Contributed by Dr. David Weinstein – Nephrologist, Belleville, ON
I wanted to share my experiences with other physicians and offices about some tools for my Electronic Medical Record in Ontario. I have been a physician in Ontario since 2015 and have been in practice since 2002. I work in both my local hospital and my private practice. My EMR and associated tools are so important for making my practice and life more efficient. It is really amazing some of the things I can do.
In the office, I seamlessly pull labs from OLIS (eHealth Ontario’s Ontario Laboratories Information System) into my EMR. I no longer need my office to call around for blood work. I have access to the data quicker and can work more efficiently. My referring doctors know not to send me blood work. This speeds up the flow through my office and saves me on monthly faxing costs.
In the office I no longer call pharmacies looking for medication lists. I can just pull recent prescriptions electronically and now I know I have accurate medication lists.
I can access records from other hospitals including blood work, radiology reports and images and dictated reports using the ConnectingOntario ClinicalViewer. It makes it so much easier to reconcile patients from other sites back into the office and make sure I have a complete picture of what is going on with my patients.
I can access hospital reports in my EMR as soon as they are finalized because my EMR is connected to HRM (OntarioMD’s Health Report Manager). I do not have to wait for anyone to mail or fax them to me anymore. In fact, I have asked my local hospital to stop sending me paper copies of EVERYTHING.
From my smartphone, or form any hospital computer, I can easily access my EMR and review patient history, medication, prior labs and notes to streamline hospital care.
As a e-Consult consultant, I can help out other physicians through the Ontario eConsult Program, but I also can challenge myself based on the difficult questions I am being asked.
I encourage all Ontario physicians to incorporate the various digital health tools into your office practice. You will work more efficiently and your patients will be happier. Contact OntarioMD at support@ontariomd.com to connect your EMR to the services I mention above as well as additional services to help you use your EMR more effectively.
It’s well known that poverty is a major determinant of health, and that one’s social and economic environments play a large role in whether a person becomes physically or mentally ill. However, little has been done in a practical way to identify and assist at-risk members of society at the primary care level.
Now, however, a project has been launched to turn things around. Initially, a two-month pilot project was conducted in 2018 that gave primary care providers a computerized tool to identify patients who are at risk of living in poverty, and who could use the support of community resources.
The project was conducted at primary care clinics in four Ontario cities – London, Sudbury, Cambridge and Toronto – under the leadership of the Toronto-based Centre for Effective practice (CEP), a not-for-profit organization which started at the University of Toronto’s Department of Family and Community Medicine to create and disseminate evidence-based improvements in primary care.
“My office screened 700 patients for poverty, and 100 were identified,” said Dr. Mario Elia, a London-based family physician and one of the pilot site leads.
Overall, 4,517 patients were screened at the four sites, and 12 percent were found to be at risk of poverty.
Of these, 30 percent were provided with customized resources and referrals to community supports at the same visit.
Dr. Elia and Claire Stapon, a manager at the CEP, spoke about the poverty screening project at a session for physicians at OntarioMD’s EMR Every Step Conference, held in Toronto in September.
Stapon said that 20 percent of Ontario families live in poverty – about 1.57 million persons. At the same time, she noted that 50 percent of a population’s health is determined by social and economic environment, according to recent studies.
Indeed, all of the following have been strongly correlated with a person’s environment: diabetes, asthma, arthritis, cancer, COPD and mental illness.
“Often, doctors don’t have the resources, and we struggle with how to help patients living in poverty,” said Dr. Elia.
The computerized intervention devised through the Centre for Effective Practice has been identified as a step in the right direction.
The tool was developed in partnership with CognisantMD, which produces Ocean software, a system that helps automate information gathering as patients arrive at a clinic. Also involved is 211Ontario, a free helpline and online database of Ontario’s community and social services.
The Centre for Effective Practice has been producing other tools used in clinics; the one created for this project has been optimized to screen for patients struggling financially.
In the pilot, staff and clinicians at the four clinics were first given education about the topic and training on use of the tool. Dr. Elia said it wasn’t difficult to implement at his clinic, as the office had already been using Ocean questionnaires to gather patient information.
All patients over the age of 18 were given tablet computers, on which the form to screen for poverty would pop-up. Questions included such examples as, “Do you ever have difficulty making ends meet at the end of the month?” and “Have you filed your taxes?”
Not only does the tool effectively identify at-risk populations, importantly, it also provides physicians with sets of local supports and resources for patients.
Low income patients who haven’t filed their taxes – because they fear they might have to pay – are often entitled to tax refunds. The tool shows doctors how to connect their patients with the right resources in order to file their returns and receive these refunds.
Other social supports are also available, making it much easier for physicians and their staff to help patients in need.
The Ocean tool integrates with EMRs and can automatically create reminders on follow-up visits to inquire about different issues.
After the pilot project ended, each of the sites had the option to stop using the tool. However, they all wanted to continue using it, Stapon said.
Now the Centre for Effective Practice wants to spread the resources to other primary care practices in Ontario. They have created a modified version of the tool for TELUS PS suite physician systems, to start. Eventually they’d like to make the tool available for all EMRs in Canada. Those who are interested in more information can visit http://cep.health/poverty.
Contributed by Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader
Recently, I accepted a 70 year old man into my family practice. He presented to our first encounter with nothing but his spouse to aid his recall. I had prior hints of his complex history but it soon became evident that neither of the pair had the memory or detail that would have been nice for this intake interview.
One of the tools I have come to cherish in such encounters is OLIS. Subtly integrated within my EMR, in a matter of a couple of clicks I am in the position to query the database for the patient in front of me. On verbal consent from this septuagenarian, I launched digital minions to fetch the last ten years of his labs. Moments later another click of a button allows me to download the retrieved treasure trove into my EMR. Less than a minute later I am pointing to a graph generated by my EMR of his hemoglobin and asking him, “ What happened to you at this dramatic dip in February 2016.?” Visibly impressed, he recalls, “Oh that is when I had my stroke and was given clot busters”. In just minutes, I was able to get a better picture of trends and perspectives that improved my ability to care for this patient without having to send him for duplicate lab tests.
Later, my questions about his diabetes were met with firm denial, yet his previous family doctor had already ordered a Hb A1c in 2015 which was reported at 6.7%. A picture of denial was emerging. The graph of his LDL cholesterol shows the classic swings of someone at one time started on a statin who later stops it only to be started again. In this case, the statin had evidently been stopped approximately a year before his stroke but promptly restarted in February 2017 fitting perfect with my lab graph. My patient and his wife look at me like I have psychic powers. I smile and thank my EMR and OLIS for the good start we were off to.
Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader
The 2017 Canadian Guidelines for Opioids for Chronic Non-Cancer Pain emphasized the importance of safely minimizing the dose of opioids that patients are being prescribed. The guidelines made it important for me as a primary care provider to reassess my population of patients on opioids and ensure that I was doing my best to implement the new recommendations accordingly. This presented a formidable challenge and led to the realization that it would be very useful to have an EMR tool to support this process.
In response, the East Wellington Family Health Team (FHT), the Guelph FHT, the eHealth Centre of Excellence (eCE), and TELUS Health partnered to create an Opioid EMR Toolbar (Figure 1) using content informed by the Guidelines and work done by the Centre for Effective Practice (CEP).
Figure 1. Opiod EMR Toolbar
The toolbar provided a practical and effective way to implement the new guidelines into my practice through the following capabilities:
The figure below illustrates the steps I took in using the toolbar to implement the new guidelines.
Figure 2. Steps used to systematically manage my population of patients on opioids.
During this process, I also found it very helpful to participate in Academic Detailing sessions provided by the CEP. These are one on one sessions in which an expert from the CEP met me at my office and reviewed key topics including:
Non-pharmacological and non-opioid options for the management of patients living with chronic non-cancer pain
Managing opioid therapy for patients living with chronic non-cancer pain
Managing care for patients living with opioid use disorder
Results
The toolbar gave me the information that I needed, when I needed it, provided individualized patient decision support, and saved me a lot of time on documentation. I was able to spend more time with my patients. They felt engaged and well informed.
Within nine months of the adoption of the toolbar I was able to safely taper the dose of opioids for a significant number of my patients and there was a statistically significant reduction in the overall MEQs I prescribed over this time period (p<0.05).
I really hope that others will find similar success in helping their patients manage their pain safely and effectively. The Guidelines have paved the way for us, and the Opioid Toolbar has proven to be an effective vehicle to help get us there.
Resources available
The Opioid Toolbar is now available to all users of Telus Practice Solutions EMR. The simplified version of the toolbar used for this quality improvement initiative is available through theeHealthCentre of Excellence for PS EMR (Oscar under development). eHealth coaching sessions are also available through the eCE (with Mainpro+ credits) for primary care providers across the Waterloo-Wellington Local Health Integration Network.
The Academic Detailing sessions are free-of-charge and free of commercial interest. Physicians can earn Mainpro+ credits for each AD session. More information and the process of signing up for a session is available on the Centre of Effective Practice website.
References:
Busse, J.W. (2017). The 2017 Canadian guideline for opioids for chronic non-cancer pain. Hamilton, ON: McMaster University.
Need help supporting your patients in managing their pain? Visit the Ontario Pain Management Resources for a coordinated program of tools from partner organizations across the province.
The above editorial describes the author’s desire and need for a single national Electronic Medical Record (EMR) in primary care. He speculates that many of our problems in primary care could be solved by such an instance, from the sharing of records between clinics to research, to specialist access to notes. He cites single health systems in the US and Singapore as examples of how and why this could work. This is an interesting perspective, but one which may be overly simplistic and not shine the light on the whole picture. There has been significant progress and development made in the digital health space in Ontario over the past ten years and this should be recognized and celebrated. This, coupled with a relentless focus on systems integration across the continuum of care, is where we should put our energy.
Although we have much in common as family doctors across the country, we all ask very different things from our EMRs. Practice environments are not the same in inner city urban centres, suburban practices, rurally, in university health clinics or aboriginal care centres. This delivery complexity needs to be appreciated. Nationally over 80% of family doctors already have purchased an EMR that works for them and are using it fulsomely. In Ontario, this is over 85%. Physicians own their systems. They have made significant investments in these … financially, in time spent recording information about their patients, and in blood sweat and tears producing clinically useful data. We should appreciate this effort and use the systems to their maximum. Much has been accomplished and advancing from where we are is a very tenable option.
Switching to one EMR solution that attempts to meet the needs of 43,500 family doctors nationally is an impossible task. And the disruption in care created by “ripping and replacing” would take decades to recover from. Canadian provinces have collectively invested billions of dollars in EMR development, deployment and mature use. We cannot afford as a society or at any level of government to start over again. That said, fundamental health system reform, advances in integrated care models and associated compensation reform should be the driver that defines how integrated digital health platforms can and should be presented at the local, regional, provincial and national level.
Satisfaction ratings with individual EMRs is actually quite high in provincial surveys. Even with multiple EMRs on the market, connectivity is improving year over year (witness Netcare in Alberta, Connecting Ontario and Clinical Connect in ON and Saskatchewan’s eHealth portal). In Ontario, information from virtually every hospital is pushed directly into EMRs within minutes of it being generated via Health Report Manager. Lab results from everywhere can be queried and downloaded through OLIS. Integration with drug and immunization repositories is occurring now. eReferral and eConsult systems are up and running and are becoming more and more integrated into the point of care.
As we evolve into an increasingly cloud-based environment the perceived advantages of a single EMR product or database are no longer compelling. What is most helpful is gaining access to data for clinical, research and system planning purposes. This is less a technical issue than a policy one. Integration and interconnectivity are the key. We are getting closer and closer to this daily, with the advent of single sign on, contextual launching of external digital tools from the EMR, data standards and data movement. The most unpredictable factor is a human one: even when standards exist, having people use them consistently is a challenge. A single EMR does not fix this. Endless dropdown lists and tick boxes do not either. In primary care nothing is more important than the patient narrative. We can never lose this.
Choosing a single EMR vendor has other dangers in creating a monopolistic environment. This makes us vulnerable as a health system and as a profession. Currently, Ontario has certified 11 EMR vendors and 12 EMR products to a set of core requirements that improve constantly over time. This allows progress to occur incrementally on interconnectivity, data portability and system functionality. Having a single vendor control the entire market means that we are at the whim of one company whose business interests may not be aligned with those of clinicians or patients. We lose our collective influence.
Open source software is not the solution to this problem either. Although it has the advantage of being inexpensive and in some cases free, it has the disadvantage of needing as much if not more support as proprietary EMRs do. Most physicians lack the knowledge, skill and desire to program and produce changes in their EMRs themselves. They just want to get down to the work of looking after patients. Multiple different customized instances of an open source EMR do not improve the situation overcurrent state in any way.
It may seem on the surface that having a selection of EMRs nationally is folly. But experience has shown that competition drives change and innovation. We do not disagree that there are aggravations in navigating from an EMR to a viewer or external portals, but this is a solvable problem. The key is to build bridges allowing access to data that is required for a clinician at the point of care. We maintain privacy, confidentiality and security more effectively this way. Data for secondary use can be liberated easily through these structures if we create the right policy and business drivers. All of this comes at far less risk and with a far better user experience for the average doctor. Banks have done it. Retailers have done it. We are doing it.
At OntarioMD we believe in more choice not less. We want to encourage new software products to enter the market to speed up the pace of innovation. Some of these are EMRs, some are apps that make an EMR fly. We want to let doctors be doctors, not computer engineers or data scientists. And ultimately, we think that patients should be the first and last point of approval regarding the secondary use of their personal health data. These are our principles. We strongly believe that the best way to accomplish them is via our current approach to EMR selection, certification and improvement. One EMR system for all is simply not a realistic option.
