Final eHO EMR Benefits Report Jan2013

Benefits Realization

Study

Medical Records in

Ontario

Final

eHealth Ontario

January 2013


Study for Electronic

Medical Records in

Ontario

Final Report to

eHealth Ontario


for Electronic

Medical Records in

Benefits Realization Study for EMRs in Ontario

PwC

Acknowledgements

This study would not have been possible without the support of Steering Committee members and several clinical

leaders who participated in this study and facilitated access to their clinics and colleagues. We thank them and their

teams for their commitment of time, knowledge and expertise. Their insights and first-hand experience in

pioneering and advancing the use of electronic medical records in primary care settings in Ontario provided a rich

study environment to better understand the current and potential benefits that can be realized through the use of

electronic medical records in Ontario.

Clinical Leaders Steering Committee Members

Dr. David Barber

Queen’s Family Health Team

Emmanuel Casalino

Senior Director, Physician eHealth Program

eHealth Ontario

Dr. Sonny Cejic

Commissioners West Family Health Organization

Dr. Anne Duvall

Peer Leader OntarioMD

Barrie & Community Family Health Team

Dr. Anne Duvall

Barrie & Community Family Health Team

Dennis Ferenc

Director, Funding, Reporting and Change Management

OntarioMD

Dr. Sanjeev Goel

Wise Elephant Family Health Team

Simon Hagens

Director, Benefits Realization & Quality Improvement

Canada Health Infoway

Dr. David Kaplan

North York Family Health Team

Dr. David Kaplan

Primary Care Physician Lead Central LHIN

North York Family Health Team

Dr. Stephen McLaren

Markham Family Health Team

Dr. Wei Qiu

Director, EMR Adoption and Benefit Realization

eHealth Ontario

Christine Sham

Manager, eHealth Liaison Branch

Ministry of Health and Long-Term Care

Patricia Sullivan-Taylor

Manager, Primary Health Care Information

Canadian Institute for Health Information


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Table of ContentsAcknowledgements 2

1. Executive Summary 1

2. Introduction 10

3. Methodology 12

3.1 Phase 1: Validation and Evolution of EMR Benefits Realization Framework 12

3.2 Phase 2: Analysis of Benefits Realization 14

3.3 Study Limitations 19

4. Case Study Results 21

4.1 Provider Survey Results 21

4.2 Indicator and Interview Results 24

5. Modeling and Forecasting 33

5.1 Diabetes Management 33

5.2 Increased Influenza Immunization Rates 35

5.3 Increased Colon Cancer Screening Rates 37

5.4 Staff Time Reduction Spent on Administrative Tasks 39

5.4 Summary Findings 41

6. Discussion 43

6.1 Laboratory Management 43

6.2 Communication and Coordination of Care 44

6.3 Chronic Disease Management 45

6.4 Health Promotion, Screening and Prevention 47

6.5 Efficiency 48

6.6 Medication Management 49

7. Recommendations 51

8. Concluding Remarks 54

9. References 55


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Appendix A: Interviewee List

Appendix B: Consultation Guide

Appendix C: Revised EMR BR Framework

Appendix D: EMR BR Framework- Case Study Indicator Subset

Appendix E: EMR Maturity Model Criteria Description

Appendix F: Organizational Survey

Appendix G: Provider Survey

Appendix H: Site Visit Interview Guide


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1. Executive Summary

Electronic medical records (EMRs) are a key enabler of health system transformation, with the potential to achieve

widespread benefits, including: delivering improvements in patient care processes; enabling positive health

outcomes at individual and population levels; creating efficiencies; and reducing costs.

Ontario’s Action Plan for Health Care (Ministry of Health and Long-Term Care, 2012) defines “faster access to

stronger family health care” as a key imperative, and also focuses on improving the overall health of the population

while ensuring that the right care is delivered at the right time, in the right place. In addition, the government’s

transformative Excellent Care for All Act (S.O. 2010, c14) will ensure that Ontarians receive health care of the

highest possible quality and value, and puts the needs of patients first, placing greater accountability on providers

to ensure that the best available evidence is used to make decisions about patient care. Most recently in December

2012, the government announced two very impactful changes to the health system, including the signing of the

Physician Services Agreement with the Ontario Medical Association the creation of Health Links, placing primary

care providers at the centre of the health system and ensuring that patients receive faster care, spend less time

waiting for services and are supported by a team of health care providers at all levels of the health care system

(Ministry of Health and Long Term Care, 2012).

With these and other initiatives underway, it is clear that Ontario’s health system will be undergoing significant

transformation, and changes in the delivery of primary care figure prominently in the government’s strategic

initiatives. With 80% of health care encounters occurring in primary care settings (Canadian Medical Association,

2011), the vast majority of patient data is collected and managed at the primary care level, and the transformative

changes to be undertaken will be reliant on information management programs and tools. The broad and mature

adoption of electronic medical records (EMRs) by primary care providers and their staff will support the required

transformation and the realization of benefits such as improvements in patient care, positive health outcomes at

individual and population levels, efficiencies for providers and system-wide cost reductions. The strategic and

ongoing focus on advancing the availability and use of electronic medical records (EMRs) across the province is

essential.

A key lever in this strategic transformation is the Physician eHealth Program (PeHP), which is now in its fourth

year investing in community-based physician offices to support the adoption and use of EMRs. The PeHP has

achieved several outcomes in the past four years, including the enrolment of over 9,000 physicians in the EMR

Adoption Program. Having achieved a critical mass of EMR adoption across the province, the PeHP has further

developed its focus on benefits realization in 2012 and beyond, opting to undertake a study to identify the nature of

the benefits realized through program investments to date, and those that can potentially be realized with

continued investment and broader adoption of EMRs. To further understand and assess the potential benefits to

be realized, PeHP engaged PwC to conduct a benefits realization study with a focus on:

The benefits that a select number of advanced users of EMRs in primary care practice settings sites have

realized, directly and indirectly through EMR adoption and usage; and

The potential benefits that may be realized through widespread, mature adoption of EMR use across

Ontario in the future.

Methodology

The methodology for the study was designed by PwC in consultation with the PeHP team to articulate current and

potential benefits from the use of EMRs and recommendations for widespread EMR benefits realization across

Ontario. Two phases of activities from August to December 2012 were undertaken to complete this study:


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Phase 1 entailed the validation and evolution of a comprehensive framework for assessing the benefits

realized in Ontario as a result of EMR use in primary care settings; and

Phase 2 focused on the analysis of current and potential benefits realized across Ontario through increased

and sustained use of EMRs.

The work completed during Phase 1 set the stage for successful evaluation while simultaneously building the

necessary support among stakeholders through validation of the existing benefits realization (BR) framework. The

approach emphasized the purpose of the framework and the effective positioning of potential benefits that can be

realized by patients, providers and the health system.

Of the original indicators, 21 were identified as priority indicators, laying the foundation for a longer term BR

Framework and measurements that may be used for future analysis. The priority indicators were identified,

specifically for assessment in Phase 2 of the Benefits Realization study based on known available EMR

functionality, maturity of use and feasibility of measurement at case study sites. Based on the current availability of

information and the maturity of EMR users, a set of indicators was selected to assess benefits through a case study

approach at six primary care practices across Ontario. Following the case studies, the set of indicators was further

distilled to reflect data availability and relevance, and a final selection of 11 indicators in five categories was used to

evaluate benefits:

Laboratory Management,

Communication and Coordination of Care,

Chronic Disease Management,

Health Promotion, Screening and Prevention, and

Efficiency.

Phase 2 focused on assessing both current and potential benefits realized through EMR use. Case studies were

designed to understand the benefits realized through the use of EMRs in the six selected clinics across Ontario that

were identified as high performing users of EMRs. While the emphasis of the study was to understand both

quantitative and qualitative processes and outcomes as per the indicators defined in the BR framework, due

consideration was given to identifying relevant insights, experiences and lessons learned that supported benefits

realization and demonstrate the role of EMRs (both direct and indirect) in realizing these benefits. Emerging from

the cases studies was a sixth category of study (Medication Management) and for which qualitative benefits have

been discussed.

Evidence for the case studies was collected from surveys, interviews, direct observation and data extraction from

EMRs. Following the collection of data from the Case Study sites, the PwC team undertook a modeling exercise to

forecast the potential benefits of EMR use in Ontario in five to ten years. Benefits were extrapolated from selected

indicator values collected during the site visits and further validated and substantiated with peer reviewed

literature. The modeling involved three steps:

1. A comparison of current values of indicators for case study sites considered high performing, or advanced

users of EMRs and those for other practices in Ontario.

2. An assessment of the relative benefit realized through advanced EMR use by the case study sites compared

to other practices in Ontario.

3. Extrapolation of relative potential benefits to the entire province, providing benefit estimates (such as

potential avoided costs or quality of care outcomes), if all providers in Ontario adopted an EMR and

achieved similar results to the high performing users of EMRs examined in the case studies practices.


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Case Study Results

The surveys of providers at case study sites indicated very high support for benefit statements attributed to EMRs.

Key results of the provider surveys include the following:

Quality of Care: 93.0% of survey respondents strongly or moderately agreed with eight statements

presented for benefits of EMR use related to quality of care;

Communication and Coordination of Care: 98.0% of survey respondents strongly or moderately agreed

with three statements presented for benefits of EMR use related to communication and coordination of

care;

Efficiency of Practice: 81.5% of survey respondents strongly or moderately agreed with nine statements

presented for benefits of EMR use related to efficiency of practice; and

Patient Experience: 94.4% of survey respondents strongly or moderately agreed with two statements

presented for benefits of EMR use related to overall patient experience.

Indicator and Interview Results

As described above, the priority indicators that were identified in Phase 1 were assessed for each of the six case

study sites. Findings from indicators and interviews were reviewed together with a sixth category, Medication

Management, which emerged in discussion with several providers during the interviews.

Key results that were identified through the case studies are as follows:

Turnaround time for lab result availability to receipt in EMRs has declined from as much as 5 days to virtually

instaneously. For most study sites, a minimum of 50% decrease in turn around time was reported with results

returned into their EMR. This timely access to test results affords the opportunity to expedite referrals and improve

access to care, and to make timely decisions related to treatments. In addition, physicians perceived the EMR to

improve ordering efficiencies.

The time to receive discharge summaries after patient discharge has declined from as much as 14 days to

virtually immediately where EMRs are integrated with tools such as the Hospital Report Manager or through

direct connectivity with hospitals. These reductions in time spent waiting for discharge summaries and referrals

expedite and facilitate the coordination of care such that patient needs can be addressed in a timely fashion.

The time from referral decision to when the referral is sent to specialist has declined from as much as 7 days to

less than 1 day. Some physicians were able to complete the referral and send it to the specialist with the patient in

the room. Overall, it was observed that the EMR improves physicians’ ability to make timely referrals, expediting

the care process and facilitating inter-office communications.

100% of the care team members have remote and local access to EMRs. This access to information at any time

and in any place was noted by all as a tremendous asset to providers and their patients, improving the ability to

communicate within clinics and often with providers outside of clinics, with overall results including improvements

in the efficiency of patient care.

Up to 70% of diabetic patients, 18 years and over, have an HbA1c level of 7% or less. With the ability to identify a

target diabetic population, physicians and care teams are better able to develop care plans tailored to populations.

Overall, provider survey respondents agreed that EMRs improve the management of chronic diseases. 92.5% of

survey respondents also reported that the EMR system supports patient education. For example, the EMR provides

access to handouts, references or tools to trend patters for BMI, blood sugar, labs. Collectively, the educational

materials and tools help patients better understand and manage their chronic conditions.


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Up to 80% of practice populations received an influenza immunization, up to 56% of practice populations had a

screening test ordered for colon cancer, and up to 82% of practice populations have had their blood pressure

measured by their primary care provider within the last 15 months. Provider survey results emphasize the role of

the EMR system in promotion, prevention and screening activities. Provider survey results report that 92.6% of

survey respondents agree that EMRs improve patient safety and the proactive monitoring of overdue tests/ exams.

It should be noted that the provincial target for colorectal cancer screening is 40% (Health Quality Ontario, 2012)

and that the values reported by all the case study sites exceeded the provincial average.

Up to 50% less time was required by high performing practices to complete clinical/administrative

documentation by using pre-populated templates, forms and stamps. Overall, 77.7% of survey respondents agreed

with the statement that EMRs “improve the efficiency (reduction in effort) of my practice” and of those 44.4%

strongly agreed with the statement while 33.3% moderately agreed. These survey responses mirror the comments

collected during the interviews on overall practice efficiencies.

Up to 89% of survey respondents agree that EMRs support patient safety through the ability to identify patients

on prescriptions that have drug recalls. Physicians and care team members reported an important patient safety

benefit of the EMR is the ability to quickly extract patient lists for specific medications that have been recalled.

Additional patient safety benefits were identified in relation to improved legibility of prescriptions.

Modeling and Forecasting

A model was developed to forecast potential benefits and “the art of the possible” in Ontario if all providers wereadopting and using EMRs at the same level as the advanced EMR users in the case study sites. Benefits wereextrapolated from indicators collected through the case studies, and supported with peer reviewed literature.

Four indicators were selected from the BR framework for forecasting based on the availability of data for eachindicator at the various sites as well as the availability of supporting evidence to extrapolate these indicators tobenefits for Ontario. These include:

Chronic Disease Management - Improved diabetes management

Health Promotion, Screening and Prevention – Increased influenza immunization rates

Health Promotion, Screening and Prevention – Increased colon cancer screening rates

Efficiency - Staff time reduction spent on administrative tasks

Each indicator along with its associated benefit and benefit estimate is provided in the table that follows. Althoughthe selected benefits forecast only a portion of benefits expected from EMRs and that a variety of contributingfactors influence the values of these indicators (e.g. financial incentives to increase screening rates), they indicatesubstantial potential benefits to be realized if all providers in the province were to become high performing users ofEMRs in 5 – 10 years.


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Summary of Forecasted Benefits

Indicator Qualitative Annual Benefits Potential Annual FinancialImpact by 2017

Percentage of patients, 18 years andover, with diabetes mellitus in whomthe last HbA1c was 7.0% or less (orequivalent test/reference rangedepending on local laboratory) in thelast 15 months

Patient and health system benefitsfrom management of complicationsand co-morbid conditions arisingfrom diabetes, including:

- 566 fewer foot amputations- 341 fewer cases of ESRD- 17,400 fewer MI cases- 3,100 fewer stroke cases

$125 million

($17 M from reduced footamputations, $26 M fromreduced kidney disease, $44Mfrom fewer MI, $38M fromfewer strokes)

Percentage of patient population, age65 and older, who received aninfluenza immunization

Patient and health system benefitsrelated to illness prevention,avoidance of clinic and/or hospitalvisits

$40.6 M in reduced health caresystem costs

Percentage of practice population,age 50 to 74, who had a screeningtest ordered for colon cancer

Identification and diagnosis ofcancers and malignancies at earlystages for improved prognosis andquality of life for patients

- 220 fewer Ontarians diagnosedwith stage 4 cancer;



- 703 additional Ontarians with nocancer or stage 0/stage 1 cancers

$38.0 M in reduced colon cancertreatment costs

Percentage reduction in time spenton administrative tasks

Increased staff capacity through areduction of 1.4 million hours thatcan be allocated to other tasks,including the provision of patientcare

$40.0 M in increased staffcapacity

Discussion

Through an approach that has focused on case studies of advanced EMR users in Ontario and forecasting of further

potential benefits, this study has demonstrated that Ontario’s investments in EMR to date have yielded noteworthy,

tangible benefits. These benefits are diverse and have accrued to patients, providers and the broader health system.

Case study participants provided a unique vantage point to convey valuable insights into benefits from their first-

hand experience in pioneering and optimizing the use of a variety of EMR tools and functionalities across their

patient care teams.

While the earliest benefits have been shown to be realized by providers and their patients, modeling and forecasting

has demonstrated that continued investment in EMRs across the province can heighten the impact of EMR use on

the broader health system, with the potential for EMRs to have very significant direct and indirect impacts.


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While it is acknowledged that the potential benefits of EMRs are broad, the current study focused on six categories

with key benefits discussed below.

1. Laboratory Management

EMRs provide clinicians with more timely access to laboratory information, aiding care decisions

and enhancing the patient experience. The ability to receive lab results through direct transmission to EMRs

has reduced the time to receive those results by 50% on average (compared to a paper-based environment).

Consequently, clinicians are now well enabled to respond to results quickly and effectively. This timely access to

test results, while either in their clinics or from remote locations, affords the opportunity to make timely decisions,

provide prompt and appropriate care, expedite referrals, and improve patients’ access to care. The value of having

comprehensive lab information in a timely manner through all potential sources of lab information provides a

comprehensive profile for patients to form a basis for clinical decision-making. In addition, the increasing

prevalence of patient portals linked to EMRs, patients and/or proxies can have online access to results, allowing

them to review lab results when and where it is convenient for them. These initiatives can improve patients’

experiences with their care, and provide them with some comfort, understanding and ownership in care processes.

2. Communication and Coordination of Care

EMRs facilitate improved scheduling and coordination of patient visits, improving access to care.

EMRs provide physicians and care team members with the improved ability to schedule patient visits, improving

patients’ access to care and efficiency of the care team. Physicians and team members reported that improvements

in scheduling and organization facilitate their ability to hold same day appointments open, improving access to

care. Ontario’s Health Action Plan (Ministry of Health and Long-Term Care, 2012) identifies improved availability

of same-day appointments as a key focus in improving access to primary care.

EMRs improve the availability and sharing of information among interdisciplinary team members

and enhances quality and efficiency of care. The ability to access patient information at any time and in any

place was noted by all as a tremendous asset to providers and their patients. EMRs also improve the ability to

communicate within clinics and often with providers outside of clinics, with overall results improving the efficiency

of patient care. Quality of care, and the patient experience overall, is improved for patients by ensuring all

providers have access to the same patient information.

EMRs facilitate the sharing of information with specialists, thereby improving the continuity and

efficiency of care. EMRs support the ability to make much more informed and efficient referrals to specialists.

With the ease and improved efficiency of making referrals (an approximate reduction in time of 85% to make a

referral), the EMR allows primary care clinicians to quickly provide the specialist with key pieces of information

needed to understand the patient’s condition.

Expedited delivery of hospital reports to EMRs facilitates timely and appropriate care. Case study

sites reported a reduction of 85% in time spent waiting for discharge summaries as a result of the transfer of this

information to EMRs. The timely access to this information can further reduce patients’ wait times for required

post-discharge care, and allow providers to put appropriate follow-up care into place in the out-patient setting.

3. Chronic Disease Management

EMRs are a necessary and effective tool to manage the health of defined patient populations. EMRs

are being used increasingly by clinicians to manage the health of patient populations, such as patients with

diabetes, chronic obstructive pulmonary disease (COPD), and others. Physicians and their care teams are

increasingly relying on their EMRs to effectively manage the care of patients with chronic conditions that are costly


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to the system overall and have many related co-morbidities constraining health system capacity. It was evident that

case study sites were using their EMRs for these purposes as well; for example, clinicians reported the ability to

identify patients with specific conditions and plan and monitor their care, and identified this as a very significant

benefit of EMRs. Clinicians reported a high degree of willingness and enthusiasm to better manage the health of

defined patient populations in their practice through the support of their EMRs, and acknowledged that in the

absence of EMRs this undertaking would be quite costly and time consuming.

EMRs provide valuable tools to help both care providers and patients with care management and

education. Engaging patients through education and care planning activities ensures that they are active

participants in their health. Patients that are better informed on what their target values for key indicators (e.g.,

HbA1c) should be are better able to keep their conditions under control. As data capture and reporting capabilities

improve, EMRs will further allow practices to identify a baseline and trend information to ensure their diabetic

cohort of patients are monitored for those clinical needs which require careful management and are prone to

downstream co-morbid complications.

The broad and mature use of EMRs can reduce the costs and burden of illness associated with

caring for Ontario’s growing diabetic population. Through the modelling and forecasting exercise,

potential savings and a reduction in complications associated with diabetes were identified. These complications

and illnesses include foot amputations, diabetic kidney disease, stroke and myocardial infarction, all of which

typically require acute care hospitalization. While yet to be realized, EMRs are a contributing factor to potential

savings related to diabetic-related illnesses that are in the range of $125 million annually by 2017. Diabetes must

be actively managed in the community and primary care settings and with active patient participation, in order to

complications such as those forecasted above. Without EMRs and related enablers, it would be very challenging to

do so, given the support that EMRs provide to actively identify diabetic patients, keep their conditions under

control, and communicate on an ongoing basis.

4. Health Promotion, Screening and Prevention

EMRs allow clinicians to survey patients and to proactively arrange screening and prevention

activities, while concurrently improving the efficiency of preventative care. While several reporting

capabilities related to screening and prevention are in their early stages of development, advanced users of EMRs

indicated that they were able to generate information to identify and communicate with patients for preventative

purposes. Without the EMR, this type of prevention activity is much more complicated, requiring manual and

time-consuming chart reviews. Now, patients are contacted easily and in a timely fashion for preventative care.

The potential benefits of increased screening and prevention (including vaccination) activities over time can have a

tremendous impact on the health of the population as a whole, and on the sustainability of the health system.

The widespread use of EMRs can increase the rates of influenza vaccination and yield potential

related health system savings. The forecasted reductions in illness and costs are highly dependent on the

mature, proactive use of EMRs on a province-wide basis to identify those at risk, to facilitate communication to

encourage those patients to receive the flu shot, and to track compliance. The management of influenza must be

actively managed in the community and primary care settings and with active patient participation and willingness

to receive vaccination. EMRs enable this challenge, with many interviewees discussing their ability to vaccinate a

broader group of patients by leveraging information available in their EMRs.

Use of EMRs can support the prevention of colon and other cancers through improved screening

rates and other preventative care. Case studies revealed that EMRs can greatly facilitate the ease with which

clinicians manage and deliver preventative care for their patients. Although preventive care is a relatively new (and

in some cases, advanced) area of EMR use for many clinicians, the ability to identify patients requiring screening


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and in turn receive and act upon results is possible with EMR use today, and many provincial organizations (e.g.,

Cancer Care Ontario) recognize the power and potential of EMRs to support preventive care. Modeling and

forecasting activities suggested that the potential costs that can be realized through the prevention of four stages of

colon cancer through advanced EMR use is in the range of $38 million annually by 2017. By ensuring that

screening protocols and alerts are incorporated in all EMR specifications, there will be an increased ability to

identify those patients requiring screening on a widespread basis.

5. Efficiency

EMRs facilitate clinical transformation in the primary care setting, improving the effectiveness and

efficiency of clinical and administrative activities. The introduction of EMRs into the primary care setting

has the potential to be transformative in nature. EMRs enable changes in workflow and clinical decision-making,

and can greatly improve the way that clinicians interact with their patients on a regular basis. Benefits associated

with the effectiveness and efficiency of patient encounters and the general flow of patient activity allow greater

throughput and access to care, including same day visits. These benefits have tremendous impact on patients,

providers and the system as a whole, by reducing wait times for primary care, allowing providers to see more

patients daily, and reducing the number of unnecessary visits to hospitals.

EMRs improve the productivity of administrative staff. It is evident that there is some productivity lost in

the early stages of adoption of EMRs with many clinicians and administrators, with many reporting that there is a

period of approximately one year while all grow accustomed to working with electronic records. However,

interviewees and the forecasting model both suggest that there are significant opportunities to improve the overall

capacity among clinic staff, particularly among administrative staff and/or nurses who were previously spending

time doing administrative tasks. The greatest value in this increased capacity lies in the opportunities and potential

benefits associated with redirecting time from non-value added tasks, to those that improve efficiency, allow for

direct patient interaction, and improve the overall patient experience. The reductions in the time required for

administrative tasks through the use of EMRs, estimated at 50%, was used to model the potential benefits if EMRs

were broadly and maturely used across Ontario. The exercise estimated that approximately 1.8 million hours or a

possible $40 million could be saved annually by 2017, providing increased capacity for clinic staff.

6. Medication Management

EMRs support the ability to rapidly identify impacted patients when drug warnings are issued,

improving patient safety. A tremendous benefit of EMR use identified by many providers through the course of

the study was the ability to identify large numbers of patients to whom certain drugs have been prescribed. These

patients can be very quickly identified, and alternate means of treatment can quickly be administered, preventing

any downstream implications. As such, EMRs can have a tremendous impact on quality of care, and most

importantly, patient safety. The ability to quickly target these patients and act is almost impossible in a paper-

based clinic environment.

Access to complete medication profiles in the EMR increases efficiency and improves the accuracy

of medication management. With accurate and complete medication profiles in EMRs, clinicians are able to

quickly and accurately manage care. Prescriptions are easily monitored, and patient concerns can be addressed.

There are also potential costs avoided by the health system due to unnecessary hospitalization from adverse

medication effects.

Electronic prescribing and renewals via EMRs have improved medication management efficiencies

and patient safety. The sharing of medication information across the care team has resulted in greater

efficiencies in the patient care process and improved patient safety. Perhaps the most significant change noted by

physicians has been the generation of a printed prescription, eliminating error-prone handwritten prescriptions


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and reducing the need for delays arising from “call backs” from pharmacists to physicians seeking clarification on

prescriptions. With EMRs, this risk to patient safety and disruption in workflow is avoided.

Recommendations

Findings from this study provide compelling evidence to continue to advance EMR adoption and maturity across

Ontario. The benefits that have been demonstrated by EMR use in the selected case study settings and the

accompanying forecasting of province-wide benefits demonstrate the “art of the possible” for Ontario. With the

implementation of a number of focused recommendations, the potential for wide ranging and transformative

benefits of EMR use can be further realized by providers, patients and the health care system as a whole.

The following five recommendations are presented to policy-makers, funders, implementers and adopters of EMRsin Ontario in support of continued benefits realization.

1. As an essential enabler and one of many important health information technology tools to

improve care delivery and related patient outcomes in primary care settings and beyond,

continued investments in EMRs should be made to ensure broad adoption and realization of

benefits across Ontario. Through the course of the study it was widely acknowledged that without the use

of EMRs, the ability to realize the identified benefits is compromised. Indirectly and directly, EMRs are critical

enablers of enhanced patient care. Continued investment in EMRs and increased physician participation in the

EMR Adoption Program are essential.

2. Continue to support increased maturity of use among current and future adopters of EMRs.

The effective realization of benefits is highly supported by EMR maturity (defined as the level of adoption and

use of the EMR in the practice setting). A continued focus in advancing EMR maturity among users will

contribute to a greater diversity of benefits with system-wide impact.

3. Continue to invest in effective change management strategies and user support that extends

beyond the initial period of EMR implementation. Mature use of the EMR requires access to training

when and where it is needed by all types of users, and should be available well beyond the initial

implementation phase as users transition through the “adoption curve”. For example, following an initial

period of use that allows clinicians to master essential EMR functions, training could be further made available

to address and support more sophisticated needs associated with reporting and analytics for population-based

planning and care.

4. Improve the management of information within and across patient care settings through

focused efforts related to interoperability of systems, improved quality of data, and the flow of

data across care settings. The ability to achieve advanced use and benefits of EMRs will be supported by

increased systems integration, improved quality of data, and improved sharing of data across care providers.

Improvements in information management through initiatives such as OntarioMD’s Hospital Report Manager

and CIHI’s Voluntary Reporting System are showing promising benefits, and similar initiatives should be

encouraged.

5. Continue to invest in focused benefits realization studies. Focused studies will afford the opportunity

to measure more of the indicators that were defined in this study as part of the Benefits Realization Framework

and have a greater understanding of the full scope of current and potential benefits realized by EMRs in

Ontario.


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2. Introduction

Health care systems across Canada and around the world are undergoing transformations to improve quality of

care, access to care, value for money, and the patient experience (Commonwealth Fund, 2011). In Ontario, there is

an increasing emphasis on ensuring that these attributes are all central to the delivery of primary care, providing

the foundation of a strong health care system.

Ontario’s Action Plan for Health Care (Ministry of Health and Long-Term Care, 2012) defines “faster access to

stronger family health care” as a key imperative, and also focuses on improving the overall health of the population

while ensuring that the right care is delivered at the right time, in the right place. In addition, the government’s

transformative Excellent Care for All Act (S.O. 2010, c14) will ensure that Ontarians receive health care of the

highest possible quality and value, and puts the needs of patients first, placing greater accountability on providers

to ensure that the best available evidence is used to make decisions about patient care. Most recently in December

2012, the government announced two very impactful changes to the health system, including:

the Physician Services Agreement reached between the Ontario Medical Association and the government in

December 2012 (Ministry of Health and Long-Term Care, 2012), supporting the realization of significant cost

savings and efficiencies across the health system and promoting the use of electronic communications and

consultations to increase access to care; and

the creation of Health Links (Ministry of Health and Long-Term Care, 2012), placing primary care providers at

the centre of the health system and ensuring that patients receive faster care, spend less time waiting for

services and are supported by a team of health care providers at all levels of the health care system.

With these and other initiatives underway, it is clear that Ontario’s health system will be undergoing significant

change, and changes in the delivery of primary care figure prominently in the government’s strategic initiatives.

With 80% of health care encounters occurring in primary care settings (Canadian Medical Association, 2011), the

vast majority of patient data is collected and managed at the primary care level, and the transformative changes to

be undertaken will be reliant on information management programs and tools. The broad and mature adoption of

electronic medical records (EMRs) by primary care providers and their staff will support the required

transformation and the realization of benefits such as improvements in patient care, positive health outcomes at

individual and population levels, efficiencies for providers and system-wide cost reductions. The strategic and

ongoing focus on advancing the availability and use of electronic medical records (EMRs) across the province is

essential.

In supporting, promoting and accelerating the adoption of EMRs across the province, eHealth Ontario’s Physician

eHealth Program (PeHP) is a key initiative in advancing the province’s transformative agenda and Ontario’s

eHealth strategy and primary goal of establishing and maintaining electronic health records (EHRs) for all of

Ontario’s 13 million residents (eHealth Ontario, 2013). EMRs are a partial and necessary component of EHRs,

which hold all relevant health information about a person over his/her lifetime (Hodge, 2011). Since 2009, the

PeHP has invested in community-based physician offices to support the adoption and use of EMRs. Together with

its delivery agent OntarioMD, the PeHP has achieved several outcomes, including the enrolment of over 9,000

physicians in the EMR Adoption Program. The program is currently focused on:

Further equipping and enabling community-based physicians with tools to enhance the use of EMRs;

Maximizing clinical and business value of EMRs;

Providing change management support and promoting the adoption of best practices; and

Fostering the evolution and sustainment of EMRs and related benefits.


PwC 11

Having achieved a critical mass of EMR adoption across the province, the PeHP has further developed its focus on

benefits realization in 2012, opting to undertake a study to identify the nature of the benefits realized through

program investments to date, and those that can potentially be realized with continued investment and broader

adoption of EMRs. Specifically, the current and potential impacts of the use of EMRs on patients, providers and

the health system are of interest.

To further understand and assess the current and potential benefits to be realized, PeHP engaged PwC to conduct a

benefits realization study with a focus on:

The benefits that a select number of advanced users of EMRs in primary care practice settings sites have

realized, directly and indirectly through EMR adoption; and

The potential benefits that may be realized through widespread, mature adoption of EMR use across

Ontario in the future.

In collaboration with the PeHP team, PwC conducted this study through a two-phased approach from August to

December 2012. This report presents the study in its entirety as follows:

Section 3: Methodology, outlining the methodology applied to Phases 1 and 2

Section 4: Results, presenting the findings arising from the studies of six primary care clinics considered

high performing adopters of EMRs

Section 5: Modeling of Benefits, identifying potential system-wide benefits from EMR use

Section 6: Discussion, reporting on the themes and insights emerging from the results

Section 7: Recommendations, outlining key actions to be taken in order to realize potential benefits across

Ontario

Section 8: Concluding Remarks


PwC 12

3. Methodology

The methodology for the study was designed by PwC in consultation with the PeHP team to articulate current and

potential benefits, and to develop recommendations for widespread EMR benefits realization across Ontario. Two

phases of activities from August to December 2012 were undertaken to complete this study:

Phase 1 entailed the validation and evolution of a comprehensive framework for assessing the benefits

realized in Ontario as a result of EMR use in primary care settings; and

Phase 2 focused on the analysis of current and potential benefits realized across Ontario through increased

and sustained use of EMRs.

3.1 Phase 1: Validation and Evolution of EMR Benefits RealizationFramework

The work completed during Phase 1 set the stage for successful evaluation while simultaneously building the

necessary support among stakeholders through validation of the existing benefits realization (BR) framework. The

approach emphasized the purpose of the framework and the effective positioning of potential benefits that can be

realized by patients, providers and the health system.

3.1.1 External Validation of the Framework

The PeHP program had developed an initial draft of a BR framework, inclusive of several categories of

measurement, hypotheses and sixty indicators. This framework was used as the basis for consultations to obtain

feedback and was the subject of further refinement and validation.

A total of 21 consultations were conducted with a variety of representatives including physicians, family health

teams, the Ministry of Health and Long Term Care, government agencies, Local Health Integration Networks

(LHINs), and other jurisdictional EMR programs (Alberta and British Columbia), (see Appendix A for a complete

list of interviewees). Interviewees were provided with a copy of the interview guide and the draft EMR BR

Framework for review prior to the interview (see Appendix B, Consultation Guide).

Stakeholders were asked to select indicators that could describe whether or not EMRs have had an overall impact

on patients, providers and the health system. A formal system for scoring indicators was not used, however

stakeholders reviewed the indicator list and based on their experience and perspective, were able to identify those

indicators they felt would be meaningful and useful to measure.

3.1.2 Development of BR Framework and Indicators

A workshop was held in September 2012 to review all feedback and define the preferred BR framework and

indicators for the case studies and any future benefits realization studies. Workshop discussions were informed by

insights from consultations, a preliminary BR framework assessment, benefits literature and PwC’s experience with

related benefits realization studies.

At the workshop, project team members from the PeHP, Ontario MD and PwC assessed potential indicators based

on the following criteria:


PwC 13

Relevance: Assessment of the importance of the indicator for the objective/hypothesis question e.g. Does

the indicator support an understanding of the impact of the EMR on quality of care from the patient’s

perspective?

Feasibility: Assessment of the ease and cost of measurement e.g. is the data currently available?

Ease of interpretation: Assessment of the ease of interpreting the indicator, e.g. Is the indicator well

understood by multiple stakeholders, without requiring extensive explanation?

Traceability to the EMR: Assessment of whether the indicator can be directly attributed to EMR use e.g.

is there a clear and demonstrable correlation between the use of EMRs and the indicator?

Of the original indicators, 21 were identified as priority indicators, laying the foundation for a longer term BR

Framework and measurements that may be used for future analysis. The indicators were also classified into nine

categories of benefits (see Appendix C, Revised EMR Benefits Realization Framework). Priority indicators were

identified, specifically for assessment in Phase 2 of the Benefits Realization study based on known available EMR

functionality, maturity of use and feasibility of measurement at case study sites. A total of 14 indicators were

initially selected for the EMR BR Framework - Case Study Indicator Subset (see Appendix D), with study questions

in related categories including the following:

Table 1 : Case Study Questions

Category Study Questions

Laboratory

ManagementDoes EMR use reduce lab result turnaround time?

Communication and

Coordination of CareDoes EMR use improve access to information between settings?

Does EMR use facilitate referral to specialists?

Does EMR use facilitate interdisciplinary/team care?

Do physicians access the EMR remotely to provide patient care?

Chronic Disease

ManagementDoes EMR use improve chronic disease management?

Health Promotion,

Screening and

Prevention

Does EMR use improve preventative services provided?

Efficiency Does EMR use improve efficiency of care?


PwC 14

3.2 Phase 2: Analysis of Benefits Realization

Phase 2 focused on assessing both current and potential benefits realized through EMR use. In order to undertake

this assessment, a series of case studies were undertaken within six primary care settings. The information

collected within these sites together with peer reviewed studies served as inputs to a modelling exercise that defined

potential benefits that could be realized with advanced EMR use and adoption across Ontario.

3.2.1 Case Studies

At the core of the second phase were the case studies, designed to understand the benefits realized and key lessons

learned through the use of EMRs in selected clinics across Ontario that were identified as high performing users of

EMRs. While the emphasis of the study was to understand both quantitative and qualitative processes and

outcomes as per the indicators defined in the BR framework, due consideration was given to identifying relevant

insights, experiences and lessons learned that supported benefits realization and demonstrate the role of EMRs

(direct and indirect) in realizing these benefits.

Case Study Site Selection Process

In order to select case study sites, a preliminary list of ten primary care clinics was compiled by the PeHP and PwC

with input from stakeholders, including OntarioMD. Each potential site was assessed based on the following

preferred criteria.

EMR Maturity/Experience

Location / Geography / Site Type

Vendor System and Integration

Available and Accessible Documentation

Innovation

Willingness to Participate

1. EMR Maturity/Experience: The case study site will ideally have an EMR in use by clinicians for at least

three years and demonstrate mature use of the EMR. The OntarioMD EMR Maturity Model (EMM) illustrated

in Figure 1 was used as a guide to provide information on EMR effectiveness and to identify sites that were

considered “high performing”, with the ability to measure the impacts on the various indicators. See Appendix

E for a more comprehensive description of the EMM.


PwC 15

Figure 1: OntarioMD EMR Maturity Model

2. Location / Geography / Site Type: To ensure representation from across Ontario and different clinic types,

geographic factors were considered e.g. urban and rural, in addition to different primary care clinic types, e.g.

small practice groups, large groups.

3. Vendor System and Integration: Representation from clinics using a variety of Ontario-certified vendor

systems was considered. Another site consideration was to select those with various degrees of connectivity

and interoperability (connectivity with OLIS, and access to electronic receipt of hospital reports).

4. Available and Accessible Documentation: The ability of the sites to provide access to documentation that

would facilitate measurement of the indicators in the framework was an important criterion.

5. Innovation: Practices that were seen as being innovative and leading edge in the way they use their EMR

were rated more highly.

6. Willingness to Participate: The willingness of sites to participate in all aspects of the study was an

important criterion.

Candidate sites were contacted and asked to participate. Six practices agreed and were the subjects of the case

studies.

Case Study Tools and Assessment

Case studies were conducted at the selected six practices. The case studies focused on addressing the following high

level study questions as a means of gathering information related to the subset of indicators, advanced application

of EMRs within the clinical setting and lessons learned:

How are EMRs used in high performing clinical practices?

What are the best practices and lessons learned with regards to adoption and use of EMRs?


PwC 16

Evidence for the case studies was collected from the following four sources. Descriptions of the tools and methods

are described below:

Surveys (Organizational and Provider)

Interviews

Direct observation

Data extraction

Surveys

Prior to the case study site visits, two surveys were administered by PwC:

1. Organizational Survey: This survey focussed on gathering general background information related to

context, organizational resources and EMR users. It was completed by the Clinical Lead or designate at the

site.

2. Provider Survey: Physicians, physician assistants and nurse practitioners were invited to complete an

online provider survey prior to the site visit. This survey focussed on gathering information on EMR

adoption and current use. All providers were given the option of completing the tool; however, those who

had been selected for an interview were required to complete it.

a. Provider Survey Part 1: EMR Benefits- Part 1 of the survey focused on providers’

perception of benefits realized from EMR use.

b. Provider Survey Part 2: OntarioMD Progress Survey- Part 2 of the survey focused

on the measurement of maturity across key functional areas, and was representative of

OntarioMD’s EMR progress survey.

The survey responses provided valuable information prior to the site visits about each practice, as well as: EMR use

and adoption; EMR maturity; and, general perceptions around EMR use. The information obtained was used to

tailor the interview guide for each individual on-site visit. The Organizational and Provider Surveys are presented

in Appendices F and G respectively.

Interviews

On-site interviews were conducted with clinicians and team members (including administrative staff) whose

responsibilities involved interaction with some aspect of the EMR. For the physicians, the Clinical Lead along with

other physicians (a representative number relative to the size of the practice) were interviewed. A total of thirty-

nine physicians and clinical staff were interviewed across the six sites.

The interviews contained open-ended and closed questions to expand the data gathering and to increase the

number of sources of information. A structured interview guide was developed and emailed to each interviewee

prior to the interview (see Appendix H). As well, the case study subset of EMR indicators was also provided to the

site prior to the site visit (Appendix D). Qualitative data from the interviews were used as a proxy for indicator

measurement where EMR date extraction was not feasible.

Direct Observation

Where possible, the study team observed clinician and staff use of the EMR while on-site. This supported the

information gathering related to workflow and specific use of EMRs in the practice setting. In addition, it served to

validate the information obtained through the surveys and interviews. Because of Personal Health Information

restrictions, the study team did not partake in any activities related to direct patient care or where unique patient

identifiers were visible to the study team.


PwC 17

Data Extraction

With assistance from Clinical Leads, IT leads, or data analysts, EMR reports were extracted from the EMR systems

in each site, where possible, in order to measure benefits related to specific indicators.

3.2.2 Final Revisions to Benefits Realization Framework

Following the completion of all case study site visits, the framework and indicators were reviewed and discussed

with members of the Steering Committee. Based on data obtained and feedback received, the framework was

revised for analysis and reporting purposes. The Steering Committee agreed to focus case study analysis on

indicators that would be representative of the BR framework and were most readily accessed and quantified and/or

qualified. The revised BR framework with five categories and eleven indicators is presented in Table 2:

Table 2: Final BR Framework for Case Study Reporting Purposes

Category Indicator

Reference

Number

Indicator

Laboratory Management LM2 Average time between laboratory time of service and test resultsavailable in EMR

Communication and

Coordination of Care

CC1 Average time to receive discharge summary following inpatientdischarge

CC3 Average time from referral decision to when the referral is sent

CC4 % of practices where the care team has access to and uses theEMR system

CC5 % of physicians who have remote access to EMR and use it forpatient care

Chronic Disease

Management

CDM1 % of PHC clients/patients, 18 years and over, with diabetesmellitus in whom the last HbA1c was 7.0% or less in the last 15months

CDM2 % of patient population, age 18 and older, with diabetes mellituswho received testing for diabetic complications

Health Promotion,

Screening and

Prevention

HPSP1 % of practice population, age 65 and older, who received aninfluenza immunization

HPSP2 % of practice population, age 50 to 74, who had a screening testordered for colon cancer

HPSP3 % of practice population, age 18 and older, who have had theirblood pressure measured by their primary health care providerwithin last 15 months

Efficiency E1 % change in time to complete clinical/admin documentation


PwC 18

The values collected from case study sites for the indicators in this framework are referenced and discussed in

Section 4, Case Study Findings.

3.2.3 Modeling and Forecasting of Benefits

An important activity undertaken in Phase 2 was the modeling and forecasting of the potential benefits associated

with broad, mature use of EMRs in Ontario in five to ten years. A fundamental assumption is that this timeframe

will allow widespread and more mature use of EMRs, similar to the advanced users of EMRs today, as represented

by the case study sites. Benefits were extrapolated from indicators collected through the EMRs during the site

visits and further validated with peer reviewed literature. It is to be noted that two studies (Hillestad et al, 2005

and Manitoba Health, 2012) have been referenced on multiple occasions for forecasting purposes, as the scope of

these studies are in alignment with this benefits realization study.

As outlined in Figure 2, development of each of the benefit estimates was an iterative approach. The EMR BR

Framework was used to guide the development of potential EMR benefits. Indicators from the framework were

selected for forecasting based on the availability of data for each indicator at the various sites as well as the

availability of supporting evidence for the extrapolation of these indicators to province-wide benefits.

Figure 2: Approach to Developing Benefit Estimates

Comparative Indicators

The first step consisted of comparing current values of indicators for leading practices and those for other practices

in Ontario. For each indicator selected, minimum, maximum and average values were calculated based on data

collected on site. In order to compare this with the current standard in Ontario, a search of the literature and data

collection agencies (e.g. Statistics Canada and Canadian Institute for Health Information) was conducted. Where

possible, Ontario estimates were used, although in certain instances Canadian or other provincial estimates had to

be used as a proxy. This comparative estimate is an average value of the indicator for the entire province.

The maximum value for each indicator collected on site was used as the projected indicator for Ontario practices in

five and ten years. This was done in order to assess the full potential if all Ontario practices realized benefits similar

to the high performing EMR-enabled practices, as represented by the case study sites.

Associated Relative Benefit

The second step involved assessing the relative benefit for the high-performing practices compared to other

practices in Ontario. Although indicators provide some sense of the expected benefit, they are not realized benefits

per se. For example, the share of the population that is immunized suggests improved health outcomes and avoided

health care costs, however the immunization rate must be extrapolated in order to estimate these actual benefits. A

search of the literature was conducted to attribute a benefit to each indicator. The search prioritized impacts on

resource use or costs.

Indicator estimatefrom site visits

Comparative indicator foraverage Ontario practice

Associated RelativeBenefit

Ontario Extrapolation Ontario Benefit Estimate

Benefit Indicator


PwC

Extrapolation to Ontario Population

In the third step, relative benefits were extrapolated to the entire p

collected for each benefit such as the number of benefit recipients in the province and the costs of various

resources. In order to estimate the benefit

projected to 2017 and 2022. The Ontario data was estimated using a number of sources including Ministry of

Finance population projections and Cancer Care Ontario

estimated using various techniques to extrapolate to provincial levels.

Ontario Benefit Estimate

The obtained benefit estimates provide an indication of the potential avoided costs

providers in Ontario adopted an EMR and

are calculated using identified formulae and financial impacts are presented in 2012 dollars

Selected Indicators

The figure below outlines the indicators selected for modelling by benefit category (Effic

Screening & Prevention and Chronic Disease Management). As mentioned above, other indica

feasibly modeled due to the lack of data extracted

interviews conducted.

Due to study limitations and the inability to model and forecast benefit values for a

that the findings represent a subset of potential province

EMR use. In addition, the above indicators themselves

populations. For instance, benefits associated with influenza immunization were estimated in the over 65 age group

only based on available evidence.

3.3 Study Limitations

Limitations of the study approach include the following:

Generalization of Findings: The

the representativeness of the findings

considered as directional and a foundation for

through broad and mature use of

• Improved diabetes management

Chronic Disease Management

• Increased influenza immunization rates• Increased colon cancer screening rates

Health Promotion, Screening & Prevention

• Staff reduction in time spent on administrative tasks

Efficiency

Extrapolation to Ontario Population

third step, relative benefits were extrapolated to the entire province. In order to do this, additional data was


resources. In order to estimate the benefit five and ten years from now, the number of benefit re


Finance population projections and Cancer Care Ontario data. Where local data were not available, proxies were

echniques to extrapolate to provincial levels.

The obtained benefit estimates provide an indication of the potential avoided costs or quality of care outcomes

providers in Ontario adopted an EMR and achieved similar results to the high performing case study sites

and financial impacts are presented in 2012 dollars.

The figure below outlines the indicators selected for modelling by benefit category (Efficiency,

Prevention and Chronic Disease Management). As mentioned above, other indica

led due to the lack of data extracted from EMRs or the inability to derive estimates from the

Due to study limitations and the inability to model and forecast benefit values for all indicators, it is acknowledg

that the findings represent a subset of potential province-wide benefits that can be derived from broad and mature

ition, the above indicators themselves capture a subset of benefits and often for specific patient

. For instance, benefits associated with influenza immunization were estimated in the over 65 age group

imitations of the study approach include the following:

: The intentional focus on six practices with advanced use of

the representativeness of the findings for the province as a whole. Accordingly, the findings should be

a foundation for “the art of the possible” for benefits that can be realized

broad and mature use of EMRs in primary care settings across Ontario.

Improved diabetes management


Increased influenza immunization ratesIncreased colon cancer screening rates

Health Promotion, Screening & Prevention

Staff reduction in time spent on administrative tasks

19

rovince. In order to do this, additional data was


years from now, the number of benefit recipients was


. Where local data were not available, proxies were

or quality of care outcomes, if all

case study sites. Values

iency, Health Promotion,

Prevention and Chronic Disease Management). As mentioned above, other indicators could not be

s or the inability to derive estimates from the

ll indicators, it is acknowledged

wide benefits that can be derived from broad and mature

and often for specific patient

. For instance, benefits associated with influenza immunization were estimated in the over 65 age group

practices with advanced use of EMRs limits

, the findings should be

benefits that can be realized


PwC 20

Sampling: Case study sites were selected based on identified criteria and in consultation with OntarioMD

and the PeHP at eHealth Ontario. Accordingly, the results reflect this sample bias. In addition, survey

participants were identified by the clinical leader rather than being randomly selected, which helped ensure

that interviewees were advanced EMR users but also introduced a sample bias.

Attribution of Benefits to EMRs: It is difficult to establish a strong correlation between EMR use and

measures among the different practice environments because there are many other variables that

contribute to outcomes measured by the indicators (e.g., interdisciplinary care, well established workflows,

payment models, etc.). Anecdotal evidence was acquired to support findings, and define the nature of the

attribution of EMR use to benefits realized. In many instances, the benefits are indirectly attributable to

EMR use, but it was widely acknowledged that several benefits cannot be realized as quickly nor as

effectively in the absence of EMR use, i.e. in a paper-based clinical setting.

EMR Maturity: While maturity of EMR use is improving, the use of EMRs is still evolving across

Ontario. Although the case study sites were identified as advanced users of EMR, there was variability in

EMR maturity and connectivity to other systems. Accordingly, interview data was not always comparable

across sites as interviewees were not able to provide a consistent perspective on EMR capability and, as a

result, provided varying levels of detail regarding EMR use and impact.

Lack of Data Quality, Standardization, and Extraction/Reporting Capabilities: To varying

degrees, each site had difficulty extracting high quality, standardized data from its EMR. Accordingly, it

was difficult for the sites to report EMR impact on specific indicators.

Lack of Baseline Measures: All case study sites estimated pre-implementation indicator values in the

absence of measured baseline information for the selected indicators. Indicator values prior to EMR

implementation were typically estimated from respondents’ memories and as a result, may not be accurate.

Ability to Forecast EMR Adoption and Use: The modeling approach assumes that, by 2017, all

community-based practices in Ontario will have adopted EMRs and will benefit from EMRs to the same

degree as the case study sites. The pace of EMR adoption in Ontario over the next five years is uncertain

and will likely not be on a “straight line” basis, i.e., rates of adoption and benefits realization will likely vary

on a year-to-year basis. Although there was a large increase in EMR adoption in Canada from 2009 to 2012

with the Commonwealth Fund Survey reporting an increase from 37% to 56%, a linear increase to 2017 and

in turn 2022 cannot be assumed.

Limited Evidence for Modeling: The model addresses a limited number of benefits based on data

collected by EMR practices to date and available evidence in the literature. For some indicators, practices

were not able to extract the data from their EMR. For other indicators, although values could be extracted,

there was insufficient evidence regarding the impact of the indicator on cost or quality of care outcomes

(e.g., average time to receive charts after emergency department). In addition, some benefits of EMRs are

not yet reflected by indicators so the benefits cannot be estimated (e.g., immunization in young children).


PwC 21

4. Case Study Results

Findings obtained from the six primary care case study sites are reported in the section below. The findings reflect

the quantitative and qualitative benefits that have been measured and realized by the six sites, with data compiled

from provider surveys, site visit data collection as per the selected indicators and in-person interviews. This section

presents results of the provider surveys, followed by indicator and interview results in alignment with indicator

categories.

Following the presentation of findings and modelling and forecasting results in Section 5 that follows, a discussion

is presented in Section 6 with a focus on the broader potential benefits that can be realized through mature EMR

adoption and use across Ontario in primary care settings.

4.1 Provider Survey Results

The survey of 28 physicians, physician assistants and nurse practitioners from the six case study sites focused on

providers’ assessments of the impact of EMRs on quality, communication and coordination of care, efficiency, and

the patient experience in the primary care setting. Results, demonstrating levels of agreement with specific impact

statements, were very positive and are presented in the four bar chart figures that follow.

Figure 3: EMR Impact on Quality

*Statements have been truncated (See Appendix G for complete survey questions).

70.4 70.455.6

40.7 48.1

85.2

33.355.6

29.6 25.937

48.1 37

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40.7

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PwC 22

The eight survey questions posed reflect a very broad definition of “quality”, addressing aspects that include:

Quality of care delivered

Chronic disease management

Patient safety and proactive monitoring of conditions

Clinical decision-making

Remote access

Needs-based planning

Practice improvement

Very strong levels of agreement were received in response to all of the questions posed, reflecting the significant

range of impact and benefits that providers believe may be directly or indirectly attributed to the use of EMRs. On

average, 93.0% of respondents either strongly agreed or agreed with statements presented for EMR benefits related

to quality of care.

Figure 4: EMR Impact on Communication and Coordination of Care

Questions around the impact of EMRs on communication and coordination of care were more narrowly focused on

internal sharing of information, supporting interdisciplinary care coordination and overall practice’s ability to

coordinate patient care. 100% of survey respondents agreed or strongly agreed that the use of EMRs made a

positive impact on those activities related to communication and coordination of care, indicating the tremendous

impact that EMRs can have in the clinical practice setting.

92.6 92.674.1

7.4 7.425.9

Improves the sharing of patientinformation with providers internal

to our practice

Supports interdisciplinary carecoordination in our practice

Enhances our practice’s ability tocoordinate patient care

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PwC 23

Figure 5: EMR Impact on Efficiency

*Statements have been truncated (See Appendix G for complete survey questions).

Nine survey questions were posed around efficiency, again reflecting a broad definition of “efficiency”, addressing

aspects that include:

Efficiency of ordering lab tests and prescriptions

Practice productivity (increased output and reduction of effort)

Time spent responding to call backs or other pharmacist requests

Availability of test results (turnaround time)

Administrative efficiencies

Preventative care incentives

Claims management processes

Management of overhead costs

Overall, 81.5% of survey respondents strongly agreed or agreed with statements presented for EMR benefits related

to efficiency of practice. Findings suggest that while the majority of respondents perceive their EMR system to

positively impact the efficiency of their practice, there is some level of disagreement around the efficiency of certain

aspects of EMR use (vs. a paper-based environment). This is most pronounced around the ability of EMR use to

positively impact claims management processes and the management of overhead costs.

63 59.344.4

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77.8 70.4

44.4 44.4

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18.518.5

44.429.6

29.6

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PwC 24

Figure 6: EMR Impact on the Patient Experience

The two questions posed around patient satisfaction and patient education indicated strong levels of agreement,

with 94.4% indicating that EMRs have a positive impact on both. However, the majority of respondents simply

agreed (rather than strongly agreed) with these statements. This suggests that the large majority of respondents

perceive their EMR improves the overall patient experience, but that there could be other, and perhaps stronger,

contributing factors to patient experience.

Survey results are further referenced in support of the findings presented on the indicators and interviews below.

4.2 Indicator and Interview Results

As described in Section 3, above, the priority indicators that were identified in Phase 1 were assessed for each of the

six case study sites. Data to support the priority indicators were obtained from interviews, provider surveys and

EMR data extractions. Benefits are assessed and presented as per the five categories and indicators identified in the

EMR BR Framework Case Study Subset and in Table 2. In addition, findings and anecdotes from interviews related

to each of the five categories are presented, with selected supporting quotes from providers. A sixth category,

Medication Management, emerged in discussion with several providers during the interviews. Although there were

no indicators studied for Medication Management, the interview findings are presented.





5. Efficiency


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PwC 25

4.2.1 Laboratory Management

The management of laboratory information was determined to be a key area of interest and a feasible area to assess

in the current EMR environment. Primary care settings are connected (to an extent) to community (private)

laboratories through a direct feed enabling them to receive laboratory results electronically into their EMRs. This

simulates the benefits that will be obtained as the Ontario Laboratories Information System (OLIS) is rolled out in

primary care settings. Some physicians indicated very recent connection to the OLIS but results and/or trends were

not available at this time.

The impact of EMR use on Laboratory Management was assessed through a combination of provider survey results

and interviews for one case study indicator. Results are presented in Table 3 below.

Table 3: Laboratory Management Indicator Results

ID # Indicator Definition Source Indicator Values

LM2Average time from laboratory time ofservice and test results available inEMR

Interview Pre EMR: Total turnaround ≈12 hours to 5 days

Post EMR: Real time – 24 hours

Responses from the provider survey indicated that 100% of participants felt that the EMR reduces the time from

when a laboratory test result is available to when the result is received by the EMR. However, indicator values

varied among case study sites. Some case study sites reported having laboratories physically on site. Their pre-EMR

laboratory turn around time averaged 24 hours for routine bloodwork and was generally within 12-24hours with an

EMR. As expected, the time for transmission of results was not a significant factor prior to EMR implementation as

results were commonly “walked over”. However, sites that previously relied on paper delivery of results from

community laboratories and which now receive electronic reports directly into their EMR reported a noticable

difference in the turnaround time post-EMR implementation. Paper-based results were reported to take

approximately 3-5 days, but those sites now report receiving information in “real time” when the result is ready for

distribution. For most study sites, a minimum of 50% decrease in lab result turn around time was reported with

results received electronically in their EMR.

Physicians also perceived EMRs to improve the efficiency of ordering lab tests. Findings from the provider survey

indicated that 63% of respondents strongly agreed that the EMR enhances the efficiency of ordering lab tests,

prescriptions etc. contributing to the overall management of laboratory information.

Additional Interview Findings

Some physicians reported accessing their EMRs remotely in the morning before their clinic day or on weekends to

prepare for the day or week. Consequently, test results requiring immediate follow-up were able to be addressed

sooner by scheduling the patient for a follow-up visit, making a referral, or sending a prescription to the pharmacy

(depending on EMR capability). It was also reported that some physicians are able to access lab reports on their

smart phones, making remote access even easier.

Physicians are able to access lab results in “real time” throughout the day in

many locations. Some physicians indicated that they enjoyed the ability to,

throughout the day, go through their “inbox” (the results also were in the

patient chart) and sign off results as they come in, demonstrating how some

physicians have adopted a change in workflow to manage laboratory

information. Previously, results may have been signed off in batches at the

end of the day; now, physicians can access their EMR in the clinic room, in

their offices or in hallways, enabling them to review and sign laboratory

“I access labs and chartsfrom many locationsthroughout the day. As aresult I can make fasterdecisions related to nextsteps in patient care”.


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results from many locations throughout the day.

A few case study sites reported the use of a patient portal in conjunction with their EMRs. Some sites reported that

their patients’ experiences were improved through the sharing of laboratory results via a secure patient portal.

Physicians reported a reduction in patients’ anxiety by enabling them to check their laboratory results themselves

from home, and others indicated that their patient portal allowed them to post comments along with the results

they selected for sharing with patients. This helped patients better understand the context of the result.

4.2.2 Communication and Coordination of Care

Communication among health care providers and coordination of care were both identified as key areas of interest

for the case studies. In particular, the need was identified to better understand how the use of EMRs has impacted

both intra-office and inter-office communications. Study sites were more responsive to discussing and identifying

benefits related to intra-office communication and coordination, as the use of EMRs in supporting inter-office

communication is perceived to be in its very early stages.

Case study findings related to five defined indicators regarding communication and coordination of care are

presented in Table 4.

Table 4: Communication and Coordination of Care Indicator Results


CC1Average time to receive dischargesummary following inpatient discharge Interview

Pre EMR: 4 to 14 days

Post EMR: Real time to 48 hours

CC3Average time from referral decision towhen the referral is sent Interview

Pre EMR: 1 to 7 days

Post EMR: Real time to 1 day

CC4% of practices where the care team hasaccess to and uses the EMR system

Provider Survey

Interview100%

CC5% of physicians who have remote accessto EMR and use it for patient care

Provider Survey

Interview100%

For indicators CC1 and CC3, interviewees were able to estimate a pre-implementation value depending on their

personal experiences. While those estimates of pre-implementation values ranged significantly among providers,

the reduction in times quoted were, on average, significantly lower demonstrating reductions in time spent waiting

for discharge information and/or referrals in the range of 85% or more. These reductions in time spent waiting

for discharge summaries and referrals expedite and facilitate the coordination of care such that patient needs can

be addressed in a timely fashion. For indicator CC1, physicians reported that, prior to EMR implementation,

hospital discharge summaries were available within 1-2 weeks of discharge and are now available with tools such as

the Hospital Report Manager or direct connectivity, either in real-time or within two days.

With respect to referrals and indicator CC3 specifically, physicians were able to estimate the average time to

complete a referral letter and send it to the specialist. Physicians widely reported that the referral process1 is much

more efficient with EMRs because of the pre-populated data in the referral forms. Some physicians also reported

using macros or templates to further support the process. This finding was also supported in the provider survey

1 Herein refers to as “from referral decision being made to the reference request letter completed/faxed.”


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with 70.4% of respondents reporting that EMRs improve administrative efficiencies through the use of features

such as pre-populated templates, forms and stamps. Following the development of the referral letter, there was a

mix of workflow processes reported. Some physicians reported they sent out the referral letter themselves through

the EMR with attachments while other physicians reported consolidating the letter and supporting documentation

to send to a referral clerk/ nurse for submission and tracking. Overall, it was observed that the EMR improves

physicians’ ability to make timely referrals, expediting the care process and facilitating inter-office

communications.

For indicator CC4, 100% of practices reported that their entire care team has access to the EMR. Survey responses

further emphasized the access and importance of EMRs in providing interdisciplinary care and intra-office

communication; 92.6% of survey respondents strongly agreed that the EMR system supports interdisciplinary care

coordination in their practice. In addition, 92% of respondents strongly agreed that the EMR system improves the

sharing of patient information among providers internal to the practice.

For indicator CC5, it was evident at all sites that providers are accessing the EMR and using it remotely for patient

care purposes. 85.2% of survey respondents strongly agreed that EMRs support remote access and use of

information by providers for patient care. The ability to access patient information at any time and in any place was

noted by all as a tremendous asset to providers and their patients. EMRs also improve the ability to communicate

within clinics and often with providers outside of clinics, with overall results improving the efficiency of patient

care.


Interviews with clinic staff revealed many additional benefits of care coordination

from EMRs. For example, EMRs facilitate the ability of physicians to set aside

dedicated time for same/next day appointments for patients with acute needs.

Physicians and team members reported that improvements in scheduling and

practice organization facilitate their ability to hold same/next day appointments

open. In addition, EMRs provide physicians and care team members with the ability

to view everyone’s schedule to better coordinate care across team members.

With respect to communication across the team, it

was overwhelmingly reported that the illegibility of

hand-written clinical notes was formerly a challenge

when sharing information among team members. Interviewees reported that the

sharing of legible information in the EMR has improved the quality of care delivered.

Team members are now able to communicate with one another in real time, ask

questions and assign tasks among the team. The patient chart is now accessible to

many multiple care team members at the same time, a feature that was not possible

in paper.

Through the use of EMRs, most physicians reported that the information they

provided in referral letters to specialists was more comprehensive, especially for complex cases. It was also

reported that specialists appreciate the extensive clinical information provided as part of the referral and facilitated

by EMRs. Some physicians reported that they were able to quickly select attachments e.g. diagnostic test results, to

send along with the referral letter.

“EMRs improvescheduling,resulting inincreased capacityand organizationof our practice, allof which results inincreased accessfor patients”.

“EMRs improvetransfer ofinformation tospecialists - it iseasier to provideconsultations withlots of relevantinformation”.


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Lastly, there was consensus among users of the Hospital Report

Manager (HRM) (whereby dictated and transcribed hospital reports are

transformed into a standards-based data schema that can be directly

updated into the patient’s chart in an electronic format) that it has

decreased the average time to receive hospital reports. The

implementation of HRM has reduced transcription time and

significantly decreased hospital report turnaround time. Some practices

reported receiving hospital reports directly into their EMRs within

thirty minutes of transcription. As a result, proper clinical decisions can

be made more effectively to improve the quality of care for patients.

4.2.3 Chronic Disease Management

Chronic disease management is an emerging area of interest related to EMR use. Case study sites reported that

EMRs facilitate significant and improved changes to the way chronic conditions are managed. Both quantitative

and qualitative findings were significant, with physicians expressing a desire to expand their use of EMRs for this

purpose.

The impact of EMRs on the management of patients with chronic conditions was assessed through a combination

of provider survey results, interviews and EMR data extraction. Findings related to the three defined indicators are


Table 5: Summary Chronic Disease Management Indicator Results


CDM1

% of PHC clients/patients, 18 years andover, with diabetes mellitus in whomthe last HbA1c was 7.0% or less in thelast 15 months

EMR Data ExtractionRange: 41 - 70%

CDM2

% of patient population, age 18 andolder, with diabetes mellitus whoreceived testing for all of the following: Hemoglobin A1c Full fasting lipid profile screening Nephropathy screening Foot examination Blood pressure measurement Obesity/overweight screening

EMR Data Extraction 34%

Overall, provider survey respondents agreed that EMRs improve the management of chronic diseases. Specifically,

70.4% strongly agreed with the statement and 25.9% moderately agreed. 92.5% of survey respondents also reported

that the EMR system supports patient education. For example, the EMR provides access to handouts, references or

tools to trend patters for BMI, blood sugar, and other labs. Collectively, the educational materials and tools help

patients better understand and manage their chronic conditions.

CDM1 and CDM2 were measured across all sites, with values ranging from 41-70% and 34% respectively. These

results demonstrate the ability to identify a target diabetic population and deliver appropriate, evidence-based care.

Physicians and care teams are better able to monitor specific clinical indicators such as HbA1c, and develop care

plans tailored to populations. 85.2% of provider survey respondents agreed that EMRs enable practices to perform

“Through HRM and my EMR, Ireceive reports from the localhospital as soon as they areprepared. No more calling thehospital for reports. I have theinformation immediatelyavailable to review”.


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needs-based planning e.g. plan for a specific patient population/community. Without EMRs, this is very time

consuming, costly and a nearly impossible task.


It was evident in discussions with physicians and care team members that they were all motivated to better manage

the health of various patient populations. There appears to be a movement away from “chair to chair care” with an

increasing emphasis on patient populations. Sites reported that because they are easily able to identify patient

populations, they are able to proactively follow up with patients, schedule recall appointments or send them for

further testing as needed.

Nurse practitioners reported that their practices had many patients with chronic diseases, and they found that the

use of EMR tools, e.g. diabetes template/ flow sheet, was very useful when seeing diabetic patients. Relevant

information was quickly accessible and consolidated, and the flow sheet ensures that best practice guidelines are

incorporated into care delivery. Care team members are aware of what needs to be attended to during the visit,

improving efficiency and what they should be planning for in the coming months in order to manage the condition.

Most physicians and care team members reported using trending orgraphing tools as patient education materials e.g. blood pressure,weight, HbA1C were commonly trended. It was reported that the abilityto review consult notes, labs etc with patients builds confidence of careand enhances communication”. In addition, some physicians noted thatthey were beginning to communicate with patients (especially thosewith chronic conditions) via secure email.

4.2.4 Health Promotion, Screening and Prevention

Keeping Ontarians healthy through health promotion, prevention and screening initiatives is an area of benefits to

be explored through the use of EMRs. This aspect of the study is complementary to that of chronic disease

management, with a focus on targeting at risk populations to improve quality of care.

The impact of EMRs on health promotion, prevention and screening was assessed through a combination of

provider survey results, interviews and EMR data extraction. Findings related to the three defined indicators are


Table 6: Health Promotion, Screening and Prevention Indicator Results


HPSP1% practice population, age 65 andolder, who received an influenzaimmunization*

EMR Data Extract Range: 52 - 80%

HPSP2% of practice population, age 50 to 74,who had a screening test ordered forcolon cancer


HPSP3

% of practice population, age 18 andolder, who have had their bloodpressure measured by their primaryhealth care provider within last 15months


“For diabetes care I can trendA1C for several years – youcan discuss and show thepatient how they are doing”.


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Overall, EMR data extraction was quite feasible for the above selection of indicators, suggesting that case study

sites have been working towards standardizing their data input in order to use the data in a meaningful way to

maintain a healthy population. For each of the three indicators, identified patients who had received appropriate

preventative treatments (as per the indicators) were greater than 50% and as high as 82%. The role of the EMR in

facilitating the identification of patients, communication with those patients, and ordering and/or documentation

of the required testing is very important. Providers indicated that these tasks are greatly enabled by EMRs, and

much more difficult to accomplish in a paper-based environment.

Provider survey results further emphasize the role of the EMR system in promotion, prevention and screening

activities, with 92.6% of survey respondents agreeing that EMRs improve patient safety and the proactive

monitoring of overdue tests/ exams. Enabling case study sites to track their patient populations through the EMR

and compare their indicator values to provincial benchmarks gives them an opportunity to identify areas for

improvement in health promotion, screening and prevention activities.

Sites are in the early stages of generating reports to proactively screen their patient populations, and priority areas

of focus can be linked to financial incentives for preventative care. It should be noted that the provincial target for

colorectal cancer screening is 40% (Health Quality Ontario, 2012) and that the values reported by all the case study

sites exceeded the provincial average. In addition, 44.4% of provider survey respondents strongly agree, while

44.4% moderately agree that EMRs facilitate preventative care incentives e.g. through cohort management for

influenza immunizations.


All of the case study sites reported that they were motivated to use

EMRs for population health purposes. Physicians and care teams

performed simple searches with minimal parameters to identify target

populations for disease prevention. For example, as part of its family

health team quality improvement plan, one site reported pulling lists of

eligible/ not eligible patients for activities such as cervical cancer

screening, breast cancer screening and colon cancer screening, and

sharing the list among physicians to coordinate screening tests.

Another common example discussed with interviewees was the EMR’s

ability to support efforts to increase influenza immunization rates. Not only have practices adopted processes for

targeting populations and sending reminder letters (or emails where available) but they have also developed and

tested new ways of measuring their flu vaccination rates, including a dashboard that presents vaccination rates

among patients of physician peers.

Some physicians and care team members reported that they were better able to track preventative health tests and

recalls, with the EMR generating reminders for the proactive scheduling of wellness visits. Sites also reported that

they engage patients in community wellness talks through identification of those in target populations, and speak to

them about prevention and promotion topics relevant to their cohort. EMRs afford providers the ability to be very

proactive and interactive with patients in managing their own health.

“EMRs provide the ability tosurvey your practice to findpeople who are due forpreventative procedures orcare, including finding allthe people who have not hada pneumovax.”


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4.2.5 Efficiency

Obtaining a better understanding of the overall practice efficiencies realized through the use of EMRs was a focus

for the case studies. As discussions evolved, it became evident that practice and provider efficiency was a recurring

theme that was applicable to several other discussion categories as well. Consequently, results are presented for

one indicator only in this section, but findings about efficiencies created are also referenced elsewhere in this

report.

Table 7: Summary Efficiency Indicator Findings


E1

% change in time to completeclinical/admin documentation by usingpre-populated templates, forms andstamps

Interview ~ 50% decrease

Overall, 77.7% of survey respondents agreed with the statement that EMRs “improve the efficiency (reduction in

effort) of my practice” and of those 44.4% strongly agreed with the statement while 33.3% moderately agreed.

These survey responses mirror the comments collected during the interviews on overall practice efficiencies.

With respect to clinical and administrative documentation (indicator E1), physicians were able to report overall

that there have been efficiency changes related to certain activities. For example, 92.6% of survey respondents

agreed with the statement that EMRs “enhance the efficiency of ordering lab tests, prescriptions, etc” (63.0%

strongly agree and 29.6% moderately agree). During interviews, physicians reported that the auto-population of

templates (where appropriate, e.g. lab requisition form, s.o.a.p. format encounter notes and others) was an added

benefit and saved time for themselves and their administrative staff in completing fields such as demographics.

For indicator E1, forms (including templates with the ability to auto-populate existing EMR data) and stamps (e.g.

s.o.a.p note or diabetic assessment template used to capture information) were acknowledged as a benefit to clinical

and administrative documentation. However, physicians and care team members found it difficult to quantitatively

assess the impact, with most estimating the time savings at 50% when compared to a paper-based environment.

Survey results support the benefit of EMRs in administrative efficiencies with 70.4% of providers perceiving EMRs

to improve administrative efficiencies such as through the use of pre-populated templates, forms and stamps.


In addition to the discussions around the above indicator, there was significant

discussion on the efficiencies gained (or transferred to other activities) related

to EMR use. There was a general consensus from interviewees that EMR

features such as reminders allow for more efficient clinical encounters (e.g.

patient physical exams), and not surprisingly, physicians and care team

members reported that their time is not spent “flipping through papers” or

searching for misfiled results. Instead, clinicians reported being able to address

their list of planned activities such as reminding patients they are due for certain tests, procedures, medication

refills, etc.

“I have more efficientclinical encounters.The time is spent onmore important thingsrather than writingout prescriptionrenewals etc.”


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Nurses and nurse practitioners frequently commented that they would call patients with test results or to discuss

care plans. They all reported that being able to instantaneously access the patient file while on the call allowed them

to have more detailed conversations with patients, providing greater confidence and support to patients.

Nurses also reported efficiencies in workflow related to patient arrival at the practice. For example, front desk staff

can check-in the patient which will appear in the schedule as “patient in waiting room”. Following the completion

of initial assessments, the nurses will then change the patient status in the schedule so that the physician knows the

patient is ready to be seen; this avoids duplication of work among providers and improves the efficiency of the

patient visit. In addition, physicians can view their clinical schedules in real time and be able to utilize their “break”

time more efficiently to dictate notes, clean up their inbox messages, review next patient’s files and other clinical

duties.

4.2.6 Medication Management

Although medication management was not formally identified as an area for study during case study site visits,

interviewees and survey data provided information on how EMRs have impacted the management of medication

for their patients. EMR benefits were consistently reported related areas such as medication recalls and medication

history. Other processes such as ePrescribing were “gray areas” of discussion and varied among practices.

Physicians and care team members reported an important patient

safety benefit of the EMR is the ability to quickly extract patient

lists for specific medications that have been recalled. Survey

results suggest that 88.8% of respondents agree that EMRs

enable practices to identify patients for changes in medication

based on new evidence such as drug recalls.

Physicians reported that they do not spend time “flipping through the chart” to look at historical information. The

medication history is in one place (i.e. CPP) in the EMR, and is up to date. With the EMR, physicians reported

being better able to track current and expired prescriptions and respond to requests with a comprehensive patient

history at their disposal.

Physicians reported that their overall workflow to prescribe medications and

refill prescriptions has evolved more efficiently. For some sites, EMR medication

alerts and reminders were used and found to be beneficial and efficient; however,

other sites reported that their medication alerts and reminders were not reliable.

In some instances, community pharmacies are provided with secure access to

EMRs. The sharing of medication information across the care team supports

improved patient safety reducing potential call backs to the physicians for

clarifications in dose or instructions.

Provider survey results report that 63% of respondents strongly agree that EMRs

enhance the efficiency of tasks such as the ordering of lab tests and renewing prescriptions. 77.7% of respondents

perceive the EMR to reduce the number of call backs and or time spent responding to pharmacist requests for

physician verification of prescriptions. In advance of the development and delivery of a provincial Medication

Management System, interviewees reported using a form of electronic prescribing or “ePrescribing” and electronic

prescription renewals facilitated by their EMRs. Some practices reported renewing prescriptions and sending them

directly through the EMR to pharmacies which improved the prescription renewal turnaround time. Other

practices reported using the EMR to document and print prescriptions. The legibility of electronic prescriptions

was reported to be an important benefit related to patient safety.

“the EMR can be used to find all thepatients on this medication inorder to alert them to the warningor change medications if needed”.

“Prescriptions arefacilitated with directfax to inbox andcomputer fax topharmacy, no papergenerated, less time,and fewer errors”.


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5. Modeling and Forecasting

A model was developed to forecast the potential benefits of EMR use in Ontario based on similar levels of EMR use

as evidenced by the advanced users of EMRs assessed in the six case study practices. Benefits were extrapolated

from indicators collected through the case studies, and supported with peer reviewed literature. Where possible,

benefits are estimated on a population basis and forecasted to 2017 and 2022.

It is acknowledged that the approach to modeling and forecasting of benefits was limited by the sample size (six

case study sites), the ability to attribute benefits to EMR use and to generalize those findings across the province.

In addition, there is limited evidence in the literature for many of the selected indicators. However, the modeling

exercise is intended to demonstrate the “art of the possible” and to highlight the benefits that can accrue based on

mature adoption and use of EMRs across Ontario.

This section provides modeling and forecasting of benefits in relation to the following four indicators which relate

to three of the categories presented in the previous section. Forecasted benefits are further discussed in section 6,

Discussion.

Category 3: Chronic Disease Management

Diabetes management

Category 4: Health Promotion, Screening and Prevention

Increased influenza immunization rates Increased colon cancer screening rates

Category 5: Efficiency

Staff time reduction spent on administrative tasks

5.1 Diabetes Management

Costs for managing chronic diseases represent 58% of all annual health care spending in Canada, at a cost of $68

billion a year, and is growing. In addition, the indirect costs associated with income and productivity loss are

estimated at $122 billion, or nearly double the health care costs (Public Health Agency of Canada, 2011). The cost of

diabetes alone was estimated at approximately $12.2 billion in 2010 and is expected to rise by another $4.7 billion

by 2020 (Canadian Diabetes Association, 2009). Ontario is one of the provinces with the highest growth rates in

diabetes, and its population with diabetes is expected to quadruple over 20 years (Canadian Diabetes Association,

2009).

According to the Auditor General of Ontario, prevention is the most cost-effective strategy for coping with chronic

diseases. At present, evidence is largely related to the management of chronic disease, although some instances of

EMR benefits related to prevention have been noted, with findings suggesting that EMRs help identify patients at

risk for undiagnosed type 2 diabetes (Klein Woolthuis et al, 2007). Diabetes complications account for 69% of limb

amputations, 53% of kidney dialysis and transplants, 39% of heart attacks and 35% of strokes which are associated

with significant costs (Auditor General Report, 2012).

Benefit Model

This section estimates the potential avoided costs from reduced amputations, diabetic kidney disease and

macrovascular complications (e.g. heart attack and stroke) as a result of improved diabetes management by


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leveraging EMR use. It should be noted that avoided costs are measured in isolation for survivors. Also, costs of

managing the disease are not included.

The case studies observed that the highest performing practices had a proportion of patients with diabetes mellitus

in whom the last HbA1c was 7.0% or less at sites visited was 70%. As a provincial comparison, a study completed in

2003 found that, among a random sample of non-academic family physicians, less than 30% of diabetic patients

had HbA1c levels at or under 7% (Harris et al, 2003). The value of 30% was used as the Ontario average for diabetic

control.

The adherence to HbA1c target levels was used as a proxy for mid- to long-term diabetic control. The probability of

complications was calculated for patients in diabetic control, then for patients otherwise. These probabilities were

then multiplied according to the mix of patients in both scenarios (i.e. 70% diabetic control for advanced EMR

users, and 30% diabetic control for Ontario average).

The probabilities of complications were based on a Manitoba Health study (Manitoba Health, 2012). In terms of

lower limb amputations, those in diabetic control have a 2.6% chance of developing peripheral neuropathy followed

by a 0.5% chance of requiring amputation given their neuropathy condition. Patients off control face a 4.6% chance

of developing neuropathy followed by a 2.8% probability of needing amputation.

In terms of diabetic kidney disease, patients in diabetic control have a 2% chance of developing microalbuminuria,

with an 8% probability that this will evolve into macroalbuminuria. There is then less than 1% chance that that will

lead to end stage renal disease (ESRD). Alternatively, patients who are not in diabetic control have an 8% chance of

developing microalbuminuria, a 17% chance that that will lead to macroalbuminuria and a 5% probability that this

will further evolve into ESRD.

The likelihood of macrovascular complications, myocardial infarction (MI) or stroke, increases with the number of

years the patient has had diabetes. On average, Canadians with diabetes have had the disease for nine years (ICES,

2005). Therefore, the risk of MI and stroke after 9 years from the Manitoba Health study was used. Patients in

diabetic control face a 1% risk of MI compared to 4% for patients not in control. Similarly, patients in diabetic

control face a 0.5% risk of MI compared to 1% for patients not in control.

The probability for each complication was multiplied by the number of diabetics in Ontario in order to obtain the

number of complications. The projected number of diabetics in Canada in 2020 was obtained from the Canadian

Diabetes Association and estimates for 2017 and 2022 were extrapolated. The number of diabetics in Ontario was

estimated as a percentage of Canadian diabetics, assuming an equal share to total population (i.e. 38%).

The cost of each complication was taken as the average cost as reported by Manitoba Health, representing a proxy

for the costs of similar complications in Ontario.

Assuming current state whereby 30% of the population is in diabetic control, on an annual basis it is estimated that

diabetes leads to:

1,170 lower limb amputations;

611 cases of ESRD;

43,000 MI; and

Average % diabeticpatients with

HbA1C<7%: 30%Max rate in sites

visited: 70%

Reduced risk of footamputation, kidneydisease, MI and stroke

Number of diabeticsprojected in Ontario in

2017: 1.3 MProjected in 2022: 1.5 M

Benefit = Increased number ofdiabetics in control * avoided

cost per complication perpatient in diabetic control

Diabetes management:


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11,200 stroke cases.

Assuming a future state whereby 70% of the population is in diabetic control, annual occurrences would be reduced

to:

604 amputations, or 566 fewer amputations at $30,000 each;

270 cases of ESRD, or 341 fewer cases at $70,000 each;

25,600 MI, or 17,400 fewer cases at $2,600 each;

8,100 stroke cases, or 3,100 fewer cases at $12,700 each.

Based on the modeling exercise described above, it was estimated that proactive management of diabetes can

potentially save the health system $17 million in amputation costs, $26 million in ESRD treatment costs, $44

million in MI costs and $38 million in stroke costs (cost estimates are on an annual basis). Projecting another five

years forward results in further cost avoidance. Effective use of EMRs and other eHealth platforms could enable

providers to actively monitor their patients’ conditions to prevent their health from deteriorating. Without EMR

and related enablers, it would very challenging to achieve those goals. Results are shown in Figure 7 below.

Figure 7: Annual potentially avoided costs of select diabetes complications

5.2 Increased Influenza Immunization Rates

It is estimated that influenza costs the Canadian economy about $1 billion every year. This includes both health

care system costs as well as lost productivity, with approximately 1.5 million workdays lost annually (Canadian

Healthcare Influenza Immunization Network, 2009).

Effective use of EMRs has the ability to improve immunization rates by helping identify patients in need of specific

immunizations and providing reminders to physicians (and potentially patients) for updates. Some EMRs integrate

evidence-based recommendations for vaccines using patient demographic and clinical data such as gender, age and

family history to target patients requiring immunization. Others may also provide reminders to offer or review

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Diabetic kidney disease

Foot amputations


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immunizations during routine visits or provide reminders for patients to schedule care. Reminders to patients

generated by EMR systems have been shown to increase patient compliance with preventative care

recommendations (Hillestad et al., 2005).

Benefit Model

The estimated benefits of avoided costs to the health care system from increases in rate of influenza immunizationin the population over age of 65 are presented.

Among the high performing EMR case study sites visited, it was observed that a maximum value of 80% of patients

over the age of 65 had received influenza immunization. Comparatively, 64% of Canadians over the age of 65 are up

to date on their immunization vaccination as reported by Statistics Canada; this rate of immunization is used as the

baseline for comparative purposes

The model for estimating the benefits associated with increased rates of influenza immunization was based on a

model developed by the Canadian Health Services Research Foundation (CHSRF) (Dahrouge et al., 2012). It

models the difference in the number and costs of General Practitioner (GP), Emergency Department (ED) and

hospital visits for vaccinated patients compared to unvaccinated patients, resulting from prevented flu episodes as a

result of the vaccination. Based on the findings of Gross et al. (1995), CHSRF estimated that individuals are 50%

less likely to develop an influenza-like illness if vaccinated. This estimate was then used in combination with the

probability of episodes irrespective of vaccination status to obtain risks of GP visits, ED visits and hospital visits for

vaccinated and unvaccinated patients. The costs associated with each type of visit as well as vaccination were

obtained from various sources (as per the CHSRF study, Dahrouge et al., 2012).

The model was modified to incorporate the case study sites’ maximum rate of immunization (i.e. 80%), as well as

adapt the target population to individuals over age 65 in Ontario only. The projected target population was

obtained from the Ontario Ministry of Finance Projections for 2017 and 2022.

Compared to the baseline population (vaccinated at 65%), and as per the modeling exercise described above, it was

estimated that the effective use of EMRs could support a reduction in the number of family physician visits by

over 20,000, hospitals visits by over 7,000 and ED visits by over 9,000 in 2017. This would be associated with

avoided costs totalling $40.6 million in 2017. Projecting another five years forward, cost reductions of $48.5

million to the health care system could be realized in 2022. Results are presented in Figure 8 below.

Averageimmunization rate in

Canada: 64%Max rate in sites

visited: 80%

Immunization leadsto a 12% reduction

in GP visits, EDvisits, and hospital

visits

Cost of GP visit: $35,ED visit: $220,hospital visit: $6,417Ontario projectedtarget population in2017:2.4 M, in 2022:2.8 M

Benefit = (Vaccinated pop postEMR– Vaccinated pop base-Line)* (Cost of vaccinated

pop) + (Unvaccinated pop postEMR– Unvaccinated pop base-Line)* (Cost of unvaccinated

pop)

Influenza immunization:


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Figure 8: Annual avoided costs from increased influenza immunization

5.3 Increased Colon Cancer Screening Rates

The costs for managing chronic disease represents 58% of all annual health care spending in Canada (Public Health

Agency of Canada, 2011), and it has been shown that there are opportunities to improve the care delivered by

enhancing provider decision support with the provision of more timely and comprehensive patient information.

Therefore, disease prevention is an area of potentially high leverage for EMRs to improve health care (Hillestad et

al., 2005).

EMRs can support disease prevention by assisting clinicians in (Hillestad et al., 2005):

Identifying people with a potential chronic disease (e.g. through predictive-modeling algorithms);

Improving screening and testing by tracking the frequency of preventative services and reminding

physicians to offer needed tests;

Distributing reminders to patients and modifying patient behaviour through web-based education; and

Adjusting preventative therapy (e.g. based on the use of easily accessible and regularly updated guidelines).

Benefit model

This section of the study focuses on estimating a subset of the benefits of EMRs associated with preventative care,

specifically the increase in colon cancer screening. The benefit is measured as the number of patients who are

diagnosed at earlier stages of cancer rather than later stages, leading to higher quality of life and avoided costs of

cancer treatment.

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Note: ∆% = percentage change

Based on Cancer Care Ontario statistics from 2010, it is estimated that 53% of Ontarians between the age of 50 and

74 are screened according to guidelines for colon cancer through fecal occult blood test (FOBT) within the past 24

months, sigmoidoscopy within the past five years, or colonoscopy within the past ten years. In comparison, the

maximum rate reported by sites visited was 60%. This represents an increase in screening rate of 7% that is

potentially facilitated through advanced EMR use.

Individuals who are not screened are more likely to be diagnosed once they show cancer symptoms, which are likely

to be associated with later stages of cancer. For patients who are screened, a positive FOBT will lead to a

colonoscopy which, if abnormal, is more likely to be associated with earlier stages of cancer. The probabilities of

being diagnosed with colon cancer, at various stages, were estimated for individuals who are not screened and

individuals who receive an FOBT every two years, and these probabilities are used for modelling purposes.

Organized colorectal cancer screening programs in Canada most commonly use fecal tests as the primary screening

tests for individuals aged 50 to 74 with average risk (Canadian Partnership Against Cancer, 2009) and therefore

this type of test was assumed for modelling purposes. Probabilities of various stages of cancer being diagnosed were

based on evidence from the Manitoba study (Manitoba Health, 2012) and have been applied to the Ontario

population for the purposes of this study. These probabilities were then multiplied according to the mix of patients

in both scenarios (i.e. 60% screening / 40% no screening for patients of advanced EMR users and 53% screening /

47% no screening for Ontario average) to obtain the change in the number of patients diagnosed at each stage of

cancer through advanced EMR use. These estimates were then were multiplied by the stage-specific cost of treating

colon cancer obtained in the literature (Telford, 2010).

The probabilities of various stages of cancer occurring in the absence of FOBT (Manitoba Health, 2012) are the

following:

0.5% chance of showing cancer symptoms

85% chance that, given symptoms, it is not stage 1 cancer

Given it is not stage 1, 42% chance it is stage 2

Given 58% chance it is not stage 2, 56% chance it is stage 3 and 44% chance it is stage 4

The probabilities associated with FOBT screening (Manitoba Health, 2012) are the following:

3% chance of positive FOBT

Given FOBT, 58% chance of abnormal colonoscopy

Given abnormal result, 83% chance it is stage 0

Given 17% chance it is not stage 0, 31% chance it is stage 1

Given 69% chance it is not stage 1, 46% chance it is stage 2

Given 54% chance it is not stage 2, 65% chance it is stage 3 and 35% chance it is stage 4

The probability for each cancer stage was multiplied by the number of individuals in Ontario eligible for screening

(the target population). The target population in Ontario in 2017 and 2022 was obtained from the Ontario Ministry

of Finance population projections.

Average adherence tocolon cancer screening

guidelines: 53%Max rate in sites

visited: 60%

Reduced chance ofdeveloping stage 2,stage 3 and stage 4cancer

Ontario projectedtarget population in2017: 4.3 MProjected in 2022:4.6M

Benefit = (∆% stage 1 + ∆ % stage 2 + ∆ % stage 3 + ∆ %

stage 4)*Ontario targetpopulation

Colon cancer screening:


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Based on the modeling exercise described above, it was estimated that the optimal use of EMRs (with a maximum

screening rate of 60%) could potentially lead to:

220 fewer Ontarians diagnosed with stage 4 cancer;



703 additional Ontarians with no cancer or diagnosed with stage 0 or stage 1 cancer.

Costs of treatment are estimated to be the following: $15,537 for treating Stage 1, $30,505 for treating Stage 2,

$39,176 for treating Stage 3, and $99,115 for treating Stage 4 and terminal care (Telford et al, 2010). Multiplying

the number of cases with their respective costs leads to avoided treatment costs of $38 million in 2017 and $40

million in 2022. However, it should be noted that this estimate includes the cost of treatment only and ignores the

costs of testing and the costs associated with keeping patients alive. Therefore these estimates should not be

interpreted as overall cost savings. Results are presented in Figure 9 below.

Figure 9: Annual avoided costs from increased influenza immunization

5.4 Staff Time Reduction Spent on Administrative Tasks

EMRs have the ability to reduce staff time spent on administrative tasks by different members of the inter-

professional team. These tasks include:

Pulling charts. As EMRs reduce or eliminate the need to maintain paper patient files, office staff do not

need to retrieve or re-file paper charts for office visits or other transactions, and time wasted looking for

misplaced charts is eliminated (Girosi et al., 2005).

Managing laboratory results. Benefits of EMR use can also include faster, more accurate lab order entry,

accurate matching of lab results to charts, correct routing of results to the ordering provider, auto-

completion of EMR lab order status, and validation of complete insurance information (Wolfram et al.,

2009).

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Scheduling. Although electronic scheduling does not necessarily require an EMR, EMRs enable scheduling

features to connect to patient information.

Billing. EMRs enable the capture of billable events as they happen clinically, reducing the chance of

missing billable activities and providing a thorough clinical documentation record. EMRs also generate

diagnostic and billing codes from plain language which can reduce the time spent looking up codes.

Writing in charts. Computerized data entry can reduce time spent recording patient and visit information

through shortcuts such as drop down lists and other automation such as voice dictation.

Order entry. EMRs reduce the time required to complete all fields to transmit, print, or otherwise complete

the process of ordering laboratory testing and radiology tests. EMRs can also produce downstream time

savings resulting from more complete order requests or improved legibility (Johnston et al., 2003).

Encounter management. EMRs provide increased accessibility to information required during a patient

encounter.

Benefits associated with a reduction in time spent on administrative tasks such as those described above are

defined in the benefits model and forecasting that follows.

Benefit model

Case study sites reported large time savings in performing administrative tasks, notably related to time spent with

documentation, pulling charts and scheduling. Maximum time savings were in the range of 22.5 hours/week. It

should be noted that time savings can be utilized in various ways, including redeploying staff to various non-

administrative tasks such as patient care and chronic disease management as well as reducing staff. The maximum

value of 22.5 hours was extrapolated to obtain an average number of hours saved annually per practice.

In order to estimate the number of administrative staff hours that could be redeployed per practice in a year, this

estimate was multiplied by the number of hours in a year. This estimate was further multiplied by the number of

primary care physicians in Ontario then divided by the average practice size (i.e. number of physicians per practice)

in order to obtain an estimate of redeployed hours for the province as a whole. The number of primary care

physicians (15,845) was obtained from Statistics Canada and the average practice size was assumed from data

collected on site. Therefore, the average practice size was estimated at 10 physicians. The number of physicians was

inflated by Ontario population growth to obtain estimates for 2017 and 2022.

Based on the modeling exercise described above, the annual redeployed hours were estimated to be nearly 1.8

million hours in 2017, representing 2.4 hours per physician.

The hours saved were converted to a dollar figure by multiplying hours saved by cost per hour of administrative

staff. It should be emphasized that this is not necessarily a cost saving but rather an estimate of the value of time

that could be redeployed to other clinical activities. The cost per hour of administrative work was obtained by

multiplying the number of medical secretaries (as per Statistics Canada) and the number of nurses working in

primary care offices (as per CIHI) by their respective salaries (as per Statistics Canada).

$73,000

Maximum time reductionon admin. tasks in

sites visited: 22.5hours per week

Number of PCP: 16,000Average medicalsecretary salary: $33,000

Average RN salary:$73,000

Benefit = Annual redeployed hours* cost per hour

Administrative time reduction


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The annual benefit was estimated at $40 million in 2017 and $42 million in 2022, providing increased capacity for

administrative staff, who could potentially assume a variety of practice roles, including additional administrative

tasks currently assumed by clinical staff in the primary care setting, freeing those staff to perform patient care

activities needed elsewhere. Results are shown in Figure 10 below.

Figure 10: Annual benefits of administrative staff redeployment

5.4 Summary Findings

A model was developed to forecast potential benefits of EMR use in Ontario five and ten years from now if allproviders were adopting and using EMRs at the same level as the advanced EMR users in the case study sites.Benefits were extrapolated from indicators collected through the case studies, and supported with peer reviewedliterature.

Four indicators were selected from the BR framework for forecasting based on the availability of data for eachindicator at the various sites as well as the availability of supporting evidence to extrapolate these indicators tobenefits for Ontario. Each indicator along with its associated benefit and benefit estimate is provided in Table 8below. Benefits were measured in terms of financial impact. The financial impacts represent monetary benefitsarising from certain aspects of advanced EMR use and should not be interpreted as overall cost savings to thesystem (e.g. the cost of diabetes complications are only one aspect of the costs and benefits associated withdiabetes).

Although the selected benefits provide only a portion of benefits expected from EMRs, they indicate substantialpotential benefits to be realized if all providers in the province were to become high performing users of EMRs in 5– 10 years.

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Table 8: Summary of Forecasted Benefits

Indicator Qualitative Annual Benefits Estimated Annual FinancialImpact in 2017

Percentage of patients, 18 years andover, with diabetes mellitus in whomthe last HbA1c was 7.0% or less (orequivalent test/reference rangedepending on local laboratory) in thelast 15 months

Patient and health system benefitsfrom management of complicationsand co-morbid conditions arisingfrom diabetes, including:

- 566 fewer foot amputations- 341 fewer cases of ESRD- 17,400 fewer MI cases- 3,100 fewer stroke cases

$125 million

($17 M from reduced footamputations, $26 M fromreduced kidney disease, $44Mfrom fewer MI, $38M fromfewer strokes)

Percentage of patient population, age65 and older, who received aninfluenza immunization

Patient and health system benefitsrelated to illness prevention,avoidance of clinic and/or hospitalvisits

$40.6 M in reduced health caresystem costs

Percentage of practice population,age 50 to 74, who had a screeningtest ordered for colon cancer

Identification and diagnosis ofcancers and malignancies at earlystages for improved prognosis andquality of life for patients




- 703 additional Ontarians with nocancer or stage 0/stage 1 cancers

$38 M in reduced colon cancertreatment costs

Percentage reduction in time spenton administrative tasks

Increased staff capacity through areduction of 1.4 million hours thatcan be allocated to other importanttasks, including the provision ofpatient care

$40.0 M of increased staffcapacity


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6. DiscussionIt is widely understood that the benefits of local, provincial and national investments in eHealth and EHR

initiatives can make a significant impact on patients, providers, and the health system itself take time to mature

and realize their full potential following their initial implementation. As a fundamental component of the planned

EHR to be implemented for all Ontarians and a major focus for investment, EMRs are no exception. With

penetration and adoption of EMRs occurring at differing paces by many different providers, different types and

levels of benefits are accrued over time to many stakeholders in the system.

Although the case study approach has some limitations, this study has demonstrated that Ontario’s investments in

EMRs to date have yielded noteworthy, tangible benefits. The benefits are diverse, and have accrued to patients,

providers and the broader health system. Case study participants provided a unique vantage point to convey

valuable insights into benefits from their first-hand experience in pioneering and optimizing the use of a variety of

EMR tools and functionalities across their patient care teams.

While the earliest benefits have been shown to be realized by providers and their patients, modeling and forecasting

of case study findings has demonstrated that continued investment in EMRs across the province can augment the

impact of EMR use on the broader health system, with the potential for EMRs to have very significant direct and

indirect impacts.

While it is acknowledged that the potential benefits of EMRs are broad and are not limited to those assessed, the

current study focused on six core areas that are discussed in alignment with the categories of findings presented in

Section 4, Case Study Results, as follows:





5. Efficiency


6.1 Laboratory Management

The ability to access, review and make decisions related to the timely availability of lab results in EMRs was

reported as one of the earliest and most demonstrable benefits associated with EMR use by case study sites.

EMRs provide clinicians with more timely access to laboratory information, aiding care decisions.

The ability to receive lab results through direct transmission to EMRs has reduced the time to receive those results

by 50% on average (compared to a paper-based environment). Consequently, clinicians are now well enabled to

respond to results quickly and effectively. This timely access to test results, while either in their clinics or from

remote locations, affords the opportunity to make timely clinical decisions, provide prompt and appropriate care,

expedite referrals, and improve patients’ access to care. In addition, by having results readily accessible within

EMRs, other clinicians involved in the patient’s care are less likely to order duplicate tests. Although not

specifically measured, the ability to address and attend to critical laboratory results requiring immediate attention


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may contribute to downstream effects, including better management of patients with chronic conditions and

avoided unnecessary visits to emergency departments.

While the majority of results made available electronically into EMRs are from private community-based

laboratories (e.g., Gamma-Dynacare, CML, LifeLabs, Alpha Global), results from OLIS are being made increasingly

available as the province continues to invest in connecting OLIS to primary care providers through EMRs. In

addition to results from private laboratories, OLIS enables clinicians to search and download lab results from

connected hospitals and public health laboratories. The value of having comprehensive lab information in a timely

manner through all potential sources of lab information provides a comprehensive profile for patients and forms a

basis for clinical decision-making. The benefits of OLIS connectivity to EMRs will continue to be realized over time

as integration of systems continues. It is encougaging that eHealth Ontario has made significant progresses to

connect OLIS with EMRs, which will add significant value to EMR users in community care settings.

Ready access to timely laboratory results through EMRs helps to enhance the patient experience.

While providers benefit from the ability to quickly access lab test results, patients can also benefit from having this

information readily available to them, either directly through their providers or through online portal offerings that

can be linked to EMRs. Providers are better able to address any questions patients may have around their lab test

results, and share those results with patients. With the increasing needs to engage patients in the delivery of

quality care, patients and/or proxies will need to access their diagnostic results in “real-time”, allowing them to

review lab reports when and where it is convenient for them. Importantly, eHealth Ontario has funded some pilot

projects to enable “patient portals” tethered through EMRs. These initiatives can improve patients’ experiences

with their care, and provide them with some comfort, understanding and ownership in care processes.

6.2 Communication and Coordination of Care

EMRs play an instrumental role in improving the intra- and inter-office communication and coordination of care.

Associated benefits are realized fairly early in the adoption of EMRs, providing access to the patient record for all

members within a practice, and facilitating improved sharing of information with external providers as well. These

capabilities contribute to improved access to care, quality of care and efficiency as discussed below.

EMRs facilitate improved scheduling and coordination of patient visits, improving access to care.

EMRs provide physicians and care team members with the improved ability to schedule patient visits, improving

patients’ access to care and efficiency of the care team. With 100% of care team members having access to the EMR

and 96% of respondents reporting that EMRs support interdisciplinary coordination of care, care team members

are able to coordinate a patient’s care delivery much more effectively and efficiently. Physicians reported the ability

to plan their day more effectively, and patients benefit through avoiding repeat and/or unnecessary visits to

multiple providers in the care team.

Physicians and team members reported that improvements in scheduling and organization facilitate their ability to

hold same day appointments open, improving access to care. Ontario’s Health Action Plan (Ministry of Health and

Long-Term Care, 2012) identifies improved availability of same-day appointments as a key focus in improving

access to primary care. Access to same day care in the primary care setting may reduce visits to emergency rooms

for non-emergent purposes, improving access to care across the health system.

EMRs improve the availability and sharing of information among interdisciplinary team members

and enhances quality and efficiency of care.


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The EMR allows each care team member to access the chart as required and for most, this access is also possible

from remote locations. An informed and coordinated care team supports enhanced care outcomes, promotes a

positive care experience for patients, and may produce innovative ways of addressing care planning. The ability to

access patient information at any time and in any place was noted by all as a tremendous asset to providers and

their patients.

EMRs also facilitate the ability to communicate within clinics and often with providers outside of clinics, overall

improving the efficiency of patient care. Quality of care, and the patient experience overall, is improved for patients

by ensuring all providers have ready access to the same patient information. For example, patients must no longer

share essential details (e.g., symptoms, medications) with multiple providers as the information is captured in a

legible format in one location that can be accessed by all.

EMRs facilitate the sharing of information with specialists, thereby improving the continuity and

efficiency of care.

A much touted benefit of EMRs by interviewees is the ability to make more efficient referrals and to provide

specialists with more comprehensive patient information. With the ease and improved efficiency of making

referrals (an approximate reduction in time of 85% to make a referral), the EMR allows primary care clinicians to

quickly provide the specialist with key pieces of information needed to understand the patient’s condition. In

addition, the need for specialists to spend time seeking additional administrative and/or clinical information is

greatly reduced. As a result, the referral process is expedited and specialist is better informed when making

decisions on treatment, and may avoid any duplication in diagnostics or other treatments at a later date.

In addition to the above, EMRs that interface with other locally developed software solutions (e.g., SharePoint) can

support the improved tracking of referrals, with the ability to better plan care and help patients to understand

expected wait times for specialist care. It is, however, noted that there is no synchronized eReferral platform across

the province. Referring processes still largely rely on the provider’s relationships without adequate transparency

into required information (e.g., wait times). It is recommended that eHealth Ontario further explore strategic

opportunities to improve referral processes and further enhance the value of EMRs. In the future, integration

between EMRs and planned eReferral solutions will better enable this on a province-wide basis.

Expedited delivery of hospital reports to EMRs facilitates timely and appropriate care.

Case study sites participating in the Hospital Report Manager pilot study, whereby reports are delivered directly

from hospitals to EMRs, reported a reduction of 85% in time spent waiting for discharge summaries as a result of

the direct transfer of this information to EMRs. The timely access to this information can further reduce patients’

wait times for required post-discharge care, and allow providers to put appropriate follow-up care into place in the

out-patient setting. Notably, by providing primary care clinicians with the necessary information to monitor and

maintain their patients’ care following discharge from hospitals, they are better able to reconcile medications and

prevent unnecessary hospital readmissions and ED visits.

6.3 Chronic Disease Management

Findings of this study suggest that EMRs have demonstrated significant benefits and continue to hold tremendous

potential to facilitate the management of chronic diseases in Ontario, a key priority identified by the province and

for eHealth Ontario. EMRs are being used increasingly by clinicians to manage the health of patient populations,

such as patients with diabetes, chronic obstructive pulmonary disease (COPD)/asthma, and others. Physicians and

their care teams are increasingly relying on their EMRs to effectively manage the care of patients with chronic

conditions that are costly to the system overall and consume significant resources within the health system.


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EMRs are a necessary and effective tool to manage the health of defined patient populations.

Case study sites were overwhelmingly positive in their support for the use of EMRs in managing the health of their

patients with chronic diseases. 96% of survey respondents indicated that EMRs support the management of

chronic diseases, and 92% agreed that they support patient education for disease management purposes. Hillestad

et al. (2005) reported that EMRs can support chronic disease prevention and management by assisting clinicians in

identifying people with active or potential chronic disease, targeting specific services to patients based on risks,

monitoring specific indicators for conditions, and using evidence-based guidelines for treatment. It was evident

that case study sites were using their EMRs effectively for these purposes as well; for example, clinicians reported

the ability to identify patients with specific conditions and plan and monitor their care, and identified this as a very

significant benefit of EMRs.

Specific indicators measured in the case study sites (for HbA1c values and other testing for diabetes care)

demonstrate that providers are using their EMRs for the purposes of patient identification and communication,

with the goal of ensuring that patients receive timely and appropriate evidence-based care to manage their

conditions. Case study sites demonstrated that 41-70% of their patients had HbA1c levels at or under 7%, while a

2003 study indicated that fewer than 30% of Canadian diabetics had similar HbA1c levels of 7% (Harris, 2003). As

a Health Information Technology (HIT) tool, EMRs can enable proactive management of diabetic patients and

those with other chronic medical conditions.

Clinicians reported a high degree of willingness and enthusiasm to better manage the health of defined patient

populations in their practice, rather than simply providing episodic care. EMRs currently implemented in Ontario

provide a significant capability for clinicians to do this, an undertaking that is typically costly and time consuming

in a paper-based environment. In addition to saving costs and time for providers, the potential prevention of co-

morbid conditions and complications arising from chronic diseases can avoid costs to the health system and enable

patients to maintain an improved quality of life.

EMRs provide valuable tools to help both care providers and patients with care management and

education.

Engaging patients through education and care planning activities ensures that they are active participants in their

health. Patients that are better informed on what their target values for key indicators (e.g., HbA1c) should be are

better able to keep their conditions under control. Having a patient that is better informed of his/her condition, can

see trended information for targeted indicators, and is working with the physician to better manage their care can

result in avoided unnecessary office and/or hospital visits as well.

As data capture and reporting capabilities improve, EMRs will further allow practices to identify a baseline and

trend information to ensure their diabetic cohort of patients are monitored for those clinical needs which require

careful management and are prone to downstream co-morbid complications.

The broad and mature use of EMRs can reduce the costs and burden of illness associated with

caring for Ontario’s growing diabetic population.

Through the modelling and forecasting exercise, potential savings and a reduction in complications associated with

diabetes were identified. These complications and illnesses include foot amputations, end stage renal disease

(ESRD), stroke and myocardial infarction, all of which typically require hospitalization. While yet to be realized,

EMRs are a contributing factor to potential savings related to diabetic-related complications that are in the range of

$125 million annually by 2017.


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The forecasted reductions in illness, avoidance of co-morbid conditions and costs are highly dependent on the

mature, proactive use of EMRs on a province-wide basis to manage diabetic care through prevention, education

and ongoing monitoring and management of specific conditions. Supporting the provincial government’s focus on

chronic disease management, EMRs can play a critical role in proactively managing diabetes in the community, by

equipping providers with necessary information to provide that care in the community. The above average

percentages of patients in case study clinics (41-70%) for whom HbA1c is less than 7% speaks to the impact that

EMR use can have on the health of those patients.

Diabetes must be actively monitored and managed in community settings and with active patient participation, in

order to prevent complications such as those forecasted above. Without EMRs and related enablers, it would be

very challenging to do so, given the support that EMRs provide to actively identify diabetic patients, keep their

conditions under control, and communicate on an ongoing basis.

6.4 Health Promotion, Screening and Prevention

Findings suggested that clinicians recognized that promotion, screening and prevention activities were greatly

enabled through the use of EMRs. For this category of benefits, there is great potential to realize benefits at a

health system level as EMR use becomes more mature across the province.

EMRs allow clinicians to survey patients and to proactively arrange screening and prevention

activities, while concurrently improving the efficiency of preventative care.

Case study sites were quite capable in tracking prevention and screening activities, and very knowledgeable about

the benefits they have realized to date in this regard. While several reporting capabilities related to screening and

prevention are in their early stages of development, advanced users of EMRs indicated that they were able to

generate information to identify and communicate with patients for preventative purposes. Without the EMR, this

type of prevention activity is much more complicated, requiring manual and time-consuming chart reviews. Now,

patients are contacted easily and in a timely fashion for preventative care.

The provincial target for colorectal cancer screening rates is 40% of targeted groups (Health Quality Ontario, 2012),

and all sites reported exceeding this target by a minimum of 11%. Given the incentives in place for providers and

the ability of EMRs to support the identification of targeted patients, the EMR is a valuable tool to support this

preventative activity, and the downstream benefits in quality of life for patients and potential cost savings to the

system as a whole.

The potential benefits of increased screening and prevention (including vaccination) activities over time can have a

tremendous impact on the health of the population as a whole, and on the sustainability of the health system.

Several physicians indicated an increased interest in caring for their patients through a population-based approach,

organizing educational sessions for targeted groups and standardizing their care. The benefits to these clinicians

are clear, and their EMRs support efficient ways of communicating and delivering care.

Information generated by EMRs for preventative care purposes is helpful in communicating with

patients and engaging them in self-care.

Effective prevention strategies engage patients in their care. Many sites reporting engaging patients early in their

care, interacting with them and proactively scheduling wellness visits through the use of EMRs. The ability to plan

ahead and schedule visits supports patient involvement in their care and continuous management of their health.

The widespread use of EMRs can increase the rates of influenza vaccination and yield potential

related health system savings.


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Many sites indicated their ability to track and deliver “flu shots” to their patient populations through the use of

EMRs. With those 65 and older being particularly at risk for the flu with the strong potential to result in further

complications that often result in visits to EDs and/or hospitalization, the modelling and forecasting exercise was

undertaken to assess the potential savings to the health system. While yet to be realized, EMRs are a contributing

factor to potential savings related to influenza that are in the range of $40 million annually by 2017.

The forecasted reductions in illness and costs are highly dependent on the mature, proactive use of EMRs on a

province-wide basis to identify those at risk, to facilitate communication to encourage those patients to receive the

flu shot, and to track compliance. The estimates in avoided hospitalizations and cost savings are significant, but

only relate to those in the 65 years and older cohort. The potential for additional incremental benefits has not been

defined but is not to be underestimated, as influenza impacts many in Ontario each year. Influenza must be

actively managed in community settings, requiring active patient participation and willingness to receive

vaccination. EMRs enable this challenge, with many interviewees discussing their ability to vaccinate a broader

group of patients using their EMRs as a tool.

On a similar note, many providers and patients also identified the benefit of EMRs in tracking other immunizations

(e.g. DTaP shots, zostavax etc.). Prevention of illnesses other than influenzasave costs to the health system and

enhance the quality of life for many affected populations (e.g., senior citizens).

Use of EMRs can support the prevention of colon and other cancers through improved screening

rates and other preventative care.

Case studies revealed that EMRs can greatly facilitate the ease with which clinicians manage and deliver

preventative care for their patients. Although preventative care is a relatively new (and in some cases, advanced)

area of EMR use for many clinicians, the ability to identify patients requiring screening and in turn receive and act

upon results is possible with EMR use today. Modeling and forecasting activities suggested that the potential costs

that can be realized through the prevention of four stages of colon cancer through advanced EMR use is in the

range of $38 million annually by 2017.

Many provincial organizations, including Cancer Care Ontario, Canadian Institute for Health Information, Heart

and Stroke Foundation, and others are looking to EMRs to support disease management and reporting. Each of

these organizations recognizes the power and potential of EMRs in this regard. Specifically, there is an increasing

emphasis on behalf of Cancer Care Ontario to explore the use of EMRs to support screening initiatives in the near

future to support its widely implemented Colon Cancer Check program and related clinical guidelines. By ensuring

that screening protocols and alerts are incorporated in all EMR specifications, there will be an increased ability to

identify those patients requiring screening on a widespread basis. While the example modeled is limited in scope

with a focus exclusively on colon cancer, it does suggest that the overall potential to prevent cancers through the

use of EMRs as a key supporting tool is very promising.

6.5 Efficiency

EMRs have been demonstrated to increase efficiency among clinicians and administrative staff, particularly

following an initial period of implementation that lasts for approximately one year. During this time, clinicians and

staff grow accustomed to a new way of working, and roles change with some tasks being transferred among

providers. Once this period of transition has passed, case study sites reported that there are great gains to be

realized in efficiency through the use of EMRs.

EMRs promote the ability to readily locate patient information has improved the quality and

efficiency of patient interactions.


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EMRs provide clinicians with access to comprehensive patient records that are organized and readily accessible in

one location that can be accessed by all. Without having to search for information, the quality and efficiency of

patient interactions improve. The patient experience and overall satisfaction is also improved, in part due to a lack

of having to repeat their concerns and/or health information to multiple caregivers.

EMRs facilitate clinical transformation in the primary care setting, improving the effectiveness and

efficiency of clinical and administrative activities.

The introduction of EMRs into the primary care setting has the potential to be transformative in nature. EMRs

enable changes in workflow and clinical decision-making, and can greatly improve the way that clinicians interact

with their patients on a regular basis. Findings suggested that 78% of respondents felt that EMRs improved the

efficiency of many administrative and patient care activities, including scheduling, communicating, ordering of

tests, referrals, and documentation. In particular, clinicians (92.6%) noted that order entry in EMRs increases

efficiency of requisitions and prescriptions remarkably.

Benefits associated with the effectiveness and efficiency of patient encounters and the general flow of patient

activity allow greater throughput and access to care, including same/next day visits. Specifically, many EMRs have

enabled “dashboards” with key patient information, and clinicians reported being more organized for each visit,

with readily available information and the ability to address patient concerns and care requirements quite easily.

These benefits have tremendous impact on patients, providers and the system as a whole. Gains in efficiency that

are obtained in the primary care setting can translate into reduced wait times for primary care, allowing providers

to see more patients daily, and reductions in return visits to clinics and visits to hospitals.

EMRs improve the productivity of administrative clinic staff.

Reductions in the time required for administrative tasks through the use of EMRs was estimated at 50% by

eliminating routine activities such as pulling charts, scheduling and other initiatives. The reduction in these

administrative activities provide the opportunity for administrative and/or clinical staff to redirect their clinic

activities, improving productivity of practices and in many instances, providing more time for direct patient

interaction.

The reductions in the time required for administrative tasks through the use of EMRs, estimated at 50%, was used

to model the potential benefits if EMRs were broadly and maturely used across Ontario. The exercise estimated

that approximately 1.8 million hours or a possible $40 million could be saved annually by 2017, providing

increased capacity for clinic staff.

It is also acknowledged that there is some productivity lost in the early stages of EMR implementation among many

clinicians and administrators, with many reporting that there is a period of approximately one year while all grow

accustomed to working with electronic records. However, informants and the forecasting model both suggest that

there are significant opportunities to improve the overall capacity among clinic staff, particularly among

administrative staff and/or nurses who were previously spending time doing administrative tasks. The greatest

value in this increased capacity lies in the opportunities and potential benefits associated with redirecting time

from non-value added tasks (such as pulling and filing charts, chasing paper forms, placing phone calls), to those

that improve efficiency, allow for direct patient interaction, and improve overall health outcomes.

6.6 Medication Management

The ability to improve medication management is an important provincial strategy, enabled through the use of

EMRs. Although not an explicit focus in the case studies, the findings related to the impact of EMRs on medication

management are significant and very supportive of eHealth Ontario’s strategies, demonstrating the important role


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that EMRs play in achieving this goal. A most important benefit use of the EMR for medication management is the

improvement in overall patient safety, discussed below.

EMRs support the ability to rapidly identify impacted patients when drug warnings are issued,

improving patient safety.

A tremendous benefit of EMR use identified by many providers through the course of the study was the ability to

identify large numbers of patients to whom certain drugs have been prescribed. Approximately 89% of clinicians

surveyed identified this as a benefit, and many clinicians at case study sites identified this benefit during interviews.

When drug warnings or recalls are issued by Health Canada or other bodies, the health of patients is at risk. These

patients can be very quickly identified, and alternate means of treatment can quickly be administered, preventing

any downstream implications. As such, EMRs can have a tremendous impact on quality of care, and most

importantly, patient safety. The ability to quickly target these patients and act is almost impossible in a paper-

based clinic environment.

Access to complete medication profiles in the EMR increases efficiency and improves the accuracy

of medication management.

With accurate and complete medication profiles in EMRs, clinicians are able to make more informed care

decisions. Prescriptions are easily monitored, and patient concerns can be addressed. The risks associated with

over-prescribing, or prescribing contra-indicated medications are nearly eliminated, increasing patient safety and

reducing potential hospitalizations and in some instances, fatalities. There are also potential costs avoided by the

health system due to unnecessary hospitalization.

Where other providers outside of Family practices (e.g., community pharmacies) can communicate and collaborate

with prescribing physicians, there is the opportunity to further ensure patient safety and quality of care through

enhanced clinical decision-making among interprofessional providers.

Electronic prescribing and renewals via EMRs have improved medication management efficiencies

and patient safety.

The sharing of medication information across the care team through EMRs has resulted in greater efficiencies in

the patient care process and improved patient safety. Perhaps the most significant change noted by clinicians in

the case studies has been the generation of a printed prescription, eliminating error-prone handwritten

prescriptions and reducing the delays arising from “call backs” from pharmacists to physicians seeking clarification

on prescriptions. In paper-based clinics, handwritten prescriptions continue to pose risks to patients whereby

pharmacists may make inappropriate judgments about drug choices and/or dosage. When concerns are

experienced by pharmacists, the prescribing physician must be called to confirm the prescription, interrupting the

workflow of the pharmacist, physician, and potentially office staff as well. With EMRs, this risk to patient safety

and disruption in workflow is avoided.


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7. Recommendations

Findings from this study provide compelling evidence to continue to advance EMR adoption and maturity across

Ontario. The benefits that have been demonstrated by EMR use in the selected case study settings and the

accompanying modeling of province-wide benefits demonstrate the “art of the possible” for Ontario. With the

implementation of a number of focused recommendations, the potential for wide ranging and transformative

benefits of EMR use can be further realized by providers, patients and the health care system as a whole.

The following recommendations are presented to policy-makers, funders, implementers and adopters of EMRs inOntario in support of continued benefits realization.

1. As an essential enabler and one of many important health information technology tools to

improve care delivery and related patient outcomes in primary care settings and beyond,

continued investments in EMRs should be made to ensure broad adoption and realization of

benefits across Ontario.

EMR adoption by primary care physicians in Ontario continues to increase, and over 70% of all community-

based clinicians are now enrolled in the EMR Adoption Program. Although the most recent commonwealth

survey indicates that U.S. and Canada are still behind other OECD countries in terms of primary care EMR use

(Schoen et al., 2012), significant progress has been made over the past few years, and Ontario has evolved as a

leading jurisdiction in Canada for EMR adoption and use. In addition, eHealth Ontario recognizes the

enhanced maturity level of EMR use and has placed a strategic focus on advancing maturity of use to further

realize the benefit of using EMRs and associated eHealth offerings.

There are numerous variables inherent in primary care settings that influence patient, provider and health

system outcomes, and it is at times challenging to identify the benefits that are directly attributable to EMR

adoption and use. For instance, variables such as the introduction of interdisciplinary care, enhanced

workflows, clinical care integration and payment models collectively impact improved patient care and

outcomes. However, through the course of the study it was widely acknowledged that without the use of EMRs,

the ability to realize these benefits is compromised. Indirectly and directly, EMRs are critical enablers of

enhanced patient care. Continued investment in EMRs and increased physician participation in the EMR

Adoption Program are essential.

Through this continued investment, the use of EMRs has the capability to provide a supportive underpinning

for the advancement of many current government priorities and to achieve desired system-wide benefits for

patients and the population as a whole. As an example, the recently introduced Health Links strategy for

Ontario (Ministry of Health and Long-Term Care, 2012) highlighted a new “sub-LHIN” care delivery model to

enhance the efficiency and outcome of care for patients in respective catchment areas, with access to primary

being the focus for ensuring that outcomes are achieved. Such a model would rely on enabling health

information management within primary care and between primary and acute care centres. Advanced EMR

use and clinical data management and sharing of information would provide significant value to implement

this government priority in the foreseeable future.

2. Continue to support increased maturity of use among current and future adopters of EMRs.

The effective realization of benefits is highly supported by EMR maturity (defined as the level of adoption and

use of the EMR in the practice setting). Previous studies (EMR Adoption Program Evaluation, Healthtech

Consultants, 2012) have demonstrated the value of the OntarioMD EMR Maturity Model (EMM), which


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focuses on assessing meaningful use of EMRs along six levels. The level of maturity is characterized by varying

degrees of use of EMR functionality, which in turn can support the realization of increasingly levels of benefit.

The model supports an objective assessment of EMR use, and a pilot study conducted in 2011 revealed that the

majority of EMR users in the pilot study (74%) were using EMRs for basic and/or standardized use, with fewer

(13%) showing established use (with clinical decision support, capacity for chronic disease management), and

none in the study yet using EMRs for integrated care and/or regional collaboration to address population

health needs (OntarioMD, 2011). A continued focus in advancing EMR maturity among users will contribute to

a greater diversity of benefits with system-wide impact. Continued collaboration with other jurisdictions is also

recommended to advance maturity.

3. Continue to invest in effective change management strategies and user support that extends

beyond the initial period of EMR implementation.

Mature use of the EMR requires access to training when and where it is needed by all types of users, and should

be available well beyond the initial implementation phase as users transition through the “adoption curve”.

Literature findings also demonstrated the importance of effective change management strategies to support

EMR adoption including the designation of peer leaders, workflow and process redesign, and a clear

articulation of vision and expected benefits, communication, and system support (Nagle & Catford, 2008).

Effective change management will ensure an environment open and ready for transformation and also ensure

users are better prepared for changing roles and work flow, and to adapt and mature their EMR use for

targeted realization of benefits.

Some interviewees noted that the lack of incremental training provided post-implementation hindered their

ability to learn how to use the EMR to its full potential and explore the use of all functionality. For example,

following an initial period of use that allows clinicians to master essential EMR functions, training could be

further made available to address and support more sophisticated needs associated with reporting and

analytics for population-based planning and care.

As part of the ongoing support, there is great merit in continuing with the Peer Leader support program offered

by OntarioMD. Many clinicians turn to their peers for support and rely on their advice to enhance their

experience working with EMRs. These leaders are instrumental in gaining buy-in to workflow changes,

changing the practice culture, responding to educational needs and ensuring the practice continues to progress

as challenges in the EMR journey arise.

4. Improve the management of information within and across patient care settings through

focused efforts related to interoperability of systems, improved quality of data, and the flow of

data across care settings.

The inability of EMRs to connect and share information with external entities outside of primary care has been

cited as a common barrier to EMR implementation (Ramaiah et al., 2010). For many Ontario physicians, EMRs

remain stand-alone systems within their practice group. However, it was recognized through this study that

many primary care providers are interested in advancing clinical information management (IM). There are

current physician-lead initiatives to develop an IM strategy and methodology in the province to improve the

flow of data across care settings. The integration of systems external to the EMR setting, notably OntarioMD’s

Hospital Report Manager which delivers discharge summaries and other hospital reports directly to EMRs, is

important in enhancing the continuity of care for patients and the coordination of care among providers. The

integration of the Better Outcomes Registry and Network (BORN) and OLIS with EMRs are in earlier stages,

but early feedback from study sites is promising. Future in integration of EMRs with the Medication

Management System and eReferral applications will expand and extend these benefits.

The ability to achieve advanced use and benefits of EMRs will also be supported by improved quality of data.The ability to extract data elements within a practice and to share data or patient information across settings


PwC 53

relies heavily on the use of standardized data. In addition, quality data must exist in order to generate systemalerts and for trending analysis to be meaningful. Clinicians will require training and support to improve dataquality, which shall in turn support practices’ ability to track and report performance information within andacross practice settings. Quality improvement plans should include a focus on data quality and education sothat practices can report on priority quality of care measures that impact health care system performance andenable chronic disease management and prevention and promotion strategies, among others. Strategies shouldalso be developed to ensure that EMR systems are designed and implemented to enable ease of data extractionby practices for reporting, care management and decision-making purposes.

Interestingly, there are several initiatives in Ontario and across Canada with a focus on EMR

clinical/administrative data collection, analysis and clinical information management reporting; for example,

Canadian Institute for Health Information’s (CIHI) Primary Health Care Voluntary Reporting System, and

Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and Heart and Stroke Foundation

Hypertension initiative. In addition, some practices are implementing dashboards with data captured from

EMRs, with data presented to physicians and team members to report how the physician/ practice is doing

related to managing patients with chronic conditions, prevention and promotion, screening, statistics on

referrals, etc.

5. Continue to invest in focused benefits realization studies.

Opportunities exist to collaborate with the research community and other organizations to conduct focused

EMR benefits realization studies with more quantitative and objective measurement. As EMR adoption and

maturity increase, the amount of quantitative data available will also increase. Focused studies will afford the

opportunity to measure more of the indicators that were defined in this study as part of the Benefits Realization

Framework (Appendix C) and have a greater understanding of the full scope of current and potential benefits

realized by EMRs in Ontario.

To ensure that future studies reflect current and potential strategic priorities, it is recommended that the

Benefits Realization Framework be updated on a regular (e.g., quarterly or semi-annual) basis. For example, in

its next iteration, the BR Framework should be updated to reflect a measurement focus on same/next day

scheduling of appointments and communication with patients via email in order to address the anticipated

requirements of quality plans in primary care.


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8. Concluding Remarks

For the past decade, many health information technology projects across Canada and internationally have had a

heavy focus on the development of technical infrastructure. In the past four years, eHealth Ontario has invested

significantly in a number of transformative initiatives, including the implementation of EMRs in community

settings. Through the significant dedication and leadership of eHealth Ontario, its PeHP team members, along

with delivery partner OntarioMD, the Association of Ontario Health Centres (AOHC), and clinicians across the

province, the adoption of EMRs has passed its tipping point with over 70% of community-based physicians enrolled

in the EMR Adoption Program.

It is important to realize the benefits from Ontario’s strategic investments and to optimize the value for patients,

providers and the healthcare system’s stewards. Benefits of EMR use are diverse and have significant positive

impacts on patients, providers and the health system as a whole. Improved availability, integration and

communication of health care information will result in improved care for those with chronic diseases, greater

efficiency in interactions with patients, improved patient safety, improved patient participation in their own health

care, and many other positive quality outcomes (Ontario Hospital Association, 2008). Realizing EMR benefits is a

journey. The realization of benefits occurs over time as the adoption of EMRs and their use in the clinical setting

becomes more pervasive and mature.

This study has demonstrated that there has been significant realization of EMR benefits among a select group of

advanced EMR users in Ontario. However, the full value of EMRs has yet to be realized, as adoption continues and

process and maturity of use further evolves. The potential to extend and build upon the benefits realized to date are

significant, and the further investment in EMRs will support Ontario and its population well as the health system

continues to evolve along with the needs of all Ontarians.


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9. References

1. Auditor-General. (2012). Annual Report. Office of the Auditor General of Ontario.http://www.auditor.on.ca/en/reports_en/en12/2012ar_en.pdf

2. Canadian Diabetes Association. (2009, December). An Economic Tsunami: The Cost of Diabetes inCanada.

3. Canadian Healthcare Influenza Immunization Network. (n.d.) Influenza Facts.

4. Canadian Medical Association. (2011). IM/IT Report.

5. Canadian Partnership Against Cancer. (2009, September). Quality Determinants for Colorectal CancerScreening in Canada.

6. Cancer Care Ontario. (2010). Colon Cancer Check 2010 Program Report, Appendix B, Table 4.

7. Commonwealth Fund, The. (2011). International Profiles of Health Care Systems 2011.

8. Dahrouge, S., Devlin, RA., Hogg, B., Russell, G., Coyle, D., and Fergusson, D. (2012). The Economic Impactof Improvements in Primary Healthcare Performance. Canadian Health Services Research Foundation.

9. eHealth Ontario (2013). What we do. http://www.ehealthontario.on.ca/en/about

10. eHealth Ontario (2009). Strategic Plan 2009 – 2012.

11. Girosi, F., Meili, R.C., & Scoville, R. (2005). Extrapolating Evidence of Health Information TechnologySavings and Costs. Santa Monica, CA: RAND Corporation.http://www.rand.org/pubs/monographs/MG410.

12. Harris S.B., Stewart M., Brown J.D., Wetmore S., Faulds C., Webster-Bogaert S., Porter S. (2003) Type 2diabetes in family practice: Room for improvement. Can Fam Physician, 49: 778-785.

13. Health Quality Ontario. (2012). Quality Monitor: 2012 Report on Ontario’s Health System.

14. Healthtech Consultants Inc. (2012, January 5). EMR Adoption Program Evaluation.

15. Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., et al. (2005). Can Electronic Medical RecordSystems Transform Health Care? Potential Health Benefits, Savings, And Costs. Health Affairs, 24 (5):1103-1117. http://content.healthaffairs.org/content/24/5/1103.full.pdf

16. Hodge, T. (2011). Canada Health Infoway – Infoway Connects (blog).

17. Institute of Clinical Evaluative Sciences. (ICES) (2005).

18. Johnston. D., Pan, E., Walker, J., Bates, D., and Middleton, B. (2003). CITL: The Value of ComputerizedProvider Order Entry in Ambulatory Settings. http://www.partners.org/cird/pdfs/CITL_ACPOE_Full.pdf

19. Klein Woolthuis E.P., de Grauw W.J., van Gerwen W.H., van den Hoogen H.J., van de Lisdonk E.H.,Metsemakers J.F., van Weel C. (2007). Identifying people at risk for undiagnosed type 2 diabetes using theGP's electronic medical record. Fam Pract. June; 24(3): 230-6.

http://www.auditor.on.ca/en/reports_en/en12/2012ar_en.pdf

http://www.ehealthontario.on.ca/en/about

http://www.rand.org/pubs/monographs/MG410

http://content.healthaffairs.org/content/24/5/1103.full.pdf

http://www.partners.org/cird/pdfs/CITL_ACPOE_Full.pdf


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20. Manitoba Health (2012, May). Manitoba’s Physician Integrated Network (PIN) Initiative, A BenefitsEvaluation Report May 2012.

21. Ministry of Health and Long-Term Care (2012). 2012 Physician Services Agreement Overview.

22. Ministry of Health and Long-Term Care (2012, December 6). Backgrounder: About Health Links.http://news.ontario.ca/mohltc/en/2012/12/about-health-links.html

23. Ministry of Health and Long-Term Care (2012). Ontario’s Action Plan For Health Care. ISBN 978-1-4435-8942-0. http://health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf

24. Nagle. L & Catford.P. (2008). Toward a Model of Successful Electronic Health Record Adoption.Healthcare Quarterly , 11 (3), 84-91.

25. Ontario Hospital Association. (2008). Incentives for Transformation.

26. OntarioMD Inc. (2012). Benefits Evaluation: EMR Maturity Model Framework.

27. OntarioMD Inc. (2011). EMR Maturity Model, Pilot Data.

28. Ontario Ministry of Finance. (2012). Ontario Population Projections Update, 2011-2036.

29. Public Health Agency of Canada (2011). United Nations NCD Summit 2011. http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php

30. Ramaiah, M., Subrahmanian, E., Sriram, R. D., Lide, B. B. (2010, November). Workflow and ElectronicHealth Records in Small Medical Practices. National Institute of Standards and Technologyhttp://www.nist.gov/customcf/get_pdf.cfm?pub_id=903654

31. Schoen, C., Osborn, R., Squires, D., Doty, M., Rasmussen, P., Pierson, R. and Applebaum, S. (2012). ASurvey of Primary Care Doctors in Ten Countries shows Progress in use of Health Information Technology,Less in Other Areas. Health Affairs, 31(12): 1-12.

32. Service Ontario (2010). Excellent Care for All Act, 2010, S.O. 2010, CHAPTER 14. http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_10e14_e.htm

33. Statistics Canada. (n.d.) CANSIM Table 326-0020.

34. Statistics Canada. (2006). Census 2006.

35. Telford, J.J., Levy, A.R., Sambrook, J.C., Zou, D., and Enns, R.A. (2010). The cost-effectiveness ofscreening for colorectal cancer. CMAJ, 182 (12): 1307-1313.

36. Wolfram, P. (2009). EMR-Link Lab Orders: Measuring Return on Investment (ROI). Ignis Systems

http://news.ontario.ca/mohltc/en/2012/12/about-health-links.html

http://health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf

http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php

http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php

http://www.nist.gov/customcf/get_pdf.cfm?pub_id=903654

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_10e14_e.htm

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_10e14_e.htm


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Appendix A: Interviewee List

# Stakeholder Name Title Organization

1 Fariba Rawhani Senior VP- Development and

Delivery

eHealth Ontario

2 Christine Sham &

Mark Simmons

Manager, eHealth Liaison Branch Ministry of Health and Long-Term Care

3 Sarah Hutchison CIO Ontario Medical Association

4 Brian Forster CEO OntarioMD

5 Dr. Darren Larsen Senior Peer Leader OntarioMD

6 Frank Vassallo VP, Physician IT Adoption OntarioMD

7 Jeremy Smith &

Carol Rimmer

Program Director

Assistant Director

Physician Information Technology Office,

British Columbia

8 Dan Sheplawy Program Director Physician Office System Program , Alberta

9 Terry Moore &

Brent McGaw

Regional Executive Canada Health Infoway

10 Robert Lee CIO and eHealth Lead Toronto Central Local Health Integration

Network

11 Jan Kasperski Executive Director Ontario College of Family Physicians

12 Maureen Boon Senior Advisor, Executive office College of Physicians and Surgeons of Ontario

13 Dr. Liisa Jaakkimainen Physician, Research Scientist Institute for Clinical Evaluative Sciences,

University of Toronto

14 Ben Chan CEO Health Quality Ontario

15 Patricia Sullivan-

TaylorManager, Primary Health Care

Information

Canadian Institute for Health Information

16 Rod Burns CIO Association of Ontario’s Health Centres

17 Lana Palmer Executive Director Upper Grand Family Health Team

18 Cheryl Kennedy Interim Administrative Lead Haliburton Highlands Family Health Team

19 Dr. Stephen McLaren Lead Physician Markham Family Health Team

20 Glenn Lanteigne CIO and eHealth Lead South West Local Health Integration Network

21 Plumaletta Berry Program Evaluation Analyst OntarioMD

http://www.dfcm.utoronto.ca/research/researchers/ljaakkimainen.htm


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Appendix B: Consultation Guide

IntroductionOn behalf of eHealth Ontario, PwC has been engaged to conduct a study to assess the impact of EMR adoption and

use in Ontario. This study will focus on the impact of benefits realized to date and make projections for the future

potential benefits that can be realized. The first phase of this study is to validate the current draft benefits

evaluation framework for EMRs and identify a set of priority indicators for subsequent phases of data collection

and evaluation.

eHealth Ontario’s draft benefits evaluation framework for EMRs has identified several measurable benefits for

patients, providers and the health system, and grouped them into four categories (quality of care, access to care,

efficiency of care, health care sustainability). Several proposed indicators are aligned to each of the four categories

and are presented in the framework for your review. Your comments and feedback are greatly appreciated and

extremely valuable to this validation process. If you have any questions or comments related to this process, please

do not hesitate to contact Erika Norris at 416.941.8383 ext. 13667 or [email protected]

Interview Questions1. What is your overall opinion of the EMR BE framework?

a. Are these the most appropriate categories and indicators to facilitate an understanding of the impact of

EMRs?

b. Are there any categories or indicators missing? If so, please elaborate.

2. What are the strengths of the current BE framework? What are your greatest concerns about the framework

(e.g., risks)?

3. If you had to choose the top 5 – 8 indicators that would indicate whether or not EMRs have had an overall

impact on patients, providers and the health system, what would they be and why?

4. Can you comment on the feasibility and ease of measuring those priority indicators?

a. Can these priority indicators be measured today? If so, how?

b. What are (or could be) the best sources from which to collect this data for optimal measurement?

5. What lessons learned or observations will be important to pass on to the Physician eHealth Program at eHealth

Ontario about measuring and communicating the impact of EMRs?

6. Has your organization/team conducted a study for EMRs using a similar benefits evaluation framework? If so,

can you share any results with us?

7. Are there any reports (publicly available or otherwise) that you feel would be useful to our team? If so, how can

we access them?

8. Do you have any other comments, suggestions or advice?


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Appendix C: Revised EMR BR

Framework

The following revised EMR BR Framework was finalized at the BR Framework Validation Workshop and presented

to Steering Committee members to conclude Phase 1. Of the sixty original indicators, twenty-one were identified as

priority indicators, laying the foundation for a longer term BR Framework and measurements that may be used for

future analysis.

Hypothesis/

Research

Question

Indicator Definition Ref # Category Domain

Benefit

Realizat

ion

(Time)

Type of

Analysis/Data

Source

Medication Management

Does EMR use

facilitate

medication

management?

% change in medication error rates

in terms of actual/potential

prescribing errors

MM1 Quality

Provider,

Health

System

Long-

Term

Quasi-experimental

before and after,

Administrative Data

% change in patients treated for

adverse drug reactions/eventsMM2 Quality

Health

System

Long-

Term

Quasi-experimental

before and after,

Administrative Data,

EMR data modeling

% change in call backs and/or time

responding to pharmacist requests

for physician verificationMM3

Quality,

Efficiency

Provider,

Health

System

Short-

Term

Quasi-experimental

before and after,

Provider Survey,

Interview

Laboratory Management

Does EMR use

reduce unnecessary

duplication of lab

tests?

% change in annual lab tests

duplication or unnecessary lab tests

LM1

Health

care

Sustainab

ility

Health

System

Long-

Term

Quasi-experimental

before and after,


Provider survey

Does EMR use

reduce lab

turnaround time?

Average time between laboratory

time of service and test results

available in EMR

LM2Efficiency,

Quality

Patient,

Provider

Medium-

Term


Provider Survey

Communication and Coordination

To what extent

does EMR use

improve access to

information

between settings?

(e.g. completeness

of referrals or other

documentation

passing between

care settings)

Average time to receive discharge

summary following inpatient

discharge

CC1Quality,

Efficiency

Patient,

Provider

Medium-

Term

Quasi-experimental

before and after,


HRM Data,

Provider Survey

Does EMR use

facilitate referral to

Average time from referral decision

to when the referral is sentCC3 Access

Patient,

Provider

Short-

Term

Quasi-experimental

before and after,


PwC

specialists? Provider Survey,

Interview

Does EMR use

facilitate

interdisciplinary/te

am care?

% of practices where the care team

has access to and uses the EMR

system

CC4

Access ,

Quality,

Efficiency

Patient,

Provider

Short-

Term

Organizational Survey,

Provider Survey

Do providers

access the EMR

remotely to provide

patient care?

% of physicians who have remote

access to EMR and use it for patient

care

CC5 AccessPatient,

Provider

Short-

Term

Provider Survey,

Interview


Does EMR use

improve chronic

disease

management?

% of PHC clients/patients, 18 years

and over, with diabetes mellitus in

whom the last HbA1c was 7.0% or

less (or equivalent test/reference

range depending on local

laboratory) in the last 15 months

CDM1 Quality

Patient,

Health

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS

(CIHI #39), Trending

over time

% of patient population, age 18 and

older, with diabetes mellitus who

received testing for all of the

following:

Hemoglobin A1c (HbA1c); Full

fasting lipid profile screening;

Nephropathy screening; Foot

examination; Blood pressure

measurement; and

Obesity/overweight screening

CDM2 Quality

Patient,

Health

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS

(CIHI #57-4.1 spec),

Trending over time

% of population, age 20 and older,

with diabetes mellitus who have

had an eye exam

CDM3 Quality

Patient,

Health

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS

(CIHI#58-4.1 spec),

Trending over time

% of practices that track and

identify patients with chronic

disease

CDM4 Quality

Patient,

Health

System

Medium-

Term

Provider survey,

Interviews

Health Promotion, Screening and Prevention

Has EMR use

improved the

preventative

services provided?

% Percentage of patient population,

age 65 and older, who received an

influenza immunization

HPSP1Quality Health

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS


Trending over time

% of practice population, age 50 to

74, who had a screening test

ordered for colon cancer.

HPSP2 QualityHealth

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS

(CIHI # 48), Trending

over time

% of practice population, age 18

and older, who have had their

blood pressure measured by their

primary health care (PHC)

provider.

HPSP3 QualityHealth

System

Medium-

Term

Administrative/ EMR

data, CIHI PHC-VRS


Trending over time

Population Health

Does

implementation of

EMRs help

population health

% of physicians/practices that use

EMR to do needs planning (e.g.,

plan for patient

population/community)

PH1

Health

care

Sustainab

ility

Patient,

Health

System

Long-

Term

Provider survey,


Interviews


PwC

planning?

Patient Experience

To what extent has

EMR use improved

the patient

experience?

Patient perceived improvement in

encounter experience. [Focus will

be on specific experiences e.g.,

access, outcomes, communication,

interaction, patient tools such as

scheduling appt.]

PE1 Quality PatientMedium-

Term

Patient survey

Efficiency

To what extent

does EMR use

improve physician

efficiency?

% change in time to complete

clinical/admin documentationE1 Efficiency Providers

Medium-

Term

Provider survey,

Interviews

% of physicians who use EMR as a

referral toolE2 Efficiency

Patients,

Providers

Medium-

Term


Provider survey

EMR Maturity

Extent to which the

EMR has been

adopted and used

to its full potential?

% of providers at each level of the

EMR Maturity ModelEM1

OntarioMD EMR

Maturity Model Tool


PwC

Appendix D: EMR BR Framework-

Case Study Indicator Subset

Priority indicators were identified, specifically for assessment in Phase 2 of the Benefits Realization study based on

known available EMR functionality, maturity of use and feasibility of measurement at case study sites. A total of

fourteen indicators were initially selected for the EMR BR Framework - Case Study Indicator Subset.

Hypothesis/Research

QuestionIndicator Definition Ref # Data Source

Laboratory Management

Does EMR use reduce lab

turnaround time?

Average time between laboratory time

of service and test results available in

EMR

LM2Administrative Data, Provider

Survey

Communication and Coordination

To what extent does EMR use

improve access to information

between settings?

(e.g. completeness of referrals or

other documentation passing

between care settings)

Average time to receive discharge

summary following inpatient dischargeCC1


HRM Data, Provider Survey

Does EMR use facilitate referral to

specialists?

Average time from referral decision to

when the referral is sentCC3 Provider Survey, Interview

Does EMR use facilitate

interdisciplinary/team care?

% of practices where the care team has

access to and uses the EMR systemCC4

Organizational Survey,

Provider Survey

Do providers access the EMR

remotely to provide patient care?

% of physicians who have remote

access to EMR and use it for patient

care

CC5 Provider Survey, Interview


Does EMR use improve chronic

disease management?

% of PHC clients/patients, 18 years

and over, with diabetes mellitus in

whom the last HbA1c was 7.0% or less

(or equivalent test/reference range

depending on local laboratory) in the

last 15 months

CDM1

Administrative/ EMR data, CIHI

PHC-VRS (CIHI #39), Trending

over time

% of patient population, age 18 and

older, with diabetes mellitus who

received testing for all of the following:

Hemoglobin A1c (HbA1c); Full fasting

lipid profile screening; Nephropathy

screening; Foot examination; Blood

pressure measurement; and

Obesity/overweight screening

CDM2


PHC-VRS (CIHI #57-4.1 spec),

Trending over time

% of population, age 20 and older, with

diabetes mellitus who have had an eye

exam

CDM3


PHC-VRS (CIHI#58-4.1 spec),

Trending over time

Health Promotion, Screening and Prevention


PwC

Has EMR use improved the

preventative services provided?

% of practice population, age 65 and

older, who received an influenza

immunization*

HPSP1



Trending over time

% of practice population, age 50 to 74,

who had a screening test ordered for

colon cancer

HPSP2


PHC-VRS (CIHI # 48), Trending

over time

% of practice population, age 18 and

older, who have had their blood

pressure measured by their primary

health care provider within last 15

months

HPSP3



Trending over time

Efficiency

To what extent does EMR use

improve physician efficiency?

% change in time to complete

clinical/admin documentationE1 Provider survey, Interviews

% of physicians who use EMR as a

referral toolE2


Provider survey

EMR Maturity

Extent to which the EMR has been

adopted and used to its full

potential?

% of providers at each level of the EMR

Maturity ModelEM1 OntarioMD EMR MM Tool


PwC

Appendix E: EMR Maturity Model

Criteria Description

The Ontario MD EMR Maturity Model (EMM) is defined on a scale of 1-6 and demonstrates progressive levels of

maturity. The description of each maturity level outlines the anticipated benefits that may be derived as the user

builds on existing processes. Under the requirements for Ontario MD’s EMR Adoption Program, funding

requirements for EMR use begin at Level 2 capability.

Below is a description of the EMM Criteria (OntarioMD Inc., 2012).


PwC

Appendix F: Organizational

Survey

EMR Case Studies: Organizational Survey

PricewaterhouseCoopers LLP (PwC), on behalf of eHealth Ontario, is conducting this survey as part of the EMR

Benefit Realization (BR) project that your clinical site has agreed to participate in. The intent of this survey is to

gather general background information on your practice related to context setting, organizational resources and

EMR users. The information provided will be used to tailor the site visit interview guide to better identify areas of

discussion and interviewees.

Who should complete the survey?

Only one organizational survey is required for each clinical site. Ideally the questionnaire should be completed by

the person most familiar with the clinic operations and workflow; typically this is the Lead Clinician or

Administrative Manager. The survey will take approximately 10 minutes to complete. Please check only ONE

answer per question, unless otherwise indicated. Information gathered from the survey will be kept strictly

confidential and only used for the purposes of the EMR BR Study. If applicable, responses from the survey will be

presented in aggregate within the final report.

Prior to beginning the survey, please read the following instructions:

• "Back" and Next" buttons are provided at the bottom of each page of the survey. Please use these buttons to

navigate through the survey until it is complete. Please do not use the navigation arrows in your browser to do this.

• You may stop the survey at any point and resume at a later time as long as the survey is being completed from the

same location/computer.

• When you resume the survey, you will be asked whether you want to return to the survey where you left off, or

start at the beginning.

In order to begin the survey, please click on the "Next" button below.

If you experience any technical difficulties or have any questions about this survey, please contact Erika Norris at

416 941 8383 ext. 13667 or via e-mail at [email protected]

Thank you for your participation.


PwC

A) Identification of the Organization and Context

1. Enter the following practice information:

Your Practice or Group name ___________________

Number of office locations: ____________________

Address: _________________________________

City: ____________________________________

Telephone : _______________________________

Ext: ____________________________________

2. Position of the respondent:

Lead Clinician

Member of the general practitioners team

Administrative Manager

Other ____________________

3. How long has your practice been in operation?

1 to 4 years

5 to 9 years

Over 10 years

4. How would you characterize the place where you are currently practicing?

City

Suburb

Small town

Rural

5. Are you currently or has your practice participated in any of the following quality reporting initiatives via your

EMR?

CIHI PHC-VRS

The Canadian Primary Care Sentinel Surveillance Network (CPCSSN)

Other ____________________

N/A

B) Organizational Resources

6. Please complete the following regarding the number of general practitioners/family physicians in your practice

and their FTEs?

Number of GP/FP: ________

FTEs: _________________


PwC

7. Please complete the following regarding the number of staff in your practice:

Nurse Practitioner: ___________________

Registered Nurse: ____________________

Social Worker ______________________

Occupational Therapist: ________________

Pharmacist: ________________________

Physiotherapist: _____________________

Dietitian __________________________

Other ____________________________

8. How many administration staff (managerial, clerical, reception) currently work at your clinic?

____________________

C) EMR Practice Profile

9. Select the Ontario Certified EMR system the clinic is currently using?

ABELMed Inc.

Optimed Software Corporation

Bell Canada/ xwave

P&P Data Systems Inc.

Canadian Health Systems Inc

Alpha Global iT Inc.

Jonoke Software Development Inc.

Med Access Inc

Nightingale Informatix Corporation

OSCAR EMR

MD Physician Services Software Inc.

YES Medical System

YMS

10. Please specify if the EMR system is:

Local

ASP

11. How many years has the clinic been using an EMR system? ____________________

12. Do all the healthcare providers have access to the EMR system (main patient chart)?

____________________


PwC

13. What type of health providers currently use the EMR system (main patient chart) when they see

patients? (check all applicable)

Yes No Not

Applicable

Physician(s)

Nurse

Practitioner(s)

Nurses(s)

Other

healthcare

provider(s)

14. Where is the EMR system used? (check all applicable)

Reception

Exam rooms

Other treatment areas (e.g. other providers’ offices, treatment room for emergency cases)

Staff offices

Remotely (e.g. physician homes via VPN)

Other ____________________

D) Additional Information

15. If you have any additional comments about your use of the EMR system that you would like to share with us,

please write them down in the space provided below.

______________________________________________________________

______________________________________________________________

______________________________________________________________

THANK YOU FOR COMPLETING THIS IMPORTANT SURVEY.

YOUR TIME AND SUPPORT ARE HIGHLY APPRECIATED.


PwC

Appendix G: Provider Survey

EMR Case Studies: Provider Survey

PricewaterhouseCoopers LLP (PwC) is conducting this survey, on behalf of eHealth Ontario, as part of the EMR

Benefit Realization project that your clinical site has kindly offered and agreed to participate. The purpose of the

survey is to gather information on EMR adoption and current use. The survey is being distributed to selected

providers working in the clinical practice.

There are two parts to the survey:

Part I- EMR Experience Survey- consists of 6 questions focused on provider perception of benefits of EMR.

Part II- EMR Progress Survey- consists of questions on EMR User/Practice Profile and 25 questions across

each of seven key functional areas which allows for the measurement of maturity on a continuum of one through six

(indicating progressively advanced use or practices). Each level of maturity builds upon the functionality or

maturity state of the preceding level. EMR capability starts at Level 2 based on the funding requirements under the

OntarioMD’s EMR Adoption Program. The survey tool has been developed with direct input from OntarioMD

clinician and clinic manager peer leaders. A separate link for this survey is found at the end of the

EMR Experience Survey.

Prior to beginning the survey, please read the following instructions:

• Completing this surveys will take approximately 30-40 minutes of your time

• Information that is collected during this survey will be kept strictly confidential and only used for the purposes of

this study. The responses to the survey will be presented in the report on aggregate.

• "Back" and Next" buttons are provided at the bottom of each page of the survey. Please use these buttons to

navigate through the survey until it is complete. Please do not use the navigation arrows in your browser to do

this.

• You may stop the survey at any point and resume at a later time as long as the survey is being completed from the

same location/computer.

• When you resume the survey, you will be asked whether you want to return to the survey where you left off, or

start at the beginning.

In order to begin the survey, please click on the "Next" button below.

If you experience any technical difficulties or have any questions about this survey, please contact Erika Norris at

416 941 8383 ext. 13667 or via e-mail at [email protected]


PwC

Part I- EMR Experience Survey

A) Provider Profile

1a. Your Practice or Group name

(Complete name) ____________________

1b. Contact information

First Name ____________________

Last Name ____________________

2. Since the adoption of the EMR system, how would you rate yourself as an EMR user?

Expert

Above Average

Average

Below Average

Novice

3. How many years have you been using an EMR system: (Number) ____________________

B) Impact of EMR

4. Please indicate your level of agreement or disagreement with each of the following statements related to Quality:

The EMR System…

Strongly Agree Moderately

Agree

Moderately

Disagree

Strongly

Disagree

Don’t Know or

N/A

Enhances the quality of care

delivered to patients in our

practice

Improves the management of

chronic diseases

Improves patient safety and

proactive monitoring of overdue

tests/exams

Enables the practice to identify

patients for changes in

management based on new

evidence (e.g., drug recalls)

Improves the decision-making

via the clinical decision support

tools (e.g. alerts, reminders, etc.)

Supports remote access and use

by providers for patient care

Enables the practice to do needs

planning (e.g., plan for patient

population/community)

Enables the practice to audit and

improve the practice


PwC

5. Please indicate your level of agreement or disagreement with each of the following statements related to

Communication and Coordination:

The EMR System…


Agree

Moderately

Disagree

Strongly

Disagree

Don’t Know

or N/A

Improves the sharing of

patient information with

providers internal to our

practice

Supports interdisciplinary

care coordination in our

practice

Enhances our practice’s

ability to coordinate

patient care

6. Please indicate your level of agreement or disagreement with each of the following statements related to

Efficiency:

The EMR System…


Agree

Moderately

Disagree

Strongly

Disagree

Don’t Know or

N/A

Enhances the efficiency of

ordering lab tests,

prescriptions, etc.

Improves the productivity

(output) of my practice

Improves the efficiency

(reduction in effort) of my

practice

Reduces the number of call

backs and/or time spent

responding to pharmacist

requests for physician

verification of prescriptions

Reduces the time from

when a laboratory test

result is available to when

the result is received by the

EMR

Improves administrative

efficiencies e.g. use of pre-

populated templates, forms

and stamps, report chart

pulling

Facilitates preventative care

incentives e.g. through

cohort management for

influenza immunization


PwC

Improves the claims

submission process e.g.

decrease in billing errors

Has facilitated a reduction

in net overhead costs e.g.

space, office supplies etc.

7. Please indicate your level of agreement or disagreement with each of the following statements related to Patient

Experience:

The EMR System…

Strongly

Agree

Moderately

Agree

Moderately

Disagree

Strongly

Disagree

Don’t Know or

N/A

Improves patient

satisfaction/experience with

the care they receive

Supports patient education

(e.g. electronic educational

material/references or

trending patterns such as

BMI, blood sugar levels and

labs etc?

8. Please provide examples of how the use of an EMR system has impacted the delivery of care (e.g., the impact on

quality of care, access to care, efficiency of care, etc)

______________________________________________________________

______________________________________________________________

______________________________________________________________

9. Do you have any suggestions/recommendations on how to improve EMR use? (e.g. how do we ensure mature use

of EMRs?)

______________________________________________________________

______________________________________________________________

______________________________________________________________

C) Additional Information

10. If you have any additional comments about your use of the EMR that you would like to share with us, please

write them down in the space provided below.

______________________________________________________________

______________________________________________________________

______________________________________________________________

THANK YOU FOR COMPLETING PART I OF THE PROVIDER SURVEY.

YOUR TIME AND SUPPORT ARE HIGHLY APPRECIATED.


PwC

Part II- EMR Progress Survey

Upon completion of Part I- EMR Experience Survey, participants were required to select the hyperlink provided to

take them to Part II, which was administered through OntarioMD. Survey questions can be found in the attached

document (Page 13).

OntarioMD_EMR_Maturity_Model_Framework_v1_3.pdf


PwC

Appendix H: Site Visit Interview

GuidePhase 2 – EMR Benefits Realization Case Studies

General Interview Guide

Questions

EMR Benefits1. Related to your EMR use, please describe a typical visit and how often you document/use tools within the

EMR

2. What do you think the benefits are? What do you attribute the benefits to?

3. How do you assess the clinical effects of the EMR? How do you notice if the EMR has made things

better/worse? Are there any objective data to show the effects?

Quality of Care and Access to Care4. In your opinion, what are the benefits of the EMR on patient care? Please provide examples of how you use

your EMR system to improve your quality of care and access to care.

5. Do you use the EMR system for population health services (e.g., tests/screening; CDM)

6. Has the EMR impacted the patient encounter? If so, please describe/provide examples.

7. What is missing that would help you in caring for your patients?

Patient Experience8. Do you use any specific features/capabilities of your EMR with your patients?

9. What are some of the innovative things you can do regarding patient care?

Efficiency10. Has the EMR improved efficiency of the practice, providers, etc? Please provide examples.

EMR Best Practices and Lessons Learned11. What are some of the best practices and lessons learned regarding EMR adoption and use?

12. Looking into the future, what are the possibilities for the EMR? What are your future plans?

Other Comments13. Any other comments? Can you think of anything else that might help us to learn from implementing the

EMR in your practice?

Date post:	22-Jan-2018
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Final eHO EMR Benefits Report Jan2013

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