Cost, data ownership, reliability issues plague Canada’s EMR program

The recent disappearance of records of more than 12,000 cancer patients in Ontario has raised the urgency of accelerating the country’s electronic medical records (EMR) program, but some doctors says the current government-approved EMR vendors are not up to snuff.

Dr. Ann Cavoukian, Ontario’s privacy commissioner, yesterday said she is holding Cancer Care Ontario and Canada Post responsible for the disappearance of the patient records which were send through the mail.

Cavoukian, also blogs for on the topic of privacy and security.

Cancer Care Ontario, Canada Post in hot water

“This is appalling. In this day and age, how could Cancer Care Ontario decide to send hard copies of sensitive personal data of patients through the mail? How could Canada Post have lost track of the records?” Cavoukian said.

The incident only serves to heigthen the need for more reliable EMR products, according to one Alberta-based doctor who has gone through three technology vendors before settling on a open source EMR product.

“Many doctors are eager to move to EMR but they are clamouring for more reliable and less expensive products,” said Dr. John Fernandes, a physician who is now using EMR software developed by OSCAR Canada Users Society.

The massive privacy breach was brought to light after several Ontario doctors began contacting Cancer Care Ontario and asking about their patient’s records. The personal records of some 6,490 patients, which were supposed to have been sent to doctors’ offices Canada Post’s courier service Express Post, could not be accounted for. Records of 5,440 other Ontarians were also believed to be missing.

In an interview with, Cavoukian said, after an initial investigation, some 5,000 records were later located. “The reports I got indicate that they were found in the offices of several physicians.”

The disappearance of patient records makes a case for adopting EMR systems, according to the privacy commissioner who also said her office will continue to probe the breach.

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But she also admitted that government-backed EMR programs are not being well-received by doctors. “A lot of physicians are still wary of EMR,” Cavoukian said.

“A lot of the push back comes from the hardships and cost associated with converting hard copy patient records into digital form,” she said. “Many of those who had been practicing for years will likely be hesitant to give up their hard copy files.”

Slow and low EMR adoption rates

High maintenance cost, usability issues and yes, reliability and data security are among the key concerns turning off Canadian physicians (even those already using EMR systems) from electronic health records.

The result is a dismal adoption rate for a program that has been going on for the past 10 years.

Canada Health Infoway invested no less than $1.6 billion towards some 280 electronic health (e-health) projects across the country. But as of 2009, only 36 per cent of Canadian doctors were reported to be using EMR systems as compared to more than 90 per cent in Australia, the United Kingdom, New Zealand and the Netherlands, according to a study by the Canadian Medical Association Journal (CMAJ).

At least one physician in Sarnia, Ontario has told the media that he would likely retire if he were forced to adopt EMR, which eHealth Ontario plans to implement throughout the province by 2015.

=“If the government or the College (of Physicians and Surgeons of Ontario) say you have to complete a paperless office by 2015, I’ll say ‘Goodbye, thank you, this is my license take over,” said Dr. Kunwar Singh, in an interview with the Sarnia Observer.

Singh, who is also the president of the Lambton County Medical Society, also said that funding offered by the government falls short of what doctors will eventually spend on EMR systems. He said the money offered by the government covers only a third of the $75,000 needed to convert to the electronic system.

While some progress has been made in setting up government funding, standards, patient registries and digital imaging the CMAJ reported that shortcomings include:

  • Absence of e-health policy that align IT investments with priorities of the healthcare system and healthcare provider to achieve adoption and early return of investment (ROI)
  • Failure to establish a business case for EMR systems
  • Focus on national rather than regional interoperability of systems
  • Inflexibility in approach
  • Lack of involvement of clinicians

In Ontario, some six million patients have their records on EMR systems managed by over 6,000 physicians, according to Dr. Steward Kennedy, president of the Ontario Medical Association. There are about 22,000 doctors in Ontario.

The 2010 National Physician Survey (NPS) places Ontario second only to Alberta among Canadian provinces with physicians deploying EMR systems. Alberta pioneered a the implementation funding programs to entice doctors to adopt EMR in 2001.

  • Alberta – 27.7 per cent adoption
  • Ontario – 19.8 per cent
  • British Columbia – 18.8 per cent
  • Saskatchewan – 17.8 per cent
  • Manitoba and Nova Scotia – 17.6 per cent
  • Quebec – 4.2 per cent

Hostage data and other pain points

Cost if not the only deterrent to EMR adoption, according to one physician based in Alberta.

A lot of doctors in Alberta who deployed EMR systems ended up “disillusioned” because of the unreliability of the EMR provider, said Fernandes, a 43-year-old solo practitioner with some 5,000 patients in the affluent part of Calgary Centre-North. He describes himself as an “on-and-off” EMR user.

He said doctors typically paid $30,000 to $50,000 for the hardware and software components of and EMR system and spent around $3,000 or more a year in maintenance expenditures. “But many of the government approved vendors turned out to be a disappointment,” Fernandes told “I changed vendors three times until I decided to go with the open sourced EMR solution I am using now.”

Related story – Ontario privacy commissioner seeks solution to ‘abandoned patient records’ problem

“The software they developed were not reliable and vendors were often reluctant to adopt the systems to meet the physicians’ needs,” he said. Fernandes also said many doctors complained that it was difficult to get technical support once the systems were installed.

He believed that many of the companies failed to carry out further research and development work to improve their product.

Fernandes said a number of providers also closed shop leaving doctors “stranded”. He went through three different vendors and once had his patient records “held hostage” by the provider that was bought by another company.

“I was using a system developed by RISE HealthWare. When they closed down, I had a hard time retrieving my patients’ records,” Fenandes said. (RISE was actually acquired by another company, Med Access in 2005)

“RISE told me that the (patient) records actually belonged to them. I had to pay thousands of dollars to get the data back,” said Fernandes. He said he transferred to another provider, but that vendor left Alberta as well. A third provider, Wolf Medical Software did not provide the functionality that Fernandes needed.

Cavoukian, Ontario’s privacy commissioner said electronic data ownership remains “contentious” in many situations. “But when it comes to patient records, it is clear that the data belongs to the patient. Service providers or doctors are considered custodians,” she said.

Related story – A challenge to health IT professionals – patient privacy is in your hands

“If any doctors or patients in Ontario run into similar problems where the EMR vendor is claiming they own the patient’s records, the doctor or patient should come to the office of the Privacy Commissioner and we will deal with it,” Cavoukian said.

Open source alternative

Today, Fenandes, uses an EMR system developed by OSCAR Canada Users Society. The EMR system is free and open source software (FOSS) product which means it can be downloaded for free by anyone. Users are also free to modify the program and share the developments with other users.

Fernades said there are now about 900 physicians using OSCAR across Canada. Majority of the doctors, according to the OSCAR Canada User Society chose to pay to have OSCAR installed and pay for support as well.

  • Full billing capabilities
  • Chronic disease management tools
  • A prescription module
  • Scheduling module
  • Patient controlled personal health record component that integrates with OSCAR EMR
  • A social network feature for pharmacists and physicians to facilitate drug information exchange

Related story – Hospitals examine open source approach to records

Fernandes said like the continuous development being done on OSCAR EMR. “There’s input from the physicians and the system is always improving.”

He also favours the system’s mobile features. “I can be out of my office but I always have access to my patient’s records through my iPhone,” Fernades said.

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Jim Love, Chief Content Officer, IT World Canada

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