This document provides a summary of a webinar about the UBC International Medical Graduate Program held on September 13, 2011. It discusses the Physician Information Technology Office (PITO) program, which aims to support physician adoption of electronic medical records (EMRs) in British Columbia. Some key points include: 1. PITO was created in 2007 to help physicians implement EMRs and achieve benefits like improved patient care and physician satisfaction. 2. EMR adoption rates vary significantly depending on practice size, location, and specialty. Large family practices have over 90% adoption while solo practitioners and specialists have lower rates. 3. PITO offers services like funding, implementation support, peer ment

1. UBC International Medical Graduate Program
Webinar
September 13, 2011

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

3.  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

4. 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

5.  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.

6. EMR Adoption Rates: International, National, Provincial

7. Doctors Use Electronic Patient Medical Records*
100
99
97
97
96
95
94
94
72
Percent
75
68
46
50
37
25
0
NET
NZ
NOR
UK
AUS
ITA
SWE
GER
* Not including billing systems.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
FR
US
CAN

8. Doctors Use Electronic Patient Medical Records
in Their Practice, 2006 and 2009*
2006
2009
100
98 99
92
97
96
95
89
79
72
Percent
75
50
46
42
37
28
25
23
0
NET
NZ
UK
AUS
GER
US
* 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)?”
Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
CAN

9. TARGET GROUP (~5,000):
- Full Service Family Practice GPs
- Clinics serving unattached
patients (continuity of care)
ELIGIBLE BUT UNSUITED (1,368):
- Retiring in <5 years (mostly
urban solo doctors)
- Specialists in community-based
practice (med, surg, & psych)
- Specialists with heavy
hospital or HA focus
(e.g. many psychiatrists)
- Health Authority owned
clinics (eligible but often
self-supported by HA)
NOTE: Established
goal was 70% of
target group by
2012 (i.e. 3,800
physicians)
NOT ELIGIBLE (2,404):
- Hospital-based/Diagnostic
- Anaesthesia, CCU, ED, I/P Psych.
- Pathologists, Radiologists, etc.
- Locums, Hospitalists
- Under $50k billing threshold
~5,000 (to 5,500 max)
Target Physicians *
6,368
Eligible Physicians
8,772
Total Physicians
Source: MSP pay stats 2007/2008: http://www.health.gov.bc.ca/msp/paystats/index.html and PITO data
* NOTE:: Assumes ~200
retiring solo GPs will close
practices over 5 years. New
physicians joining group
practices is additional to the
5,000 target
collected directly from

10. Three themes defining EMR adoption in BC:
1. Size/Type of Practice
2. Full Service Family Practice vs Walk-in
3. Urban vs Rural

11. 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%
• 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.
NOTE: Figures represent adoption of any EMR, not necessarily through PITO, and includes partial adoption.

12. Almost 100% EMR
adoption in many
small/rural communities
Very low adoption in
the large urban areas
The Two Extremes
Primary gaps:
• Greater Vancouver
• Greater Victoria
• Surrey/Delta/Langley
• Abbotsford/Chilliwack
• Kelowna/Vernon

13. Understanding EMR Adoption (FSFP) – By Division
Primary gaps:
• Greater Vancouver
• Greater Victoria
• Surrey/Delta/Langley
• Abbotsford/Chilliwack
• Kelowna/Vernon
Full Service Family Practice GP EMR Adoption by Community
Updated May 27, 2011

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

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

16. Based on feedback from Peer Mentors

17. 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

18. 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)

19. 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

20. 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)

21. •
•
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 selfaudits and intervention reminders – this requires work on
the part of the user.

22. Funding
Implementation & Transition Support
Technical Support Program
 Communities of Practice, Peer Mentor
Program and User Groups
Interoperability/Provincial EHR

23. 70% Reimbursement for HW & SW
 One-time EMR Costs
 Recurring EMR Costs
Up to $7,000
Up to $4,494 /year
 Hardware & Other Costs
 EMR Conversion Support
Up to $4,900*
Up to $3,000
Field Resources
MOH Private Physician Network (PPN)

24.  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.

26. • Tools
• Relationship Managers
• Physician & MOA Peer Mentors

27.  Physician-initiated
 Physician-led
 Voluntary
 Driven by Shared Care

29.  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.

30. 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.

31. 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.

32. Post Implementation Support
Impact

33.  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 performancebased, 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

34. The Theory of Technology Adoption
Credit: Adapted from Gartner “Hype Cycle”

35. The reality of EMR adoption in most practices
“Now we will use the EMR for CDM!!!!!”
“I’ll just stick with the basics for now…”
“It takes too long to enter the data in all the fields… It’s slowing me down…”
Credit: Adapted from Gartner “Hype Cycle”

36. The goal….
New Opportunities
•
•
•
•
Credit: Adapted from Gartner “Hype Cycle”
CDM
Complex Care
eReferral
etc.

37. 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
The how….
Targeted
Improvement
Support
New joint PITO/PSP support to
establish knowledge and skills
for using EMR for proactive
quality improvement
General
Adoption
Support
Credit: Adapted from Gartner “Hype Cycle”

38.  “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

39. 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

40. EMR “Meaningful Use” / “Clinical Value”
Level 5 “Community Shared Care”
•
Data transfer enables effective shared care between GP
and specialists and other care providers
Escalating Clinical Value
Level 4 “Proactive Care / Data-Driven Practice”
•
Use of registries, recalls, reminders, templates/flowsheets to measure
and follow guideline-informed care
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 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 1 – “Front Office Administration”
•
Basic Billing & Scheduling system in use – little or no clinical data or point-of-care use

41. Communities of Practice
User Groups
Peer Mentor Program
Post Implementation Support Program
Development
Maximizing Clinical Value Pilots with PSP

42. We already have some pieces that we know work well
Peer Mentors – Expert Users
Community Engagement
User Groups

43. 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

44. 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

45. PITO
Division of FP Board
EMR CoP may report to
Division governance or liaise
with Division
EMR Committee (CoP)
Strategic Support to CoP
RM
PITO Relationship
Manager
EMR X User Group
EMR Y User Group
PAC may be employed directly by Division (e.g. Prince George
Pilot)
Practice
Automation
PAC
Coach (PAC)
MD
In-practice EMR
Support
- Coding
- Templates
- Reports / Registries
Supports PSP Coordinator
with EMR-specific
knowledge
Clinic
Clinic
MD/MOA Peer Mentors
Clinic
MOA
Clinic
-
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)
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.

46. 2012 – 2015

47. 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

48. 2006-2010
2012-2015
2016+
“Enhancing
EMR Use”
FOCUS
2011
“Shifting to
Impact”
“Late Adopters and
Optimization”
“SelfSufficiency”
•Adoption
•Adoption and
Impact
•Adoption and Impact
•Interoperability
•Ongoing
Enhancement

50.  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

51. 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