Five reasons your family doctor isn’t using EMR

IDG News Service — Thu, 02 Jul 2009 13:35:12 -0400

Roughly 30 per cent of family physicians in Ontario utilize electronic medical records (EMRs), according to OntarioMD Inc., a subsidiary of the Ontario Medical Association (OMA) funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC).

OntarioMD recently completed phase one of its Physician IT project, which provided EMR funding to 3,000 out of an estimated 10,500 family practitioners in Ontario.

"It's about 30 per cent," said OntarioMD CEO Brian Forster. About four million Ontarians would be covered by those emergency medical records, which is approximately 25 per cent of patients, because roughly one million patients in Ontario don't have family physicians, he explained.

Despite recent funding scandals related to eHealth programs in Ontario, OntarioMD exceeded its target for the $150 million it received in government funding, noted Forster.

"The initial program we've executed over the last four years had a limited amount of funding. That funding was actually targeted at 2,900 physicians, but we were able to fund 3,000 because of the way we were able to optimize what we've done during those four years," he said.

OntarioMD is currently in discussions with eHealth Ontario, which is now responsible for a number initiatives from the Ontario Ministry of Health and Long-Term Care, for funding that will support the next phase of the program over the next three years.

Under the old program, which expired in August 2008, physicians were eligible for a maximum $28,600 to implement an EMR system. "The new number hasn't been finalized at this point and once it has, which we are hoping will be shortly, it will be announced," said Forster.

But there are still obstacles to widespread adoption.

Cost and funding

Cost is still the major obstacle to EMR adoption for physicians, according to Dr. Stephen McLaren, a family physician based in Markham who belongs to an 18-physician group that began developing an EMR system in 1998.

The funding that was sent out was only partial, he pointed out. "It does not completely pay or continue to pay for what you need to do, so it's nice to receive that partial funding, but I don't think we should mix it up with it being complete funding because it's not," said McLaren.

Physicians looking at EMR realize there are a lot of costs outside the funding envelope, so they are going to have to make a business case for it, he said. "For some people, they find it a difficult business case to make, although in our case, we live the value of EMR and it has been a very good investment for us," he said.

Another problem lies within the old funding model itself, according to McLaren, because it went to two different styles of practice and physicians had to align their offices with a payment scheme in order to receive the funding.

"So there's two change management pieces that happen at once," he said. "I'm not sure if in the second round of funding they will remove that obstacle or not," he said.

Limiting funding to family physicians has contributed to interoperability problems, such as a lack of intercommunication between family practices and specialists, according to Moshe Pinhas, president of Toronto-based clinical management system software provider P&P Data Systems Inc.

"The funding should be more uniformly distributed to those who want to implement it as opposed to practice or specialty ... we don't have funding in the province, for example, for specialists so specialists aren't automating it at the same rate as the family physicians," he said.

But Forster suggested looking at the objectives behind the funding.

"By 2015, they wanted Ontarians to have electronic medical records. The whole premise of the initial phase of the program was to target family health teams who are working with large bases of patients. If we get the family physician automated first, we then get records for all the patients electronically and then when we start to hook the specialist up, we've got the record that the GP then refers to them," he said.

OntarioMD doesn't expect this limitation will exist in the next phase of the program.

"The first phase was really just to prove the investment was a sound one, which I think we can definitely demonstrate because of the survey we did last year. As well, there are solutions other than just EMRs that are quite appropriate and are very suitable to specialists as well, so they may not need an EMR per say, although they need an electronic tool in order to exchange the information between the GP and the specialist," said Forster.

Workflow and training

While funding is a barrier to EMR adoption for physicians in Ontario, Forster said another large obstacle is the change to the way they practice.

"Physicians use paper records at this point. Changing to electronic medical records means there is an impact to the workflow in their office, so reengineering that workflow is a key aspect of the functionality of the EMR," he said.

OntarioMD is working on improving the circuit deployment so physicians can get the EMR up and running faster as well as training physicians on how to use them productively, he noted.

Part of OntarioMD's Transition Support Program is the Peer-to-Peer Network, which was established by Canada Health Infoway and OntarioMD along with the Ministry of Health and Long-Term Care to connect physicians with colleagues to support their adoption of EMRs.

"The network is composed of peer leaders who are physicians experienced in using electronic medical records to improve practice efficiency and patient care. Peer leaders are mentors who support their physician colleagues in selecting and implementing an EMR system," said Canada Health Infoway.

The Transition Support Program and Peer-to-Peer Network are very good projects, according to McLaren. "But the person still has to roll up their sleeves and do the end work as far as implementing ... there's a fair bit of work there and as you know work means you've got to devote some time, and getting time from physicians is a real challenge," he said.

Providing incentives for physicians to use EMR systems is a critical part of the process, according to Pinhas. "The question has always been whether or not doctors view EMR as having a reward or not," he said.

Another major obstacle, according to Pinhas, is that doctors don't realize the workflow benefits. Electronic systems eliminate errors and call backs from the pharmacists, for example, which reduces the interruptions in the day of the physician, he pointed out.

"Physicians are by and large in the business of providing professional time," said Pinhas.

EMR has to either help physicians treat patients better in the same amount of time or allow them to reduce the amount of time to treat patients at the same level of care or provide more time to increase the patient load, he suggested.

OntarioMD doesn't have numbers on whether EMR systems increase the number of patients doctors can see in one day. "What we've been hearing is that's not the issue," said Forster. "They aren't looking for this productivity boost, but better healthcare. What they're able to do when they're a team is work more effectively with the team."

In a survey of physicians using EMR through funding from OntarioMD, 68 per cent of physicians said their patient safety had improved, 62 per cent said continuity of care improved and 57 per cent reported an increase in the quality of care, Forster pointed out.

Benefits include the ability to monitor patients, such as when patients are due for annual tests; access to patient records remotely and securely, for example, when located in a hospital performing specialist work; and submission anonymous patient information for research, which helps identify preventative care.

Who gets what

The question is whether or not you want to speed up EMR adoption, said Pinhas. "I think overall there needs to be a step back in terms of what the system provides to physicians and increasing that," he said.

While EMR provides benefits to doctors, the majority of the benefit of using the EMR flows to the system and not to the individual physician who is required to purchase and use them, according to Pinhas.

What often happens is government wants EMR to take care of things like increasing emergency visits and problems with drug interaction, which the physicians would agree with, but the individual benefit to the physician's office from a workflow standpoint has to be looked at, he said.

"Studies we've seen suggest that the system in general benefits about 70 per cent and the physician benefits about 30 per cent. The reason for that is the health information is captured at the point of care, which is in the physician's office. Most patient visits are done to the community physicians, so it's captured and then sent in an electronic format to all the other health-care providers that want to use it as well as for secondary use" like research, Forster said.

Interoperability

"Some physicians won't proceed forward with an EMR unless their hospital is going to transmit all the data stored in the hospital system. But for a hospital to actually send out the data, they need a fairly expensive interface," said Pinhas.

A number of systems don't communicate with each other and there are a number of standards that exist but haven't been adopted, he said. Doctors are not willing to use an EMR if 60 to 70 per cent of the information they receive is still on paper.

"There are a lot of chicken-and-egg problems," said Pinhas.

More than 90 per cent of physicians are using EMR to write and renew prescriptions, which is a huge benefit because it does drug-to-drug interaction and allergy checking, Forster noted. But hospital discharge summaries, consultations, requests and reports among physicians are for the most part still paper-based, he said.

Efforts are underway to change this. OntarioMD is currently working with RVH and the Barrie Family Health Team to define an interface, which will provide more value as they plan to implement further abroad later this year, and two EMR projects being used for early adopter prescribing are taking place at Sault Ste. Marie Group Health and the Georgian Bay Family Health Stream, he pointed out.

"If you take a look at other countries, the physicians have adopted it more because they do get hospital discharge, they are able to get the lab results -- which is what OLIS is -- they are able to do referrals and they are also able to do electronic prescribing completely as well. We have a lot of the benefit of the prescribing, but it doesn't fully get delivered to pharmacies today," said Forster.

The Ontario Lab Information System (OLIS) is one example of a large-scale project that has tremendous benefit to physicians who use EMR, but the project is several years behind schedule, Pinhas pointed out.

OLIS would allow physicians access to all patient lab data, regardless of which lab did the work and whether it occurred in a hospital or public lab, whereas right now, they have to establish a one-on-one relationship with each individual lab in order to get the data transmitted, Pinhas explained.

"Expediting [OLIS] would say to a physician, 'Now my external data is all coming to me electronically. I really need to get going on this computer thing,'" he said.

McLaren's group heard about OLIS years before they implemented EMR in the 90s. But more than a decade later, there's still no deliverable on the project to EMRs in the community, he said.

"In the last few years, they've been accepting labs from hospitals and from private labs and making a central repository, but it's not a functional interface down to EMR, so that many people who do implement their EMR have a real difficult time actually getting electronic lab data to flow into the EMR," said McLaren.

Selecting the right EMR system

Another major obstacle, according to McLaren, is choosing the right EMR system. This requires defining needs, what problems the EMR is going to solve, and what processes must evolve in terms of workflow and actually getting value from the system, he explained.

"That whole problem-solving exercise becomes a big obstacle for most groups," said McLaren. "They get a little lost in the technical presentation of EMR and the glitz and the sexiness and very often lose sight of how they are trying to solve the problems of the paper world with electronic medical records so they can deliver better care."

One large challenge for a group practice in the paper world was keeping the filing up to date, said McLaren. "If a computer prints out a piece of paper and they send the paper to us and we put it back in our computer, that's not acceptable. We wanted other computers to populate our electronic medical records," he said.

McLaren's group interfaced with a local hospital and a local lab, which allows the group to receive lab results in near real-time and have patient records automatically updated every two hours. "The computer in the hospital pushes out all that data to me and our computer system pulls it in and electronically files it with a little pass through our electronic in basket to sign off on all the incoming data," he said.

"We've done our best not be an electronic island in a sea of paper. Unfortunately, I think we are quite unique in Ontario and in Canada. The ability to do what we've done -- there's far too many obstacles for most people to overcome," said McLaren.

Pinhas anticipates a lot of success by 2015 and a considerable amount of adoption. "But I think it's because the physicians will see a benefit to EMR, not so much because of the funding models that exist," he said.

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Five reasons your family doctor isn’t using EMR