Friday, September 26, 2008

Small fish in a big health care system: living with uncertainty

Ontario's subsidies for EMR systems have now ended, as of August 31st. By that, I mean that no new physician groups can apply for EMR funding. The groups that have applied and been approved receive funding support for three years.

About 2700 physicians have been approved, representing the majority of those of us eligible for funding. There are about 2,000 physicians in Family Health networks and similar "primary care reform" sites (mainly paid by capitation). There was an EMR lottery for those in Family Health Groups (mainly paid by Fee for Service, with a smaller amount through capitation); about 2400 physicians applied, and 800 were funded.

It is clear to me that subsidies lead to physicians buying an EMR; not all who buy will go on to adopt. In the two FHNs on my server, by 18 months, 12 physicians were using the EMR full time (all encounters), and 6 were not using it--they never started (2/3 adoption).

This was an interesting experiment. The outcome of the Ontario subsidy program was the emergence of a market leader, with about a 45% share of funded physicians, or 1101 funded users. There are 6 "second tier" EMRs, with anywhere from 139 to 221 funded physicians (5.7 to 9.1% market share); the EMR I use is one of those. 5 EMR systems have a very small share, likely too small to survive in Ontario, for a total of 147 physicians.

There is now considerable uncertainty as to what the future holds. I cannot see any indication that funding will continue for those of us who have EMRs (unlike Alberta). Funding for my group ends in early 2009. The ongoing costs of EMR are about $600 to $800 per month; this does not include things like calling the IT guy because something is not working in the office, or having to replace computers and printers etc. There are a lot of unexpected costs in an EMR practice, because we have a lot of IT equipment (which breaks randomly and doesn't last forever).

I also have not heard anything on EMR funding for additional physicians; perhaps the government had decided that it is now the responsibility of individual practices to pay for and support EMR systems. We have a federal election going on, and there is not very much talk about health care this time around. We also have a new provincial contract offer, negotiated between the Ontario Medical Association and the Ministry of Health: I cannot see any funding or support for office-based EMRs there (perhaps it was simply not part of the negotiations). There is some funding for a new diabetes registry, but I think this this may simply mean having us put patient names on a secure website--no integration with EMR, no point of care data in our e-chart. Just a data push to the registry.

The business case for EMRs at the individual practice level remains equivocal--the EMRs mainly benefit patients and the health care system. Integration would make a huge difference; by that, I mean having data from hospitals and other outside agencies flow directly into our EMRs instead of being laboriously scanned in. This is not happening, and I do not see any initiatives that are likely to make this happen in the near future.

What does this mean for me, my partners, my staff and my patients? Well, continued uncertainty. I have things working well in my own office. We now have good things happening via the EMR for my FHN (preventive services, diabetes quality initiative). This is for 14 physicians, so EMR implementation can be done within a practice or physician cluster.

For my FHT, 40 physicians, we still have two EMR systems; little to no chance of integration in the near term. 25 physicians co-locating to one big office in 2009, including me and my practice partners.

For my local area, hospital, LHIN, I still cannot see movement towards system integration.

For my province, no further funding for EMRs (for now at least). I think it is likely that the small EMR companies will now start dropping off; possibly some of the second tier companies will fail too. Physicians will have to transfer from one EMR system to another. While in Alberta, there is planning to help physicians do this, I do not see evidence of such planning or help in Ontario.

I do not know if small to medium size EMR companies can continue longer term; we still have several in Ontario. If a large financial institution in the US can fail, then the risk to small IT companies has to be substantial. I would assume that smaller companies are dependant on venture capital, and it looks like turbulence there in the next little while. If there is no capital available, or it is too expensive due to risk, then there will be problems. Physician users may not get much warning before a failure occurs.

This is not where I wanted to be after 2 1/2 years of EMR implementation. I was hoping for the availability of patient access to their own chart, for seamless flow of data to and from hospital and home care to my system and for more data portability from one EMR to another, perhaps through common standards. While there continues to be much talk, there is very little "on the ground". I was also hoping for some support for early adopters, in case of EMR failure, and ongoing funding (both for new systems and for ongoing EMRs). I am essentially done in my office; however, if my EMR system is one of the non-survivors in the next little while, I have no way of planning for a transition to another EMR system.

"May you live in interesting times" has certainly been the case in my practice; it looks like the Interesting Times are about to continue.



Anonymous said...

As a member of one of the so-called 2nd tier EMR providers, I would have to say that the "market leader" (CMA/P-S) is the likeliest to fail along with your vendor (Nightingale) and Healthscreen. It's true; now that the government largess/money has dried-up (for now) the aforementioned firms no longer have a viable business model to satisfy their shareholders. It is in fact the smaller companies that grew organically over the years that will continue to thrive.

Michelle Greiver said...

Thank you for your comment. I don't think anyone can be certain that any particular EMR culture (Organic, Locally grown, etc) has an effect on crop yield.

However, I think we can be reasonably certain that the original policies, which were to fund all EMR products meeting certification criteria, would lead to failures. 19 EMR application were originally certified; not all can survive. Physicians had to guess, especially at the initial stages.

Other provinces have chosen to limit the number of funded EMR software applications.

For me, the EMR is a means to improve the care of my patients, and to make me more efficient (a more efficient physician can take on more patients, or choose to add additional activities--research in my case). I like the product only to the extent that it does those things (and I don't like it when it doesn't). The bottom line is patient care; the business model for the corporations matters to me only in so far as it impacts on that care.

EMRs will fail. This will endanger patient care, through data loss and practice disruption. I cannot tell if government policies will simply leave family physicians to deal with this issue on our own, or whether there will be assistance for a transfer.

It looks to me like e-Health policy in Ontario is moving away from EMR at the "coal face" of primary care, and towards registries, an eHealth portal, and e-prescribing, see . I do not know how this will be achieved without computerization at the practice level.