INSIDE THE JULY 2007 ISSUE:
pharmacists and the EMR
This is a story about a conspiracy, but it doesn’t involve Elvis, JFK,
pro wrestling, or other secret societies. Rather, this tale concerns
pharmacists and physicians across the country who are using technology
in a collaborative fashion in order to enhance patient care. It’s well
known that patients frequently suffer serious setbacks due to unintended
drug interactions, prescription errors and haphazard pill-taking
No one knows, with any great certainty, how many doctors in Canada have
fully implemented EMR systems in their offices and clinics. Even the
most optimistic estimates imply that doctors using paper charts
outnumber the ones who have embraced EMR by three to one. Paper-based
doctors give many explanations for staying with the status quo.
Editor's note: Appearing to say more
than is actually being said.
News: Preventive tool promotes better patient
health; Young doctors get EMR training; Who’s on first, today?
Tech: Portable ECG monitor: no electrodes, no
cables; Google has online apps that work offline too; Palm Foleo:
smartphone companion, big screen; New Sandisk USB drives offer speed and
Scope: Multi-site clinic says goodbye to
paper. By Steve Oblin.
Physicians, pharmacists and the EMR
Physicians and pharmacists in Hamilton and Sault Ste. Marie, aided by the
electronic medical record, join forces to improve the health of patients.
This is a story about a conspiracy, but
it doesn’t involve Elvis, JFK, pro wrestling, or other secret societies.
Rather, this tale concerns pharmacists and physicians across the country who
are using technology in a collaborative fashion in order to enhance patient
It’s well known that patients frequently suffer serious setbacks due to
unintended drug interactions, prescription errors and haphazard pill-taking
regimens. According to the Ontario Pharmacists’ Association, people over the
age of 50 have a 25 percent chance of being admitted to hospital due to a
Dr. Richard Tytus, a Hamilton family physician and former pharmacist, and
Iris Krawchenko, a pharmacist in the same southern Ontario city, are working
on a remedy. In April, they launched a pilot project designed to bring the
two professions together with patients under a single cooperative umbrella.
The six-month project, dubbed Passport to Health, involves 50 cardiovascular
patients and a handful of participating family doctors and pharmacists.
Under the terms of the pilot, participating patients sign a contract
pledging to inform a designated Passport to Health pharmacist of any
medication changes within 48 hours and then work with the pharmacist to
create a medication profile, which becomes part of a portable profile
patients carry in a three-ring binder.
Every time the patient visits a physician, clinic or hospital, or picks up
medication at a drugstore, the binder is updated, much like a passport is
stamped. Patients are then required to bring the documentation to every
appointment with their family doctor, for review.
“Physicians base their treatments assuming patients are taking their
medications, but patients don’t always do this properly,” Dr. Tytus says.
“If patients are aware that compliance is a major issue with their health,
and that the pharmacist is checking, we think they will be more compliant.”
Dr. Tytus, an assistant clinical professor at McMaster University, says he
and Krawchenko have worked together previously on patient education. They
developed Passport to Health in response to patients who deal with multiple
physicians and pharmacists.
“I had patients on numerous medications and no one taking responsibility or
having complete knowledge of what they were on,” Dr. Tytus says. “We need a
way to deal with this, and Passport to Health formalizes existing
relationships between physicians and pharmacists. It extends the reach of
family physicians and recognizes the unique, specialized cognitive skills of
Passport to Health actually launched as a pre-pilot with five patients more
than a year ago, and led Dr. Tytus and Krawchenko to confirm their
suspicions that patients were not taking medications properly.
With funding from the provincial health ministry’s Family Health Team system
– a program designed to get mental heath workers, dieticians and pharmacists
and other medical professionals collaborating with family doctors – Dr.
Tytus and Krawchenko engaged four other local family doctors and several
pharmacists and got the ball rolling on a full-fledged pilot.
As the research progresses, computer technology is front-and-centre. While
patients carry paper-based documents, the other players are connected
electronically and all relevant drug information is shared within the
patient’s electronic file.
Passport to Health has an electronic component: xwave’s hosted Centricity
EMR system enables the pharmacists to access patient charts and communicate
with the physicians. The Passport to Health pharmacist will have the same
information from the doctor, regardless of which EMR system is used by the
physicians, but, currently, only the Centricity platform gives the
pharmacist access to real time data.
It has the potential to directly incorporate data generated by the
pharmacist into the patient’s chart after the physician approval. This
seamless flow of information has a powerful potential.
“With this pilot the pharmacist is actually helping to maintain that
medication profile,” Dr. Tytus explains. “The pharmacist medication profile
update is actually done in the patient’s chart. After the physician reviews
the profile and agrees to it, the pharmacist’s medication profile becomes
This translates into a personalized, relevant consultation that helps all
parties: Patients receive the benefit of a paper copy, pharmacists provide
consulting services fully knowing a patient’s medical history and profile,
and physicians end up with a patient medication profile that is supplied and
maintained by the pharmacist. As well, pharmacists are expected to provide
compliance data to doctors – an accomplishment which Dr. Tytus bills as a
Passport to Health isn’t alone. With help from sources such as Canada Health
Infoway, Group Health Centre in Sault Ste. Marie is spending $3.5 million to
develop EMRxtra, an information infrastructure that will let physicians
communicate and collaborate electronically with pharmacists in order to help
patients manage chronic conditions.
Dr. Lewis O’Brien, a family physician practicing at the Group Health Centre,
says EMRxtra will extend the centre’s current EMR capability to enable
physicians and pharmacists to communicate with each other using text
messaging through actual patient charts.
“I would send the pharmacist a note requesting a consult, right within the
chart, and they would look at the chart, do their consult and send it back
to me, all electronically.”
Dr. O’Brien says EMRxtra is being implemented as a year-long pilot with
several hundred patients in the congestive heart failure and vascular
intervention programs. “We selected these patients,” he says, “because we
thought their complicated medical arrangements could be helped by the
The pilot was launched with Group Health Centre’s co-located pharmacy, and
Dr. O’Brien says it will be rolled out to most of Sault Ste. Marie’s 24
community pharmacies as soon as all the technology issues are worked out.
“We want pharmacists to be able to see the appropriate parts of the
patient’s chart with the appropriate privacy measures, so they can have a
better understanding of that patient as a whole and make better
recommendations about pharmaceutical interventions,” O’Brien says. “It would
help everyone be in sync with the patient’s care.”
Sunny Loo, IT director with the Ontario Pharmacists’ Association’s eHealth
program, says the OPA is participating in EMRxtra with the view that
pharmacists and physicians have a history of collaborating to improve
“Community pharmacists and physicians have worked together, but they’ve
tended to work in silos,” Loo says. “They each take care of patients within
their own professional environment. The communication they end up having
with each other is by telephone or fax, and they really only send snapshots
of information back and forth. Often, a lot of the translation gets
corrupted by how patients interpret the situation.”
EMRxtra lets pharmacists “go right into” a patient’s EMR – with the
patient’s full consent, of course, Loo says.
“There’s now another avenue of communication. No longer do pharmacists have
to talk to physicians all the time, or rely on patients to interpret what
physicians have told them. Pharmacists can now go and look at the patients’
The OPA is also involved with Passport to Health, and Loo says the body is
in discussion regarding other potential projects.
While Ontario has several significant projects, it is not the only province
making gains towards physician-pharmacist collaboration. BC PharmaNet, a
database tracking nearly every instance of medication being dispensed from
community pharmacies in British Columbia, has been operating for roughly a
Dr. Ron Joe, a Vancouver family physician who is involved with the clinical
working group for the provincial e-drug initiative, says hospital pharmacies
aren’t yet hooked up and only a third of B.C.’s primary-care doctors have
signed up for password-controlled access. However, doctors who are
participating are able to use their computers to view drug dispensing that
involves their patients.
Joe says the ultimate success of the system is tied to physician acceptance
and use of EMRs, and the province hopes to achieve widespread deployment of
EMRs in doctors’ offices by 2008, the same year BC PharmaNet is expected to
begin to accommodate electronic prescriptions.
Steps are under way to make this happen. The province is looking to pilot
EMRs later this year, and there are moves afoot to upgrade the
communications software in the pharmacies to accommodate prescriptions.
As well, partners in BC PharmaNet – including Canada Health Infoway, which
is financing half the cost – are working to resolve the kinds of issues that
dominate any planning of this sort, including patient privacy, drug safety
and communications and other technical standards. The B.C. government has
legislated pharmacist participation, and drugstores must use BC PharmaNet in
order to dispense medications and receive payment for dispenses, Joe says.
Dr. Sarah Muttitt, vice-president of innovation and adoption with Canada
Health Infoway, says the agency is investing in projects like these with a
view to ultimately establishing a complete, comprehensive record of all
medications that are prescribed and dispensed – a system that would touch
all medical care providers, including physicians, pharmacists and nurses,
and work towards preventing adverse drug events, interactions and allergic
Dr. Muttitt agrees that EMRs are key. Nationally, only 23 percent of primary
care physicians are automated and using EMRs, she says, drawing figures from
several reports. Those include a recent Commonwealth Fund study that
compared Canada with seven other countries, another study Infoway conducted
with the Canadian Medical Association in 2005, and the National Physician
Survey, conducted in 2004 by the CMA, the Royal College of Physicians and
Surgeons and the College of Family Physicians of Canada.
“That’s compared to 98 percent in the Netherlands, 92 percent in New
Zealand, 89 percent in the U.K., and the U.S. was at 28 percent,” Dr.
Muttitt says, explaining that the physician EMR adoption rate varies
regionally across Canada. “This is a significant barrier to e-enabling the
Meanwhile, Health Canada is working to resolve another challenge – the
legalization of electronic signatures. Once this happens, Dr. Muttitt
explains, physicians will have the capability of prescribing electronically.
Back in Hamilton, Dr. Tytus is focused on the Passport to Health pilot. Yet,
he also has the big picture in mind. He predicts physicians will buy in when
they realize they can derive benefits.
“If we take it to the next step, and start using Passport to Health on a
wider basis, pharmacists could start communicating in a format where
physicians could use the information electronically,” Dr. Tytus says.
“Physicians would see that information from pharmacists can be easily
translated into patient charts, where it offers value.”
Casting an even wider eye to the future, Dr. Tytus foresees the day when
patients will be able to travel, and electronic systems will enable
physicians and pharmacists back home to keep a close watch.
“Patient information could be put on a memory stick and carried on a
keychain or worn around the neck. Patients could carry their data with them
wherever they went on their travels.” •
BACK TO THE CONTENTS LISTING
Speedy EMR implementations
It isn’t all about technology. A desire for change and a sense of urgency
count for a lot.
By Issie Rabinovitch
No one knows, with any great certainty,
how many doctors in Canada have fully implemented EMR systems in their
offices and clinics. Even the most optimistic estimates imply that doctors
using paper charts outnumber the ones who have embraced EMR by three to one.
Paper-based doctors give many explanations for staying with the status quo.
Financial cost is almost always mentioned but there’s another major
deterrent that receives less attention: the fear of a lengthy implementation
period and its power to disrupt the medical practice.
Failed or problem-plagued EMR implementation teach useful lessons but in
this article we limit ourselves to a close look at two large and successful
projects – one in Manitoba that is completed, and the other in Nova Scotia
that is a work in progress, to see what we can learn.
The Winnipeg Clinic is one of the largest multi-disciplinary clinics in
Canada. It was founded in 1938 and has grown to include over 50 physicians
who own and operate the clinic in downtown Winnipeg. Almost 70 years later
it still has the same address but the number of patient visits now exceeds
1,000 per day. The Winnipeg Clinic is also a partner to satellite walk-in
clinics in the Winnipeg suburbs.
Tom Malone is the CEO of the Winnipeg Clinic. He was previously the CEO of
the Assiniboine Clinic in the same city where he managed the implementation
of an EMR system for that clinic’s 16 GPs and three surgeons. In 2003, he
was hired by the Winnipeg Clinic to do the same thing there. Although the
decision to go digital preceded his arrival, Malone has been involved with
every other decision related to the project since his first day on the job.
He was willing to discuss them all, including a few he now concedes were
Although the EMR project received unanimous support overall, Malone
acknowledges that, “not all of the doctors were convinced.” On the financial
side, the plan was to finance the project by cutting the payroll. The six
clerks who worked in the medical records department were obvious targets,
but the aim was to eliminate a total of 10 to 12 positions.
Several fundamental decisions were made early in the project. On the
software side, Clinicare was chosen because of its track record of
successful implementations and its high ratings in independent surveys and
assessments. Network cabling was installed everywhere but on the sixth
floor, the home of the pediatricians. They had made a case for using
wireless Tablet PCs. The rest of the clinic was supplied with desktop thin
A thin client may look like a slim computer, but it’s a more specialized
device. A thin client doesn’t do anything unless it’s connected via a
network to a server that’s configured with special software that supports
it. The Winnipeg Clinic chose to use Citrix, which is more capable but also
more expensive than the software that’s included with Windows Server. The
thin clients sitting on the desktops in the clinic don’t have all of the
components of a standard computer. They don’t even have hard disks. They
are, in essence, advanced terminals for viewing applications and data that
reside on servers. They are inexpensive, easier to manage, and have security
advantages over standard computers (also called fat clients).
A survey on computer competency went out to the doctors and the results
showed a great variance in computer skills. Some doctors had never turned on
a computer or used a mouse, while others were very competent computer users.
Before the arrival of instructors from Clinicare, the doctors were given CDs
to help them become more familiar with computers.
In October 2006, the rollout process began in earnest. Within four months,
everyone with the exception of two physicians was using the Clinicare system
on one of the network’s 220 end-user clients. Before the end of this
stressful period, Tom Malone admitted that, “I lost sleep at this stage.”
The transcriptionists were trained at the outset, during daytime hours, so
that they would be fully operational when the doctors were added. The
doctors were trained in the evening hours by Clinicare instructors. They
received four hours of instruction in two sessions and they were trained by
specialty. Week 1 was Family Practice, Week 2 was Urology, and so on.
Doctors designated as ‘super users’ were chosen from each specialty. These
weren’t necessarily the most advanced users, but they were the doctors who
wanted change the most. There were representatives from each specialty and
they were given additional responsibilities for moving things along in their
group. Is it possible to profile physicians who are successful in making the
move from paper to electronic charts? According to Tom Malone, “The real
factor in who makes the move successfully is not age, so much as who is
adaptable and not resistant to change.”
Some computer-savvy doctors found four hours were too long for training, but
many doctors found that it wasn’t enough. Malone would have provided more
time, in retrospect, for these doctors. When groups of doctors were rolled
out, a project manager was on site. She was really stretched to the limit by
questions from the doctors. Malone says the project could have used two or
three project managers. In the initial rollout, just the basic features of
the Clinicare software were covered. Afterwards, there was noontime training
for the more advanced features.
The doctors were asked to book at a 60 percent rate for the first few weeks.
Most doctors didn’t heed this advice and booked the usual number of
patients. Malone says that “the stress was terrible for these doctors,” who
spent an extra hour or two at work each day. Now that they are more familiar
with the software, they are back to their regular hours and seeing one or
two patients more per day as a result of the new technology.
Much to Tom Malone’s chagrin, the clinic still has two doctors who have not
made the transition. That forces the clinic to continue to pull paper files
and incur the costs associated with that. They have been able to let two
clerks go, but four remain. As a result, the EMR system has yet to have the
expected impact on the bottom line. In an effort to get everyone on board,
the clinic is considering charging the two reluctant doctors for each chart
The system has proven to be easy to manage. The decision to go with
thin-client hardware has been vindicated. Consultants spend about 15 to 20
hours per week managing the fleet of over 200 devices, much of that remotely
without needing to visit the site.
Several things that Tom Malone would have done differently have already been
noted. Anything else?
“We would have insisted on trainers from Clinicare with clinical experience.
Some of the trainers didn’t have healthcare experience.” As a result of
feedback from Malone, things have changed. Clinicare claims that all of
their trainers now have such experience.
In Halifax, two thousand kilometres and 2 times zones east of Winnipeg, The
Primary Healthcare Information Management (PHIM) program was created by the
Nova Scotia Department of Health to expedite the adoption of EMR among
primary healthcare physicians in all 9 district health authorities of the
province. In the past year and a half, the program has succeeded in helping
29 percent of the province's primary healthcare physicians make the
transition. It has been aided by $4 million from Health Canada's Primary
Health Care Transition Fund, which was used to establish the Program and
assist clinics with implementation. The funding was made available on a
first come, first served basis and it is now depleted.
Following the successful launch of the PHIM program the NS government is
exploring strategies to extend funding for the gradual transition of the
remaining 71 percent of primary healthcare physicians. The Strategy Update
will be completed over the summer providing a clearer picture for the
expansion of this program.
Lisa Napier, PHIM Program Manager, provided details on how 721 users in 37
clinics crossed the digital divide in a relatively short period of time,
typically from 3 to 5 months from beginning to end for each clinic. Another
31 clinics are working their way through the implementation process
At the outset, it was determined that using a hosted solution would be more
efficient and, furthermore, that limiting the number of approved systems
would keep costs and complexity down. During the process to choose approved
EMR systems, PHIM visited doctors and nurses in all of the districts. “We
asked them what they would need in an EMR. More than 700 requirements were
identified in total”, explained Napier.
When the dust cleared, two approved choices emerged: Nightingale's
myNightingale (ASP system) and Dymaxion's Practimax (non-ASP). A non-ASP
solution was required because there are pockets in Nova Scotia where good,
high-speed internet access isn't available. All 78 clinics that have
registered in the program since late 2005 have chosen myNightingale.
A structured process has been put in place to guide the clinics in the
implementation process. Speed in implementation is important but it takes a
back seat to quality. “We've learned the hard way that skipping steps and
cutting corners doesn't pay-off,” says Lisa Napier.
Interested clinics go through a standard registration process where basic
information is gathered. Next, the clinic gets in touch with Nightingale who
visits the clinic, does an implementation assessment and comes up with a
plan detailing everything needed for the implementation, including
computers, network infrastructure, and voice recognition (if desired).
Once the clinic signs off on their Nightingale agreement, it takes 3 to 4
months to make the transition. Each clinic lines up internet services,
appoints champions who go through training first, schedules time for
training the other doctors, and so on. According to Napier, “The time varies
based on the urgency to move forward and competing pressures with each
clinic.” Clinics who wish can get it done in 3 months or even less.
The training is divided into Practice Management (two sessions for a total
of 6 to 8 hours) and Clinical (another two sessions for a total of 6 to 8
hours). PHIM is investigating modifying the delivery of training to a staged
model that delivers training material in manageable stages, enabling clinics
to master areas before proceeding to the next level.
There was concern at first whether clinics would accept the ASP model,
especially since the data is housed in a government data centre, but there
has been no negative feedback because of the lack of alternatives. “It would
have been more difficult to do the implementation with multiple solution
possibilities”, according to Napier.
The clinics mentioned many benefits of their new system but one of the most
appreciated was the automatic flow of lab and DI results from acute care
Returning once more to the issue of speed, Napier mentioned that some
clinics have gone faster than average and some have cut corners. But, she
continued, “We have learned that bending rules doesn't work. We don't want
fast implementations at the expense of quality.” •
BACK TO THE CONTENTS LISTING
SUBSCRIBE - ADVERTISE
ARCHIVES - CONTACT US