More EMR, less superhighway, says Canadian Medical Association

By Rosie Lombardi

The Canadian Medical Association’s recent Health Care Transformation in Canada report calls for a fundamental change in the way healthcare technology is developed. The CMA wants information technology development to shift from building an information superhighway for healthcare to practical applications of technology at the point-of-care. “The focus has been on building systems for electronic health records (EHR) instead of electronic medical records (EMR),” says Dr. Anne Doig (pictured), president of the CMA.

The two terms are often used interchangeably but they’re very different, she says. “EHR describes broadly accessible records of information about a patient that are accessible across medical practices and contain information that might be germane to any practitioner looking at the individual. An EMR is a longitudinal record of a patient that a doctor maintains over time, and is the equivalent of a chart.”

The emphasis on developing a big-bang solution for EHR records has been misplaced, she says. “People had good ideas about the kinds of information that might be useful to share across multiple sites, but the problem is that they started there. They forgot about the fact that you can’t even get information uploaded onto the superhighway unless you have a mechanism to capture patient data, filter it and transmit it onto the superhighway.”

The focus should have been on building electronic platforms at the point of care, which has happened to some degree in some areas, she says. But this patchwork approach is very inefficient. “For example, diagnostic imaging is largely electronic, and radiologists don’t work with film anymore. But they’re still using paper notes and faxes to get that diagnostic information to the family doctor.”

Capabilities need to be developed at the patient care level to enable electronic interactions between doctors, nurses and other specialists. “The interoperability and connectivity pieces have not been happening.”

EMR uptake by doctors in Canada is only about 30 percent, she says. “Many doctors who implemented EMRs said, ‘We wish we could connect properly to other medical entities but we can’t – but we’ll implement electronic records to serve our needs internally.’ So all those EMRs are functioning in isolation from each other.”

Too much investment has gone into building a big-bang superhighway instead of focusing on practical interoperability at the EMR level, she says. “If they had started at the ground level, we would have had 99 percent of doctors on EMRs by now. We would have pushed local health authorities to respond to our demands for downloadable lab results and other practicalities.”

The problem is that developers thought that a healthcare superhighway with universal EHR records accessible by medical practitioners anywhere in Canada were what patients needed.

“But the bulk of care isn’t such as was envisioned by the concept of a EHR. When I see my patients, the majority of time, I don’t need to go to external records to find out information about their conditions. I’m admittedly not an emergency room doctor, but I’m not talking about those circumstances, as they’re not typical. Most interactions occur at the point of care, and there’s no need to access an EHR.”

To get on the right system development track, the CMA believes the next wave of healthcare technology investment should be directed to development of point of care applications specific to the needs of individuals.

“The conversation has to happen with Canada Health Infoway. What we’re saying is, take the dollars that the federal government has finally released through Infoway, and look at what people actually need at the point-of-care.”

Many provinces have programs in place to help family doctors defray the costs of implementing an EMR, and have several approved EMR vendors for general medical practices. But specialist areas aren’t getting dollars or assistance.

”So for obstetricians, for example, this means going out and figuring out what’s missing and what they need to implement an EMR that serves their areas. Vendors should be encouraged to build apps that are specific to the needs of various specialties. Those are the investments that ought to be made.”

Although some provinces have incentive programs in place to encourage family doctors to implement EMRs, Doig doesn’t believe Infoway’s funding should be used to boost that uptake. “I would not want to see the federal money that’s been released go directly into straight cash incentives, because it’s not what the money is intended for – it’s to help make software that works so physicians will want to adopt it.”

On the connectivity front, Doig says developers need to look to local solutions first. “Most of the data I capture isn’t what other medical practitioners want to see, so the idea that we have to build so information can be shared in a global sense isn’t what we’re talking about here. What we mean is that we want interoperability and connectivity for individual clinicians.”

In her own family practice, for example, Doig says has some limited connectivity. “Because we yelled and screamed in my city, we now have lab date returned directly to our EMR via a dedicated data port. I just want my server to talk to whoever else’s server I’m working with, and do it securely. We want lab A to talk to clinic B and C and so on, and get to the point where information is quickly accessible.”

In this organic fashion, a healthcare superhighway will eventually form, says Doig. “This would work better for us instead of going to the top level and trying to address all the issues around privacy and security and what information should get shared first. It’s hard to design a system that uploads everything and then put all those rules on top.”

Posted August 19, 2010