The EMR marketplace still has some growing pains to go through

TORONTO | The rate at which Canadian physicians are adopting electronic medical record(EMR)systems is building, but that point when the number of people in an industry with a key tool outnumbers the number without it—the tipping point—is still some time away, says the Canadian Medical Association’s top technology person.

This is reflected in the numerous vendors offering different EMR systems, said Bill Pascal, the association’s chief technology officer. “When it comes to the EMR marketplace, if I put this into the lifecycle of an individual, we are probably in the late teenage years,” he said in an interview.

Pascal, who is the association’s key thinker on all issues having to do with technology and the physician community, in particular family doctors, continued, “We have a marketplace where we have a lot of what I call small ‘mom and pop’ operations.”

Like family-owned convenience stores, there are many vendors in Canada and they tend to be “very geographically based.”

For instance, there are approximately 18 products being offered in Alberta and about 12 in Ontario, two provinces where government and association-backed incentive programs are helping coax physicians to take the leap into the digital office.

Few of this score of products are offered to doctors in both provinces because many vendors don’t have a presence outside their home market, Pascal said.

“So you have a state now that is a little bit of a Wild West,” he said.

Indeed, while some companies are slowly broadening out from their regional or provincial bases, Pascal said he believes no one company is truly national, offering its products and services in every province and territory.
So far, only about 20% of physicians are using an electronic system to manage their patient records and practice operations.

Pascal could be described as the CMA’s tech guru. However, as he stressed to the Medical Post, he works in the realm of policy so when it comes to individual EMR computer systems and software he is “agnostic.”

He noted that he takes that stance even though the CMA’s for-profit arm, CMA Holdings, has a unit that markets an EMR system.

“My position is: I don’t care what product a physician chooses. My job is to try to give him some tools to work through that(EMR purchase)decision.”

With so many small and localized players in an industry, the day will come when consolidation inevitably will hit the industry and bigger, more successful players will come to dominate the marketplace.

“The problem with that(scenario)is that when we go through a market shakeout, we will probably end up with, I’d say, 10 or fewer really good EMR products left out there. It may even be less than that,” he said.
To put it in colloquial terms, the bigger fish are going to swallow the smaller fish or some small fish are going to fail to keep up and will simply die.

Rising technology standards will also drive the shake up—the companies offering lower-standard products are going to find it tough to remain in business. The standards will rise in part because physicians are going to demand better goods and services as they become more knowledgeable about products and the EMR industry.
Many of those companies will invest heavily “over the next five years” in their products and services in a bid to gain a top foothold on the market(the disappearance of some companies will be precipitated by their failure to keep up in this race).

A key standard that physicians will demand and that EMR vendors are going to have to meet to survive is a service guarantee. Physicians, especially fee-for-service family physicians, can’t afford to stop seeing patients just because their EMR system has crashed.

“A lot of companies(currently)don’t have what you would call field technicians to go and clean this stuff up,” said Pascal.

Why is the coming shakeup in the vendor community a concern to physicians? Because many doctors who have already purchased and implemented a product in their practice are going to have to find a new system.
Pascal roughly estimated that about half of physicians who today have an EMR system will in the future have to replace it with one from a different company.

Dr. Michelle Greiver is one early adopter who is confident her practice’s EMR system has longevity.
A family physician who is part of an 18-doctor practice distributed over multiple Toronto-area offices, she told the Medical Post her group felt encouraged by the fact that their vendor, Markham, Ont.-based Nightingale, had contracts with Toronto’s Mount Sinai Hospital and has received certification for installation in several eastern provinces.

Even though it is a relatively new company, she explained: “Given the fact that they were getting big contracts, we thought it was reasonable,” to go with them.

“It is a problem with being an early adopter, but we thought there was a rather reasonable chance of them surviving,” said Dr. Greiver, who noted that her group received $28,000 per doctor in provincial support to help pay for the new system. They went live last spring.
They selected Nightingale because the computer application that underpins the system is an “enterprise” solution that is found on Nightingale computer servers, not servers they would have to operate and maintain themselves.

“We wanted a server(based)outside and professionally managed, and that was the application that was going to do it,” she explained.

While Dr. Greiver is confident her group is likely to avoid any nasty future technology problems, that is a turn of events that will overtake some doctors using EMRs.

Despite how painful that experience would be for those unlucky early EMR adopters, it will be beneficial to the greater physician population as a whole, said Pascal.
He added: “We are really in an awkward situation because it will probably take five to 10 years for the EMR marketplace to mature, and sort of shrink down the number of players.”

But once that shrink-down has occurred, “the players left will be solid players.”

He noted the CMA is pursuing a multi-point strategy to help push the market along, including precipitating the consolidation, because it will ultimately benefit the physician community as a whole.

It will likely “actually speed up the shakeout of the marketplace so we don’t get physicians buying product who, in two or three years, are going to have to find out that they need to do something again.”

Those points are:

• The development of an independent “consumer report” that would provide reviews and actual physician-user feedback on different systems, perhaps with a 10-point rating criteria, and include user feedback that is screened for biases and marketing spin.

• The development of national performance standards and benchmarks for EMR systems. Pascal pointed out: “Right now, if you are an EMR vendor, you have to get certified in every province” individually. What national standards would do is help weed out the weak players from the market, he said, and the remainder would be shown to have “the financial ability to keep upgrading their standards and actually meet that bar.” Pushing up the standards also eases the headaches of the provincial technology managers with whom the EMR systems in the community actually integrate with the province’s own electronic patient information archives and physician-billing record systems. These same managers are responsible for the wiring and programming that allows physician EMR systems to integrate with provincial drug databases, hospital and telehealth systems, and independent lab databases. Provinces such as Ontario and Alberta are far along these paths, said Pascal.

• Product certifications by independent bodies, much like the Canadian Standards Association. Such independent certification would, in Pascal’s mind, minimize “the risk to physicians in choosing a product, because we(as an industry)are saying to them: ‘All right, now you have this group of products that has this sticker that says it’s approved—it’s pretty safe that if you choose one of those it will fit into the part of the IT environment you are working in, whether you are in Woodstock, New Brunswick or up in Prince Albert, Saskatchewan.’ ”

• The development of common “data transfer” standards. These are important because without them it is sometimes difficult for one software system to “speak” to another, like an EMR to a laboratory file system, “and therefore a lot of the data that a doctor may have captured in an EMR product is very difficult to export to another product.” A likely real-world scenario where this could be a problem is when a physician from one practice joins another—the records that he or she brings from that former practice must integrate with the new one. “Right now there are problems,” when this occurs, pointed out Pascal.

• Giving physicians choice. “The one thing that is very clear from our discussions with physicians is every physician works a little differently and some products map better into what a physician does than others. And therefore, we don’t support one product. I do support reducing the number but finding maybe four or five products that seem to really work well and(then)saying to a physician: ‘Choose one of these.’ “

• Get government to pay more. According to Pascal, it is the provincial and territorial governments who reap the greatest return on investment when physicians switch to an EMR—more patients are seen, with less redundancy and fewer errors, thereby saving more medicare dollars.

Observers like Pascal will know the tipping point is upon them when even the most computer-shy physician speaks approvingly of EMRs.

The experience of Comox, B.C.’s Dr. Rick Potter-Cogan, a self-effacing family doctor who describes himself as “just a simple computer user,” may be a source of encouragement.

When it came to selecting an EMR in May 2005, the decision ultimately came down to basic look and feel.
The vendor he decided to go with is Surrey, B.C.-based Wolf Medical System.

His system spans a total of 28 workstations, with about half devoted to office-support tasks and half devoted to physicians’ use.

It cost approximately $100,000 in first-year startup costs(for things like buying computer hardware and licensing the software for seven physicians).

The annual carrying cost of the system amounts to $2,400 per doctor—a cost offset by a savings of $48,000 in support-staff salary in 2006 alone, said Dr. Potter-Cogan.

He is confident the system will quickly pay for itself.
“I’m just a regular guy. I’m not really into computers
much. I just use it for e-mail quite honestly—and now my office is electronic and I can tell you I’d never go back(to paper records). It’s absolutely super.”