Physicians, pharmacists and the EMR

Physicians and pharmacists in Hamilton and Sault Ste. Marie, aided by the electronic medical record, join forces to improve the health of patients.

By Saul Chernos

This is a story about a conspiracy, but it doesn’t involve Elvis, JFK, pro wrestling, or other secret societies. Rather, this tale concerns pharmacists and physicians across the country who are using technology in a collaborative fashion in order to enhance patient care.

It’s well known that patients frequently suffer serious setbacks due to unintended drug interactions, prescription errors and haphazard pill-taking regimens. According to the Ontario Pharmacists’ Association, people over the age of 50 have a 25 percent chance of being admitted to hospital due to a drug misadventure.

Dr. Richard Tytus, a Hamilton family physician and former pharmacist, and Iris Krawchenko, a pharmacist in the same southern Ontario city, are working on a remedy. In April, they launched a pilot project designed to bring the two professions together with patients under a single cooperative umbrella.

The six-month project, dubbed Passport to Health, involves 50 cardiovascular patients and a handful of participating family doctors and pharmacists.

Under the terms of the pilot, participating patients sign a contract pledging to inform a designated Passport to Health pharmacist of any medication changes within 48 hours and then work with the pharmacist to create a medication profile, which becomes part of a portable profile patients carry in a three-ring binder.

Every time the patient visits a physician, clinic or hospital, or picks up medication at a drugstore, the binder is updated, much like a passport is stamped. Patients are then required to bring the documentation to every appointment with their family doctor, for review.

“Physicians base their treatments assuming patients are taking their medications, but patients don’t always do this properly,” Dr. Tytus says. “If patients are aware that compliance is a major issue with their health, and that the pharmacist is checking, we think they will be more compliant.”

Dr. Tytus, an assistant clinical professor at McMaster University, says he and Krawchenko have worked together previously on patient education. They developed Passport to Health in response to patients who deal with multiple physicians and pharmacists.

“I had patients on numerous medications and no one taking responsibility or having complete knowledge of what they were on,” Dr. Tytus says. “We need a way to deal with this, and Passport to Health formalizes existing relationships between physicians and pharmacists. It extends the reach of family physicians and recognizes the unique, specialized cognitive skills of pharmacists.”

Passport to Health actually launched as a pre-pilot with five patients more than a year ago, and led Dr. Tytus and Krawchenko to confirm their suspicions that patients were not taking medications properly.

With funding from the provincial health ministry’s Family Health Team system – a program designed to get mental heath workers, dieticians and pharmacists and other medical professionals collaborating with family doctors – Dr. Tytus and Krawchenko engaged four other local family doctors and several pharmacists and got the ball rolling on a full-fledged pilot.

As the research progresses, computer technology is front-and-centre. While patients carry paper-based documents, the other players are connected electronically and all relevant drug information is shared within the patient’s electronic file.

Passport to Health has an electronic component: xwave’s hosted Centricity EMR system enables the pharmacists to access patient charts and communicate with the physicians. The Passport to Health pharmacist will have the same information from the doctor, regardless of which EMR system is used by the physicians, but, currently, only the Centricity platform gives the pharmacist access to real time data.

It has the potential to directly incorporate data generated by the pharmacist into the patient’s chart after the physician approval. This seamless flow of information has a powerful potential.

“With this pilot the pharmacist is actually helping to maintain that medication profile,” Dr. Tytus explains. “The pharmacist medication profile update is actually done in the patient’s chart. After the physician reviews the profile and agrees to it, the pharmacist’s medication profile becomes fully integrated.”

This translates into a personalized, relevant consultation that helps all parties: Patients receive the benefit of a paper copy, pharmacists provide consulting services fully knowing a patient’s medical history and profile, and physicians end up with a patient medication profile that is supplied and maintained by the pharmacist. As well, pharmacists are expected to provide compliance data to doctors – an accomplishment which Dr. Tytus bills as a medical first.

Passport to Health isn’t alone. With help from sources such as Canada Health Infoway, Group Health Centre in Sault Ste. Marie is spending $3.5 million to develop EMRxtra, an information infrastructure that will let physicians communicate and collaborate electronically with pharmacists in order to help patients manage chronic conditions.

Dr. Lewis O’Brien, a family physician practicing at the Group Health Centre, says EMRxtra will extend the centre’s current EMR capability to enable physicians and pharmacists to communicate with each other using text messaging through actual patient charts.

“I would send the pharmacist a note requesting a consult, right within the chart, and they would look at the chart, do their consult and send it back to me, all electronically.”

Dr. O’Brien says EMRxtra is being implemented as a year-long pilot with several hundred patients in the congestive heart failure and vascular intervention programs. “We selected these patients,” he says, “because we thought their complicated medical arrangements could be helped by the pharmacist.”

The pilot was launched with Group Health Centre’s co-located pharmacy, and Dr. O’Brien says it will be rolled out to most of Sault Ste. Marie’s 24 community pharmacies as soon as all the technology issues are worked out.

“We want pharmacists to be able to see the appropriate parts of the patient’s chart with the appropriate privacy measures, so they can have a better understanding of that patient as a whole and make better recommendations about pharmaceutical interventions,” O’Brien says. “It would help everyone be in sync with the patient’s care.”

Sunny Loo, IT director with the Ontario Pharmacists’ Association’s eHealth program, says the OPA is participating in EMRxtra with the view that pharmacists and physicians have a history of collaborating to improve patient care.

“Community pharmacists and physicians have worked together, but they’ve tended to work in silos,” Loo says. “They each take care of patients within their own professional environment. The communication they end up having with each other is by telephone or fax, and they really only send snapshots of information back and forth. Often, a lot of the translation gets corrupted by how patients interpret the situation.”

EMRxtra lets pharmacists “go right into” a patient’s EMR – with the patient’s full consent, of course, Loo says.

“There’s now another avenue of communication. No longer do pharmacists have to talk to physicians all the time, or rely on patients to interpret what physicians have told them. Pharmacists can now go and look at the patients’ records themselves.”

The OPA is also involved with Passport to Health, and Loo says the body is in discussion regarding other potential projects.

While Ontario has several significant projects, it is not the only province making gains towards physician-pharmacist collaboration. BC PharmaNet, a database tracking nearly every instance of medication being dispensed from community pharmacies in British Columbia, has been operating for roughly a decade.

Dr. Ron Joe, a Vancouver family physician who is involved with the clinical working group for the provincial e-drug initiative, says hospital pharmacies aren’t yet hooked up and only a third of B.C.’s primary-care doctors have signed up for password-controlled access. However, doctors who are participating are able to use their computers to view drug dispensing that involves their patients.

Joe says the ultimate success of the system is tied to physician acceptance and use of EMRs, and the province hopes to achieve widespread deployment of EMRs in doctors’ offices by 2008, the same year BC PharmaNet is expected to begin to accommodate electronic prescriptions.

Steps are under way to make this happen. The province is looking to pilot EMRs later this year, and there are moves afoot to upgrade the communications software in the pharmacies to accommodate prescriptions.

As well, partners in BC PharmaNet – including Canada Health Infoway, which is financing half the cost – are working to resolve the kinds of issues that dominate any planning of this sort, including patient privacy, drug safety and communications and other technical standards. The B.C. government has legislated pharmacist participation, and drugstores must use BC PharmaNet in order to dispense medications and receive payment for dispenses, Joe says.

Dr. Sarah Muttitt, vice-president of innovation and adoption with Canada Health Infoway, says the agency is investing in projects like these with a view to ultimately establishing a complete, comprehensive record of all medications that are prescribed and dispensed – a system that would touch all medical care providers, including physicians, pharmacists and nurses, and work towards preventing adverse drug events, interactions and allergic reactions.

Dr. Muttitt agrees that EMRs are key. Nationally, only 23 percent of primary care physicians are automated and using EMRs, she says, drawing figures from several reports. Those include a recent Commonwealth Fund study that compared Canada with seven other countries, another study Infoway conducted with the Canadian Medical Association in 2005, and the National Physician Survey, conducted in 2004 by the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada.

“That’s compared to 98 percent in the Netherlands, 92 percent in New Zealand, 89 percent in the U.K., and the U.S. was at 28 percent,” Dr. Muttitt says, explaining that the physician EMR adoption rate varies regionally across Canada. “This is a significant barrier to e-enabling the physician-pharmacist relationship.”

Meanwhile, Health Canada is working to resolve another challenge – the legalization of electronic signatures. Once this happens, Dr. Muttitt explains, physicians will have the capability of prescribing electronically.

Back in Hamilton, Dr. Tytus is focused on the Passport to Health pilot. Yet, he also has the big picture in mind. He predicts physicians will buy in when they realize they can derive benefits.

“If we take it to the next step, and start using Passport to Health on a wider basis, pharmacists could start communicating in a format where physicians could use the information electronically,” Dr. Tytus says. “Physicians would see that information from pharmacists can be easily translated into patient charts, where it offers value.”

Casting an even wider eye to the future, Dr. Tytus foresees the day when patients will be able to travel, and electronic systems will enable physicians and pharmacists back home to keep a close watch.

“Patient information could be put on a memory stick and carried on a keychain or worn around the neck. Patients could carry their data with them wherever they went on their travels.”  •

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Speedy EMR implementations

It isn’t all about technology. A desire for change and a sense of urgency count for a lot.

By Issie Rabinovitch

No one knows, with any great certainty, how many doctors in Canada have fully implemented EMR systems in their offices and clinics. Even the most optimistic estimates imply that doctors using paper charts outnumber the ones who have embraced EMR by three to one. Paper-based doctors give many explanations for staying with the status quo. Financial cost is almost always mentioned but there’s another major deterrent that receives less attention: the fear of a lengthy implementation period and its power to disrupt the medical practice.

Failed or problem-plagued EMR implementation teach useful lessons but in this article we limit ourselves to a close look at two large and successful projects – one in Manitoba that is completed, and the other in Nova Scotia that is a work in progress, to see what we can learn.

The Winnipeg Clinic is one of the largest multi-disciplinary clinics in Canada. It was founded in 1938 and has grown to include over 50 physicians who own and operate the clinic in downtown Winnipeg. Almost 70 years later it still has the same address but the number of patient visits now exceeds 1,000 per day. The Winnipeg Clinic is also a partner to satellite walk-in clinics in the Winnipeg suburbs.

Tom Malone is the CEO of the Winnipeg Clinic. He was previously the CEO of the Assiniboine Clinic in the same city where he managed the implementation of an EMR system for that clinic’s 16 GPs and three surgeons. In 2003, he was hired by the Winnipeg Clinic to do the same thing there. Although the decision to go digital preceded his arrival, Malone has been involved with every other decision related to the project since his first day on the job. He was willing to discuss them all, including a few he now concedes were mistakes.

Although the EMR project received unanimous support overall, Malone acknowledges that, “not all of the doctors were convinced.” On the financial side, the plan was to finance the project by cutting the payroll. The six clerks who worked in the medical records department were obvious targets, but the aim was to eliminate a total of 10 to 12 positions.

Several fundamental decisions were made early in the project. On the software side, Clinicare was chosen because of its track record of successful implementations and its high ratings in independent surveys and assessments. Network cabling was installed everywhere but on the sixth floor, the home of the pediatricians. They had made a case for using wireless Tablet PCs. The rest of the clinic was supplied with desktop thin clients.

A thin client may look like a slim computer, but it’s a more specialized device. A thin client doesn’t do anything unless it’s connected via a network to a server that’s configured with special software that supports it. The Winnipeg Clinic chose to use Citrix, which is more capable but also more expensive than the software that’s included with Windows Server. The thin clients sitting on the desktops in the clinic don’t have all of the components of a standard computer. They don’t even have hard disks. They are, in essence, advanced terminals for viewing applications and data that reside on servers. They are inexpensive, easier to manage, and have security advantages over standard computers (also called fat clients).

A survey on computer competency went out to the doctors and the results showed a great variance in computer skills. Some doctors had never turned on a computer or used a mouse, while others were very competent computer users. Before the arrival of instructors from Clinicare, the doctors were given CDs to help them become more familiar with computers.

In October 2006, the rollout process began in earnest. Within four months, everyone with the exception of two physicians was using the Clinicare system on one of the network’s 220 end-user clients. Before the end of this stressful period, Tom Malone admitted that, “I lost sleep at this stage.”

The transcriptionists were trained at the outset, during daytime hours, so that they would be fully operational when the doctors were added. The doctors were trained in the evening hours by Clinicare instructors. They received four hours of instruction in two sessions and they were trained by specialty. Week 1 was Family Practice, Week 2 was Urology, and so on.

Doctors designated as ‘super users’ were chosen from each specialty. These weren’t necessarily the most advanced users, but they were the doctors who wanted change the most. There were representatives from each specialty and they were given additional responsibilities for moving things along in their group. Is it possible to profile physicians who are successful in making the move from paper to electronic charts? According to Tom Malone, “The real factor in who makes the move successfully is not age, so much as who is adaptable and not resistant to change.”

Some computer-savvy doctors found four hours were too long for training, but many doctors found that it wasn’t enough. Malone would have provided more time, in retrospect, for these doctors. When groups of doctors were rolled out, a project manager was on site. She was really stretched to the limit by questions from the doctors. Malone says the project could have used two or three project managers. In the initial rollout, just the basic features of the Clinicare software were covered. Afterwards, there was noontime training for the more advanced features.

The doctors were asked to book at a 60 percent rate for the first few weeks. Most doctors didn’t heed this advice and booked the usual number of patients. Malone says that “the stress was terrible for these doctors,” who spent an extra hour or two at work each day. Now that they are more familiar with the software, they are back to their regular hours and seeing one or two patients more per day as a result of the new technology.

Much to Tom Malone’s chagrin, the clinic still has two doctors who have not made the transition. That forces the clinic to continue to pull paper files and incur the costs associated with that. They have been able to let two clerks go, but four remain. As a result, the EMR system has yet to have the expected impact on the bottom line. In an effort to get everyone on board, the clinic is considering charging the two reluctant doctors for each chart pulled.

The system has proven to be easy to manage. The decision to go with thin-client hardware has been vindicated. Consultants spend about 15 to 20 hours per week managing the fleet of over 200 devices, much of that remotely without needing to visit the site.

Several things that Tom Malone would have done differently have already been noted. Anything else?

“We would have insisted on trainers from Clinicare with clinical experience. Some of the trainers didn’t have healthcare experience.” As a result of feedback from Malone, things have changed. Clinicare claims that all of their trainers now have such experience.

In Halifax, two thousand kilometres and 2 times zones east of Winnipeg, The Primary Healthcare Information Management (PHIM) program was created by the Nova Scotia Department of Health to expedite the adoption of EMR among primary healthcare physicians in all 9 district health authorities of the province. In the past year and a half, the program has succeeded in helping 29 percent of the province's primary healthcare physicians make the transition. It has been aided by $4 million from Health Canada's Primary Health Care Transition Fund, which was used to establish the Program and assist clinics with implementation. The funding was made available on a first come, first served basis and it is now depleted.

Following the successful launch of the PHIM program the NS government is exploring strategies to extend funding for the gradual transition of the remaining 71 percent of primary healthcare physicians. The Strategy Update will be completed over the summer providing a clearer picture for the expansion of this program.

Lisa Napier, PHIM Program Manager, provided details on how 721 users in 37 clinics crossed the digital divide in a relatively short period of time, typically from 3 to 5 months from beginning to end for each clinic. Another 31 clinics are working their way through the implementation process

At the outset, it was determined that using a hosted solution would be more efficient and, furthermore, that limiting the number of approved systems would keep costs and complexity down. During the process to choose approved EMR systems, PHIM visited doctors and nurses in all of the districts. “We asked them what they would need in an EMR. More than 700 requirements were identified in total”, explained Napier.

When the dust cleared, two approved choices emerged: Nightingale's myNightingale (ASP system) and Dymaxion's Practimax (non-ASP). A non-ASP solution was required because there are pockets in Nova Scotia where good, high-speed internet access isn't available. All 78 clinics that have registered in the program since late 2005 have chosen myNightingale.

A structured process has been put in place to guide the clinics in the implementation process. Speed in implementation is important but it takes a back seat to quality. “We've learned the hard way that skipping steps and cutting corners doesn't pay-off,” says Lisa Napier.

Interested clinics go through a standard registration process where basic information is gathered. Next, the clinic gets in touch with Nightingale who visits the clinic, does an implementation assessment and comes up with a plan detailing everything needed for the implementation, including computers, network infrastructure, and voice recognition (if desired).

Once the clinic signs off on their Nightingale agreement, it takes 3 to 4 months to make the transition. Each clinic lines up internet services, appoints champions who go through training first, schedules time for training the other doctors, and so on. According to Napier, “The time varies based on the urgency to move forward and competing pressures with each clinic.” Clinics who wish can get it done in 3 months or even less.

The training is divided into Practice Management (two sessions for a total of 6 to 8 hours) and Clinical (another two sessions for a total of 6 to 8 hours). PHIM is investigating modifying the delivery of training to a staged model that delivers training material in manageable stages, enabling clinics to master areas before proceeding to the next level.

There was concern at first whether clinics would accept the ASP model, especially since the data is housed in a government data centre, but there has been no negative feedback because of the lack of alternatives. “It would have been more difficult to do the implementation with multiple solution possibilities”, according to Napier.

The clinics mentioned many benefits of their new system but one of the most appreciated was the automatic flow of lab and DI results from acute care facilities.

Returning once more to the issue of speed, Napier mentioned that some clinics have gone faster than average and some have cut corners. But, she continued, “We have learned that bending rules doesn't work. We don't want fast implementations at the expense of quality.” •

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