e-health and Family Medicine 0 Discussion Document: e-health and Family Medicine

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1 e-health and Family Medicine 0 Discussion Document: e-health and Family Medicine Contact: M. Janet Kasperski, RN, MHSc, CHE Chief Executive Officer THE ONTARIO COLLEGE OF FAMILY PHYSICIANS 357 Bay Street, Mezzanine Toronto, Ontario M5H 2T7 Tel: (416) Fax: (416) jk_ocfp@cfpc.ca Website: May 1, 2008

2 e-health and Family Medicine 1 From the Family Physicians Perspective the Electronic Medical Record is Mission Critical Prepared by the Members of OCFP s Information Technology Committee under the able leadership of Dr. David Dixon (London, Ontario)

3 e-health and Family Medicine 2 INDEX 1.0 Facts Perceived Benefits Barriers and Potential OCFP Responses Apparent Lack of an e-health Strategy Limited Access to MOHLTC Subsidies Lack of Support for IT Implementation Difficulties in Choosing the Appropriate System Capital Upgrades Concerns Regarding Practice Disruption Group Decision-Making/Team-based care Technical Issues Cumulative Patient Profile/Diagnostic Coding Practicing What We Preach Diabetes Registry Our Main Message...9 Appendix A: The Commonwealth Fund: 2006 International Health Policy Survey of Primary Care Physicians in Seven Countries...10 Appendix B: Key Reference Documents...11

4 e-health and Family Medicine Facts: 1. The National Physician Survey reported the following: 18% of Canadian physicians were using an EMR in This rate had increased to 26% by 2007; however, the NPS did not determine if the user had an EMR vs. using 7 or more key features of EMR. 2. The 2006 Commonwealth Fund Survey rated Canada as having the lowest number of physicians having an EMR (23% report having an EMR; 6% report using 7 or more key features). (see Appendix A) 3. The Ontario Hospital Association is calling for an ambitious, comprehensive e-health Strategy having recognized that a dramatic expansion in the use of information and communication technology is crucial to ensuring the success of health system transformation. (Inspiring Health Care Innovation; OHA November 2006) 4. The business case for the EMR has been made already. It is thought that an EMR brings 2-4 times return on investment for the healthcare system. For the individual physician, it is probably cost neutral to slightly cost beneficial within 2 years. 5. The position paper EMR Implementation in Ontario (see Appendix B) provides an analysis of the reasons for the slow uptake in Ontario. 2.0 Perceived Benefits The perceived benefits are as follows: 1. Improves access with innovative scheduling and succinct visits. 2. Enhances continuity of care and information sharing, especially with labs, hospitals, pharmacies (lower possibility of drug abuse). Ability to embed train of thoughts into narratives. 3. Saves lives and decreases the likelihood of prolonged hospitalizations with drug management programs and inter-provider communication. 4. Provides for the possibility of one location for all the patient s records. 5. e-health/emrs are enablers for chronic disease prevention and management (CDPM). If well-designed, EMRs provide the tools that are needed for effective CDPM, other preventive and quality improvement activities. 6. Supports better patient care, increased patient volumes, improved decision-making, workflow, and quality of work life. Timely access to data, meaning having the patient s data at the point of care enables better provision of service, better use of patient and provider time. Having rapid access to data improves continuity of thought without degradation of process inherent with delay in data availability. 7. Most of the benefits accrue from sharing information among health care providers. The benefits from EMRs are limited when restricted to a local provider setting.

5 e-health and Family Medicine Barriers and Potential OCFP Responses The barriers and potential OCFP responses are as follows: 3.1 Apparent Lack of an e-health Strategy While some funds have been made available for individual practices (first and foremost, FHOs, FHNs, and FHTs), they have been allocated with little emphasis on interoperability. The original planning process failed to include a plan and a requirement to ensure that the practices were able to communicate electronically. As an example, practices within a FHT may not be able to communicate with one another. In addition, a plan has not been developed to encourage effective communication between primary care settings and hospitals, CCACs or other provider agencies. Even the most introductory use of an EMR is thwarted by a lack of support, planning and incentives. Neither hospital nor community-based laboratories have been provided with incentives to communicate electronically with their major users. Ontario s laboratory forms have been revised three times in the past two years, resulting in added burdens on those physicians whose EMRs have the capabilities of printing directly onto the form. In addition, hospital budgets rarely include funding for electronic communications with family physicians and other providers in the system. In addition, the government itself tends to rely heavily on paperbased transfer of information. For example, OHIP is not able to transmit electronically to practices the number of patients rostered or the results of preventative care activities. Unfortunately, the years of focusing on the development of technology within hospitals and other organizations such as CCACs has resulted in a failure to embrace the major providers of care located in community-based practices (i.e. family doctors). Leadership and advocacy is needed to ensure that the needs of family physicians and their patients are addressed. A co-operative approach amongst the federal and provincial governments, LHINs and the organizations reporting to them is required in order to address the need for increased communication capabilities for family physicians. We need to ensure answers to these key questions: What will technology deliver and how will it be built to do so a year from now, 3 years, 5 years, 10 years from now? What migration pathway offers the most opportunity for the safest and most readily adopted migration system? When will organizations plan and move forward together on e-strategies? When will family practices where 80% of the care is delivered be considered as the key priority sites for e-health planning? Should standards be set at the province-level? (the USA has only one standard while Canada continues to develop individual provincial standards) Should CFPC create a national Committee to act as the voice of reason at the national level to advise Infoway and to ensure strong physician involvement in the development and implementation of national guidelines?

6 e-health and Family Medicine Limited Access to MOHLTC Subsidies While FHOs, FHNs and FHTs have had finite and limited opportunities for financial support for IT acquisition, the supports for physicians in other models of care has been limited. It is our understanding that in 2008, a relatively small amount of money will be available for FHTs and then for FHNs and FHOs. Whatever funding is then left over will be used for a second lottery for FHGs. While investments continue to be made in EMRs, a specific goal of the percentage of physicians who will be supported to adopt EMRs has not been announced by the MOHLTC. Research reveals that the major benefits in implementing e-health/emrs accrue to the healthcare system in general. It is for this reason that governments across Canada and internationally have been investing in information management systems. The focus of many of the initiatives to develop specific features is to export data under the direction of government agencies. Those designed to facilitate the flow of data to providers often fail to deliver. Given the influence and benefits to government, family physicians should not bear the costs of acquisition. Moreover, many physicians have successfully implemented and are using all the key features of an EMR with benefits for patients, as well as the system. Field studies to determine the features most associated with benefits, the enablers of successful implementation and the identification of ways and means to overcome the various barriers are needed to direct future directions. Given the business case (i.e. benefits for patients and the system with neutral to slight benefits for the individual physicians in two years following implementation of an EMR), the OCFP should be advocating for IT subsidies for our physicians. The OCFP should also partner with other organizations to undertake field studies in regards to EMR features, enablers and barriers. 3.3 Lack of Support for IT Implementation OntarioMD provided up to $28,600 for physicians in FHGs. The program was supported to include transition support. Of the 2100 applicants who applied, 175 were chosen randomly. Physicians who were unprepared to implement IT in their practices had the same opportunity to access funds as those physicians who were well-prepared to undertake the major change process. The FHG lottery strategy demonstrated lack of an effective implementation strategy within OntarioMD. Research is needed into the success factors for IT implementation. The OCFP should undertake a study to identify meaningful IT implementation strategies and then promote their adoption. OCFP should advocate for funding for implementation strategies. The transition supports at OntarioMD include consultants, practice workflow design and needs analysis; however, much more funding is needed to support implementation activities within practices. 3.4 Difficulties in Choosing the Appropriate System OntarioMD provides a list of vendors; however, currently the list is quite long. Many physicians do not know which system to choose and are concerned about implementing a system that does not meet their needs. CMSs standards are being increased, so probably the list will decrease to 6-7 vendors.

7 e-health and Family Medicine 6 If new standards drive the development of other features into the system too rapidly, the software will not have an opportunity to mature. Caution is required to ensure that specification solutions are not aimed only at passing certification. They need to be integrated within the products as a whole. Care must be taken to ensure end-user usability studies are undertaken and the customer base has an opportunity to become familiar with the new specification driven product. The aim should be to ensure that every product, not only meets specifications, but is a high quality useful and easy to use product. The OCFP should identify the vendors with the resources to support future EMR standards and ensure that they have the capabilities required by physicians. By working with government and vendors, the OCFP will be able to ensure that conformance requirements do not overshadow the need for systems that meet the end-user needs. Vendors need to ensure that their product permits migration of data between systems so that physicians do not have to re-enter data. OntarioMD is working on trying to find solutions. Currently, they are working on portability since interoperability is a longer term goal. 3.5 Capital Upgrades Many of the physicians who were early adopters now require upgrades to their system. It is unknown if the limited funds will be used to support physician upgrades. It is important to reiterate that the return-on-investment appears to favour the system (government) as opposed to the physician. The OCFP should advocate for funding for ongoing capital upgrades. One case study of a group who have used an EMR for almost ten years have replaced every piece of hardware at least once and most have been replaced twice and some three to four times. Software updates are required more frequently than most patients need a medical check-up. 3.6 Concerns Regarding Practice Disruption Physicians perceive that there will be a loss of productivity due to disruption to their practice during implementation and have expressed concerns about the workload issues related to work in a dual system (i.e. both paper and EMR). While relatively new offices are truly paperless, practice disruptions can be minimized with thorough pre-planning of documents management including various diagnostic result reporting. Organizing e- transmission of a laboratory imaging, hospital reports is a vital first step that is required to drive moderate user proficiency before engaging the patient care components of an EMR. Pre-planning in a step-wise model can reduce some of the problems; however, each family physician will need to sacrifice some time to implementation of planning and roll-out. The OCFP should emphasize the fact that working in a dual system (paper and EMR) results in loss of productivity. A system for managing external forms needs to be developed and utilized on an ongoing basis. The issue relates to lack of communication infrastructure throughout the system. The OCFP should emphasize the fact that the true benefits of IT for the healthcare system are only seen when there is interoperability throughout the system. The use of non-emr based external

8 e-health and Family Medicine 7 forms should be strongly discouraged. 3.7 Group Decision-Making/Team-based care To move forward, there needs to be a shift in practice from the physician in isolation model to group practices that reflect true team-based care including ensuring that team members are fully integrated with the community. This represents an essential enabler of change from the current model of practice which results from and also enhances IT implementation in practices (i.e. in team based practices, IT becomes an essential enabler of team function). They now have to decide as a team which system to utilize, and how to best manage their information. The OCFP should educate and support physicians on how to develop and/or function within effective team structures. OCFP may wish to work with physicians in understanding and supporting physician s information management needs. The IT needs of other healthcare professionals need to be taken into account in the design of the next generation of EMRs/EHRs. The team as a whole, rather than the individual physician, needs to decide upon IT acquisition and the system process changes required to support IT implementation. A successful implementation requires ongoing team input and involvement. 3.8 Technical Issues Physicians believe that lack of network connectivity and redundancy plans for backingup data, failed hardware and the like make day-to-day operational issues difficult. This concern is reinforced by the fact that Smart Systems for Health has not been given a mandate or developed a contingency plan for failures or for back-up connectivity. Moreover, the family physician offices, including Family Health Teams, are not considered mission critical sites. The OCFP needs to reassure physicians that these issues are not insurmountable. They need to ensure that the implementation strategy addresses the issues and someone in the practice oversees the processes. The best analogy is the sterilizing the instruments. Not many doctors do the sterilizing themselves but they ensure that it is done. 3.9 Cumulative Patient Profile/Diagnostic Coding Currently, many hospitals use autofaxes to provide information to family practices. If the practice uses an EMR, the information needs to be scanned into the EMR; alternatively, it is left as part of a paper chart. With an integrated system, the information would be transported from hospital to the practice electronically. Data for the cumulative patient profile includes diagnostic codes so that information can be transferable between EMR systems. Most physicians have experience with ICD9 coding; however, comparable coding may not be used in the hospital system. Most of the information required by family doctor is in a narrative text and does not need to be coded. e-transmission of

9 e-health and Family Medicine 8 discharge notes, operative notes, pathology, imaging and consultation records etc need not rely on diagnostic coding; however, they need to be pushed from the source and pulled into the EMR in an easily searchable free narrative text. The OCFP should assist physicians to understand various coding systems or alternatively to recommend systems that will include automatic coding capabilities. Developing push-pull capabilities remains the most important aspect of e- Transmission Practicing What We Preach Many organizations assume that physicians are computer illiterate and send information via paper; however, an increasing number of physicians have a high rate of computer literacy. While IT represents a transient inconvenience for most, sending information primarily in a paper format decreases the requirement to adopt IT. Many institutions will not accept electronic information even when it is thoroughly collated, legibly typed and inclusive of all data. They prefer their own paper forms, written on illegibly, in order to access patient care. The total joint initiative as an example utilizes a form that only works for the paper-based practitioners. WSIB and most other forms are not readily managed electronically. Faxes remain the most popular communication tool in the health care system. The OCFP should advocate for a policy that supports electronic communication systems for organizations first and foremost with paper (fax, print) as a requested second option only Diabetes Registry The MOHLTC is in the process of developing a portal that will be populated over time and will start with the Diabetes Registry. The Diabetes Registry may make care more complex by requiring a duplicate recording system (i.e. entry into the patient s paper or electronic chart and entry into the Diabetes Registry). Unless the pay off is high in terms of incentives and quality of care, the implementation of the system will be very difficult. A Diabetes e-health working group is being established that will work in parallel to the Diabetes Expert Panel and indeed the Registry may be launched prior to the release of the work of the Expert Panel. Most diabetes care (i.e. more than 80%) takes place in the family practices. Information sharing is often a one way street. The family doctor provides extensive information about the patient upon referred to a specialist or to the Diabetes Education Centre. The information that family doctors receive in return may not be complete and makes it difficult to provide ongoing care. The Registry should help family physicians to access information more easily. Shared-care community-based diabetes charts through the aging at home initiative in the LHINs are one example of information flow in the community. If the Diabetes Registry is developed as a stand-alone registry and other registries are created for other disorders, the uptake, regardless of incentives will be limited. IT should exist to make provider workload less and care improved. If single standalone systems require separate access and subsequent, extra workload, they will fail in this goal.

10 e-health and Family Medicine 9 The model seems to move away from the understanding of patients that their family doctor is the custodian of their health records. Access to information when needed and wherever needed may override this concern. The OCFP needs to ensure that our Members are on the various committees to ensure that the concerns of family physicians are heard and addressed. We also need to help MOHLTC and the major healthcare organizational leaders to understand that the care of people with diabetes, indeed all chronic disease prevention and management belongs in primary care settings. Custodianship of information is not as important as access to information and all family physicians, not those who have currently been supported to acquire IT need to be able to use the registry to access the information they need on individual patients and on their practice population in order to implement meaningful practice change. 4.0 Our Main Message Information technology support, electronic medical records and an e-health strategy that ensures interoperability throughout the system are the key tools that family physicians (and their practice teams) need to provide excellent care for their patients.

11 e-health and Family Medicine 10 Appendix: A The Commonwealth Fund: 2006 International Health Policy Survey of Primary Care Physicians in Seven Countries. Use of IT Quality Initiatives

12 e-health and Family Medicine 11 Appendix: B Key IT Papers