UBC International Medical Graduate Program Webinar

September 13, 2011

DISCLOSURE

I have no known financial interest or affiliation with any commercial organizations reviewed in this presentation Carol Rimmer - Assistant Director, PITO Program

Created & funded through the 2007 PMA BCMA physician support program working alongside

the Practice Support Program and the Divisions of Family Practice Objective, Unbiased, Physician Advocates

Menu of Optional Programs / Services: Funding Implementation & Transition Support Post-Implementation Support Communities of Practice and Peer Mentor Program Clinical Innovation Support

MISSION: To support physicians in the adoption of EMR and related technology to support quality of care and physician satisfaction

GOALS:

Build CAPACITY Deliver effective TECHNOLOGY Support ADOPTION Achieve positive IMPACT

Capacity Create capacity for EMR leadership, knowledge, skills, communication and peer support at the local level

Technology Make available robust, effective and efficient solutions which meet the clinical requirements – including network, EMR, templates/tools, and interoperability (eReferral, results/reports delivery, EHR)

Adoption EMRs implemented and in at least basic use

Impact EMRs in active use to support clinical goals – chronic disease prevention & management, complex care, shared care, etc.

EMR Adoption Rates: International, National, Provincial

99 97 97 96 95 94 94

72 68

4637

0

25

50

75

100

NET NZ NOR UK AUS ITA SWE GER FR US CAN

Doctors Use Electronic Patient Medical Records*

* Not including billing systems.

Per

cent

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

9892 89

79

42

2823

99 97 96 95

72

4637

0

25

50

75

100

NET NZ UK AUS GER US CAN

2006 2009

Doctors Use Electronic Patient Medical Records in Their Practice, 2006 and 2009*

* 2006: “Do you currently use electronic patient medical records in your practice?” * 2009: “Do you use electronic patient medical records in your practice (not including billing systems)?”

Per

cent

Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

8,772 Total Physicians

6,368 Eligible Physicians

~5,000 (to 5,500 max) Target Physicians *

NOT ELIGIBLE (2,404): - Hospital-based/Diagnostic - Anaesthesia, CCU, ED, I/P Psych. - Pathologists, Radiologists, etc.

- Locums, Hospitalists

- Under $50k billing threshold

ELIGIBLE BUT UNSUITED (1,368): - Retiring in <5 years (mostly urban solo doctors)

- Specialists with heavy hospital or HA focus (e.g. many psychiatrists)

- Health Authority owned clinics (eligible but often self-supported by HA)

TARGET GROUP (~5,000): - Full Service Family Practice GPs

- Clinics serving unattached patients (continuity of care)

- Specialists in community-based practice (med, surg, & psych)

Source: MSP pay stats 2007/2008: http://www.health.gov.bc.ca/msp/paystats/index.html and PITO data collected directly from

* NOTE:: Assumes ~200 retiring solo GPs will close practices over 5 years. New physicians joining group practices is additional to the 5,000 target

NOTE: Established goal was 70% of target group by 2012 (i.e. 3,800 physicians)

Three themes defining EMR adoption in BC:

1. Size/Type of Practice

2. Full Service Family Practice vs Walk-in

3. Urban vs Rural

Category Current BC Adoption Rate

Full Service Family Practice Groups 6+ 90%

Full Service Family Practice Groups 2-5 Approaching 50%

Full Service Family Practice Solo Physicians Approaching 10%

Walk-in / Treatment Centres Negligible

Surgical Specialties 30-40%

Medical Consultants 30-40%

Psychiatry ~ 3%

Ophthalmology ~20%

NOTE: Figures represent adoption of any EMR, not necessarily through PITO, and includes partial adoption.

• EMR adoption is highest in large full service family practice (FSFP) clinics where there is sufficient scale, a practice manager, and physician leadership within the practice. Solo/small clinics see value in EMR, but the barriers to adoption are significantly higher. Often 1 or 2 physicians in a small group hold the others back due to retirement or lack of interest.

• Walk-in clinics experience significantly lower value from EMR until extensive interoperability is available for accessing lab/medication profiles in the provincial EHR, ePrescribing, eReferral, and the ability to send a visit note to the GP.

• Adoption amongst specialists is now accelerating rapidly.

The Two Extremes

Almost 100% EMR adoption in many small/rural communities

Very low adoption in the large urban areas

Primary gaps: • Greater Vancouver • Greater Victoria • Surrey/Delta/Langley • Abbotsford/Chilliwack • Kelowna/Vernon

Full Service Family Practice GP EMR Adoption by Community

Understanding EMR Adoption (FSFP) – By Division

Updated May 27, 2011

Primary gaps: • Greater Vancouver • Greater Victoria • Surrey/Delta/Langley • Abbotsford/Chilliwack • Kelowna/Vernon

EMR adoption by Specialist Physicians Total Candidates On EMR % on EMR

Ontario is in exactly the same situation (as are Alberta, Saskatchewan, and Nova Scotia)

Based on feedback from Peer Mentors

EASE OF USE The chart is never lost Record is legible Record is quickly accessible ( document phone calls, compare images etc.) System can be accessed from anywhere Rx and referral letters can be generated very easily Commonly used sentences and paragraphs can be entered with a few keystrokes No need to archive increasing amounts of paper Easy to transfer files when patients move

IMPROVE PATIENT CARE Easy to graph lab results – allows trends to be identified Easy to search the patient database – many uses:

Identify all patients with certain conditions (i.e. diabetes) By condition, determine if appropriate care is being provided Create recall lists based on care needs (CDM and preventive care) Search for all patients on certain medications (i.e. Meridia or patients with dementia on statins)

IMPROVE PATIENT CARE

Easy to have computer run constant background searches and display alerts at patient visit

Examples: Patient on Amiodarone – no LFT in last 6 mo. Patient with diabetes - no HgA1c in last 6 mo. Patient with history of heart disease – not on a statin

Easy to generate high quality referral letters with all selected attachments included

IMPROVE PATIENT CARE

Can generate Cardiac Risk scores automatically

Check for drug interactions automatically

Templates allow a standard approach to problems

Patient information can be easily printed From the web From pre-scanned material From medical websites (i.e. www.cma.ca)

• Controversial

• EMR can be used just like a paper chart

• “The use of EMR in primary care practices is insufficient for ensuring high-quality diabetes care. Efforts to expand EMR use should focus not only on integrating technology but also on developing methods for implementing and integrating this technology into practice reality.”

Crosson, J C et al Am Fam Med 2007; 5:209-214

• To optimize use of the EMR for patient care requires self-audits and intervention reminders – this requires work on the part of the user.

Funding

Implementation & Transition Support

Technical Support Program

Communities of Practice, Peer Mentor Program and User Groups

Interoperability/Provincial EHR

70% Reimbursement for HW & SW One-time EMR Costs Up to $7,000 Recurring EMR Costs Up to $4,494 /year Hardware & Other Costs Up to $4,900* EMR Conversion Support Up to $3,000

Field Resources

MOH Private Physician Network (PPN)

Outcomes-based instead of reimbursement for costs

Complete a declaration of meaningful use

Validation of meaningful use

Payments tied to achievement of specified levels of meaningful use

Useful process in building positive relationships and initiating post-implementation support.

• Tools • Relationship Managers • Physician & MOA Peer Mentors

Physician-initiated

Physician-led

Voluntary

Driven by Shared Care

Health authority results / reports distribution

eReferral

Provincial eHealth – Initial Priorities Client Registry (PHNs) CHARD – Referral Directory Pharmanet Medical List Review & ePrescribing PLIS – Lab History Review

Future: Immunizations, requisitions, etc.

STARTING A NEW PRACTICE

Best time to implement an EMR!

No existing paper charts to convert

No ingrained office workflow practices to change

Can design office space to accommodate computers, printers etc.

JOINING AN EXISTING PRACTICE

EMR in place:

Don’t get to choose system

All you have to do is learn it.

No EMR in place:

Need strategy to convert paper charts to electronic

Need change management to address office workflow issues

Need to retrofit office space to accommodate computers, printers etc.

Post Implementation Support

Impact

Measurement by just “uptake” figures has little meaning No clear clinical impact No measure of whether clinic has enhanced clinical usage with an

upgrade Funding not linked to performance/outcome

MUC Approach Shift evaluation approach and overall program strategy to performance-

based, health system/clinical impact model Developed preliminary 5-Stage Meaningful Use Criteria model based on

the US approach* Different criteria for FSFP and Specialists Can be further refined if desired to specific specialties and different types

of GP clinics

The Theory of Technology Adoption

Credit: Adapted from Gartner “Hype Cycle”

The reality of EMR adoption in most practices

“Now we will use the EMR for CDM!!!!!”

“It takes too long to enter the data in all the fields… It’s slowing me down…”

“I’ll just stick with the basics for now…”

Credit: Adapted from Gartner “Hype Cycle”

New Opportunities • CDM • Complex Care • eReferral • etc.

The goal….

Credit: Adapted from Gartner “Hype Cycle”

General Adoption Support

Targeted Improvement Support

Ongoing PSP Support/Modules can then be based on the availability of EMRs and a community of physicians proficient in using EMR for Quality Improvement

New joint PITO/PSP support to establish knowledge and skills for using EMR for proactive quality improvement

The how….

Credit: Adapted from Gartner “Hype Cycle”

“Physicians using EMR as principle method of record keeping” (PMA) – Prescribing, templates, etc

Physicians have the skills and knowledge of how to use the EMR tools to support Practice Analysis and Quality Improvement

PSP can expect a “Level 4” physician to know how to use the EMR for QI before beginning a PSP module

Summary: Problem Statement

A substantial portion of physicians on EMR are still not making full use of the EMR to support CDM (in particular) and those not on EMR have not seen the value.

1. Many physicians who have adopted EMR have not received sufficient training and support, or been able to take the time, to fully adopt the functionality to effectively support CDM

2. Many physicians who have adopted EMR have not participated or completed the PSP CDM Modules, resulting in some not being fully familiar with CDM approach

3. It takes up-front work and change to properly code data, but the benefits (clinical, financial, time) don’t occur until much later and some physicians still don’t foresee/value those benefits – a change management nightmare

4. Physicians frequently report that the way the CDM Toolkit flowsheets, templates and reports were incorporated into the EMR are difficult to use and they often don’t like those developed by other colleagues

EMR “Meaningful Use” / “Clinical Value”

Level 1 – “Front Office Administration” • Basic Billing & Scheduling system in use – little or no clinical data or point-of-care use

Level 2 – “EMR Basics” • Receiving electronic lab and other reports from health authorities and private labs • May enter a few notes and/or scan documents, but at best an “electronic paper chart”

Level 3 “Full EMR” • EMR is the “principle method of record keeping” (PMA) • Consistently entering fully structured data (problem list, allergies, prescriptions, etc.)

using generally accepted coding standards

Level 4 “Proactive Care / Data-Driven Practice” • Use of registries, recalls, reminders, templates/flowsheets to measure

and follow guideline-informed care

Level 5 “Community Shared Care” • Data transfer enables effective shared care between GP

and specialists and other care providers

Escalating Clinical Value

Communities of Practice

User Groups

Peer Mentor Program

Post Implementation Support Program Development Maximizing Clinical Value Pilots with PSP

We already have some pieces that we know work well

Community Engagement User Groups

Peer Mentors – Expert Users

Team-based approach

MD/MOA Peer Mentors Clinical context Coaching on approach, adaptation, workflow, tips

EMR Practice Automation Coach (PAC) Hands-on assistance in:

Adopting templates Consistent coding Configuring reports/queries Worfklow adjustments Applying recalls, setting up CDS

Typically a past practice manager, senior MOA

Key characteristics: Coordinated effort Delivered in the context of the priorities and other realities of the local Division of FP Expanded in-practice support (both PSP and PITO) Incentives based on clear measurable results (“meaningful use”) to offset cost and time Improved EMR tools/templates/reports to support PSP Modules Two independent but complementary jointly delivered efforts Initial prototypes to test the model

Clinic

Clinic

Clinic

Division of FP Board

EMR Committee (CoP)

EMR X User Group

EMR Y User Group

PITO

RM Strategic Support to CoP

In-practice EMR Support - Coding - Templates - Reports / Registries Supports PSP Coordinator with EMR-specific knowledge

Clinic

Practice Automation Coach (PAC) PAC

PAC may be employed directly by Division (e.g. Prince George Pilot)

MD

MOA

MD/MOA Peer Mentors - Clinical Context - Approach - Tips / Tricks

PITO funded, may be reimbursed through the Division (e.g. Chilliwack & White Rock Pilots)

May be combined PITO/PSP role (e.g. Prince George pilot)

PITO Relationship Manager

Currently CoPs and support roles are being funded and coordinated directly through PITO. PITO is currently undertaking pilots with Prince George, White Rock, and Chilliwack Divisions of FP to deliver/coordinate these services through the Division governance. This model could be expanded in the future as a truly local delivery model. It is envisions that by ~2016, PITO’s role in this support model would diminish and any local support required would be through Divisions.

EMR CoP may report to Division governance or liaise with Division

2012 – 2015

Environmental Factors – Drivers & Considerations

It is important to recognize that the environment has changed since 2006: Divisions – Require EMR leadership, peer support, special projects

PSP – Require EMR readiness, EMR tools, clinic-based EMR support

Demographics – Significant portion of physicians retiring, causing

delay in EMR adoption rate

Adoption curve – We are into the late adopters now who are more

conservative and less technology savvy, and typically in smaller practices

Vendor market – The EMR market has consolidated significantly, but

with an expanded maturity and popularity of specialist-oriented and open source solutions

2006-2010

2011 2012-2015 2016+

“Enhancing EMR Use”

“Shifting to Impact”

“Late Adopters and Optimization”

“Self-Sufficiency”

FOCUS •Adoption •Adoption and Impact

•Adoption and Impact •Interoperability

•Ongoing Enhancement

By 2015 All physicians know how to use the EMR for QI, and

can fully benefit from GPSC/SSC incentives

EHR/eHealth interoperability makes practice operation efficient – dependent on: HA results/reports delivery Access to EHR (medication/lab/allergy profile and DI

reports) ePrescribing eReferral eRequisitions

SUPPORT: Clinic-based support model aligned with Divisions PITO Relationship Manager supports the EMR CoP (Division “EMR

Committee”) Local Practice Automation Coaches (PACs) with EMR product-specific

knowledge support clinics in adopting & using advanced functionality Local Physician and MOA peer mentors provide clinical/workflow

support Local EMR user groups exist for all locally popular EMRs

VALUE: Clear value proposition EMR in active use for quality improvement and allows full benefit of

related GPSC/SSC incentives EHR/eHealth Interoperability makes practice operation efficient