be used;
• It is advisable to obtain written consent before proceeding. The CMPA article offers a number of useful criteria to include in a consent form;
• Maintain the privacy of your patient's personal health information. This includes both anatomical information that could identify that individual (e.g. facial features, tatoos or other unique skin lesions) and digital information (file naming conventions or image tags). The former is something that most clinicians will easily recognize, however for filing purposes, an image could be tagged with the patient's first and last name. If ever uploaded on a public website, even if the anatomical identifiers are avoided, Google is incredibly efficient at indexing names and images. Using an individual's first and last name, one could be unpleasantly surprised to be presented with images of that individual doing a simple Google image search;
• Another caution. When embedding images in presentations, remove all personally identifiable information from the original files before sharing the presentations.

It may take a little more effort up front, however this is part of the due diligence necessary when dealing with sensitive patient information.

Future Practice — September 2013

The latest issue of Future Practice explores the changing world of eHealth, provides an overview of the current and potential future state of provincial EMR funding programs, and looks at how doctors are using Twitter. Dr. Steve Hawrylyshyn and Dr. Naheed Dosani discuss the need for eHealth competencies from the resident physician perspective. Edited by Pat Rich, Future Practice provides an insightful view of topics that are at the leading edge of traditional clinical practice.

Highly recommended reading!

EMR Proficiency — Have You Received Enough Training?

EMRs are complex software applications. The basic capabilities, such as clinical documentation, writing a prescription, and viewing lab results, are generally easy to use — but what about the more sophisticated functions? Think about your formal EMR training: was it limited to 1–2 days at the time of EMR implemention or have you subsequently received additional training? For the majority of EMR users, the likelihood is that the former is true. What this means is that there are many features you may be blissfully unaware of in your EMR. Some of these may be shortcuts or new ways of performing certain tasks that could save you and your staff hours per week. Each hour saved means $$ in your pocket.

Some of the ways that physicians and their practice teams keep up with the advances in their EMR are through annual user conferences or by setting up a local user group where one of the members of the team presents to the others on a certain functionality and essentially becomes the teacher for that particular capability. Alternately, each practice is recommended to have a super-user. This is someone who has received additional training to use the EMR and is able to answer questions and troubleshoot without the need to contact technical support. The super-user can be a physician, nurse, or administrative staff member — essentially anyone who has an interest and can take on and maintain this responsibility. Over time, by having additional expertise onsite in your practice, the benefits will be significant — not only financially, but also in terms of reduced stress when unexpected problems occur.

Vendors are continually enhancing their products. As provinces evolve beyond provincial certifications for EMRs (other than the ability for systems to share information more effectively), this process will accelerate. The reason for this is simple. With EMRs becoming ubiquitous in medical practices, and as the technology matures, the competition for new clients and to retain existing clients will intensify. The best products will begin to differentiate themselves through enhancements to usability, design, and functionality. In the not-too-distant future, all products will be able to do all basic functions, but the more advanced functions will frequently be the key differentiators. How will you keep up if you do not receive training on an ongoing basis? Another important reason to update your in-office training is staff turnover. Physicians join and leave practices, staff come and go, and frequently these users are not effectively trained to use the EMR beyond the basic functions. Often the trainer is someone who learned from someone else within the practice, resulting in the duplication of any poor processes that were passed on to that individual.

There is no getting away from the fact that ongoing training has a cost. At the same time, why would you invest all of your time, energy, and money into a tool that you use every day of practice and yet only use a small part of the functionality? Or have developed time-intensive workarounds for tasks for which there may be a simple solution?

Your EMR is a tool that needs to be effectively used. In order to do so, it is to your benefit to keep up to date with new features and functions beyond the quarterly update bulletin that your vendor sends out. Do yourself and your practice a favour: contact your vendor and arrange a training session. This is an investment that will pay for itself multiple times over, both in terms of time savings and costs.

Is Data Exchange Being Held Back by Paper?

Fax technology slotted in perfectly with paper processes and quickly revolutionized the way that information was communicated. Within a few years of introduction, fax machines were cheap, good quality, and virtually ubiquitous. However, because they were so successfully adopted, faxes also created dependencies in terms of the way that organizations shared information between one another.

In a report by Healthcare IT News, a new study by HIMSS Analytics examined the current state of information exchange among U.S. hospitals and found that if a hospital was not participating in a health information exchange (HIO), 64% of data sharing was conducted via fax. In addition, 63% of the same HIOs processed faxed information into an electronic format via scanning. This is a common phenomenon in physician offices. Reports and related information are transmitted between practices by fax. In those practices, running EMRs, if the faxes are not received electronically using a fax modem, they are scanned into the EMR setting up a repetitive cycle of printing and digitization.

Achieving widespread information exchange means getting beyond the “if it ain’t broke, don’t fix it” thinking that is also prevalent. The first prerequisite is that a viable information exchange option exists; the second, that one is willing to give up existing dependable processes that are an integral part of workflow. Despite producing a lot of paper, fax technology is very efficient and dependable; however, there are ways to integrate faxing effectively into an electronic workflow. If you are not yet using a fax server with your EMR software, or even standalone, this should be seriously considered. In a 2012 article on CanadianEMR, “Do You Need a Fax Server for Your Practice?” this topic was covered in some detail and is well worth reading.

Bottom line: Because we do not yet have widespread data interoperability between different EMRs and between multiple providers and sites within the healthcare system, faxing will likely be around for some time. The best strategy is to optimize your existing setting, integrate electronic faxing into your workflow process, and be prepared to transition tasks that currently require fax technology once other sites are set up for different forms of data exchange.

Medical Legal Aspects of Telehealth

The September issue of CMPA Perspective includes an insightful article on the exciting new world of telemedicine, how the use is proliferating, and what needs to be considered in terms of jurisdictional licensing, standards, patient consent, and privacy. Telehealth (or Telemedicine) is becoming mainstream as a result of widespread use across multiple geographies and reimbursement fees that are being developed as the efficiency of providing care at a distance becomes better established.

However, as in other areas of medicine and care delivery, a change in clinical process can lead to new and unforeseen issues that need to be addressed. Jurisdictional differences exist between provinces with respect to privacy, policy, record keeping, and licensing requirements — and demand careful consideration before proceeding. In addition, the patient’s location is critical when determining whether a physician is eligible for medical legal coverage in the event that an action is initiated. It is important to be fully conversant with the regulatory and medical/legal requirements in your province or jurisdiction before proceeding.

In a 2004 article in the BC Medical Journal titled “Legal issues confronting 21st-century telehealth”, lawyer Gary Dunn identified many of these same issues that are referenced in the CMPA piece. Considering it was written 10 years ago, Dunn’s article was forward thinking and insightful.

As telehealth consultations become more commonplace and integrated with electronic medical records, it is important to consider whether there are medical legal risks to be identified based on specific populations of patients or geographic location. If you are unsure, contact the CMPA or your provincial licensing body for assistance.

Best Practices — Converting from Paper to EMR

Converting paper charts during EMR implementation is generally seen as one of the greatest barriers to switching over a practice. Chart conversion is a time-consuming and resource-intensive task; however, there are several things your practice can do to help shorten and reduce the pain of chart conversion. In order to maximize the benefits of your EMR, you will need to pre-populate the record with important clinical and demographic information. The following simple steps will improve your successful transition from paper charts to an EMR.

Develop a plan that both indentifies the process you will use to capture the information from your paper charts and establishes realistic timeframes within which to complete the process. Consider 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. Not only is this expensive, but also it can end up corrupting the data in the new system.

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), consult letters, immunizations, screening test dates/results, and advance directives.

Here are some tips and best practices 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.
• If you have more than one physician in your practice, it is important to agree upon a single standard paper template to collect this information. This will allow you and your staff to pre-populate summary information and makes the data you may want to transfer to your EMR more readily accessible and faster to input into your EMR. It also gets you and your practice used to documenting your patient visits in a structured manner that will likely be similar to most EMR systems.
• 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.
• When choosing how to enter the data, remember that discrete information such as immunizations or labs, if entered as a .pdf or TIFF file will not populate any of the data fields in your EMR. As a result, any alerts in your system will not be reflected in this data.
• 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 clear 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.