Dr. C. Burnett, MBChB, DTM
Niverville Medical Clinic

My EMR experience
We moved to Manitoba in 1997, a change from a semi-automated office environment to a mainly paper environment. The computer would be used for billing purposes only. It was a hard adjustment and we started looking for a Canadian EMR very quickly, perhaps too quickly as what we ended up doing was expanding the billing system we already had to a full EMR. The transition might have been easier for the staff as they had only a scheduling component to learn but the dangers of not looking around and acting too soon quickly became apparent. We changed vendors 18 months later. Our first entry in the market was driven more by idealistic ambition than financial prudence and business principles, costly and valuable lessons.

Fast-forward eight years and in 2005 we moved to what might be called a green field site, a clinic that had only periodic physician services, part of an RHA primary care health centre. We had inherited perhaps 300 charts but essentially no active practice. We decided to eventually implement an EMR but wanted to take the time to look and plan. It took six months, during which time we realized that we did not have the physical space for the 1500 charts we had amassed during those first six months of operation. Something had to happen soon to enable us to continue practicing, without sitting on top of boxes and boxes of charts.

Experience made vendor choice easier
We investigated three vendors in depth, with onsite demonstrations and numerous questions. We discovered that the level of comfort with the technology varied from team member to team member. Our experience before enabled us to ask some of the right questions this time. We settled on a vendor by January and actually managed an implementation plan that had us going live by February 15th, 2006.

We have had our challenges since and know that there will be more to come, but even our most computer phobic physician, my wife, would not go back. This was a system we paid for, all the hardware and the software was eventually bought by the clinic and we see this as a realistic investment in our workplace. I know that it is saving us money and time, and I think it also is creating a work environment that is enjoyable.

I want to add three lists to this narrative, the first is a list of the whys, why we did this, the second is a list of what’s, a time line and process map for our implementation and the last is a list of errors that we did, well certainly the ones we know now and what we might do different the next time.

Why we introduced an EMR

1. New office so much easier to start fresh than transfer later
2. Limited physical space to store records
3. Problem with reading our own and our colleagues handwriting
4. Time savings translated into overhead costs and patient flow
5. Reduced ‘lost’ results
6. Ability to trend results easily, especially for Chronic Disease management
7. Patients actually expected it (more of a novelty for us then them)
8. Same software as other FFS practices in the region, possible future compatibility
9. Web link enabled use of EMR in local ER
10. Safety issues re drug reactions, legibility, e-prescribing
11. Made financial sense
12. Ability to time shift work and work from home when children in bed. (Negative factor if you also find that spouse has also gone to bed!)

The lessons we learned

1. Take your time and plan
2. Define clearly what you want to see in your EMR and what you want it to do.
3. Make sure you try the programs out yourself and not just a demonstration
4. Ask others who use the software about ease of use and support, even better if you can go and visit their site.
5. Ask about the local support of the product
6. Ask about the upgrades, when, how and how much
7. Future look to see what else is going on around you and how you may connect.
8. Make sure that you schedule enough time to train
9. It will hurt, however you do it, sorry. It's worth it
10. Schedule regular half day refreshers, one in the first three and 12 months and then yearly, especially if you have new staff and physicians.
11. Worth paying for a training session for new physicians, two to three hours is enough.
12. Go the whole way, the first time. Don’t do half and half, it prolongs the pain.
13. Don’t let people “voice dictate”. It is better to buy them an on-line typing course if required and help them to use the automated features of the software.
14. After about six months no one needed the old paper notes. We scanned only recent notes and relevant investigations.
15. Don’t accept the paper records when transferring patients into your practice, scan what you want and send it back, it’s not your storage problem now.
16. Paperless does not mean paperless. Get over it; we have plenty of trees still.
17. Think upfront regarding privacy (CMA wizard a great help) and back-ups.
18. Your service provider may not be your IT guy, need to seriously look for this expertise locally, can be a staff member.
19. You can’t have too many drops, or telephone access points (just not next the sink!)

Our master plan

1. Initial decision to look for an EMR, taken at a team level.
2. Designated leader.
3. Writing a scope document that had the essential element we wanted to see:
   1. Patient charting
   2. Registration and scheduling
   3. Billing
   4. Prescribing
   5. Result tabulation
   6. Backup and audit
   7. Usability
   8. Local support
   9. Patient information integration
   10. Off site access
   11. Affordable
4. Looking at the market, what was being used in Manitoba and what was used in local practice. Essentially who to avoid and who to talk to further.
5. Narrowing the list to three contenders
6. Early discussion as to prices.
7. Designated lead has hands on experience with all three.
8. Two are invited to clinic to demonstrate the product.
9. Team discussion regarding merits and comparing to original scope document. Cost also an important factor.
10. A primary candidate was identified.
11. Further discussion and visit to a site with chosen EMR.
12. Final discussion and creation of contract with vender. Issues of software support, training and IT issues also addressed. (It was around this time we decided to contract with our vender for billing support – the smartest decision we made.)
13. Ordering hardware and installation, including cabling.
14. Internet provider contracted.
15. Plan the implementation timetable, including closing the clinic for training. Set a go live day and plan backwards. If it looks tight then advance your go live date. Do not try and work at the same time as training staff.
16. Communicate to your community what you are doing, including a privacy policy.

Now these were our steps, they are not the only way and, as I admitted, we made some errors.