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.


Monday, September 15, 2008

Our future: deciding on ASP vs local

We are coming to the end of the three year initial period; our EMR contract runs out early in 2009. My group now has to decide whether to stay on our local server (located at the hospital), or to move to the provincial ASP server.

We are not the only group deciding on this. There are now three approved EMRs on the ASP server; many of my colleagues, especially the ones in larger, distributed groups, have started considering this issue.

For those getting lost in this jargon, "local" means a server that you own and manage. The machine does not have to be in your office; it can be located elsewhere, for example, at the hospital (all physicians access remotely), or in a physician's office, with colleagues in other offices accessing remotely.

ASP, or "Application Service Provider", means the server and all the software sits in a large server elsewhere, and you just rent space. You don't own the server or the software, only the data; everything that sits outside of your office is managed for you. No worries about upgrading the server, about operating systems becoming obsolete, etc.

Google, gmail, google docs could all be considered as ASP. Your copy of MS Word that sits on your computer is "local".

Seems like ASP is an obvious solution, since who wants to manage a server and all its hardware and software. However, like everything else in life, it is much more complicated than this.

First of all, the ASP server is hosted by SSHA; we have not had an ideal relationship with them. SSHA has had many growing pains, see the 2006 Operational report by Deloitte and Touche. They supply our internet connection with the server, and speed continues to be an issue. Moving to ASP means more of a relationship with SSHA, and we are worried about this. Rightly or wrongly, we do not have much confidence that the server will be well managed.

Second, the SSHA ASP model for the EMR we use is new; like most groups considering this, we don't want to be the first. We simply do not know what issues will arise through the data transfer.

Our local server will soon be three years old. We now have additional physicians on it, new Allied Health Professionals, family medicine residents and medical students, locum physicians, and more administrative staff, all adding data. For example, we now have 70 registered users just for my FHN of 14 physicians. The other FHN on our server likely has a similar number of users, and our Family Health Team is still actively recruiting Allied Health Professionals.

Our IT guy manages the server, but I wonder if this is enough for an enterprise of this size. While we continue to think of ourselves as small businesses, I think we are now at least a middle-sized company (but we do not function as one). I worry about whether we can continue to manage a server without a formal IT department. We now have an IT committee, consisting of two physicians from each FHN (I am on that committee), but I am not sure we have the needed expertise. One of the physicians has been putting in an extraordinary amount of time troubleshooting issues that come up.

Our government funding will be coming to an end in early 2009; to my knowledge, there is no more funding forthcoming, unlike our colleagues in Alberta (they get ongoing funding). There may well be considerable costs for managing our server and the rest of our IT, and I am definitely worried about what will happen when we start to talk about costs with my FHN colleagues who are still sitting on the fence with regards to EMR.

I still favour ASP (cautiously), but there is a lot of uncertainty in our IT committee. The uncertainty is certainly justified; we simply don't feel that we have the information we need to make a decision as of yet.

I am also looking at moving to the new FHT office in 2009; our main lease was finally signed, and we can start the renovations in the next few months. We will have 5 practices, with 3 to 6 physians in each practice, all moving to the same floor of a building, but maintaining their own practices. We will have the main office of the FHT, with our Allied Health Professionals located there. This comes to about 21,000 sq feet, and includes a lab. I have the layout of my new office (I am moving with my current two partners). I now have to think about what to do with my IT (wired access points, where to put the wireless etc). The plan is to have the entire FHT office on EMR.

Despite all this uncertainly, things are generally good at my office. The programs we have implemented for preventive services are working well. My staff told me that several patients came in to the office to pick up FOB kits after the reminder mailing, and all of our FHN secretaries knew to include a requisition when the kits were being picked up. We are now on our 5th or 6th cycle of mailings for paps and mammos, and everyone knows to expect phone calls with questions or to book a pap after mailings.

I have now moved to three days a week, since the beginning of September, with very little disruption; my schedule looks reasonable, and I can see several open spots for next week. I can see that I do not need to reduce the size of my practice for now, as I can manage 1300 patients with the EMR and the additional Allied Health from the FHT. We even have a new resident on block time (more or less full time with us) this month, and are functioning well. My desk continues to be clear of paper.

My staff are now scanning everything that comes in for both of my partners; the volume of scans is increasingly problematic. We still do not have any electronic transmission from the hospitals, from Diagnostic Imaging facilities, or from specialist. Nothing.

I think I am managing well within the walls of my office. The rest of the system continues to present problems; solving those is out of the hands of family physicians like myself, and we continue to wait (and hope) for leadership in the IT front at the local and provincial level.


Friday, September 05, 2008

Diabetic audits: measuring quality with EMRs

My most recent diabetic audit has just been completed. The results are:

2004: BP<=140/90: 65%;

LDL less than 2.6: 50%

A1C <= 8.4%: 74%

2006: BP<=140/90: 82%; <=130/80: 66%;

LDL less than 2.6: 63%, <=2: 40%

A1C <=8.4%: 81%; <=7%: 48%

Missing: BP 19 patients, LDL 26 patients, A1C 20 patients

2008: BP<=140/90: 90%; <=130/80: 83%

LDL less than 2.6: 79%; <=2: 52%

A1C<=8.4%: 81%; <=7%: 42%

Missing: BP 0 patients, LDL 5 patients, A1C 3 patients

The averages for my practice are:


BP 125.8 / 76.8;

LDL 2.32;

A1C 7.37


BP 121.7 / 71.4;

LDL 2.17;

A1C 7.42

I am happy with those results. I can see that I have steadily improved my results for BP and cholesterol control; however, my A1C results for 2008 are slightly worse than for 2006.

Before I discuss this, I would like to talk about how I track these diabetic results. The EMR auditing process is not as good as I would like, but it is significantly better than what I was doing on paper.

The 2004 audit was done prior to the EMR. I had a co-op student from the local high school, and she did the audit. I used billing data from my old billing/scheduling program to get a list of my diabetic patients. At that time, I put in an initial quality improvement step: the student put a yellow sticky note with a reminder (example: LDL) in the progress notes of all patients not at goal while she was doing my audit. I wrote a short article about this process for Canadian Family Physician.

The 2006 audit was done by my resident (all residents have to do a quality improvement project), and entered in Excel. She did this in August 2006; this was four months into the EMR, so not all of the diabetic data was in electronic form yet. That is why there are so many missing results. I had already started using diabetic flowsheets; the time required for audits was significantly shorter than on paper. At that time, I put in reminders for myself to check the flowsheet every 3 months, and started sending Actions to my front staff more aggressively when parameters were not at goal (example: cholesterol high, call patient and ask her to double up on lipitor). I also started using pop-up alerts.

The 2008 data is much more complete. All patients now have flowsheets. My secretary did the audits for me, and I have asked our new resident to do the initial audit for my practice partner.

The EMR audit process is not perfect; I would like, for example, to have a program that automatically extracts all of the last BP results for every diabetic (as well as all LDLs, and all A1Cs). This is not available, so I generate a list of diabetics from the EMR, and the data is manually extracted from the flowsheets and entered in Excel. It is still much faster than using paper charts: all the data is in the flowsheets, so once the chart is loaded, you access everything in a single area. The data is clear, legible, and easy to find.

I would like to have this data available for all of my colleagues in my FHN; I have asked residents to do the audits for others in my group (with permission from each physician), so we will get additional practices done. If I had automated audits, like I do for our preventive services, I could get this done more often and for all of us. I think that it is important to track your results, so you can set goals and see if your Quality Improvement program works. You can see what I am currently doing to try to improve diabetes care here.

I should start talking to my Family Health Team about spreading this to all FHT physicians. It would certainly be possible to do audits for all 40 physicians; we likely will need a bit of funding dedicated to such a project.

I now have an interesting quandary. I don’t know if I can improve on BP or LDL anymore; I can see that I need to maintain my current efforts. However, my A1C average is getting a bit worse. The recent ACCORD study randomized diabetics to tight (aim for A1C <6.0%). The group in the tight control had an average A1C of 6.4%, while the standard group's was 7.5%. The results: "As compared with standard therapy, the use of intensive therapy to target normal glycated hemoglobin levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events."

My average A1C is 7.42%, which is very similar to the standard group's results in ACCORD; based on this study, I am not convinced that I should change my management. Perhaps guideline developers should consider changing the A1C target to between 7 and 7.9%.