In this fourth entry in our video series on the EMR Quality Dashboard, OntarioMD CMO Dr. Darren Larsen discusses the importance of good data quality and how analytics can help patient care through population health management.
Contributed by Surya Qarin, OntarioMD Practice Management Assistant
Anyone that has known me long enough knows I have spent much of my life in and out of hospitals – and that’s not because the doctors are cute. As a matter of fact, Etobicoke General’s nurses and I are on a first name basis now, and they know exactly which vein works best when drawing blood, and which ones “hide.”
As a child, I was hospitalized every other week for severe asthma. It seemed to subside after I turned 12… at least I thought it did. I didn’t even think asthma was a real issue for adults. I’d always been told people outgrow it. But this is not the case: According to the Centers for Disease Control and Prevention, 9.7% of women aged 18 or older have asthma and are more likely to die of asthma than men. Adults are also four times more likely to die of asthma than children. Asthma Canada stats show that up to 250,000 Canadians are living with severe asthma.
Asthma returned to my life a few years ago, as a moderate condition. I had become more active, believing it would help with my other health issues (which it did). As long as I took my puffers before and after working out, I would not have any issues with breathing.
Then flu season hit, and I got sick a few times between December 2016 and February 2017. Those who know me understand my strong belief that I am super woman and do not like to complain about being sick or having “a little cold.” Unfortunately, this was not just a small cold: it had turned from a cold, to bronchitis, to full blown pneumonia by April 2017. Even then, I still refused to see a doctor. One day, on my drive home from work, I felt a sharp chest pain, and something didn’t seem right. I was not just having a little difficulty while breathing as I had been the last few months. I actually could not breathe.
Gasping for air, I pulled over, sent a quick text to my sister and drove to Humber River Hospital. There, I realized how difficult it would be for me to get my medical records: My family doctor was not affiliated with the hospital, nor was Etobicoke General. They were, however, able to pull my past drug history from my pharmacy and go based off that information. I was stabilized and discharged.
A few days later, my breathing difficulties returned. I went into Etobicoke General, and they were able to pull my history right away and admit me to hospital within the hour. Turns out my lungs had started shutting down due to the pneumonia and asthma, and as it was high-humidity and high-allergy season, being outside did not help me. During my stay in the hospital, my family doctor received hospital reports via Health Report Manager (HRM) and he was kept updated on my condition, as were my respirologist and cardiologist.
After a few weeks of recovery, I thought all was well. However, I caught a “cold” again in October, and this time things deteriorated fast! I ended up in hospital yet again. My respirologist was made aware of my condition in real time via the hospital’s EMR and was able to work with the other respirologist on duty and doctors working on my case to provide the best course of treatment given my history. My current spirometry test results were easily available for the clinicians, and the instant connectivity between those on my medical team helped improve my care and recovery process.
Once again, my family doctor’s ability to receive hospital reports to his EMR through HRM enabled him to follow-up accordingly, ensure I had the contacts I needed for my health, schedule regular testing, and most importantly, help ensure that I didn’t end up in the hospital again. I’m happy to say that I have not been hospitalized overnight since November of 2017.
As a member of the team at OntarioMD, I help clinicians across the province understand the value that EMRs and digital health tools such as HRM can bring to their practice and the quality of patient care they’re able to provide. But being a patient in the health care system has really demonstrated the importance of these tools to me first-hand. If you’re a clinician who has questions about optimizing your EMR use, or you want to connect to HRM or the wide range of other digital health tools in Ontario, contact OntarioMD at email@example.com.
Submitted by OntarioMD Dr. Adam Stewart
This blog post was originally published on April 22, 2018, on Dr. Adam Stewart’s website at www.stewartmedicine.com.
Information and data have value in every industry. The value of data in health care is only beginning to bloom. Who owns it, though?
Patients undoubtedly have rights with respect to their medical records. It goes unrecognized by most, however, that physicians own the value of data with their electronic charts.
Patients have rights to the content of the data within their medical records. The charts contain their personal information. This is unquestionable. However, the value of data comes from its structure and the organization, which is fully dependent on the physician who generates and maintains the medical record.
The organization of a patient’s chart may vary from being a barely legible handwritten paper chart to the other end of the spectrum of being a complex Electronic Medical Record (EMR) with the advanced data structure. Across the spectrum, the exact same patient information (content), can have widely different functionality and analyzability (value). This quality differential is entirely dependent on the physician and there can be extreme differences when comparing the charts, and thus data quality, of one physician to another.
Governments covet the value of the aggregate, even anonymized, data within EMRs for planning and policy purposes. Pharmaceutical companies share a similar craving for the data for marketing and development purposes. Innumerable interest groups and organizations equally desire data that relates to their agendas. (The legalities and ethics of sharing or selling data are beyond the scope of this article. Rather, the intent of this article is to identify and raise awareness of the value of EMR data that physicians possess).
As per College of Physicians and Surgeons of Ontario (CPSO), “patients have a right of access to their personal health information that is in the custody or under the control of” a physician.1 Patients can request copies of their charts. Even if the original chart was in EMR format, though, what the patient is entitled to and receives is either a printed paper copy of the records, or an electronic PDF document saved on a CD or memory stick, for example. In these formats, the data has relatively nil to minimal value because it is not structured in a way that is easily navigated and analyzed.
Physicians, and staff hired by physicians are the ones who input the notes and structure the data within their charts. Many physicians further build and customize tools within their EMRs to aid in the documentation. Physicians are the ones who pay for the EMR software, training, and vendor support. Physicians are the ones who are responsible for funding all of the computer hardware, technical support, and the physical space in which to house the infrastructure. Accordingly, in every sense, physicians own their EMRs.
One might try to argue that part of the payment to physicians from Ontario Health Insurance Plan (OHIP) for their services includes the generation and maintenance of the medical record.2 However, OHIP simply mandates and includes payment for physicians to “keep and maintain appropriate medical records”.3 It specifies nothing with respect to a standard of quality. The CPSO has more specific requirements.1 However, even a legible and complete paper chart meets those standards of care. Anything above and beyond the minimum baseline of those requirements has value, and that value is derived from, and therefore owned by, the physician who generates and maintains that chart.
There is obvious variability with respect to the quality of data within physicians’ EMRs. The difference from one extreme to another highlights the differences in the value of EMR data. Physicians own that value.
Patients have rights to the content of their individual data. Physicians own the organization, structure, functionality, and analyzability of the data. Physicians own their EMRs. It follows that physicians own the value of the aggregate data within their EMRs. These are careful and important distinctions.
Contributed by OntarioMD Peer Leader Dr. Yves Raymond
Recently, Newfoundland physician Dr. Thomas Hall contributed an opinion piece to CanadianHealthcareNetwork.ca, the online home of The Medical Post. Hall’s article – which can be read here (if you’ve registered for a Canadian Healthcare Network account) – argued that while EMRs are useful for connecting health care databases and analyzing patient data, using them during patient encounters risks the doctor being seen as distracted and lacking empathy.
I commented on the website that I find it interesting that we’re quick to blame technology when, in fact, it is how the user chooses to use the technology that is the real issue. In my comment, I also took the liberty to rewrite Dr. Hall’s article substituting paper charts for EMRs as evidence that his arguments could still be made if the medium were paper rather than EMRs. My version is below. Leave a comment below this post to let us know your take on this important issue.
Paper charting no doubt helps remember what you did, but what do they do to the more subjective nonverbal parts of our patient encounters in office?
Over the last number of months, I have been talking with both psychiatry colleagues in Newfoundland and with staff at the British Columbia Psychiatry Association about their thoughts on paper charting in a family physician’s office. Generally, they felt, and I agree, that paper charts in a physician’s private office as a place to write notes after an undistracted face-to-face patient encounter is potentially helpful. However, in my informal conversations with these physicians, they all expressed serious concerns about the possibility of being distracted and the perceived lack of empathy that may arise from their use of paper charts in the office while examining a patient. This is a serious problem, as most family physicians use paper charts in their exam rooms while seeing patients.
Also problematic is that a family physician’s day is approximately one-third to one-half filled with some components of psychiatric care. I often ask physician colleagues the question: “What do you think of a patient who checks their agenda during their appointment?” Almost exclusively physicians answer with words such as annoying, wasting my time, rude, or with even more intense expletives. This is just a normal human reaction when we think our time is being wasted or we’re not being taken seriously. We physicians have to be aware that the reverse is also true for patients who perceive similarly in encounters where the physician is constantly looking at and writing notes into a paper chart.
Apart from the obvious perceived lack of caring and empathy that paper charts in patient rooms may exacerbate, there also should be serious concerns about what a physician might miss by being distracted by writing notes into a paper chart. A small enlargement of one side of a patient’s neck, clubbed nails, thinning hair, a small facial droop, a facial expression crying out for help from a patient’s partner sitting across the room, etc. These subtle things will undoubtedly be increasingly missed as physicians are pressured to enter more notes that often serves no purpose other than liability coverage and administrative information.
Paper charts will eventually be in every physician office in the country but the “leaders” in our profession, who are often too removed from complicated day-to-day front-line patient care, need to be more proactive about policies that will minimize these pitfalls. As an example, here is some advice from Nobel Prize winner Dr. Lown, author of The Lost Art of Healing:
“Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures … Doctors of conscience have to resist the industrialization of their profession.”
Could rules be established by medical associations to suggest paper charting use be reserved to outside patient rooms? This would also require a potential increase in physician remuneration to manage the increased work that would result from extra notes entry at the end of the day.
This post was contributed by Dr. Adam Stewart. The original entry can be found on his blog at https://www.stewartmedicine.com/blog/emr-is-not-the-problem
These days, it seems there is an anti-EMR proclamation to match every anti-vaccination decree. As the old adage goes, “You can lead a horse to water, but you cannot make it drink.” For the skeptics, by the end of this article, hopefully the water will reveal itself to be a little more palatable.
Paper vs Basic EMR vs Advanced EMR:
In its most basic form, EMR is used simply as an electronic typewriter and appointment scheduler. As a next step in advancement, the EMR user takes advantage of features like prescription writers, some basic note templates for common types of visits, and perhaps using a few simple “reminders” to aid in patient care. This would be classified as “Basic” EMR use. “Advanced” use of EMR includes taking advantage of features such as searches, complex reminders, and many of the other innovative features that EMR systems have to offer.
Even in its most basic form, EMR transcends paper charts in arguably every way imaginable.
EMR has become a Scapegoat:
Critics of EMR often claim that much of their day is spent entering data into a computer, rather than face to face patient care. They are frustrated and feel this type of administrative work is a waste of valuable physician time and expertise. This is all totally understandable and merits improvement. However, EMR is not to blame here. EMR is simply the tangible instrument for the deeper issues and causes here.
It is not the EMR that is causing nor necessitating the diversion of physician time. Rather, it is the increasingly burdensome administrative requirements of today’s clinical practice. It is the CPSO and MOHLTC requirements that mandate thorough documentation. It is the mounting complexity of each and every patient, compounded by a growing number of clinical practice guidelines for each of their chronic conditions. It is the incentives and corresponding metrics that amplify administrative burden. It is government and hospital policies that mandate documentation requirements.
Whether or not each of these factors is misguided is beyond the scope and purpose of this article. The fact remains, though, that the digression in clinician time is due to factors like these, and not because the EMR is somehow demanding the clinician’s time.
EMR is not the problem here. It is the solution. The administrative burden caused by all of the above factors would undoubtedly be even more time consuming and inefficient if not for EMRs.
One Click is Faster than Fifty Keystrokes:
Even in its most basic form, EMR as a word processor with elementary templates for notes is exponentially more efficient than hand-written paper charts – not to mention the legibility factor.
Imagine a patient who presents with a respiratory infection. Assessment reveals clinical suspicion of pneumonia. A chest x-ray is ordered and the patient is prescribed amoxicillin. Ultimately, the physician will need to document a chart note, complete an x-ray requisition, and write a prescription.
The chart note may look something like this, and took 2:26 minutes to write:
The hand-written chest x-ray requisition may look something like this, and took 1:11 minutes to write (not including the time it would have taken to manually retrieve the paper requisition):
The hand-written prescription may look something like this, which took 43 seconds to write:
This paper-based encounter took a total of 4:20 minutes in paper-work.
In comparison, using an EMR with just basic features, the same encounter required a total of only 1:37 minutes to write the chart note (1:05 minutes), prepare the x-ray requisition (29 seconds), and write the prescription (13 seconds).
Here, basic EMR use saved 2:43 minutes in administrative and charting time in this simple visit example. This is not to mention all of the time saved in chart retrieval and filing, the administrative time saved by electronically faxing the prescription and requisition, and the added efficiency of tracking a pending test result.
If one assumes an average time savings of even 3 minutes per visit, multiplied by 100 patient visits per week, that amounts to 5 hours of physician time saved each week, in just this simple example.
In actual practice, the efficiency savings are even greater when one considers the difference in time saved with more complex visits such as chronic disease management, like diabetes flowsheets, and so on. For instance, EMRs allow easy graphing of measurements such as blood pressures, weights, and A1C levels, so as to have this type of data readily available within a couple of key strokes, thereby improving the ease and quality of clinical decision making.
Metrics and Population Health Management:
There are deserved merits and criticisms for most of the popular metrics that physicians are asked to track, and the incentives that are sometimes tied to them. These types of discussions are beyond the purpose and scope of this article.
That aside, the benefits of screening for cervical cancer in women are relatively non- controversial. Imagine, for example, a family practice that has 600 applicable women who are to be screened every three years with a PAP smear. Using an EMR, a simple search takes just a minute or two to generate a recall list. With advanced features such as bulk emailing, hundreds of women can be notified and recalled using less than ten minutes of a staff time. Whereas with paper charts, the amount of administrative burden required to find and recall every single woman who is overdue for her PAP smear is enormous, not to mention subject to a tremendous amount of human error and inaccuracy.
Magnify this example by the similar administrative burden (or savings with EMR) of recalling patients for the multitude of other tests they require (Colon Cancer screening, Mammograms, Immunizations, Blood Pressures, certain blood tests, Bone Density Tests, etc). There is simply no logical justification for the use of paper charts over EMR, neither in terms of efficiency nor quality of patient care.
Other EMR Advantages:
EMRs carry other sorts of advantages that paper charts cannot offer, including but not limited to:
– Accessibility (i.e. remotely from outside of clinic)
– Safety checks such as drug interaction warnings
– Intra-office messaging features
– Efficiency of sending referrals (that are high quality and comprehensive)
– Ease of ability to track pending tests and referrals
– Ease and potential for data retrieval and analytics
Even its most basic form, the immediate and tangible advantages that EMR offers over paper charts are clear. This is not to mention the spectrum of advanced capabilities not explored within this article. EMR should not be a scapegoat. Frustrations with current administrative burden should be more appropriately directed at its more insidious root causes. If anything, EMR and technology will continue to assist as solutions, rather than be obstructions.
– Dr. Adam Stewart
May 14, 2017
Back in December 2016, I was doing some work around proton pump inhibitor (PPI) costs in Ontario and did some digging into my EMR data to see what savings could be found.
Here was my Twitter thread about the topic.
In short, I identified 414 of my patients on a PPI, 314 (76%) of which were on rabeprazole or pantoprazole, the two cheapest options. I calculated the potential monetary savings by switching every patient in my practice who is on a more expensive PPI (esomeprazole, lansoprazole, omeprazole, dexlansoprazole) to generic rabeprazole; projected tally would be $22,340 over the course of a year. Not an insignificant sum.
It’s one thing to project a cost savings. But would it actually work?
I embarked on a very simple intervention in January 2017. Using my EMR (Telus PS Suite), I created a reminder that would place the note “Consider switch to cheaper PPI” on the chart of every patient on esomeprazole, lansoprazole, omeprazole, dexlansoprazole, or pantoprazole.
That reminder would appear on their chart, and would prompt a discussion at their next appointment about a potential trial of rabeprazole.
(I am intentionally omitting the issue of de-prescribing from this analysis, as de-pescribing PPIs has been another important undertaking in my practice, yet this analysis was strictly looking at looking at cost-saving from cheaper PPIs. The above reminder did prompt many instances of de-prescribing, but these were not as easily quantifiable retrospectively. In addition, I bristle at the idea of openly quantifying and applauding the cost savings from de-prescribing, as it would rightfully raise the question in patients’ eyes whether we are de-prescribing out of concern for their health, or simply to save money. This analysis looks at cost-savings from switching from one PPI to another, the goal of which is to produce no clinical negative change).
Of the patients who were engaged in a discussion, many were found not to be appropriate for a rabeprazole trial, either because of intolerance or lack of efficacy from previous trials of rabeprazole. Other patients were not open to a trial because of lack of interest in “rocking the boat” or because of an upcoming trip and concern about impacting travel insurance.
28 patients (some private pay, some publicly-funded) who required ongoing PPI therapy (due to ongoing indication or due to previous failure with PPI wean) agreed to a rotation to rabeprazole as a trial. 7 patients described a clinical worsening of symptoms (most within the first two weeks), and requested to be put back onto their initial PPI (5 patients on lansoprazole, 1 on pantoprazole, and 1 on omeprazole). 21 patients saw no clinical change, and those 21 have been found to be stable at the 3-month mark post-rotation (11 on lansoprazole, 4 on omeprazole, 4 on esomeprazole, and 2 on pantoprazole).
The cost savings were as follows (using rabeprazole 20mg tablet, $0.24/pill):
- Esomeprazole – $1.86 per pill ($1.62 savings/d, $591.30/yr per patient)
- Omeprazole – $0.41 per pill ($0.14 savings/d, $51.10/yr per patient)
- Lansoprazole – $0.50 per pill ($0.26 savings/d, $94.90/yr per patient)
- Pantoprazole – $0.30 per pill ($0.06 savings/d, $21.90/yr per patient)
Total yearly savings from these 21 patients now stable on rabeprazole: $3657.30
A few things to take away from this:
- This was a ridiculously simple intervention, and took me virtually no time to create the reminder or to have those discussions with patients.
- This should be a wake-up call to the Ministry of Health on the importance of working with physicians on finding efficiencies in our system. Physicians know where these efficiencies are, so allow innovation and creativity, reward it appropriately, and we’ll find the money.
- It is critical that the first script for the rabeprazole be of short duration (I prescribed two weeks), otherwise 3 months of wasted pills for the 25% failure rate would have erased some of the cost savings.
- Most practices will likely see greater savings than I achieved in my practice, as I have been consciously working to prescribe exclusively rabeprazole for some time now. Even if you assume my prescribing rate to be on par with the Ontario average (2200 patients), extrapolating this out to Ontario’s population of 13.6 million, this simple intervention would amount to a provincial total of $22.6 million.
- Note that most of the savings were found in switching patients from esomeprazole. Please don’t use it unless you are absolutely handcuffed. It is insanely expensive compared to others in the class.
All of us have these opportunities in our practices for small interventions that we may actually find some element of satisfaction in evaluating, especially with the power of a well-functioning EMR behind us.