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On Oct. 2, 2010, a group of EMR experts convened at the University of Waterloo for a workshop focused on these ques- tions. The event gave the participants — including EMR-savvy physicians from Kitchener-Waterloo and the surrounding region of southwestern Ontario as well as other EMR stakeholders — a forum for open debate about key challenges and opportunities. Individual presentations and group discussions culminated in specific recommenda- tions for local and governmental action. The following report highlights the workshop’s key discussion points and outcomes. Organized by the Rogers Healthcare Group in partnership with the National Institutes of Health Informatics and the University of Waterloo, the event was sponsored by HP Canada, Nightingale Informatix, the Ontario Medical Association and Practice Solutions. The benefits of EMR: First-hand experience Dr. Sonny Cejic described how, in 2009, his prac- tice implemented an EMR system for scheduling/ billing and clinical documentation. “In just one year, he said, “I can confidently state that EMR has resulted in improved quality of care.” He outlined some specific improvements: • Thanks to the medical interaction checking fea- ture, he can be certain about whether a drug he is thinking of prescribing interacts with other drugs a patient may be taking. • He can put alerts on a patient so that important information (e.g. drug allergies) appears whenever the chart is opened. The system can be set up to give different levels of alerts so “information overload” doesn’t occur. • He can put recalls in the system so that, for ex- Dr. Sonny Cejic WHILE ELECTRONIC MEDICAL RECORDS (EMR) HAVE CERTAINLY GAINED GROUND IN CANADIAN MEDICAL OFFICES, THE VISION OF FULL EMR IMPLEMENTATION IN CANADA IS STILL FAR FROM REALITY. IN FACT, CANADA RANKS LAST AMONG COMMONWEALTH COUNTRIES IN TERMS OF ADOPTION AND USE OF EMR BY DOCTORS. WHAT’S STOPPING EMR FROM REACHING CRITICAL MASS IN THIS COUNTRY? WHAT CAN BE DONE TO ACCELERATE THE PROCESS? Adoption 100% NL NZ NO UK AU IT SE DE FR US CA * - % reporting at least 9 of 14 clinical IT functions Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Use * EMR USE AND ADOPTION IN INDUSTRIALIZED COUNTRIES Accelerating EMR adoption and use Why are Canadian physicians so reluctant to embrace the benefits of electronic medical records? We assembled a group of EMR experts to explore the reasons and suggest ways to overcome them Participants Moderator: Michael Martineau, consultant and columnist on electronic health issues Dr. Sonny Cejic, physician, London Dr. Mel Cescon, physician, Kitchener Sam Chebib, president and CEO, Nightingale Informatix Andrew Chun, business development manager, Personal Systems Group, HP Canada Dr. Chris Cressey, physician, Palmerston Shirley Fenton, director, National Institutes of Health Informatics Gary Higgs, integrated CIO, Grand River and St. Mary’s General Hospitals, Kitchener Sarah Hutchison, executive director, information management, Ontario Medical Association Dr. James Kavanagh, physician, Cambridge Kirk Miller , manager, Guelph Family Health Team Matt Pavlik, manager, sales, MD Physician Services Norman Shaw, Ted Rogers School of Management, Ryerson University Graham Strong, OD, professor, School of Optometry, University of Waterloo SPONSORED EVENT REPORT

SponSored event report Accelerating EMR adoption and use

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➡On Oct. 2, 2010, a group of EMR experts convened at the University of Waterloo for a workshop focused on these ques-tions. The event gave the participants — including EMR-savvy physicians from Kitchener-Waterloo and the surrounding region of southwestern Ontario as well as other EMR stakeholders — a forum for open debate about key challenges and opportunities. Individual presentations and group discussions culminated in specific recommenda-tions for local and governmental action. The following report highlights the workshop’s key discussion points and outcomes.

Organized by the Rogers Healthcare Group in partnership with the National Institutes of Health Informatics and the University of Waterloo, the event was sponsored by HP Canada, Nightingale

Informatix, the Ontario Medical Association and Practice Solutions.

The benefits of EMR: First-hand experienceDr. Sonny Cejic described how, in 2009, his prac-tice implemented an EMR system for scheduling/billing and clinical documentation. “In just one year, he said, “I can confidently state that EMR has resulted in improved quality of care.”

He outlined some specific improvements:• Thanks to the medical interaction checking fea-ture, he can be certain about whether a drug he is thinking of prescribing interacts with other drugs a patient may be taking.• He can put alerts on a patient so that important information (e.g. drug allergies) appears whenever the chart is opened. The system can be set up to give different levels of alerts so “information overload” doesn’t occur.• He can put recalls in the system so that, for ex-

Dr. Sonny Cejic

WHIlE ElECTRONIC MEDICAl RECORDS (EMR) HAvE CERTAINly GAINED GROUND IN

CANADIAN MEDICAl OffICES, THE vISION Of fUll EMR IMPlEMENTATION IN CANADA IS STIll

fAR fROM REAlITy. IN fACT, CANADA RANKS lAST AMONG COMMONWEAlTH COUNTRIES IN

TERMS Of ADOPTION AND USE Of EMR by DOCTORS. WHAT’S STOPPING EMR fROM REACHING

CRITICAl MASS IN THIS COUNTRy? WHAT CAN bE DONE TO ACCElERATE THE PROCESS?EMR Use and Adoption in Industrialized Countries

Adoption

100%

NL NZ NO UK AU IT SE DE FR US CA

* - % reporting at least 9 of 14 clinical IT functions

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

90%80%70%60%50%40%30%20%10%

0%

Use *

EMR UsE and adoption in indUstRializEd coUntRiEs

➡Accelerating EMR adoption and useWhy are Canadian physicians so reluctant to embrace the benefits of electronic medical records? We assembled a group of EMR experts to explore the reasons and suggest ways to overcome them

Participants• Moderator: Michael Martineau,

consultant and columnist on electronic health issues

• Dr. Sonny Cejic, physician, London

• Dr. Mel Cescon, physician, Kitchener

• Sam Chebib, president and CEO, Nightingale Informatix

• Andrew Chun, business development manager, Personal Systems Group, HP Canada

• Dr. Chris Cressey, physician, Palmerston

• Shirley Fenton, director, National Institutes of Health Informatics

• Gary Higgs, integrated CIO, Grand River and St. Mary’s General Hospitals, Kitchener

• Sarah Hutchison, executive director, information management, Ontario Medical Association

• Dr. James Kavanagh, physician, Cambridge

• Kirk Miller, manager, Guelph Family Health Team

• Matt Pavlik, manager, sales, MD Physician Services

• Norman Shaw, Ted Rogers School of Management, Ryerson University

• Graham Strong, OD, professor, School of Optometry, University of Waterloo

SponSored event report

ample, a reminder about a colonoscopy appointment appears in two years.• He can see test results even when on call or on weekends, resulting in better triag-ing/treatment decisions.• It has become easier to mine data for research purposes (for example, to calcu-late the average A1C level among diabetic patients to determine how they measure up against current standards).• Enhanced teaching capacity: he can easily send notes to learners to explain, for example, why a certain chart was not properly completed.

Administrative benefits include the following:• With legibility no longer an issue, there are fewer callbacks from pharmacists.• Multiple providers can access and enter data into patient charts at the same time.• There are no more problems with lost charts or reports.• Electronic review and sign-off of results are faster than with the previous paper-based system.• Paper-based filing and chart pulling has decreased to very low levels.• Medical information can be easily transferred to other parties (e.g. insurance providers).• The EMR system is more secure than paper-based charts.• Documentation in Dr. Cejic’s three family medical centres has become more uniform.• Fewer clerk hours are needed for billing, which saves costs.

The transition to EMR was accom-panied by a few predictable challenges, Dr.Cejic said. Entering data from old charts into the new system takes time. There is a learning curve and, for some learners, a certain amount of resistance. Many of these challenges can be sur-mounted by enlisting “super-users” to help other users become competent and confident about using EMR.

Lessons learned from early EMR experiencesOnly one-third of the 28,000 physicians practising in Ontario have adopted EMR, noted Kirk Miller, who manages the business operations of a 48-doctor family health team. The fact that 24% of Ontario physicians are over 60 may have some-thing to do with this low adoption rate. As they near retirement, some doctors may be more hesitant to radically change their way of doing things.

barriers faced by such practitioners include the technical aspects of EMR, doubts about clinical utility, certification, incompatibility between systems, and resource/training issues. The only way to surmount these barriers is to address the practice issues that matter most to them: • The stress of practicing medicine.• The financial aspects of practice.• The welfare of patients.

The meaningful use of EMRA large discrepancy currently exists be-tween the rate of EMR adoption and the level of meaningful use, said Dr. Mel Cescon. Getting the full benefits of EMR requires using the system beyond basic functions such as scheduling and billing.

Some medical practices choose to re-tain some of their old paper-based systems after adopting EMR. Dr. Cescon’s family health team decided to transition to a fully paperless environment. “Giving up the ‘security blanket’ of paper forces people to

What happened to the vision?Dr. James Kavanagh: “Four years ago, we had a meeting in which we articulated a vision that all EMR vendors would have a way of communicating — a central repository in which data could be stored and synchronized. The vision got snuffed out at the governmental leadership level.”

Dr. Sonny Cejic: “I believe it will still happen, but we need to reach that critical mass, which we obviously haven’t done yet.”

Gary Higgs: “One way or another, the linkage between family health practices and hospitals needs to be more seamless and fluid, whether through a central repository or some other means.”

Shirley Fenton: “Our governments could help drive the process forward by funding health informatics programs at the college or university level.”

Michael Martineau: “We have not done a sufficiently good job articulating the benefits of EMR. We need to move the discussion beyond straight cost-benefit and talk about the level of patient care enabled by EMR.”

Persuading the non-users: Suggestions from the workshop • Mention that EMR will increase their chances of interesting a successor to their practice.• Go over the figures from cost-benefit analyses.• Point out how the system makes things much easier from a medico-legal perspective, as it keeps track of all transactions.• College audits are much simpler with EMR than with paper-based systems.

Dr. James Kavanagh

Gary Higgs

Shirley Fenton

Kirk Miller Dr. Mel Cescon

change the way they work, and I believe this is where the real efficiencies accrue,” he said.

“One of the most useful things enabled by our EMR system is patient education. With a few clicks, I can create a graph based on a patient’s cholesterol levels. Such visual snapshots add greatly to the impact of discussions with patients. I can send the data to a team dietitian, with a note requesting suggestions for improving the patient’s lipid profile. The system is also searchable, enabling us to access, for example, all information pertaining to a patient’s knee.

“We have designed our EMR system so that pharmacists have limited access to patients’ profiles. I can send prescription repeats to pharmacists with a digitized signature. The system also allows me to access a database of ‘prescription favou-rites.’ for instance, I can call up my ‘go to’ drug for malaria prophylaxis, which saves on inputting time.”

Dr. Cescon and his colleagues decided to make patient charts accessible to all health providers on their team and have people sign confidentiality agreements,

rather than setting privacy levels to limit access. He said he is confident that this transparent approach helps foster trust and teamwork.

Toward an action plan: Drivers and barriersWorkshop moderator Michael Martineau explained that on a population basis, the adoption and use of new technology fall into a distinct pattern (see diagram below). Innovators and early adopters tend to ap-proach new technology with a mindset of “why not,” while laggards generally do without the technology — or wait until they can no longer do without it. In between these two extremes lie approxi-mately two-thirds of buyers, whose habits are more amenable to change:

• The early majority (pragmatist) buy-ers tend to focus on proven applications. They are liable to choose products from market leaders, insist on strong references, and request demonstrations of the product being considered.

• The late majority (conservatives) are motivated by the desire to keep up with their peers and/or competitors. As a group,

The pattern of technology adoption

• Pragmatists• Focus on proven applications

• Likely to choose products from the market leaders

• Insist on strong references

• Want to see the product in use

• Conservatives• Stay even with competitors or peers

• Highly risk-averse

• Extremely price-sensitive

• Need “out of the box” solutions

2.5%Innovators Early

Adopters13.5%

Early Majority34%

Laggards16%

Late Majority34%

thE pattERn of tEchnology adoption

➡Getting doctors to ‘drop the clipboard’Dr. Chris Cressey: “We should use real-life examples from our own experience to show other doctors how EMR can bring about a different level of care by virtue of its ability to identify practice trends and gaps.”

Sarah Hutchison: “The OntarioMD program has listened to physician feedback about the importance of change management. Staff are now focused on helping doctors with this aspect of EMR adoption. Canada Health Infoway has also invested more money in peer leaders.”

Sam Chebib: “The vendor community has to innovate enough that adoption becomes easier from a change manage-ment perspective, and we have to be prepared to demonstrate a true return on investment. Right now we’re putting the burden on doctors and excusing vendors from opening up the market.”

Norman Shaw: “Ease of use is paramount. Classic academic research has consistently shown that if the product is user-friendly and has benefits, it will be used.”

Kirk Miller: “We need to have a clinically knowledgeable person who can go out and make the business case to doctors. The approach of sending ‘facilitators’ to do the job has been tried and didn’t work.”

Dr. Sonny Cejic: “It might make sense to give doctors who use the system effectively some kind of bonus.”

Dr. Chris Cressey

Sarah Hutchison

Sam Chebib

Michael MartineauDr. Mel Cescon

Norman Shaw

Who’s putting the brakes on EMR?Dr. James Kavanagh: “To my mind, the proportion of laggards among doctors is much higher than the 16% touted as the population average. Many doctors are happy with their current status and see EMR as a hassle. They’re making a lot of money and don’t think anything needs to be fixed.”

Matt Pavlik: “Currently, half of the doctors in a family health group have to agree on an EMR product in order to receive a government subsidy. This requirement is counterproduc-tive, as many of these practices consist of doctors who share call but otherwise work independently. They want to make their own decisions and don’t have the need or desire for a shared system.”

Dr. Sonny Cejic: “I think the biggest roadblock is perceptual. Doctors see EMR as more work and don’t understand how it saves them time. They need to be shown, with hard data and evidence, how an outlay of 2% [of office costs] can increase productivity by 5%.”

Graham Strong: “There has been disproportionate — and unhelpful, I believe — preoccupation with practice management issues. We need to keep the focus on quality and standards of care.”

Kirk Miller: “If patients knew they were not getting bang-for-buck with paper-based systems, the cost of EMR ownership would fall. Patients need to be informed about the value of EMR, so they vote with their feet by choosing doctors who have it.”

Andrew Chun: “There needs to be an infrastructure — an ecosystem, as it were — such that doctors who may be interested in adopting EMR have the steps laid out for them in a logical and user-friendly sequence.”

they tend to be risk-averse and extreme-ly price-sensitive. They seek a product that “works out of the box.”

The habits of the late majority can determine whether a new technology stalls or reaches critical mass. barriers to EMR adoption include:• Cost (purchase, implementation, operation).• Lost productivity and impact on workflow.• Small practice size.• Perception of inadequate return on investment.• Satisfaction with current paper-based system (if-it-ain’t-broke-why-fix-it syndrome).• Lack of EMR products that meet individual practice needs.• Confusion about the array of products on the market.• Lack of expertise (computer skills, project management) with EMR.• Security and privacy concerns.• Imminent retirement.

A lot of these barriers, Martineau said, can be distilled to fear on the part

of physicians: fear of change, fear of being unable to master the technology, or fear of looking incompetent in front of patients. The fact is, doctors who take the leap into EMR are unanimously satisfied and would never consider going back to paper. It’s the transition that scares them. before tackling such issues as interoperability, he said, we need to focus on how to ease the transition for doctors. Once that problem is solved, the free market will look after the rest.

Toward an action plan: RecommendationsThe workshop drew to a close with a group discussion about how to develop an action plan that would help accelerate EMR adoption and use by physicians. A summary of the key conclusions:• Priority adoption needs: Articulat-ing the value proposition, addressing fear, clarifying the roadmap at the gov-ernmental level.• Priority use needs: leadership, men-torship, explaining the value of mean-ingful use. ■

Organized by

in partnership with

Key reCOMMeNDAtiONS FOr eMr ADOPtiON AND MeANiNGFul uSe

For vendors For policy-makers For peer leaders/mentors

• Explain how the system helps manage doctors’ caseload and fits into their workday.

• Dispel the myth that EMR systems are not useful or cost-effective for solo practices.

• Tackle the cost issue head-on and make a stronger business case.

• Continue to innovate with ease of use in mind.

• Explain how the system helps manage doctors’ caseload and fits into their workday.

• Dispel the myth that EMR systems are not useful or cost-effective for solo practices.

• Tackle the cost issue head-on and make a stronger business case.

• Continue to innovate with ease of use in mind.

• When communicating the benefits of EMR, keep the focus on key physician concerns: time, money, patient care.

• Provide extra support to doctors and other staff during the transition period.

• Teach EMR in “layers,” starting with basic clinical functions.

• Launch awards program for clinics with the best use of EMR.

• Publicize individual success stories and challenges in various media to raise physician and public awareness.

Sponsored by

®

Andrew Chun

Graham Strong

Matt Pavlik