1. Canada’s First Primary Care Informatics Consulting Firm
Canada’s Rank in OECD
Studies
A Failure of EMR Policy in Canada
Karim Keshavjee, MD, MBA, CPHIMS
E-health Conference, Vancouver Canada
June 1, 2010

2. Outline
The Problem
Policy Analysis
Economic Analysis
Implementation Factor Analysis
Conclusion

3. Canada Lags in E-health Use
E-health Tool Use in 7 OECD Countries
0
10
20
30
40
50
60
70
80
90
100
AUS CAN GER NET NZ UK US
Country
%ofPhysicians
Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: primary care doctors'
office systems,experiences, and views in seven countries. Health Aff (Millwood) 2006; 25(6): 555-571.

4. Percentage of Physicians Who Use an
EMR in their Practice in Canada
9.8%
2007 National Physician Survey
http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/ENG/National/pdf/Q39/Q39_NON_CORE.only.pdf
Accessed Jun 11, 2010

5. Why?
Not for lack of trying
Lots of Programs and $$$
EMR implementation is
complex

6. Natural History of EMR
N=112
100%
Implemented
EMR in 1999-2000
40%
Inefficient
Users
25%
Efficient
Users
35%
Back to Paper
Adapted from: Keshavjee K, Burgess K, Pairaudeau N, Kyba R. 7 Years after EMR Implementation:
A Tale of Woe and Hope. Poster presented at E-health 2007 conference.
http://www.infoclin.ca/assets/7yearsafteremrimplementation_poster_final.pdf Accessed Jun 11, 2010

7. Macro EMR Policy
Framework Developed in 2007
For Intel of Canada
Do Governments and
Implementers Acknowledge
the Following Issues?
Keshavjee K. EMR Implementation in Ontario. A Position Paper to increase the deployment of Electronic
Medical Records in Ontario. http://www.infoclin.ca/assets/intel%20emr%20white%20paper.pdf Accessed Jun 11, 2010.

8. Macro Policy Framework
Recognize the societal value of
EMRs?
Involve professional civil society?
Create an enabling e-environment?
(security, standards, interoperability)

9. Macro Policy Framework
Encourage markets for new services?
Leverage network effects?
Engage patients and patient advocacy
groups?

10. Economic Drivers
Framework by Wang, Bates, Middleton
Economic drivers of EMR uptake
Adapted for Canadian Context
Examines ROI for all players
Wang SJ, Middleton B, Prosser LA, Bardon CG, et al A cost-benefit analysis of electronic medical
records in primary care. Am J Med. 2003 Apr 1;114(5):397-403.

11. Implementation Programs
A best practices EMR implementation
framework
17 Factors Required for EMR success
12 Factors are Statistically Significant
(and Materially Significant)
Keshavjee K, Bosomworth J, Copen J, Lai J, Kucukyazici B, Lilani R, Holbrook A M. Best Practices in EMR Implementation:
A Systematic Review. Proc. of 11th
ISHIMR Conference, 2006.
http://www.infoclin.ca/assets/emr%20poster%2011-08-06.pdf Accessed Jun 11, 2010

12. Governance
Pre-Implementation Implementation Post Implementation
Project Leadership
Involve Stakeholders
Technology Usability Factors
Work-flow Redesign
Training
Implementation Assistance
Privacy & Confidentiality
Support
Technology
Process
People
Feedback and Dialogue
Choose Software
Sell Benefits & Address Barriers
Data Pre-Load and Integration
Early Planning
Incentives
User Groups
Business Continuity

13. Methodology
Compare EMR programs in Ontario,
BC, Alberta and New York City
Key Informant Interviews
Review of Documentation
Scores are un-weighted
No = 0 Partial = 0.5 Yes = 1

14. Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis

15. EMR Policy Framework Element NY Ontario
Albert
a BC
Funding all physicians (specialists and GPs) 1 1 0.5 1
Provide long-term, sustainable funding 1 1 1 0.5
Provide Practice Management Services 1 0.5 0 0.5
Provide Information Management Services 1 0 0 0.5
Provide CDPM Incentives 1 1 0.5 1
Self-Help and Peer Sharing 1 1 0 0.5
Engage Key Medical Players 1 0 1 0
Provide Key ICT Infrastructure (secure e-mail) 1 0 0.5 0.5
Set and Implement Interoperability Standards 1 0.5 0.5 0
Engage Patients and Patient Advocacy Groups 0.5 0 0 0
Rigorous Monitoring & Evaluation 1 0 0 0
Score 10.5 5.0 4.0 4.5
Maximum Score = 11 No = 0 Yes = 1 Part = 0.5

16. Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis

17. US Canada
Costs
Initial
Cost Annual
Over 5
years Cost Annual
Over 5
years
Hardware[1]
$6,600 (q 3 yrs) $13,200 $10,000 (q 3 yrs) $20,000
Implementation[2]
$3,400 $3,400 $5,000 $5,000
Software[3]
$1600 $1600 $9600 $4,000 $4,000
Support[4]
$1500 $1500 $9000 $2,400 $12,000
Scanning[5]
- - $12,000 $60,000
Productivity Loss
[6]
$11,200 $11,200 $5,000 $5,000
Gov’t Subsidy - - -$28,000 -$28,000
TOTAL Cost/MD $46,400 $78,000
Economic Analysis

18. US Canada
Benefits (Savings)
COST $46,400 $78,000
MD Benefits
Chart Pulls[7]
$5 600 $15,000 $4,800 24% $5,760
Transcription[8]
$9,600 28% $13,440 0 0 $0
Charge Capture[9]
$383,100 2% $15,324 $188,000 0% $0
Billing Errors $9,700 78% $15,132 $9,400 $0 $0
Total MD Benefit $58,896 $5,760
Health System Benefits
Drug Reactions[10]
$6,500 34% $8,840 $6,500 34% $8,840
Drug Utilization $109,000 15% $65,400 $109,000 15% $65,400
Lab Utilization $27,600 8.80% $4,858 $27,600 8.80% $4,858
Radiol. Utilization $59,100 14% $16,548 $59,100 14% $16,548
System Benefit $95,646 $95,646
Net (Benefit-Cost) $108,142 $23,406
MD Net Benefit/Loss $12,496
-
$72,240

19. Net Loss to Physicians Who
Implement EMR in Canada:
$72, 240
Over 5 Years

20. Still think physicians are
‘resistant to change’?

21. Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis

22. No. Success Factor NY Ontario Albert
a
BC
1 Governance 1 0 0 1
2 Project Leadership 1 0 0 1
4 Choose Software 0 1 0.5 1
5 Sell Benefits/Address Barriers 1 0 0.5 0.5
6 Pre-load/Integration 1 0 1 0.5
7 Tech Usability 1 0 0.5 0.5
8 Early Planning 1 1 0.5 0.5
9 Workflow Redesign 1 0 0.5 0.5
10 Implementation Assistance 1 1 1 1
11 Training 1 1 1 1
13 Feedback & Dialogue 1 0 0.5 1
16 Information Incentives 1 0.5 0 1

23. Canadian Provinces Do Poorly on
Economic and Policy Drivers of
EMR Uptake

24. So What?
Do poor policies lead to poor uptake of
EMRs?
Global: Yes, Canada lags the World
Local: We don’t know
Alberta, BC and Ontario Won’t Publish Their
Evaluations
(New York City Does)

25. So What?
Physicians hear from their colleagues
and decide to ‘wait and see’
Industry notices ‘resistance to change’
We have invested tens of millions in
EMR with very little to show for it

26. Summary
Canadian Policies Not Conducive to EMR uptake
Economic Drivers Need Improvement
EMR Services Do Not Meet Global Best Practices
EMR Policies Need to be Updated
Focus on the Frameworks