The document discusses the need for next generation electronic medical records (EMRs) as current EMRs are not delivering hoped-for value and cannot be improved solely by vendors. It proposes a new solution architecture integrating EMRs, telehealth, clinical decision support systems, analytics, and research capabilities to create a learning health system. This system would provide team-based and population care, integrate multiple stakeholders, and accelerate EMR research and development to better address evolving healthcare demands.

1. Karim Keshavjee MD, MBA, CPHIMS
Kashif Mirza MBBS, MSc
Ken Martin MSc, CPHIMS
EMR | EHR
THE NEXT GENERATION

2. OUTLINE
• The Problem
• An evolving and demanding environment
• Methods
• Solution Architecture
• Mock-ups of potential solutions
• A pathway forward
• Conclusion

3. 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

4. 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

5. PHYSICIANS NEED TO BE AIR TRAFFIC
CONTROLLERS FOR THEIR PATIENTS
…..A NEED FOR BETTER TOOLS

6. 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

7. 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

8. 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

9. 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

10. 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

11. 2
2
4
10
4
0
4
2
0
2
4
6
8
10
MD
Nurse
Nurse Practitioner
Pharmacist
Social Worker
Mental Health
Worker
Dietician
Occupational
Therapy
TEAM-BASED CARE – CARE COORDINATION –
CIRCLE OF CARE
Refer
Care Coordination
Circle of Care

12. CIRCLE OF CARE Dr. Alex - FP
Joe Schmoe
Dr. Cardy- Cardio
Nurse - Judy SW - SamanthaRemote 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

13. 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

14. 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
View Patient Portal

15. SIGN UP FOR NEW GUIDELINES

16. ENROLL PATIENTS INTO CDSS
16

17. SIGN UP FOR RESEARCH

18. SOLUTION ARCHITECTURE
EMR 1 EMR 2 EMR 3
Routing
Server
Telehealth
Server
CDSS Forms Server
Patient
Portals
Analytics ServerResearch
Clinical Trials

19. 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