The age of persuasion…

Herding Cats

Historically, certain large corporations and autocratic governments have been fond of a persuasive technique known as “The Big Lie.”   Essentially, you hire cabal of P.R. flacks to repeat what you want people to believe over, and over, and over, until they start to believe it.

It’s a technique which is deceptive, disreputable, underhanded… and effective.   AND, it’s being used right here in New Brunswick to shore up the failing provincial EMR program.

Despite the fact that Velante and the NBMS have only one fifth of the doctors they had hoped would be signed on to the monopoly EMR program, they are trumpeting success, and inciting others to jump on the bandwagon.

Well, my boastful friends, you might want to check the bandwagon’s wheels.   I think you have a flat.

While you are bragging about your Pyrrhic victory, you are emptying the bank account of our membership fees to pay for your P.R. and I.T. people, and ignoring the fact that apart from a relative few conscripts, doctors don’t like your EMR.  And they are voting with their feet.

Here’s an example of what has been foisted on us by proponents of the NB EMR monopoly.   Their text has been italicized for emphasis.   This was posted by Accreon, the money-making partner in the NBMS/Accreon union which gave birth to Velante.

Posted by Accreon   |   December 9, 2013

“Physicians in New Brunswick (Canada) now have access to an electronic medical record (EMR) solution that is integrated with the government’s provincial electronic health record (EHR).  This is a significant achievement.”  

It is significant because VelanteNBMS have slammed the door on a large number of doctors in New Brunsick with their “My Way or the Highway” philosophy.   Early adopters of EMR technology, some of whom are using software which is equal or superior to the Velante offering, have been shunned, ostracized, and denied the option to integrate with the provincial EMR by a secret data sharing contract they collaborated upon.  Please note:  “significant” is not synonymous with “desirable.”

“What does it mean to be integrated with the government’s electronic health record?

Simply put, doctors are part of a network of interconnected providers.  From the first day a physician is up and running with the NB EMR, he or she has electronic access to lab and other test results for all their patients, regardless at which hospital the test was completed.  As more and more physicians begin to use the NB EMR, doctors will be able to refer patients to other doctors electronically for consults, forwarding only the relevant parts of the patient chart to the consulting physician.  In turn, the consulting physician will be able to provide his or her report to the referring physician electronically, automatically updating the patient’s chart in the EMR.”

Simply put, doctors are your gateway to health.   We all have access to lab results and diagnostic imaging reports.    We have always had this.  I use Telus Health and I have been electronically consulting other physicians for three and a half years with my EMR.    The Velante plan simply creates two classes of doctors.   Those who toe the party line and buy into Velante, and those who exercise their (?temporary) freedom of choice to choose the EMR which best suits their needs.

Velante is anti-choice.

But they are happy to take your money.

“Once the provincial Drug Information System becomes available, all prescriptions ordered and dispensed will be available to the doctor through their EMR.  And for the Department of Health, a single integrated EMR substantially controls the cost to NB for building and maintaining interfaces between multiple software packages.”

I get the drug database idea.   I should say, I got it.  Have had it for three and a half years.  Never mind the fact that at least one EMR competitor has offered to pay all startup and ongoing costs of interconnecting with the Department of Health computers.   Apparently, the braintrust at Velante thinks you SHOULD look a gift horse in the mouth.

“While other provinces did get an earlier start with their introduction of electronic medical records, few achieved this type of integration on Day 1.  How is a cash-strapped province like New Brunswick able to pull this off?  The answer lies in being results-oriented, collaborative and a bit creative.”

Well, in fact, Velante doesn’t have this type of integration either.   They hope for it.  But it is not reality, and it remains to be seen if it will ever happen as promised.    As far a how NB has managed to sign on the few doctors it has to the provincial EMR, the answer is, sweet talk, federal grants, and bending the rules.  Collaborative?  Don’t make me laugh.   Collaboration is not in the Velante lexicon.

“In 2012, the provincial government assigned responsibility for launching NB’s EMR Program to the New Brunswick Medical Society (NBMS).  With the involvement of the Department of Health (DOH), NBMS, through its EMR delivery company, Velante, conducted a rigorous procurement process based on national standards for EMR solutions, that saw 18 responses to the public Request for Proposal process.  The process of selecting the EMR involved physicians, technical and software experts, and government partners.  In the end, a single EMR product was selected.”

Translation:  They chose one of several good systems and then excluded all others in the interest on making a profit for Accreon.   Physician preference, as clearly demonstrated by the early adopters, was not a consideration.

“At the same time, NBMS was working with the DOH to establish the integration components and build the interfaces and processes necessary to ensure a valuable software solution for doctors.  Fast-forward about 13 months and the NB EMR Program’s first group of participating physicians has gone live.”

Whatever that means.    Meanwhile Velante and the NBMS are in cahoots, working diligently to ensure that the doctors who laid the real groundwork for a physician-friendly, usable provincial EMR system “go dead.”   Is the system implemented “valuable” to doctors?  I think not.  Valuable to Velante, mais oui!

“The assignment of this program to NBMS has enabled New Brunswick to implement an EMR program with minimal initial investment from the provincial government.  This is a great achievement by NBMS and the Province, and a testament to the efficacy of the Government’s decision to assign responsibility to them.”

In other words, the province gets to freeload off the backs of doctors, as the NBMS drains it’s coffers paying Velante employees.  Meanwhile doctors – many of them completely unreceptive to Velate pitchmen – continue to pay for the program through their annual membership fees.   Great deal for the Department of Health.  Great deal for Velante.  For doctors… meh…

“And doctors are signing on.”

At least 110 of 1600 in the province have shown some interest in the scheme.   Lured by federal subsidies and sweetheart deals.

Sixteen are actually using Velante’s software.

Sixteen.   After a year of intensely marketing their monopoly, even offering to break their own rules about not funding the expensive process of moving data from the old EMR to their product.  That’s the best they can do.

“To date, approximately 450 physicians, nurses and medical administrative staff are enrolled in the program.  These leaders will lead the way having bought into a vision that is now a reality.  It is anticipated that their colleagues will rapidly join them in using the physician-selected solution.”

I repeat.   Sixteen are actually using the software.  Don’t count your chickens before they are hatched.   Velante had hoped to have 600 doctors (note: not nurses and admin staff) committed to their program by now.  They are miles short of the goal.  Plus, the real leaders are those who made a conscious choice of EMR’s and paid for it on their own dime, not those who were cajoled, lured, and bullied into accepting the unpopular Velante EMR vendor.

Make no mistake about it.   The monopoly was not established by a reasonable consensus process.   The monopoly was established by a small number of well-placed NBMS members and staff, and solidified with the secret exclusionary Data Sharing Agreement.  No doubt Accreon played a significant role in shutting out all other software vendors.

What the smiling Accreon cheerleaders seem to have forgotten is that, like cats, physicians are strong-willed, independent, intelligent, and not easily controlled.

And, though we may at times seem docile and content, when required, the claws can come out.

Good luck with the herding.

Got a couple of hours?

Image

If you are interested in learning more (a lot more) about doctor’s opinions and experiences with EMRs, take a look at the following report from Accenture.   It provides an in-depth comparison of EMR utilization in Canada with that in seven other western industrialized  countries.    

Canada-specific information can be found in pages 32-56 of this slideshow-format report.

Interestingly, “I.T. systems that can’t talk to each other” is the number three reason why many doctors are hesitating to make the jump to EMRs, trailing only cost and privacy concerns in this regard.  This echoes one of the concerns noted in the United Kingdom, as noted in my previous blog.   Information “walled gardens” must be avoided.    Yet in some jurisdictions, ours included, this serious flaw is being deliberately built into the system.  

Interoperability and the ability for I.T. systems to efficiently share data is key.   Deficiencies in these key features is one of the reasons why New Brunswick’s provincial EMR program has fallen seriously short of expectations.

http://www.scribd.com/fullscreen/143445324?access_key=key-2362e0w0dbcc9hrocikv&allow_share=true&escape=false&view_mode=slideshow

Forcing a fit…

Making it Work

Making it work takes a little longer.  Making it work takes a little time. –  Doug Bennett

The EMR experience in the United Kingdom should not be ignored.   Painful lessons have been learned about putting all your eggs in one basket with a single monolithic electronic record system.   In the article linked below,  some of the analysis refers to the hospital-based EHR rather than the office-based EMR which is the focus of this blog, but the findings can easily be extrapolated.

New Brunswick is plunging headlong to the same disastrous muddle that has befallen our British cousins.   It bears thinking about.

We don’t all work the same and even within medical specialties there are differences in how people use computers and what software suits their eye.   Choice is THE key element in physician satisfaction with EMRs.   Forcing a fit is never a good idea.

“There are huge differences between a surgical specialty practice, primary care and hospital systems. The result of a one-size-fits all mentality in healthcare is a lowest common denominator approach to building solutions which has led to generic, yet shockingly expensive, products that are not well liked or used.”  – Daniel Cane, CEO of Modernizing Medicine

Anyone listening?   Is that a path we want to go down?

I think not.

It’s time for doctors to decide what they want in an EMR.    Time to stop the tail from wagging the dog.   I.T. professionals are key players in developing more fully functional electronic medical record systems, but we should be telling them what we need.  Physicians need to lead, not follow.  Software vendors need to find out what works for us, then make it happen.   And if they can’t do it, we should find someone who can.   That’s the beauty of a free and open marketplace.   It fosters innovation and healthy competition.

A good first step would be ending the EMR monopoly in New Brunswick.   It is ludicrous that physicians in this province are being offered only one EMR solution.   No one would tolerate going to a restaurant with only one item on the menu.   Yet that’s the choice offered by Velante, as they attempt shepherd us into their shearing barn.

Fortunately, physicians don’t herd well.

“EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.” –  Dr. Farzad Mostashari

Well said.

We need a variety of systems that talk to each other.    It’s not a question of whether it can be done.   It’s a question of will.

As you are about to read, health IT authorities in the United Kingdom have made it quite clear that “interoperability is a key priority …  If there is not sufficient progress or we continue to see barriers that create data silos or ‘walled gardens’ we will… consider other options to achieve our policy intent.”

This is the kind of leadership and vision that is sorely lacking in New Brunswick.  Both our Department of Health and our Medical Society would do well to take a lesson from the British experience with electronic medical records.   There needs to be more emphasis on enabling health care providers, more vision and innovation, and, above all, we need to learn from those who have gone before us.

Enjoy the read.

http://www.canhealth.com/tfdnews0907.html

Crunching numbers…

Numbers

The New Brunswick provincial EMR monopoly is expensive.

Most of the startup costs are being borne by the taxpayer.   Ongoing costs will be split between the Province and the physicians who use the system.  The company set up to administer and promote the monopoly, Velante, pays it’s salaries and expenses through a combination of New Brunswick Medical Society funds and user fees.

Even if you don’t use a EMR, you are paying for Velante.   By you, I mean doctors and John Q. Public.

According the the financial statements of the New Brunswick Medical Society as of December 31, 2012, Velante had cost the NBMS $266,233 and overall was showing a single year loss for 2012 of $522,000.   It will be interesting to see what the numbers are for 2013, with increased costs for salaries and a new office at 418 York Street in Fredericton.

According to Velante’s glossy promotional material, each physician signing on with Velante incurs startup expenses of $24,000.   This costs the taxpayers $16,000 per fee-for-service physician and $24,000 for salaried doctors.   Assuming that the the most recent numbers circulated by the NBMS are accurate, there are about 55 of each of these.   That means the taxpayers are subsidizing the startup of the EMR program to the tune of $2,200,000.

Physicians who have chosen non-Velante EMR software have cost the taxpayer $0.   Zip.   Nada.

Non-Velante EMR users have paid their own way, in many cases shelling out over $20,000 in startup costs, with recurring  monthly costs in the same range as the $395 claimed by Velante.

Until recently, Non-Velante EMR users had never complained about the cost of their EMR.   At least, not until the provincial government and NBMS established their unfair and discriminatory subsidization of Velante products for the favoured few who have bought into what Velante is peddling.   AND locked us out of the Department of Health computers, thereby hobbling the capabilities of our software.

I support an inclusive EMR system which would permit users to choose the EMR which they prefer.    I also support the elimination of the “stacked deck” employed by Velante, and enshrined in the secret data sharing deal and juicy cash handout schemes concocted by NBMS and the Province.    Interconnection with the provincial Department of Health computers should be available to ALL doctors, regardless of which EMR they use, provided that there is no cost to the taxpayer.

I’m willing to pay my own way in order to use the EMR I chose.   I’ve been doing it for almost four years.  Many of my non-Velante friends have been doing the same for even longer.

We deserve to be treated fairly.   Nothing special.   No handouts.   No subsidies.   Just get out of the way and let us do our jobs.   Caring for patients.   Isn’t that what this is all about?

There are a LOT of doctors in New Brunswick who think the same way.

Trouble is, nobody is listening.

La dolce vita…

Image

When in New York last year, just before Christmas, we were walking from our hotel in Chelsea south to visit the site of the World Trade Centre terrorist attack.   It was a cold day, particularly by New York standards, and the wind whistled up from the financial district, chilling our fingers and noses to the point of pain.  As we continued down the Avenue of the Americas, I commented that people driving by must know that we are Canadians.   Over the entire two mile walk, in the late morning of a weekday, we saw no more that a dozen or so pedestrians.   As we neared Ground Zero, we were all starting to feel the effect of the windchill and, seizing an opportunity, we ducked into a car dealership to warm up.

These were no ordinary cars.   Even a rube like me could see that right away.   A couple of them had grille ornaments that I didn’t recognize.   One looked like a trident.  Turns out it is the Masserati symbol, reputed to have been designed by one of the seven Maserati brothers, Mario, based on a statue of Neptune at Bologna’s Piazza Maggiore.  It was first used on the Maserati Tipo26 in, you guessed it, 1926.  Store that away for your next round of Trivial Pursuit.

Tipo26

Maserati Tipo26

After a few minutes of feigning interest and ability to buy one of these beautiful luxury sports cars, we were ready to be on our way.   I got one of the kids to snap my picture next to a Porsche.  The woman greeting customers asked if she could help us with anything.    I said “No.  We just wanted to look at your cars.   They are amazing” then added “If I ever lose my mind and sell the house, I will be back to buy one.”   She smiled knowingly, like she was the keeper of some arcane and vaguely amusing knowledge nugget.

The knowledge was probably this:   the car I hinted I might buy if I were insane sells for over $700,000.  Even if I could magically transport my house to downtown Toronto and sell it at a vastly inflated price, it still would not pay for the car.  What she probably did NOT realize is this:  even if I had $700,000 to spare, I would never buy one of these cars.    The concept of owning a car that expensive is ridiculous and obscene.   Even more so if you consider what would happen to it on New Brunswick roads.  Plus, I’m not sure you could weld a trailer hitch onto it, so how would I pull my pop-up camper?

Which brings me to my topic for the day:  things that might be nice for EMR users, but which are not going to happen in this lifetime.  At least not in New Brunswick.

Critics of EMR technology often raise the issue of how the computer gets in the way of normal conversation.   Communication is more than words.   Eye contact, body English, along with pitch, tone, rate of speech and cadence all contribute to effective communication.   It’s difficult to carry on a normal conversation while simultaneously typing notes.   Some are better than others at doing it, but there is always some loss of nuance when computers are interposed between humans.

There must be a solution.

There is.   It’s called a “scribe.”

Now, I thought scribes were only found in the Bible, working hand-in-hand with Pharisees, maybe keeping track of accounts receivable for usurious money-lenders.  Or perhaps in a medieval  monastery, copying religious tomes by candlelight, with a quill pen.

Apparently I am behind the times.

Scribes are basically transcriptionists, who accompany doctors as they assess patients.   Armed with an iPad or laptop, they laboriously transcribe a record of each patient encounter, which then can be pasted into the EMR.  In the United States there are estimated to be in the neighborhood of 10,000 scribes assisting physicians in a variety of clinical settings.    The cost is $20 to $25 per hour, usually paid for by the doctor.    It’s claimed that cost is offset by greater efficiency, and patients are said to appreciate the undivided attention.

Will we see scribes popping up in doctor’s offices in New Brunswick?   Not likely.   At least, not in the office of any family doctor I know, where office overhead already runs in the range of 30 to 40 percent, and where the Department of Health may at any time try to impose another cap on Medicare billings.  Most people I know don’t even hire an office nurse anymore.

The one place where we may see scribes might be in the Emergency Department.    There, cost would be borne by the health care corporation, and there is already a demonstrated willingness to add Nurse Practitioners and Physician Assistants to the traditional doctor/nurse combo.  Judging by the number of people who visit the E.R. and the typical time they wait to be seen, anything that would help to move things along would be a bonus.

For more information about how scribes have been deployed in the U.S., check out this article, recently reprinted by the Globe and Mail:

http://www.theglobeandmail.com/life/health-and-fitness/health/how-scribes-are-helping-doctors-treat-the-patient-not-the-chart/article16343254/

How sweet it is!

Sounds familiar…

Image

Attention Comrades!

Glorious Leader has great news for you!

Horse and buggy not working for Motherland.   Brilliant Central Committee patriots know very well!

New system much, much better!

We use open, transparent process with more than 400 choosing things!

New transport vehicle has four wheels, windows, steering disc, comfy chairs, mirrors for looking backward, safety straps, key for making engine go, and much more!

Rolling off factory some time in future!

No other buggy needed.   This the best!

Cost is cheap, cheap, cheap!   Trust comrade on this one!

Some countries have many type buggy.   Wasteful.   Shame on capitalist swine!  Why you need choice?   Just do as told!

Joking!

Try our Lada.   You love it!  You not like, you come talk us, we listen very good!

For glory of Central Committee!

Oligarchy…

Oligarchy

The time has come to reveal the text of the secret agreements made between the New Brunswick Medical Society and the NB Department of Health, the basis of the execrable EMR vendor monopoly which has been foisted upon the rank-and-file doctors  in this province.

It’s not too late to salvage this debacle.  These agreements can be amended.

First we need to answer the question:  who speaks for us?

http://emrdocs.wordpress.com