EMR Implementation in Ontario Part 3

Policy Options to Increase EMR Uptake in Ontario

Policy solutions available to government to allow greater use/access of EMR in Ontario

1. Open up EMR subsidies to all physicians who wish to computerize. OntarioMD has a large pool of funds which have not been utilized for over 4 years. The expenditure of these funds should be accelerated. A larger pool of physicians applying for subsidies means faster growth of the EMR industry in Ontario, which will lead to increased economies of scale and decreased costs. Over time, the subsidies required to get physicians on-board will decrease. Subsidies should be provided on a ‘percent of cost’ sharing basis with a cost ceiling rather than a fixed sum subsidy.

A percent of cost sharing model allows subsidies to vary over time (and even decrease as economies of scale and technological innovation drive down price) without creating feelings of inequities or resentment. The current fixed sum subsidies give physicians and vendors the option of cutting corners and forcing vendors to bring down their prices to the level of the subsidy and allowing physicians to shirk their part of the payment.

Physicians need some incentive to incur the time and energy to actually implement an EMR in their practice. Incentives can be built into the subsidy model by providing a graded subsidy based on utilization of the system. For example, physicians who take the step of purchasing an EMR may automatically get 50% of their costs reimbursed at the end of each year.

However, if they are using it for documenting all their patients, they could get 60% of costs reimbursed. Those who are actually capturing data and are able to maintain electronic patient summaries should have 75% of their costs reimbursed. In no case should physicians be able to get more than they paid for an EMR.

In addition to utilization incentives, providing incentives for patient care can also help improve adoption of technology. The current policy of providing pay for performance incentives and bonuses has already created a pent-up demand for EMR amongst physicians in Ontario. Many are waiting for the subsidy to be extended to them so they can adopt the technology.

2. Allow subsidies to be used for change management, practice management and project management support. This support should not be optional, as many physicians do not understand the need for it; yet it is crucial in increasing the rate of success of EMR implementations.

The National Coordinator for Health IT in the United States has identified the high rates of failure as an important deterrent to widespread EMR rollout. This money should not be given to EMR vendors, as their track-record for providing this service is quite poor. The best way to provide this service, is to set standards for project management, change management and practice management and get service companies to deliver to that standard.

3. Include the OCFP – ask them to provide large-scale education to clinicians about EMR technology and the potential benefits to them and their patients. EMR technology is much more complex than most medications, yet education on EMR is much less available to physicians. The MOH needs to provide the funding to the OCFP to make this happen.

4. Include the CPSO – ask them to update their medical records policies to promote the benefits of EMR and to support its uptake by physicians. CPSO ambivalence toward EMR is a significant deterrent to EMR use.

5. Establish and deploy communications standards faster and e-enable more communications between disparate systems. SSHA and OntarioMD have been reviewing and developing standards for many years. Very few have been deployed. Two things will help them move ahead faster. First is to engage clinician health informatics expertise and key opinion leaders in the key interoperability projects.

Second is to roll out the standards in small projects with key benefits that can be realized in a short period of time –3-6 months. Then aggressively roll out the standards to additional volunteer sites as soon as they are stabilized. Physicians who regularly use EMR become accustomed to the reward of instantaneous access to information and the flexibility of accessing it from any location, which affords doctors more of the mobility that other professions have been embracing.

6. Establish e-prescribing for all medications for all people in Ontario. The single most important driver of EMR uptake in the UK and Australia was the requirement for all physicians to use it for prescribing. This policy change will have three major benefits with little extra work on the part of physicians:

i. It will lead to widespread EMR uptake, as there will be a more compelling need for having one.

ii. Clinicians will have better information about existing medication-use amongst their patients –leading to improved prescribing and increased patient safety.

iii. It will provide greater transparency about medication prescribing which will lead to better policy decisions about drug benefits coverage.

7. Engage patients in use of EMR – Patient engagement will pressure physicians to join; patient empowerment is required for improvement to health care. Patients with chronic diseases are particularly interested in having access to information about themselves, and want to participate in their own care. Patient advocacy groups such as the Heart and Stroke Foundation and the Canadian Diabetes Association can help with empowering patients to seek out information about themselves.

MOHLTC should make patient data in their databases accessible to patients. Once patients get access to some data, they will start to ask for more, and pressure their physicians to make more available. Patient empowerment programs such as the Dossia5 program in the US have been very successful in engaging patients in self-care and self-management. Patient empowerment is required for improvement to health care.

8. Encourage the uptake of interoperability standards for medical devices. With very little effort on the part of clinicians, interoperability with medical devices will make available immediately a significant amount of patient data which already exists. This will improve patient care significantly and will help realize the value of the data patients collect everyday. Many patients collect data about their blood pressure and blood sugar.

This information ends up being ignored in many cases because it is difficult to view and analyze without information technology. In addition to blood pressure and blood sugar data, there are an increasing number of devices which can measure weight, ECG and other patient physiological variables and can report this information remotely. These devices are making remote monitoring of patients an increasing reality. Being able to monitor and take care of patients in their home can decrease costs for the health care system while simultaneously increasing quality and patient safety.

Conclusion

The slow uptake of EMRs in Ontario can be traced to a few policy decisions made in the late 1990s and early 2000s. These policy decisions include providing a fixed subsidy for EMR, not subsidizing the cost of change management and project management and not implementing interoperability early on.

The non-inclusion of the Ontario College of Family Practice and the College of Physicians and Surgeons of Ontario were also important oversights. It is not too late to turn the tide of EMR implementation in Ontario. Careful redesign of subsidy programs, engagement of key stakeholders and provision of important services can lead to more successful EMR implementations and a virtuous cycle of end user engagement and adoption of EMR technology.

Appendix

Recommendations for MOHLTC

Cast a wider net on the Medical Community to capture greater intake
Change policies on EMR incentives
Fund/Subsidize Transition Support Projects and Practice Management Services
Continue to provide pay for performance incentives for preventive care and chronic disease management. Consider expanding these incentives to additional chronic diseases and preventive care categories.
Engage key physician associations such as the Ontario College of Family Practice and the College of Physicians and Surgeons of Ontario in its efforts to roll out EMR.
Generate patient interest and support by advertising the benefits of e-health through various media – print – medical journals, newspapers; conferences, radio, TV, etc.
Legislate the practice of E-Prescriptions as in Australia and the UK.

Recommendations to SSHA

SSHA should hire clinician informatics expertise and engage key opinion leaders in their e-health roll out efforts.
SSHA needs to create sufficient expertise to support the demand that legislation of E-Prescriptions will generate
SSHA needs to improve orientation packages and make them more useful and user-friendly to the medical community.
SSHA needs to improve its services, and provide timely and consistent ongoing assistance to the medical community.
SSHA needs to roll out projects on an iterative and incremental basis, testing as it goes along. Pioneering physicians should be given the utmost support to make their implementations work. Once pioneer physician implementations are working, SSHA should analyze the experience to improve productivity, lower costs and generalize the solutions.

Recommendations to OntarioMD

OntarioMD needs to change its funding model to include project management, practice management and change management consulting as part of the EMR subsidy.
OntarioMD needs to change its funding model to a `percentage of cost` model instead of a fixed sum model. The current model encourages cutting corners and leads to increased risk of failure.
OntarioMD should provide physicians with more vendor-specific information and allow physicians to share information about vendor experience.

Article by;
InfoClin Inc.
Toronto, Canada
www.infoclin.ca

Part 3 in series of 3:

SGMS EMR