like to..." laments Dr Kalyani Srinivasan, a GP in Fredricton,
NB, about the thought of switching from paper records
to a computerized system. "But the cost in time,
money and effort is tremendous and I don't have
any of the above to meet the challenge."
It's a familiar refrain. Ask almost
any Canadian physician if they're planning to adopt
an electronic medical record (EMR) system and the answer
invariably begins, "Sounds great, but...."
In fact, Canadian docs came dead
last in EMR use compared to other industrialized nations'
physicians in a survey last year by prestigious US-based
healthcare charity the Commonwealth Fund. Just 23% of
Canadian primary care physicians have computerized their
patient files, in stark contrast to Holland's sparkling
98% mark. If those were MCAT scores, the Dutch would
walk away with all the big grants and the cushy fellowships
and Canada wouldn't even get into med school.
EMR systems have been shown to help reduce adverse events,
improve communication between health providers and keep
a tighter lid on health record privacy.
Sure, the prospect of going electronic
can be intimidating, but it doesn't have to paralyze
you. Follow these six simple steps to guide you through
the research and implementation of an EMR software system.
LEARN WHAT'S OUT THERE
Research, research, research. And then do some more
research. That's the advice from Dr Alan Brookstone,
a Vancouver GP and the creator of Canadian EMR, an industry-funded
project designed to help Canadian doctors choose EMR
Your most important source should
be your fellow physicians, he says. (But don't forget
to make sure they aren't shareholders or board members
of the company they recommend.)
Vendors may offer demonstrations
of their products to help you get a better look at them.
Or you could go to a nearby clinic to check out their
Don't rely on the internet too
heavily; just sifting through the software company's
website and separating the gibberish from the gems could
take longer than it took to earn your MD.
It's important to include all of
your practice's physicians and staff in the decision
process to ensure everyone is on the same page, adds
More research sources will soon
be available, including a full version of Dr Brookstone's
Canadian EMR project, which will feature a comparison
tool to allow physicians to look at other physicians'
ratings of EMR software based on a number of criteria.
(The site, which is not yet fully operational, has a
physician-only blog located at emruser.typepad.com.)
Canada Health Infoway is also developing a set of standards
that it intends to use to certify EMR software.
It takes too long
"It won't save any time, at least at the
onset," worries Dr Gayle Garber, a GP in Conception
Bay South, Newfoundland. But does she think it
would lead to a more efficient practice after
the system gets going? "I imagine so," she admits.
"I guess it's a real time-saver. The list of drugs
is right in front of you, up to date, and you
can go online at the same time and look up diagnoses."
The initial investment of your time during the
early going will likely pay big dividends later,
once the software is up and running.
NO PRACTICE IS AN ISLAND
Interoperability has been a buzz word in the medical
information technology (IT) community for some time
now it refers to EMR software's ability to interface,
or mesh, with other physicians' EMR systems, lab reports,
prescription forms, billing information and other computer-based
functions. In Canada, however, EMR interoperability
is still in its infancy. "Everyone has their own computer
systems and we don't have a strategic [national] plan,"
says U of T health policy professor Kevin Leonard, PhD.
"What happens is when a doctor needs to use a system
in an ER for instance, they don't have all the information
that's relevant because it's stored in somebody else's
electronic or even paper files."
One solution that may emerge, suggests
Dr Brookstone, is a model based on geography: physicians
from one region could pool their resources and purchase
an EMR software that they could all use, giving them
better bargaining leverage with the EMR company as well
as any hospitals or labs that might need to learn to
use the software's formatting, as well as the ability
to interact electronically with one another when transferring
patients or records back and forth. Based on the success
of physicians in Auckland, New Zealand, where almost
every doctor is on the same EMR program, Dr Brookstone
is working with the Vancouver Coastal Health region
to coordinate a similar effort. Calgary Health Region
also has a collective approach underway now, called
Medical Doctor's Electronic Record Association.
Dr Srinivasan, the Fredricton
GP wracked with doubts about EMR, in many ways
represents all Canadian docs' internal struggles
about making the switch. In her estimation, the
hassle and expense simply don't outweigh the benefits.
But is this a classic example of a false dilemma?
"You're either with us or against us" a
rhetorical tool as old as time, with adherents
as various as Jesus, George W Bush and Darth Vader
is, in fact, a logical fallacy. The best
solution, as years of practising medicine and
raising children have likely taught you, often
lies somewhere in the middle of the spectrum,
in shades of grey.
Believe it or not, the majority
of Canadian doctors believe that EMR is a good
thing in almost every regard, according to the
last CMA Physician Resource Questionnaire in 2002.
So why don't the majority of Canadian doctors
take the plunge? "Doctors are busy and afraid
to change," explains Dr Sands. "They're afraid
of tipping the apple cart." Nevertheless, he says,
the effort will pay off. He compares it to quitting
smoking: "Once you have made the jump, you don't
ever want to go back everything is better."
One of the most important things to learn during your
research is the degree of support the company offers.
Larger companies may be able to offer more comprehensive
and responsive technical support than smaller start-ups.
Also, be sure to verify that either
your current computers can run the software, or that
your budget will cover buying new computers. "There
needs to be a computer in every exam room," says Dr
And don't be ashamed to ask for
help that's what the tech support is there for.
TALK OUT LOUD
To be on the cutting edge in adding notes to a patient's
record physicians used to rely on their handy dictaphone.
Doctors would record their notes and a transcriptionist
would type them up, then the doctor would certify their
accuracy and finally the notes would be appended to
the chart. While this may not sound like ancient history
to many MDs, the future of discharge summaries is voice
recognition software, according to Dr Danny Sands, director
of medical informatics at Cisco Systems and professor
of medicine at Harvard. Many EMR software programs now
offer voice-recognition compatibility as standard, he
notes. "I like it better than dictating," he says. "When
you're doing a dictation you can dictate wherever you
are sometimes you see doctors dictating their
notes in their cars. But if you are doing voice-recognition,
you are doing it on the screen in front of the PC
it's great, you get the notes done, signed and you don't
wait." Depending on your preference, you might add voice-recognition
as a criterion in making your selection.
It's not secure
Though many doctors express
anxiety about how privacy legislation will apply
to electronic records, that worry is largely unfounded,
says Dr Sands.
Concerns nevertheless persist.
"I'm not sure the companies are doing enough to
protect patient records," says Dr Garber. "Every
day you read something about somebody hacking
into something somewhere. Bank records and social
insurance numbers and all that stuff."
Many such stories were shared
by participants at an EMR privacy conference in
Regina earlier this month. One was the story of
Stephanie MacDonald, a medical clerk in Calgary
who monitored the records of her lover's wife,
an ovarian cancer patient, to make sure she really
was sick. She was slapped with a $10,000 fine.
Another recounted the case of a healthcare worker
who accessed the EMR files of persons he met while
working at a tanning salon, scouting for potential
On the bright side, EMR login
tracking means that rats like these get caught,
whereas there's no proof with paper records. Dr
Sands says computerized records are sufficiently
protected. "Generally, computer systems do a better
job than paper," he says.
SIGN UP AND SET GOALS
After you and your colleagues have narrowed down your
shortlist to one final candidate, you are ready to sign
the contract. Depending on your situation, grants may
be available through Canada Health Infoway, as well
as from your provincial government.
Dr Sands recommends you set milestones
with the vendor. "Put in guarantees on achievements
and service quality," he says. The software companies
may not always be amenable to such demands in the contract,
but setting goals can make a huge difference in the
implementation process, he says.
The specifics of the training should
be established in the contract as well. Dr Brookstone
offers a tip on training: "Implementation is particularly
successful in larger groups where physicians get together
on a regular basis" often without a vendor's
trainer present "and assist one another with
the EMR," he says. Training with your colleagues and
trading hints and shortcuts about particular features
how to design custom reports, create lists, prescribe
more quickly etc. is often more useful, after
you have learned the basics, than receiving further
training from the vendor.
"At my old institution," says Dr Sands, "we hired someone
to go through our paper records and enter stuff on the
computer. That was a colossal waste of money
it wasn't cost-effective. A better way to do it is to
recognize that paper records will be with you for some
time." Once your EMR software is up and running, begin
doing all your new documentation on the computer, he
says. But don't stress about filling in every bit of
information from the paper records right away; instead,
when a patient arrives for a visit, he says, add a few
new pieces of information.
Dr Brookstone agrees with the partial-fill
strategy. He recommends initially inputting some basic
patient information: personal and demographic details
(which can hopefully be transferred from your electronic
billing software), current medications, allergies, significant
test results and baseline EKGs, if they are available.
"What physicians find is for the first couple of visits
they may need the paper record there," he says. "But
if the patient is well known to the practice, you may
not need the paper record because you'll remember the
last few visits. Then, begin to build the record on