Karim Keshavjee MD, MBA, CPHIMS

Kashif Mirza MBBS, MSc

Ken Martin MSc, CPHIMS

EMR | EHR

THE NEXT GENERATION

OUTLINE

• The Problem

• An evolving and demanding environment

• Methods

• Solution Architecture

• Mock-ups of potential solutions

• A pathway forward

• Conclusion

THE PROBLEM

• EHR | EMRs

• Don’t deliver the value we hoped they would

• Vendors can’t afford to do the necessary R&D to fix

the problem

• Spiraling costs threaten the sustainability of health care

• A need for a new paradigm for EHR | EMRs

EVOLVING AND DEMANDING ENVIRONMENT

• Continuous, rapid changes in evidence

• Explosion of new technologies (Big Data, Genomics, Proteomics, mHealth apps, Diagnostics, Tablets)

• Consumer movement amongst patients

• Payers are looking for more value

• Pay for performance and outcomes

• Chronic disease explosion

• 1% and 5% driving 50-80% of expenditures

PHYSICIANS NEED TO BE AIR TRAFFIC

CONTROLLERS FOR THEIR PATIENTS

…..A NEED FOR BETTER TOOLS

METHODS

• Reflection and review of 15 years of projects

• COMPETE I, II, III – EMR & CDSS implementation

• CPCSSN - >750 Providers, ~1M patients, pan-

Canadian Chronic Disease Surveillance Network

• Heart and Stroke’s Hypertension Management

• Several others

• Interviews with over 90 health care stakeholders

Future Medical History

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Joe Schmoe M 45 (Jan-25-1966) (2 Joe Schmoe’s in database)

Team Based Care

Population Care

Medication List

Ramipril

Propranolol

Diltiazem

ASA

Indocid

Garamycin

Penicillin

Problem List

CAD

Hypertension

Gout

Back pain

Risk Factors

Smoker

Family History

CAD –Father d. 58

HTN–Mother

DM –Mother

√ √ √

Dashboard

Patient Engagement

+

+

+

+

Depression

Circle of CareCare Coordination Refer Specialist Refer TelehealthResearch CDSS

Circle of CareCare Coordination Refer Specialist

Future Medical History

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Joe Schmoe M 45 (Jan-25-1966) (2 Joe Schmoe’s in database)

Team Based Care

Population Care

Medication List

Ramipril

Propranolol

Diltiazem

ASA

Indocid

Garamycin

Penicillin

Problem List

CAD

Hypertension

Gout

Back pain

Risk Factors

Smoker

Family History

CAD –Father d. 58

HTN–Mother

DM –Mother

√ √ √

Dashboard

Patient Engagement

+

+

+

+

Depression

Chest pain

Date: May 1992

S: Chest pain

O: Normal

A:R/O CAD

P: Refer Cardiology

Angina

Date: Oct 1992

S: Chest pain

O: ECG abnormal

A:CAD

P: Diltiazem

CAD

Date: Jan 1993

S: Chest pain

O: ECG abnormal

A:CAD

P: Propranolol

Red Eye

Date: Aug 2002

S: red eye, sticky

O: No abrasion

A:Bact Conjuntivitis

P: Garamycin optic

Refer TelehealthResearch CDSS

Future Medical History

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Joe Schmoe M 45 (Jan-25-1966) (2 Joe Schmoe’s in database)

Team Based Care

Population Care

Medication List

Ramipril

Propranolol

Diltiazem

ASA

Indocid

Garamycin

Penicillin

Problem List

CAD

Hypertension

Gout

Back pain

Risk Factors

Smoker

Family History

CAD –Father d. 58

HTN–Mother

DM –Mother

√ √ √

Dashboard

Patient Engagement

+

+

+

+

Circle of CareCare Coordination Refer Specialist

Depression

Refer TelehealthResearch CDSS

Brain

H&NEye Ear

HeartLung

Liver Stomach Spleen

Intestine Colon

Kidney Bladder

Breast

Prostate

Ovary Uterus

Depression

Schizophrenia Anxiety

PTSD

Personality

Pituitary

Thyroid Diabetes

Adrenal PCOU Limbs L Limbs

FUTURE MEDICAL HISTORY

22

4

10

4

04

2

0

2

4

6

8

10MD

Nurse

Nurse Practitioner

Pharmacist

Social Worker

Mental HealthWorker

Dietician

OccupationalTherapy

TEAM-BASED CARE – CARE COORDINATION –

CIRCLE OF CARE

Refer

Care Coordination

Circle of Care

CIRCLE OF CAREDr. Alex - FP

Joe SchmoeDr. Cardy- Cardio

Nurse - Judy SW - Samantha Remote Nurse

Nancy

Dr. Alex

Dr. Cardy

Samantha

He lives alone. Anything we should be worried

about?

I’d dial back his BP control. 120 systolic may be too

aggressive for him. Probably keeping it around 150

would be best.

I’ll arrange Meals on Wheels and transport to his

local church on Sundays. He didn’t get his license

renewed this year

Age

>

Sex

0-5 6-18 19-50 51-64 65-80 >80

855

M

53 118 322 168 156 38

1049

F

56 121 426 205 172 69

PATIENT ENGAGEMENT

Heart

Lung

Colon

Prostate

Depression

Thyroid

Diabetes

Area of Risk Readiness Importance Comment Current Goal KOPRA

for Change

Smoking Counseling

On Statin

Regular PSAs

Hx Fam Polyps

Refuses colonoscopy

In denial of Fam Hx

On Rx

Uncontrolled DM Risk

PAM

Literacy

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SOLUTION ARCHITECTURE

EMR 1 EMR 2 EMR 3

Routing

Server

Telehealth

Server

CDSS Forms Server

Patient

Portals

Analytics ServerResearch

Clinical Trials

CONCLUSION

• EMR adoption has peaked in North America, significant penetration in primary care

• EMRs as currently constituted are unlikely to help transform health care

• EMR vendors are unable and can’t afford to do the necessary R&D

• We need new governance structures that integrate multiple stakeholders

• Learning Health Systems may be the right structures?

• Governments, EMR vendors and researchers and academics need to consider new

models of partnership that can accelerate R&D in the EMR space