ehealth Policy Paper September 2013

ehealth Policy Paper

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 GLOSSARY DATA GOVERNANCE: The exercise of decision-making and authority on matters relating to data and information. i DATA STEWARDSHIP: Responsibility for the appropriate management and protection of the data contained in an electronic medical record or electronic health record. ii E-HEALTH: The provision of health care services supported by modern electronic information management tools, processes and resources. iii ELECTRONIC HEALTH RECORD: A compilation of core health data submitted by various health care providers and organizations, accessible by numerous authorized parties from a number of points of care, possibly even from different jurisdictions. ii ELECTRONIC MEDICAL RECORD (EMR): An electronic version of the paper record that doctors have traditionally maintained for their patients and which is typically only accessible within the facility or office that controls it. ii LOCKBOX: A security feature that allows access to a patient's personal health information, or portions thereof, to be restricted to certain users at the specific request of the patient. Often used interchangeably with the concept of masking. ii MASKING: concealing of a patient s personal health information, or portions thereof, at the specific request of the patient in order to limit/control the information disclosed to other providers. Often used interchangeably with lockbox. ii PERSONAL HEALTH RECORD: Also referred to as patient health record. An electronic record typically created and maintained by the patient, sometimes using a third-party online service. Unlike EMRs/EHRs, which are typically created and maintained by a health care professional or facility, the term PHR commonly refers to a compilation of information personally gathered and maintained by the patient regarding his/her health. The patient controls access and information inputted into the PHR. ii i Thomas G. The DGI data governance framework. Orlando, FL: The Data Governance Institute; 2012. Available from: http://datagovernance.com/dgi_framework.pdf. Accessed: 2013 Aug 20. ii Canadian Medical Protective Association. Electronic records handbook: implementing and using electronic medical records (EMRs) and electronic health records (EHRs). Ottawa, ON: Canadian Medical Protective Association; 2009. Available from: http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/pdf/com_electronic_records_handbooke.pdf. Accessed: 2013 Aug 20 iii Alberta. College of Physicians & Surgeons. CPSA vision for ehealth. Edmonton, AB: College of Physicians and Surgeons of Alberta; 2012 Sep. Available from: http://www.cpsa.ab.ca/libraries/information_for_physicians/vision_for_ehealth.pdf. Accessed: 2013 Aug 20. Page 1 of 23

26 27 SECONDARY USE: The use of personal health information for purposes other than the provision of health care, for example, for research or health system planning. ii Page 2 of 23

28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 EXECUTIVE SUMMARY The Ontario government has been working on a provincial strategy for an ehealth system for over a decade. Such a system has the potential to improve care for the patient by linking databases, records and information from across the entire care continuum, to help ensure more effective, efficient and seamless exchange of information. While the development of an electronic health record (EHR) has been a high priority initiative for many years, and the Government s 2015 goal for system establishment remains, there is still much progress to be made. Unfortunately, there has been minimal system engagement with health care providers. Physicians and other health care providers are best suited to support strategy development and implementation given their unique and critical role in the provision of care. Physicians should be considered leaders in the ehealth environment, and involving them in the decision making process is critical. As such, on behalf of Ontario s physicians, the Ontario Medical Association (OMA) has a key role to play in the development of an ehealth system strategy. The OMA is supportive of the movement towards ehealth use. Wise utilization of ehealth technology can help empower the physician-patient relationship; it can improve access, quality, and safety of care. However, the effective rollout of an ehealth system must be supportive of physicians. Physicians must be provided with the tools and resources to become ehealth experts. Health care provision is laden with complex situations that involve confidentiality, privacy, and ethical decisions to be made. The introduction of an electronic system must not undermine any of the core values that underpin the trust inherent in the doctor-patient relationship and should be put in place to improve upon the current paper system. It is fundamental that the open exchange of information and trust that currently exists between patients and the physicians be maintained; this cannot be compromised with the introduction of an electronic system. In addition, security and access issues must not impede proper patient care. They must be non-disruptive; and the system, with the proper safeguards in place, must be easily accessible. The proper functioning of an ehealth system is dependent on physician participation and therefore physicians must be partners in governance and any decision making committees for system success. Furthermore, in order for an effective ehealth system to function, integration between systems is essential. The true benefit of the EHR cannot be realized without the integration of various electronic systems. It is important that a framework/strategy be developed for the integration of current and future electronic systems, including electronic medical records (EMRs) held in independent physician offices/hospitals, laboratory systems, medication management systems, as well as Independent Health Facilities (IHFs), Community Based Specialty Clinics (CBSCs), Public Health Units, and many more. In addition to the importance of the integration of electronic systems, the proper safeguards must be in place to ensure that physicians have uninterrupted access to records. This will help prevent risks to patient care. The development of Ontario s ehealth strategy must ensure system integration remain a priority. Page 3 of 23

65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 This paper will review the history of ehealth in Ontario, and will provide recommendations for ongoing strategy development. INTRODUCTION ehealth relates to the provision of health care services supported by the use of modern electronic information management tools, processes and resources. 1 The Electronic Health Record (EHR) brings together information registered with health care providers and the provincial health care plan. The EHR should be viewed as a network of linked records and information contributed by multiple health professionals involved in patient care. Eventually, EHRs will include data from hospital information systems, community care clinics and other providers involved in the patient s care 2. EHRs indicate system integration and interoperability, and extend beyond individual electronic medical record (EMR) systems which are housed in independent offices. It is important to note that the EHR does not exist as a single entity. Rather, the EHR includes the myriad of individual systems (such as EMRs) and linked repositories containing patient information. An EHR exists at the system level, and ideally would be a compilation of core health data from multiple sources (eg. physicians, physiotherapists, pharmacists, laboratories), which would include the EMR as one component of the Record. It is comprised of different records submitted by health care providers and organizations and accessible by authorized individuals from a number of places of care, and occasionally from different jurisdictions, for the purpose of delivering health care. Interprofessional documentation is expected to increase over time. The OMA began its foundational ehealth work with a focus on EMRs. Considerable progress has been made in this area, and the OMA is now moving forward and focusing on the broader electronic environment in addition to advancing the EMR work. By 2015, it is anticipated that the majority of Ontario physicians will be practicing in an ehealth environment. The OMA supports ehealth initiatives that enable physicians and patients to provide and receive quality care. There are important policy questions that should be considered by decision makers as the provincial ehealth framework is developed in Ontario. The OMA s role is to represent and advocate for patients and physicians interests in planning, developing and implementation of Ontario s ehealth Strategy, and therefore, the OMA has a key role to play in the strategy development process. This aligns with the work that began in 2008 with the development of the Physician IT Strategy. As part of this work, some of the following principles were developed. These principles should be used to frame the discussion around the physician s role in ehealth: 1. Health IT must support and improve patient care. 2. The integrity of the physician-patient relationship must be preserved in the ehealth environment. 3. Privacy and security of health information must be protected. 4. Professional and clinical autonomy must be preserved. 5. Physicians must be supported in the exercise of their rights and the discharge of their obligations. 6. ehealth is a strategic investment that must be available to all physicians. Page 4 of 23

105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 7. Physicians must have accountable-representation with direct input into the planning development and implementation of Ontario s ehealth environment. 8. Support and incentives are necessary for adoption and sustainability. 9. ehealth must evolve through needs based innovation. 10. The government must continue to fund physician ehealth implementation costs to expedite implementation and obtain greater benefits. 11. Healthcare IT applications and systems must align with physician usability and workflow; training requirements must be minimized and efficiencies should be gained through the use of ehealth. Physicians must be equal partners at the decision making table; it is critical that the physician voice and perspective be a key contributor to this process. The physician-patient relationship represents the cornerstone of the health care system, and therefore physicians must provide insight into the ehealth decision making process. While it is important that other health professionals be engaged in ehealth strategy development, it is expected that physicians will be of the most active users of the system, in addition to being those responsible for the collection of the majority of the information. Therefore, physicians should participate in all stages of strategy and system development. Health care provision is laden with complex situations that involve confidentiality, privacy, and ethical decisions to be made. The introduction of an electronic system must not undermine any of the core values that underpin the trust inherent in the doctor-patient relationship and should be put in place to improve upon the current paper system. It is fundamental that the open exchange of information and trust that currently exists between patients and the physicians be maintained; this cannot be compromised with the introduction of an electronic system. In addition, security and access issues must not impede proper patient care. They must be non-disruptive; and the system, with the proper safeguards in place, must be easily accessible. The proper functioning of an ehealth system is dependent on physician participation and therefore physicians must be partners in governance and any decision making committees for system success. The OMA believes that ehealth has the ability to transform patient care and enhance the quality of health information, statistics and research if properly implemented. Successful implementation is dependent on a provider-oriented strategy. Such a strategy will enable physicians and other providers to provide better care for their patients within offices, clinics and local institutions. It will also enable providers to be more productive and efficient. The OMA strategy respects the professional independence and choice of Ontario s physicians, and recognizes that ehealth must deliver true value to physicians and patients, without imposing a security or financial risk to the system, or making practice workflow more onerous. EHEALTH CLIMATE ehealth Ontario was established by the provincial government in September 2008 as an independent agency of the Ontario Ministry of Health and Long Term Care (MOHLTC). In 2009, the MOHLTC and ehealth Ontario signed a Memorandum of Understanding tasking ehealth Ontario with providing a single harmonized coherent province-wide ehealth strategy and aligning the strategy through multiple points of accountability. The mandate of ehealth Ontario includes the integration of all provincially funded health care system information initiatives that support Page 5 of 23

147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 clinicians and patient care delivery, that are actually or potentially province-wide in scope. ehealth Ontario is responsible for the delivery of an EHR, with decision making authority for the EHR lying with the MOHLTC. At the current time, the 2015 provincial goal of having a functional Electronic Health Record remains. 3 As such, the OMA must be proactive in the development of a Physician strategy. OntarioMD (OMD) is a wholly-owned subsidiary of the OMA that provides physicians with easy access to information and resources to help them transition from paper records to EMRs to improve the delivery of patient care and practice efficiency. OMD was established to manage the Physician IT Program established by the MOHLTC and the OMA. OMD manages the EMR Adoption Program, funded by ehealth Ontario, which assists physicians with the adoption and implementation of funding eligible EMR offerings. OMD s vision is to promote adoption and use of EMRs to ensure the system s investment reaches its utmost potential. The College of Physicians and Surgeons of Ontario (CPSO) has recently released an ehealth Statement outlining the role of the College, physicians, and other health system stakeholders in the ehealth environment. Specifically, the CPSO encourages physicians to commit to ehealth learning and ehealth literacy, and using ehealth to benefit patients. It is important to note that this is a statement as opposed to a policy; it does not mandate physicians adoption of any technology and it reflects the CPSO s commitment to ensure the effective progress of ehealth development and implementation. 4 The MOHLTC has recently released Bill 78, An Act to amend certain acts with respect to electronic health records (ephipa) 5. This Bill seeks to formalize many issues that arise in the ehealth environment. ephipa is expected to go through the legislative process in the fall of 2013. A. EHR Scope Information required for patient care should be accessible through the EHR. This must include the bidirectional flow of data. However, in order to have a seamless, efficient, and effective rollout of EHRs, a phased approach to implementation, beginning with key providers (physicians, pharmacists, nurse practitioners, labs, hospitals etc) and cornerstone repositories is recommended. The system should be accessible and should rely on the existing professional accountability of regulated health professionals for appropriate use. In our current system, access to patient information is based upon a fundamental respect for privacy; only the information necessary for the purpose should be shared or accessed. This is done with either express or implied consent and in accordance with professional accountability for one s actions. The same principles must underpin the EHR strategy. While the eventual goal is to have all healthcare providers as participants in the electronic system, physicians must be enabled through this process, and participation must remain voluntary until a comprehensive strategy is in place that will add value and improved quality to the care process. Mandating physicians to adopt electronic practices prior to the development of a comprehensive electronic health care system could pose obstacles to the success of a provincial electronic system, as physician support is critical. Recommendation: Physician participation in the EHR must remain voluntary until a comprehensive strategy and a functional system is in place. Page 6 of 23

188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 Physicians must be provided with the tools and resources to become proficient in ehealth in order to ensure patients receive the best quality care. GOVERNANCE Governance deals with the mechanisms that are used to guide, steer or regulate the course of an organization or system. 6 ehealth is broad and diverse and includes many players, and therefore no single entity should be entirely responsible for its development, control, and ownership of data and the system. The ehealth field includes the public, or recipients of healthcare delivery, physicians and their clinical practices, policy and information management processes, as well as technology required to enable the field. 1 At the present time, there is no formal governance structure responsible for the oversight of Ontario s ehealth agenda. As a result, the approach to decision making has been fragmented. The development of an effective governance model will require a framework of policies that establish the rules of engagement around the use of the EHR, and the obligations and accountabilities of those participating. Such a governance model will be subject to applicable laws. The MOHLTC must discharge its strategy and policy duties in a clear and transparent manner. Because the health care system is in the early stages of developing this framework, decision makers must refrain from being over-prescriptive in the initial strategy, since key questions about governance, control of information, and data quality/integrity remain unanswered. Ontario lags behind other jurisdictions in ehealth integration. Therefore, a long term view enabling the integration of different systems is required. It is imprudent for the MOHLTC to manage all parts of this system, particularly interactions between physicians and their patients; providers must be involved in this process. As such, the OMA has a critical role to play in the development of a governance framework. In addition to the need for an ehealth system governance strategy, issues related to data governance and data stewardship have yet to be solved around the data within the EHR. Data governance can be defined as the exercise of decision-making and authority on matters relating to data and information. 7 There is significant value in ensuring that all stakeholders are aware of and understand the respective obligations of participants so that these varying obligations can be anticipated in advance and incorporated into an effective data governance framework. These obligations should be delineated in a data sharing or information management agreement that will govern physicians and other health care providers use of the EHR managed by the MOHLTC and/or ehealth Ontario. In addition, a governance framework must address questions around secondary uses of information. Data issues as identified by requests for information and indicators in Health Links and Ontario s Quality Improvement Plans (QIPs) are two relevant examples of initiatives currently underway in Ontario requiring the disclosure of data for secondary use purposes. In order to meet the needs of both the physicians and the government s initiatives, a framework for dealing with data requests and management issues is essential. The goal of this framework should be to balance system level accountability with patient confidentiality. As data stewards, physicians play a critical role in the development of this framework. To this end, the OMA, together with the College of Physicians and Surgeons of Ontario (CPSO), the Canadian Medical Protective Association (CMPA) and other stakeholders should develop a data governance strategy to support physicians on such matters. The Page 7 of 23

230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 development of this strategy should also support the implementation work which must occur. This work should include the OMA. Recommendation: The OMA s Data Governance Working Group should include other health system stakeholders to identify and make recommendations to Government on data governance, access and secondary use of data. The developed data governance framework must balance the need for data with the confidentiality/trust inherent in the physician-patient relationship. A. Electronic Medical Records: A Fundamental Building Block An electronic medical record (EMR) is the electronic version of the paper record that doctors have traditionally maintained for their patients and which is typically only accessible within the facility or office that controls it. 8 Certified EMR products provide healthcare providers with a tool to manage their patient population and provide continuity of care. In addition, EMRs offer providers with information management and decision-support tools, and will ultimately integrate with the provincial EHR. Physicians in Ontario have made significant strides in the uptake of EMRs. This has been a critical step in the development of ehealth in Ontario. At the present time, approximately 70% of primary care physicians are using EMRs, with the goal of 85% uptake by 2014. EMR data captures the clinical encounter between the physician and the patient, as well as other important personal health information such as family and social history, and therefore, the data housed within physicians EMRs is the cornerstone of the system-wide EHR. This data serves many purposes including but not limited to the provision of patient care, analysis at a patient population or practice level, as well as on a system level. While this data is essential to the system-wide EHR, it is essential that the fundamental relationship between physician and patient be respected and maintained. While the majority of EMR users are primary care providers, the number of specialists using EMRs is increasing. There is a variation in specialist needs, which should be considered as enrolment increases and progress is made by vendors. The OMA should be involved in this work. As previously discussed in the section on data governance, there is currently no clear framework governing what information should and should not flow from a physician s EMR to the systemwide EHR. In addition, there are no provincial data standards for coding in an EMR, and thus it is difficult to extract information for reporting at a provincial level. There are currently initiatives underway, such as those led by the Canadian Institute for Health Information (CIHI), and Canadian Primary Care Sentinel Surveillance Network (CPCSSN), which collect data from individual EMRs to perform health data analysis at the practice level. As outlined in the section on governance, there is no framework governing the flow of data. To this end, individual physicians are making decisions regarding data sharing. For this reason, it is important that the expectations of physicians with respect to patient data be clarified. This is in the best interest of both the physician and the patient. The OMA together with OMD are at the forefront of this process, and should take the lead in the development of a data stewardship framework, to guide physicians Page 8 of 23

271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 through this process. This work must consider the unique practice situations of physicians in different fields of medicine as the framework is developed. As the health care system is evolving with a greater focus on quality improvement and benchmarking, and as system level expectations of physicians are increasing, it is critical that EMRs evolve. EMRs must be developed to enable quality improvement and benchmarking as functions within the systems. Such capability should include practice management and audit functions, as well as patient profiling. Recommendations: Various specialities needs should be considered in specifications of EMRs. EMRs should evolve to incorporate quality improvement and benchmarking functions within the systems. CONSENT MANAGEMENT When considering the implementation of the ehealth agenda and consent management specifically, it is critical that the system is practical and clear for physicians to use, while at the same time protects patient confidentiality and permits patients to exercise their existing legal rights. It is crucial that the patient-physician relationship be preserved. One of the key challenges emerging in ehealth is the need to educate Ontario s physicians, other health care providers, and Ontario s public about the changing environment and their roles within it. Jurisdictional research demonstrates that the majority of patients accept having their information flow within the system to support the delivery of health care services. Since it is anticipated that only a small minority will choose to not participate, an opt-out system for patient participation is recommended. This mirrors the current paper system. Necessary information will be shared as appropriate within the circle of care, and information will be withheld only upon express request. The current design of the system is such that should a patient opt out of the EHR, no patient data would be included. From a clinical perspective, physicians must be advised if clinical data is blocked. Dangerous decisions can be made if physicians are unaware of deficiencies in the patient record. While patients should have the right to withhold information related to the healthcare encounter from the system, the OMA believes that basic patient demographic information should not be masked in the system. This would allow for the creation of a unique identifier for all patients within the EHR. To this end, PHIPA should be amended so that basic identifiers are not defined as personal health information when they are used to identify an individual (as opposed to linking it with other personal health information). This would allow authorized users within the EHR to confirm that the patient exists in the system, but respect patients rights to confidentiality. In addition, from a system perspective, it will make managing patient identification more effective. Recommendation: PHIPA should be amended so that demographic information is not defined as personal health information when used solely to identify a patient to allow the creation of a unique identifier for all patients in the EHR. A. Information Masking Page 9 of 23

311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 Information Masking refers to the blocking of a patient s personal health information (or portions of the record) at the request of the patient in order to limit or control the information that is disclosed to other health care providers. 8 Similarly, a lockbox (not a defined term under PHIPA) is a security feature allowing access to a patient s personal health information, or portions of, to be restricted to certain users at the specific request of the patient. 8 Current legislation enables patients to create a lockbox and mask information within the record. While the OMA believes that it is in the patient s best interest to have their information shared across providers within their circle of care, the OMA understands the need to keep with legislation and provide patients the option of masking information or creating a lockbox within the EHR. Also consistent with legislation, physicians generally do not need a patient's express consent to include his or her health information in an EMR/EHR, or to share patient information with other health care providers for the purpose of providing treatment. Physicians can rely on a patient's implied consent to share information within the circle of care, which includes those health care professionals who need to know the information for the purpose of providing care. This is done for the purpose of providing the best quality care. While the OMA understands that some patients may opt to mask information, current technology poses a barrier to consistently addressing this process. As the current system stands, small field level masking may not be reasonably achievable in most systems, which means that the patient cannot choose to mask only certain elements of the patient encounter. To this end, the patient must choose to either include or mask the entire record. This can have consequences on proper patient care. In addition, patients who wish to mask information are often unaware of the potential implications of this choice, and how detrimental it can be to the quality of care they ultimately receive. It is important to consider that information masking requests occur in exceptional circumstances, and thus the system should be mindful about the need to balance resources. The OMA believes that the physician has a role to play in this process in assisting patients to understand the consequences of masking; however, it is unreasonable to require physicians to provide education on government legislation and policy. It is critical that the MOHLTC take responsibility for informing and educating Ontario s public about masking. As part of this education, the public must be informed of the potential implications of the decision to mask some/all information. It is imperative that the government take responsibility for ensuring the public is aware of this. Physicians should be able to discuss general information related to masking to patients if called upon to do so and therefore, adequate education and support materials must be provided to physicians so that they understand and can inform patients about masking. In addition, physicians must be provided with the skills to ensure that their professional and ethical obligations are maintained should a patient request that information be masked. 8 It is expected that the role of the physician in this process will evolve as technology advances. The MOHLTC must turn its attention to questions around whether there are circumstances in which a physician should be able to access masked information without patient consent and, if so, how each instance should be handled. The OMA should collaborate with the CPSO and the MOHLTC in determining this policy. Recommendations: The MOHLTC has a duty to inform the public about masking and the potential consequences of masking on patient care. Page 10 of 23

354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 Physicians must be given the resources necessary to provide patients with general information about masking, should patients request such information. The OMA should collaborate with the MOHLTC to determine situations in which a physician should be able to access masked information. B. Data Sharing The system should view ehealth and the inclusion of central data from various sources as an iterative process. While the ultimate goal may be to have repositories housing patient information, the system is not prepared for that at the present time. It must evolve, with certain elements being added based on development. Individual EMRs housed in physicians offices and hospitals represent fundamental components of the EHR, as they contain critical patient level information collected by physicians. As EMRs develop, additional elements should become automatic feeds into the system wide EHR. Decisions regarding the inclusion of data fields must include the OMA, as these decisions must make clinical and technical sense. One challenge frequently identified in sharing EMR data relates to how the data is captured within EMR software. This is due, in part, to varying designs and interpretation of the data fields as well as variances in physician charting practices. 9 At the present time, the OMA does not support all information from EMRs feeding into the EHR. However, the OMA does believe that as the system develops and becomes interoperable, access to all relevant information feeding from the EMR into the EHR would become the desirable end point. Such relevant information may be in the form of a core data set, defined by providers and other health system stakeholders. Therefore, clear guidelines and processes must be established to address the data capture inconsistencies that currently exist within EMR systems. The OMA, the CPSO and the MOHLTC must all play a part in setting and evaluating these guidelines. As has been repeated throughout this paper, a fundamental principle that cannot be overlooked is public trust. Physicians have legal and ethical obligations to respect patient confidentiality. The maintenance of trust and the open exchange of information are critical components that contribute to the relationship that exists between patients and physicians. In order to ensure the future state EHR reaches its potential, the public must have confidence in the confidentiality and security provisions of the ehealth system, and this relationship must be preserved. It is vital that patient confidentiality be balanced with reasonable use and access to data. Recommendation: Data capture inconsistencies that currently exist within EMR systems must be addressed. OMD, the OMA and the MOHLTC must work with vendors to ensure that the appropriate data can be transferred. C. Electronic Communication with Patients Online communication tools such as email are commonly used forms of communication by the general public, but physicians must exercise caution in using them to communicate with or about patients. Email and other online communication tools such as message boards are not inherently secure forms of communication, and thus their use poses risks. 1 Ultimately it is anticipated that communication via email and other online tools between patient and physician will become the expectation, and therefore, the proper technical safeguards must be established to ensure appropriate safety protocols are in place. Physicians must ensure that all online patient interaction Page 11 of 23

395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 is well documented within the EMR. The OMA supports the movement towards the use of electronic communication with patients, provided it is done in a secure fashion. From a technical perspective, it is important that there be a process to include emails within the EMR s patient record, much like patient encounter notes within the paper chart. Given that standards will need to be developed to deal with this practice change, there is a role for the College of Physicians and Surgeons of Ontario (CPSO) and the Canadian Medical Protective Association (CMPA) in this framework. The CMPA has recently released an updated statement on the use of email with patients. 10 This statement outlines the importance of understanding the legal risks associated in communications by email with patients. In addition, patients must be aware of the potential risks and be willing to assume such risks. A consent form signed by the patient should be included in the patient chart. Physicians should establish policies and procedures for handling email communications using reasonable technical safeguards. Others within the organization/practice must also be informed of such policies and risks. There has been experience in the United States with electronic communication between physicians and patients. Adoption had been slow due to reimbursement disincentives, medical culture, licensing issues, and liability concerns. The American Medical Association and American Medical Informatics Association advise that physicians develop a patient-clinician agreement and consent form that should be discussed with and signed by each patient prior to use of electronic communication. 11 In 2004, Kaiser Permanente (KP) began rolling out their current EHR (which can be compared to what Ontario would refer to an EMR), known as KP HealthConnect (KPHC). Part of this system included a password protected email system (secure messaging) enabling physicians and patients to communicate electronically. There has been a significant increase in the uptake of this secure messaging, which has been associated with a decrease in office visits, an increase in measurable quality outcomes (in primary care) and excellent patient satisfaction. KP enthusiastically promoted secure messaging to both patients and physicians. In addition, prior to implementation, physicians were given specific communication training regarding the use of secure messages. The software used by KP allows users to easily embed other information, such as lab results or patient handouts into reply messages. 11 While KP s system is very different from Ontario s EHR, lessons can be learned from KP s experience: should Ontario move to incorporate electronic communication into the EHR, it is essential that proper training is provided and that the system be seamless and user friendly, so as to enable most efficient and effective exchange of information to ultimately provide better patient care. The need for security measures extend beyond physician-patient interaction and must also include communication between professionals relating to patients. Other forms of social media, such as Facebook, Twitter, LinkedIn, teaching sites, and associations sites are also used by some physicians in professional capacities. It is important that physicians recognize that online behaviour is held to the same high standard as in any other professional or public venue. Discussing matters related to patients on social networking or professional websites can constitute a breach. When using social media, the doctor-patient relationship must be maintained, and physicians must be mindful that issues related to copyright, libel, and defamation still apply. 12, 13. As such, it is recommended that physicians understand the implications of using social media. Page 12 of 23

438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 As part of the 2012 Physician Services Agreement (PSA), a change to the schedule of Benefits to enable physicians to consult with their colleagues using secure email has been implemented. 14 This change indicates that the system is beginning to evolve and embrace the use of email in the provision of healthcare services, provided it is done securely. As such, technical solutions must be developed and implemented to meet physicians needs. This will be discussed further on the section relating to econsult. Recommendations: Systems should be developed to support secure messaging among physicians and patients. Physicians should refer to CPSO Policy on the use of social media. INTEROPERABILITY AND INTEGRATION: KEY PIECES OF THE EHR When considering the technical perspective of the EHR, it should be emphasized that in order for an effective ehealth system to function, integration between systems is essential. The true benefit of the EHR cannot be realized without the integration of various electronic systems. This would include the ability to connect hospital systems with lab systems, eprescribing and drug information systems, EMRs, and any other repositories containing patient information. A bi-directional flow of information is critical to ensure that all providers can input and access relevant and appropriate information within the EHR. In addition, EMRs managed by different vendors must be interoperable with one another. At the present time, a system wide challenge relates to how the data is captured within different EMR systems. There are different designs within data fields as well as variances in physician documentation practices. As the system evolves it is anticipated that EMRs will become interoperable. It is important that a framework/strategy be developed for the integration of current and future EMRs. OMD and the MOHLTC should lead the development of this strategy to ensure compatibility. The development of such a strategy would enable physicians to move seamlessly between EMR systems should changes be made. In addition to the importance of the integration of electronic systems, the proper safeguards must be in place to ensure that physicians have uninterrupted access to records. This will help prevent risks to patient care. There are various systems that must be a part of the integrated EHR. Three critical components include a drug information system and eprescribing, ereferral and econsult tools, and an integrated lab system. These components are required for an effective patient centred record; the integration of them is in the best interest of the patient as well as the healthcare system at large. A brief discussion of these systems follows. As the system matures, other pieces could be developed and linked as well. In addition to these tools, a personal health record, developed for the patient, will help enable the effective and efficient exchange of information. A. eprescribing and Medication Management Physicians have expressed that eprescribing tools are of great value, and the OMA is in favour of authorized persons using esignatures for prescribing and ordering tests. There are system improvements to be gained through the development of a drug information system (DIS), as long Page 13 of 23

478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 as the proper system safeguards are in place. Physicians want access to information about the medications their patients have been prescribed and are taking, and therefore it is critical that the regulatory and technical roadblocks which seem to be impeding the progress of Ontario s Medication Management system (MMS) are quickly addressed. This includes eliminating regulatory and policy obligations for hand written information. Research from the Meaningful Use work in the United States has shown that greater development of eprescribing tools has led to greater adoption of several functionalities associated with e-prescribing, consistent across both primary care physicians as well as specialists. 15 Recommendation: The Ministry/eHealth Ontario must advance with the procurement of a provincial MMS, and/or support interim solutions The policy obligations for hand written information by pharmacies should be addressed to ensure the uptake and success of Drug Information and Medication Management Systems. B. ereferral and econsult An ereferral system that integrates with provincial EMRs has the ability to offer advantages to patient care and satisfaction, physician workload, as well as system efficiency. Currently, referrals often depend on an unstructured process; there are many different processes for submitting referral requests, compiling information, and preparing the patient. Communication by fax leaves room for error, and there is much confusion by the patient. Work is being done by OntarioMD together with the MOHLTC and ehealth Ontario to define the business requirements for a provincial ereferral program. This system would be designed manage end-to-end electronic referrals (e.g. EMR to EMR) as well as accommodate those who do not have an EMR. It is critical that any system that is developed have a simplified workflow. This would have significant benefits to patients, as it would simplify the experience and ensure greater communication. An econsult is a physician to physician service where the referring physician can obtain the opinion of another physician due to the nature of the case. Both the request and opinion are sent electronically through a secure server, enabling a specialist to provide an opinion without having to see the patient. The Ontario Telemedicine Network is leading much work in this area, specifically related to dermatology and ophthalmology. As part of the 2012 Physician Services Agreement, physicians will now be paid a fee for econsults. This also includes the ability for physicians to receive advice from a specialist by secure econsult. 14 While there is the potential for great utility in an econsult service, it is important to consider that in some areas of medicine, an econsult may not be as thorough as a traditional patient consult. Since the system is changing, and e-communication between physicians, as well as between patient and physician is becoming more commonly used, it is important that the OMA be further engaged in the development of econsult tools, practices, and standards. It is also important that those physicians who are not part of the econsult system are not at a financial disadvantage. econsult will impact different medical specialties in different capacities. Any strategy for making econsult tools more mainstream must consider this. Page 14 of 23

519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 ereferral and econsult tools can provide great benefits to the system, however, because they impact different medical specialities in different capacities, physicians and the OMA are best suited to inform decision makers on implementation. In order to ensure progress is made in tool development and uptake, the MOHLTC should approve multi-year funding to OntarioMD for the development and implementation of ereferral and econsult tools. Recommendations: OntarioMD and/or the MOHLTC must continue to fund the development and implementation of ereferral and econsult tools. The OMA should support dissemination, implementation and change management associated with use of these tools including ensuring the consideration of all fields of medicine. C. OLIS/Lab work The Ontario Laboratory Information System (OLIS) is a stand-alone data repository connecting hospitals, community laboratories, public health laboratories and practitioners. As a provincewide, integrated repository of tests and results, OLIS will contribute to fundamental improvements in patient care by providing practitioners with timely access to information. 16 There is great utility in integrating this lab information system to EMRs and ultimately the EHR as it develops. At the current time, the results in OLIS are limited to OHIP funded tests. There is a risk involved here, as physicians must be aware of all lab work done on a patient. In addition, OLIS must be integrated into public health databases to ensure effective information sharing. Furthermore, at the current time, OLIS is only patient query. As the system evolves from an active pull of information from EMRs into a direct push of information into EMRs, there will be even greater value to physicians. To this end, making this technical change should be a system level priority. The integration of systems must be completed to deliver comprehensive lab information to EMRs. Recommendation: All lab tests (as opposed to just those funded by OHIP) must be included in OLIS OLIS must be integrated into public health databases OLIS should enable full integration of lab results with EMRs. D. Personal Health Record Part of the provincial commitment to create an EHR by 2015 includes granting Ontarians control over information contained in the record. The goal of this is to support patient-centred care. 17 Personal Health Record (PHR) systems are patient-facing portals that contain patient health information and allow patients to interact with the health system. 18 A PHR is typically created and maintained by the patient (sometimes also referred to as a patient health record), sometimes using a third-party online service. Unlike EMRs/EHRs, which are typically created and maintained by a health care professional or facility, the term PHR commonly refers to a compilation of information personally gathered and maintained by the patient regarding his/her health. The Page 15 of 23

559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 patient controls access and information inputted into the PHR. 8 The OMA views the most effective and efficient opportunity for a PHR as one in which patients would be able to view their health record, which would essentially act as a patient portal integrated into the EHR. This would grant patients the opportunity to play an active role in becoming increasingly engaged and aware of their health, while not placing additional burden on the physician. While patients may maintain a record of their health and well-being within such a portal, the physician cannot be expected to view and play a role in maintaining this Record. Attention must also be placed on the risks associated with misunderstanding medical data in the Record accessed by the patient. Recommendation: The OMA supports patient access to the EHR as the first line for a PHR. Where patients choose to utilize a stand-alone PHR that is not integrated with the EHR physicians have no role in managing or monitoring this record.. E. Vendor Database In addition to the functionality of all of the above-mentioned systems, it is crucial that providers have access to key information about various EMR vendors. Such information must be provided to them in order for a well-informed decision to be made. A database that incorporates key information about the various vendors must be maintained and be kept available to those seeking EMR vendor information. Recommendation: A database containing key vendor information should be maintained and accessible to providers. F. Obstacle: Stand Alone Portals While it is recognized that the ideal state of the EHR will take time to develop, and that interim solutions may be required, the OMA cautions against the development of stand-alone portals. Such portals are put in place to address gaps in the system and may have interim benefits; however, they do not integrate or link with the high level ehealth strategy, and thus may pose problems down the road. As such, when possible, as new components of the system are developed, they must integrate and be part of the broader EHR strategy. Recommendation: Standalone portals should not be part of the provincial ehealth strategy and thus should not be funded. WHAT THE OMA CAN DO TO HELP Given the critical role of physicians in the delivery of health care, the OMA is in a unique position as it represents and advocates for the needs of physicians. In addition, it is able to lead the profession by analyzing and recommending practice changes. To this end, the OMA is able to Page 16 of 23

594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 bring the perspective of physicians to the decision making table to ultimately help influence the decision making process by ensuring it is practical, functional and supportive to physicians, as well as support physicians as new electronic tools are developed. A. Guidance through Cultural Changes With the move towards an ehealth system, which will ultimately include greater access for patients to their records, patients will become increasingly involved in their health and healthcare. To this end, a shift in the way information is handled will be required. Historically, physicians have taken a protective approach in the disclosure of results, which has always been viewed as being in the best interest of patients. Traditionally, physicians have had the opportunity to review and disclose results to the patient, without providing the patient the option of obtaining these results directly from the source (i.e. the laboratory). Moving forward, patients may have a choice in their level of involvement; while many will still presumably opt for the traditional system, in which physicians deliver the news, others may wish to view these results directly from the EHR. This represents a huge cultural shift in the delivery of healthcare. This new system will need to be transparent and enable patients to take an active role in their health and be informed recipients of healthcare services. Furthermore, patients will need to be educated to ensure they have a full and clear understanding of the implications of their choice. It is critical that this shift be given careful consideration, and that the OMA work together with provincial decision makers to facilitate this change. While patients are encouraged to take a more active role in their health, and while patients will inevitably gain greater access to information through the use of the EHR, a lag time between the time the results are input and the time they are viewable by patients is recommended. This would allow physicians to do a preliminary review of test results before they are viewed by the patient. This would allow the physician to input notes to ensure that patients are better able to interpret the results they are viewing. Further thought must be given to how patients will have access to their own records, being mindful of the desire to reduce a patient s anxiety in their clinical encounter. Additional consideration must be given to these situations to ensure that both patients and physicians are supported through these transitions. B. Education on EMR/EHR Use EMRs housed in physician offices are the cornerstone of the EHR. For this reason, it is in the best interest of the healthcare system that physicians embrace ehealth, and become active, informed participants and users of the system. In order for this to be as effective and efficient as possible, physicians should be provided with proper training. This training should be offered on both a micro and a macro level. The more detailed training should come from the health organizations (in the case of hospitals), or Peer Leaders as evidenced by the highly regarded change management OMD Peer Leader Program, on how to best use EMRs. At a higher level, there should be broad training on the various components of the EHR, which would include the integration of the various Page 17 of 23

631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 platforms. It is highly recommended that the OMA and OMD be actively engaged and involved in the provision of education to physicians. While ultimately it will likely be expected that physicians will be able to use the system effectively, something of this magnitude should not be mandated until an effective system is in place. While education of physicians is always recommended and encouraged, any policy change with respect to physician participation should be grandfathered in. C. Education on Meaningful Use While it is important that education be provided to those who are beginning to embark on the EMR/EHR journey, it is equally important to provide continuing education and encouragement to those physicians who have achieved proficiency in managing health care interactions through the EMRs and are ready to move to more advanced levels of usage. These physicians should be taught how to use their EMRs to help manage their patient population, support better office management, and inform quality improvement activities. OntarioMD s EMR Maturity Model and Progress Reporting, developed with direct input from clinicians, can effectively measure the evolution of maturity use over time, drive optimal use and develop broader cross-jurisdictional comparisons on adoption. 19 This has been developed as part of OntarioMD s change management approach to support current users in optimizing their EMR use. It is a detailed maturity roadmap representing the existing and potential capability of an EMR in the evolving ehealth landscape. An iterative approach is used to enable physicians to assess their progress towards achieving the full benefit of an EMR within their practice with continuous support from OMD. Continued funding to achieve meaningful use of EMR systems is recommended to ensure system success. D. Engaging Physicians who do not have EMRs While the OMA views great benefits in ehealth for physicians and the system at large, it is understood and accepted that during this period of transition, some physicians will be unwilling or unable to adopt an EMR. It is important that these physicians are not disadvantaged in the care that they can provide, and that there is no negative impact on their patients. To that end, during this period of transition, until a functional system is in place, reasonable options must be available to ensure that traditional patient care is not impeded. In addition, during this interim phase of EHR system development, options should also be explored to support physician access to electronic information absent the adoption of an EMR, such as using the OMD Portal, in order to connect with the ehealth system at large. Regional hubs, such as cgta, will help facilitate this, especially for physicians working across multiple sites and settings. Until a comprehensive strategy and system is in place, the expectation should not be that physicians will be required to use an EMR; however, there will be the expectation that they connect with other elements of the system, such as OLIS or other online communication tools. This system must be functional and seamless. No policies related to participation should be implemented until a fully functioning EHR is in place. Following this period of transition, the OMA is hopeful that the ehealth system will be one in which physicians will want to participate. It is expected that this system will improve upon the current paper-based system, and that it will be of greater value to both physicians and their patients. It is ultimately believed that the EHR will become a tool that will be seamlessly used in the health care system. Page 18 of 23

672 Recommendations: 673 674 675 676 Policy changes with respect to physician participation in the EMR should be grandfathered in The OMA and OMD should lead training on EMR/EHR use, as well as Meaningful Use (Maturity Model) 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 OBSTACLES The EHR is a tool that has the potential to offer great benefits to Ontario s healthcare system. ehealth can offer improvements in system efficiency, and also, if used effectively, it can help improve patient care. However, in order for ehealth to meet the desired provincial goals, there are several obstacles that must be overcome. A. Absence of a Transparent Provincial Strategy In 2009, ehealth Ontario was tasked with the development of an ehealth strategy for the province of Ontario. While considerable work has been invested in various software and plans, the system has yet to see any concrete governance strategy or plan for ehealth in Ontario. In addition, there is little communication on the progress being made. This poses a risk to the system, as not only is the EHR taking a great deal of time, but in the process many physicians are becoming disengaged, and the public has become sceptical. As such, the MOHLTC, ehealth Ontario and other health system stakeholders must now work together to expedite the process of creating a governance strategy for ehealth in Ontario. Since it is expected that this strategy will take many years to become operational, the MOHLTC and ehealth Ontario should collaborate with other health system stakeholders, including the OMA, to develop intermediate steps to support providers through transitions. B. Lack of Engagement of Important Stakeholders It is of utmost importance that decision makers at the provincial level engage and embrace the input being offered by key system stakeholders. Such stakeholders, such as the OMA and physicians at large, represent those who deliver health care to Ontario s population. These physicians are best suited to make recommendations and advise on the appropriate strategy that should be taken in Ontario. To date, there has been uneven engagement of the OMA and physicians in this decision making process. It is critical that the OMA, on behalf of all physicians in Ontario, be a key player as decisions are made. Without the input of physicians, there will be a lack of understanding of how care is provided. ehealth has the potential to be a powerful tool, but without careful consideration and engagement of the informed stakeholders, the tool s potential will not be realized. C. Vendor Issues Page 19 of 23

707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 As discussed previously in the section on interoperability/integration, a current system-wide challenge relates to how the data is captured within EMR systems. Different EMR vendors have different designs within data fields. This poses significant issues to physicians using different EMRs, as the information cannot be readily exchanged or interpreted. A technical strategy must be developed in order to ensure that the various EMRs are able to integrate. The absence of this will hinder the potential utility of EMRs, and the ehealth system at large. In addition, as previously mentioned, there must be a transparent system/database managed to provide physicians with the necessary information on the various vendors in the marketplace. D. Language and Terminology As part of the overall ehealth strategy, it is important that some consistent terms be operationally defined and subsequently communicated to health system stakeholders, contributors, and users of ehealth technology. At the present time, many use terms such as EMR, EHR, and ehealth interchangeably, and this poses much confusion for those who are involved. The OMA recommends that common terms be defined at provincial level to ensure that all involved are using consistent terminology. E. Privacy Privacy and security are important components of any healthcare environment, including an ehealth system. It is critical that the system abide by legislation and regulations, and that there is no threat to the fundamental trust relationship between the physician and the patient. However, the provision of safe, effective, and timely health care cannot and should not be impacted because of overzealous privacy rules and interpretations. The ehealth system should improve upon the current paper system; proper patient care should drive healthcare delivery, with privacy being respected and maintained throughout the process. Recommendations: 731 732 733 734 735 736 737 A transparent ehealth strategy is critical in the success of the tool; the OMA must be an equal partner in developing this strategy. A technical strategy is required to ensure the interoperability of systems. Consistent terms must be defined at the provincial level. Privacy must be maintained throughout the process, but it should not impact the delivery of care. 738 739 740 741 NEXT STEPS This paper aims to provide OMA members with a sense of the current ehealth landscape in Ontario, as well as to provide some recommendations for future ehealth work that must be taken at both the professional and the provincial level. Of critical importance is the development of a Page 20 of 23

742 743 744 745 746 747 748 749 750 751 752 753 754 provincial ehealth strategy that captures the needs of physicians in Ontario. The OMA has made this a priority, and will work to partner with the MOHLTC and other decision makers to ensure the creation of a physician oriented ehealth strategy. Of fundamental importance to the development of this strategy is the creation of a data governance framework that maintains the integrity of the physician-patient relationship, as well as the data housed within physicians EMRs. The OMA will engage with physicians and other key stakeholders in the development of this framework. The OMA plans to undertake policy work related to the evolving role of ehealth, telehealth, electronic communications with patients, and the personal health record. Physicians will be engaged through the development of this policy work. The OMA respects the professional expertise and leadership of Ontario s physicians, and is committed to ensuring that physicians are at the forefront of building a stronger, higher quality healthcare system. Page 21 of 23

References 1 Alberta. College of Physicians & Surgeons. CPSA vision for ehealth. Edmonton, AB: College of Physicians and Surgeons of Alberta; 2012 Sep. Available from: http://www.cpsa.ab.ca/libraries/information_for_physicians/vision_for_ehealth.pdf. Accessed: 2013 Aug 20. 2 ehealth Ontario. Electronic health records: EHRs explained. [Internet]. Toronto, ON: ehealth Ontario; 2013. [about 6 screens]. Available from: http://www.ehealthontario.on.ca/en/ehrs. Accessed: 2013 Aug 20. 3 Ontario. Ministry of Health and Long-Term Care. Ontario protecting privacy in electronic health records [Backgrounder]. [Internet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2013 May 29. [abut 2 screens]. Available from: http://news.ontario.ca/mohltc/en/2013/05/ontario-protecting-privacy-in-electronic-health-records.html. Accessed: 2013 Aug 22. 4 College of Physicians and Surgeons of Ontario. ehealth statement draft. Toronto, ON: College of Physicians and Surgeons of Ontario; 2012 Oct 14. Available from: http://policyconsult.cpso.on.ca/wp-content/uploads/2012/11/draft-ehealth-statement.pdf. Accessed: 2013 Aug 21. 5 Bill 78, An Act to amend certain Acts with respect to electronic health records, 2nd Sess, 40 th Leg, Ontario, 2013 (first reading 29 May 2013). Available from: http://www.ontla.on.ca/bills/bills-files/40_parliament/session2/b078.pdf. Accessed: 2013 Aug 20. 6 Canada Health Infoway. Pan-Canadian Change Management Network. A framework and toolkit for managing ehealth change: people and processes. Toronto, ON: Canada Health Infoway; 2011 May; p. 4. Available from: https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/88-a-framework-and-toolkit-formanaging-ehealth-change. Accessed: 2013 Aug 20. 7 Thomas G. The DGI data governance framework. Orlando, FL: The Data Governance Institute; 2012. Available from: http://datagovernance.com/dgi_framework.pdf. Accessed: 2013 Aug 20. 8 Canadian Medical Protective Association. Electronic records handbook: implementing and using electronic medical records (EMRs) and electronic health records (EHRs). Ottawa, ON: Canadian Medical Protective Association; 2009. Available from: http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/pdf/com_electronic_records_handbooke.pdf. Accessed: 2013 Aug 20 9 Holmes C. The problem list beyond meaningful use. Part I: The problems with problem lists. J AHIMA. 2011 Feb;82(2):30-3. Available from: http://journal.ahima.org/wp-content/uploads/jahima-problemlists.pdf. Accessed: 2013 Aug 20. 10 Canadian Medical Protective Association. Using email communication with your patients: legal risks. Ottawa, ON: Canadian Medical Protective Association; 2013 Jun. Available from: https://www.cmpaacpm.ca/cmpapd04/docs/resource_files/infosheets/2005/pdf/com_is0586-e.pdf. Accessed: 2013 Aug 20. 11 Baer D. Patient-physician e-mail communication: the Kaiser Permanente experience. J Oncol Pract. 2011 Jul;7(4):230-3. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3140444/pdf/jop230.pdf. Accessed: 2013 Aug 20. Page 22 of 23

12 Canadian Medical Protective Association. Etiquette + technology = better communication. Ottawa, ON: Canadian Medical Protective Association; 2013 Jun. Available from: http://www.cmpaacpm.ca/cmpapd04/docs/resource_files/web_sheets/2013/pdf/w13-003-e.pdf. Accessed: 2013 Aug 20. 13 Canadian Medical Protective Association. Using social or professional networking websites can breach confidentiality. Ottawa, ON: Canadian Medical Protective Association; 2010 Jun. Available from: https://www.cmpaacpm.ca/cmpapd04/docs/resource_files/perspective/2010/02/pdf/com_p1002_7-e.pdf. Accessed: 2013 Aug 20. 14 Ontario. Ministry of Health and Long-Term Care. Northern Health Travel Grant (NHTG) virtual care options. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2012 Dec 10.Available from: http://www.health.gov.on.ca/en/pro/programs/phys_services/docs/nhtg_is_vh_en.pdf. Accessed: 2013 Aug 20. 15 Patel V, Jamoom E, Hsiao CJ, Furukawa MF, Buntin M. Variation in electronic health record adoption and readiness for meaningful use: 2008-2011. J Gen Intern Med. 2013 Feb 1. [Epub ahead of print]. 16 ehealth Ontario. Ontario Laboratories Information System. [Internet]. Toronto, ON: ehealth Ontario; 2013. [about 5 screens]. Available from: http://www.ehealthontario.on.ca/en/initiatives/view/olis. Accessed: 2013 Aug 20. 17 Ontario Liberal Party. Moving forward, together: the Ontario Liberal plan, 2007: highlights. Toronto, ON: Ontario Liberal Party; 2007. Available from: http://www.raccoliberal.ca/images/highlights%20movingforwardtogether%20eng.pdf. Accessed: 2013 Aug 20. 18 Alberta Health Services. Engaging the patient in healthcare: an overview of personal health record systems and implications for Alberta. Edmonton, AB: Alberta Health Services; n.d. Available from: http://www.albertahealthservices.ca/org/ahs-org-ehr.pdf. Accessed: 2013 Aug 20. 19 OntarioMD. EMR Maturity Model & Progress Reporting. Toronto, ON: OntarioMD. Available from: https://www.ontariomd.ca/portal/server.pt/community/emr_maturity_model reporting/. Accessed 2013 Aug 23 Page 23 of 23