Zen and the art of home electrical maintenance…

Switch

Last evening around 8:30, I performed my first useful act of the day.   I replaced a faulty dimmer switch in our kitchen.   How did I manage to get through an entire day without doing anything productive or useful?   Easy.   I attended the Annual General Meeting of the New Brunswick Medical Society.

At the meeting, some educational sessions were held, some speeches and reports were given, and a succession of doctors made motherhood statements about how the Society needs to be united and how we need to ensure that the NBMS serves the needs of all doctors.

All well and good.   No argument here.

The problem occurred when attention was turned to the topic of electronic medical records.   We heard some interesting statistics about how many doctors are using the Provincial EMR system offered by Velante, and some questionable (only because they have been wrong so many times before) projections about future conscripts to the system.   And we heard about how things are looking good for Velante now that the taxpayers are kicking in $1.5 million dollars a year to support the program.

Good for them.   I am happy that the subsidized program is doing what they wanted it to do.

It’s a different picture entirely for doctors who use one of the competing EMR packages.    These doctors, numbering well over 100 across the province, have been actively denied electronic access to their patients’ medical data.   This unfortunate state of affairs came about when, on June 13, 2013, the NBMS and the Province of New Brunswick signed a document entitled “Data Sharing Agreement.”    This document contains within it a provision that only one EMR vendor – the one marketed by Velante – will be permitted to interconnect with Department of Health databases.

This provision, his along with hefty government subsidies to Velante clients, creates a very uneven playing field for the other vendors.   It is, at its heart, an anti-competitive document.

Velante is ballyhooed as a “doctor-controlled” company, even though only two of the seven members of its board of directors are MDs.   So how well, as an offshoot of the NBMS, does it manage to hold to the principle of serving ALL NB doctors?

Answer:  it doesn’t.

Velante serves only its clients and the I.T. company Accreon, which owns 49 percent of Velante.  Early adopter of EMR technology and people who have recently chosen other EMR systems which better fit their needs are marginalized and their legitimate concerns are ignored.   The only time the NBMS is willing to give them the time of day, is when they are trying to lure them into switching vendors, as they dangle the bait of wads of taxpayer money.

You may think “But wouldn’t it be better if all NB doctors used the same EMR?”   This might appear to be an attractive option at first glance but there are a few problems with this concept.  Lets’s start with the three obvious ones.

First of all, not all NB doctors need the kind of EMR Velante is offering.    It is a “bells and whistles” system which is much more complex and expensive than many doctors need.    Second, the establishment of a single vendor and a province wide monopoly is bad for the consumer.   I have commented extensively on the reasons for this and will not repeat the rationale here.   Suffice it to say, when has a monopoly ever been good for the consumer? Thirdly, and most importantly, New Brunswick does not exist in a bubble.    Even if we were to have every doctor in the province using the same EMR, what happens when patients leave the province, or immigrate from other parts of Canada, or other countries?  Are their healthy records portable?  How do we manage the transfer of electronic data?

The solution is interoperability.

In order to have an optimally functional EMR system on a national and international basis, we need to ensure that data can be readily exchanged between different, competing EMR products.  This is where we are headed, and this is the essence of interoperability.   Numerous technology experts have commented that interoperability is the future, and we need to encourage and welcome it.   Patient health information is not owned by the EMR vendors and it is immoral and very likely illegal to refuse to permit the migration of data from one EMR product to another.   In other words, the days of the “walled silos” of isolated, patient information are coming to an end.    The EMR vendors know that that this is coming, and the forward-thinking ones are preparing for the end of proprietary, selfishly guarded databases.

Yet in New Brunswick, the NBMS and the Department of Health have colluded to prevent non-Velante users from having equal access to their patients’ data.

New Brunswickers need to recognize this.   The NBMS, in particular, needs a better vision for the future.   A corporate monopoly is short sighted.  We need a provincial EMR system which is inclusive and welcomes diversity and personal choice.

The naysayers have said “Oh, it’s so complicated to transfer information from one system to another.   It will never happen.   It’s too hard.”    While I agree, it may be difficult and expensive at this time to move data from one system to another, it is unlikely that this will persist indefinitely.   One has only to look around to see examples of technological advances which a decade or two ago seemed like science fiction, but are now reality.    Smart phones are one example.   Cars that park and drive themselves another.   There are thousands of examples of technological advances which the pessimists though could never happen which are now part of everyday life.

Interoperability between EMR products is not an unclimbable mountain, but neither is it a molehill.   It will be achieved, and it will happen in the not-too-distant future, but it requires effort, buy-in, and a can-do attitude.

Let’s make it happen.

I will be going to the NBMS Annual General Meeting again next year.  Next time I hope to be able to report, at day’s end, that more has been accomplished than fixing a light switch.

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The escape clause…

Aston

The 2014 New Brunswick Medical Society Annual General Meeting has come and gone.  It has been a year since I presented a motion to the general membership which would require that the leadership of the Society not impede EMR user’s from having electronic access to their patients’ medical reports found in the Department of Health databanks.

So, what has happened since the membership voted overwhelmingly in favour of that motion?

The short answer is:  nothing.

Following the approval of the motion we entered a prolonged and unproductive period of dithering and blithering.   Here are some of the stumbling blocks along the long and winding road:

1. Non-Velante users are told the NBMS board needed time to determine how best to implement the resolution.

2.   We learn that the CEO of the NBMS signed a Data Sharing Agreement in June which prevents all non-Velante EMR users form electronically accessing patient data.  He denied the existence of this document at the 2013 Annual General Meeting, despite having signed it three months previously.

3.  The NBMS says the Minister of Health refuses to talk about renegotiating the exclusionary Data Sharing Agreement.

4.   The NBMS leadership reveals that Velante is not meeting enrollment predictions.  Their business plan is in jeopardy.

5.   Minister Flemming then says he is willing to discuss all the options, including renegotiating the Data Sharing Agreement.

6.  Mr. Flemming says maybe the province will take over the management of the EMR system, and void the Data Sharing Agreement by giving 180 days notice, as provided for in the agreement.

7.  Minister Flemming ends up doing nothing of the sort.

8.  The NBMS leadership transmogrifies the request for access to patient data to a request for financial help converting to the Velante system, despite that nobody was publicly asking for that, and it had nothing to do with the AGM motion.

9.  The NBMS negotiates a $1.5 million dollar per year clause in the Fee For Service contract with the Province, thereby pounding a bung into the sinking ship.   Thank you taxpayers!   (I thought I would say it, since nobody else did)

At the 2014 NBMS Annual General Meeting the leadership offers an explanation for why the year-old motion has gone precisely nowhere.  They go over much of what has been outlined above.   Then they release the ultimate bogeyman.  The Lawyer.   The membership is advised that the board has received legal counsel advising them that if they void the Data Sharing Agreement, they could be sued by the owners of the EMR package marketed by Velante, the New Zealand company, Intrahealth.  The spectre of bankruptcy for Velante and quite possibly the New Brunswick Medical Society is raised.  Everyone quivers in fear, and the annual review continues on another topic.

Now, this raises a couple of questions.   First of all, what the hell did the leadership think they were doing when they signed the cockamamie Data Sharing Agreement in the first place?  Why did it take a formal access to information request to bring the Agreement to light?

But, more importantly, how can you have an agreement, which says right there in black in white that it will remain in force indefinitely, which has an escape clause you can’t use because if you do, you will be sued and bankrupted?

It’s like buying a parachute with no ripcord, and not finding out about it until your plane has already augured-in and you are plummeting toward earth at terminal velocity.

It’s like James Bond buying an Aston Martin with an ejection seat, but finding out when it comes time to use it, that the car is a hardtop.

What a tangled web we weave.

 

 

 

Setting the record straight…

Bad!

I received yet another public scolding from the leadership of the New Brunswick Medical Society recently.  It really is getting a bit tiresome.   “Sit down and shut up” might have worked well for badly-behaved elementary student in the 1960’s, but this is 2014, I am 56, and it’s not working at all for me.

Here’s what Dr. Hansen had to say on March 18:

Provincial EMR program in the news

I was pleased to take questions from the media about our EMR program. With over 250 physicians already enrolled for the program, I believe it is quite likely that we will hit the Department of Health’s estimate of 300 physicians in our first year of operation, which is quite an achievement. The Minister of Health has recently stated that he is open to renegotiating several elements of the Program, which is good news. We look forward to addressing some challenges with the Program with the Department of Health while we move forward with dozens of implementations over the next months. Velante is already the largest EMR provider in the province. Members are reminded that there are only two weeks left to enrol!

I must say that I am personally disappointed at some of the criticisms of the program and more directly, public attacks against the leadership of the NBMS. Some have gone to the media without voicing their concerns to us first; others have made claims that are inaccurate in public fora. There are legitimate concerns about this new and fast-paced program, and some have been raised in proper forums for informed discussion and debate. Some members will not choose to adopt the Velante program, and that is an understandable decision. But to be clear, the EMR program is similar to those in other provinces; costs taxpayers a fraction of some estimates made by members in the media; and no patient’s health information is being kept from any health provider. We look forward to discussions with the Department of Health to improve the program and will endeavour to better explain the Program’s details to members.

Lets just set the record straight on a few issues which seem to be a bit off the mark in the latest President’s Letter from the NBMS and in the imbedded links in the original document:

1)  Velante is NOT a physician-run company.   It has a seven member board of directors.   Two of the directors are doctors.   Three are Accreon executives, one is the CEO of the NBMS (who is NOT a doctor), and one is a UNB business professor.  That’s the way it was in October.   Correct me if I am wrong.

2) I did not go “to the media.”  They came to me.   I turned down invitations for interviews twice before Minister Flemming came out with the news that Velante was failing to meet conscription goals.

3)  I DID go to the NBMS multiple times with concerns about the EMR program.   I got the distinct impression that nobody was listening.  One letter I sent to the President went unanswered for two months.  I finally got a reply when the media started to question the viability of the Velante plan.   The reply I got was more of a reprimand than an answer to my legitimate questions.

4)  At last fall’s NBMS Annual General Meeting, the membership approved a resolution which directed the NBMS to not interfere with doctors using other EMR products interconnecting with Department of Health computers.  The leadership did not follow the direction of the membership and continued to obstruct early adopter of EMR technology.

5)  At the AGM, the CEO of the NBMS denied the existence of the secret Data Sharing Agreement, despite the fact that he had signed the document three months earlier.   We only found out about it after another doctor used right-to-information legislation to get a copy of it.  The CEO has never explained how he was able to sign this agreement and then seem to be unaware of its existence.

6)  Velante is not the the largest EMR vendor in the province.   At last report there were 34 people using a limited version of the advertised product.   Practice Solutions has 60 or more satisfied customers who received no handouts and were happy to pay the going rate for a top-quality, fully-functional EMR.

7)  The Minister of Health did say he was willing to renegotiate the secret Data Sharing Agreement.  What Dr. Hansen fails to mention is that the leadership of the NBMS refuses to even discuss permitting more than one approved software vendor, in defiance of the wishes of the membership.

The bottom line:

Increase in fee-for-service payments to doctors over 4 years (if the contract is ratified):  4%

Increase in NBMS membership dues over the last four years: 39%

Number of taxpayer dollars being offered per year  to convince doctors to jump aboard the S.S. Velante:  $1,500,000

Number of doctors in New Brunswick:   1600

Number of doctors who signed a form indicating they are interested in EMRs:   350

Number of doctors said to be using a limited version of the Velante product:  34

Number of doctors using the Velante product who will tell you that they are satisfied with the Velante product, and that it has lived up to the claims of marketers:   ???

The leadership of the NBMS is pulling out all the stops in its effort to bail out Velante.   The latest move uses taxpayer money – redirected from a general fee increase – to try to convinced the many satisfied Telus Health and Oscar users to jump ship.   Problem is, we don’t want the money.   We like our EMRs, and we can’t be bought.

Make no mistake about it, medicine in New Brunswick is under an all out attack by those who wish to shape healthcare in their own image.   The NBMS, like Nero, fiddles while Rome burns, and Accreon is calling the tune.

By what authority has the leadership of the NBMS transformed our Society from its traditional role as protector of patients and doctors to a public relations company for a failing information technology project?

Remember, not a single New Brunswick doctor was using Intrahealth software prior to the Velante scheme.   The only reason anyone uses it now is because salaried doctors were given the system for free, and a handful of fee-for-service doctors were given thousands  of taxpayer dollars as an incentive to adopt the system.  At least one Saint John family doctor has been offered the Velante system for free, because he trains a lot of residents, and Velante clearly subscribes to the “get ’em young and bend them to your will” philosophy.

Any reasonable person would conclude that a product that cannot sell itself on its merits and survive without government subsidy is not much of a product.   Yet this is exactly the sort of product that the NBMS has chosen to offer us as the ONLY authorized software package in the provincial EMR system.

There are better systems available, but our Medical Society doesn’t want us to use them, and is willing to throw money at the problem until doctors either knuckle under to their will, or the Society is bankrupt.

Stop the merry-go-round, I want to get off.

A fresh start…

Image

I don’t know about you, but I for one am sick and tired of the defeatist approach to the concept of multiple EMR vendors in this province.   Sometimes it seems that the parade of excuses goes on forever.

We can do without the negative thinking.  Pessimists and nay-sayers need to stop obstructing progress and make way for others with vision and a “can do” attitude.

There are those who believe EMR vendor’s just can’t make it in this province unless they sign up 500 clients and have a secret contract to hobble the competition.  These same people note that there are fifteen vendors currently supplying doctors in this province.    Even though these vendors only have a handful of clients, they seem to be doing just fine, despite being undermined by the Data Sharing Agreement.   Velante’s claim that their product can only survive by cutting the legs out from under the competition speaks volumes to the weakness of their business plan.

A well planned business should stand on it’s own two legs, and not need to be propped up by government handouts and secret deals which foul the waters for competitors.

Play fair or get off the field.

Nobody wanted the Velante system to fail, but fail it has.

The Minister of Health says the province may step in to bail out the sinking Velante vessel.  Ironically, that may result in another plan just as expensive and centralized as the current one which will compel doctors to use a “one size fits all” EMR.   That’s a scenario which is to be avoided.

Here is my plan:  It’s cost effective, provides for freedom of choice for doctors, and will improve health care outcomes.

  • Admit the Velante plan has failed.   Let’s cut our losses and disband or remodel the company.  Cut Accreon out of it.   Intrahealth should be able to continue to provide support to the 34 doctors currently using their software.
  • Tear up the Data Sharing Agreement.
  • Allow any vendor who is prepared to pay the cost of interconnecting with DOH computers to do so.   Any vendor who cannot pay the cost can still function under current conditions, just as they have been all along.
  • Establish a system of “Sentinals.”   By this I mean a group of doctors selected from all parts of New Brunswick, who are advanced EMR users, each with practices of over 2000 patients, who are making full use of their EMR’s including the use of standard ICD-9 disease coding.
  •  Employ a provincial Health Statistician whose job it will be to collect data from the Sentinel physicians in order to provide statistics on disease prevalence and control, medication use, immunization rates, and utilization of health care resources – all on a quarterly basis.   With even a dozen doctors participating, you will have a sample of 24,000 or more, which should be adequate to provide reliable figures for the province to use.
  • Sentinal physicians would receive a monthly stipend to compensate them for the additional time and effort required to keep their records in a state which permits easy data mining.

This plan would accomplish several important goals:

  • Physicians would be free to choose the EMR which best suits their needs, or continue to use a paper based system.   Over the next 10 or 20 years, the proportion of doctors using EMRs is going to grow with out any help, as new doctors don’t want paper charts, and are part of a more tech-savvy generation.
  • Physicians could choose an EMR which interconnects with DOH databases if they wish, or a simpler system – which is likely to be the choice of many specialists – with more limited capabilities.
  •  Physicians who do not interconnect can still access the provincial EHR, as they can now, using the existing portal.
  • The Department of Health would benefit from access to data from a representative sample of the population, which if designed properly by a competent statistician, would give very accurate and usable information.
  • Early adopters could take on the role they should have had all along, as the greatest supporters and promoters of EMR technology.
  • The I.T. industry would receive a boost by having the opportunity to write software packages which could perform functions such as data migration, for patients who move from another province and are able to bring their electronic medical file with them.   We will need people to develop apps and provide security and data encryption programs for tablets and laptops, maybe even smartphones.
  • The only downside to this plan is that Accreon would lose one of its cash cows.   Even this might not be much of a loss, as that cow is currently producing sour milk, and not much of it.

This system, implemented properly would realize tremendous savings to the province while still providing the data the department needs.   Doctor buy-in and satisfaction would rocket upward.   The I.T. sector for small local players would get a huge boost.

The time has come for NB EMR 2.0.

Are you in, or out?

Keeping an open mind…

brain

 

Benoit Essiambre is a Moncton-based software developer with a keen interest in seeing an end to the Velante monopoly.   His vision of the future of electronic medical records in New Brunswick stands in stark contrast to the exclusionary “take it or leave it” philosophy of the New Brunswick Medical Society and their wealthy business associate Accreon.   Essiambre would like to dismantle the information silos that have been cobbled together for private profit, and foresees a day when we are free from barriers to open, yet secure, exchange of health care information.

Here’s what he has to say:

As a software developer, there is one aspect I feel qualified to comment on which didn’t get much attention and may explain NBMS’s mistakes with Velante.

To software guys like me, it is obvious that when choosing software, one of the most important aspect to look at is vendor lock-in. This has been well known in the software world for a long time. Non technical organisations are starting to realize it too. For example, the UK government has a guide (https://www.gov.uk/service-manual/making-software/choosing-technology) warning of lock-in when choosing software.

In the private world companies are quite averse to lock-in from other companies. That is why open source is gaining so much popularity in the tech business world. One area where it is particularly critical to not bestow control is core data infrastructure. By this I mean the systems that holds the most important data and that controls how and what other systems interface and communicate with it.

Medical records are one of the most important documents in the medical world, so it makes absolutely no sense to stash them in a single system controlled by a single private company and let them charge for access.

This doesn’t mean that proprietary software is always bad. I have created many closed source applications myself. But these systems are better as addon components or for tasks that require special and unique proprietary technology, not to hold and process your core data. The risk that your data will be held hostage and that you will have to pay inflated prices for continued proper access is too high. 

You can add clauses to contracts to try to keep access rights to your data however this ignores technological limitations. Information and data complexity is a fundamental, even mathematical, property of software systems. It is nearly impossible to make independent and closed systems data formats compatible with each others in changing and evolving applications. At the very least, if you have to migrate to a different system, you will have high costs, a difficult transition period and a situation where you will require help from the company you are leaving which will have no incentives make things easier in your departure.

There are better alternatives. Some people have suggested allowing multiple EMR systems and thus some competition which is certainly an improvement over a monopoly. However, even better, some type of systems are developed under the “open source” model. This means that companies working on the system are required to make public the source code used to build the system. It means multiple companies can work on the system, improve it and compete on offering support and services for it. Developers usually cooperate publicly on forums as you can see here (http://oscarmcmaster.16.x6.nabble.com/) for the Oscar EMR used by thousands of doctors accross the country.

I was recently part of the implantation of Oscar EMR in a new clinic in Moncton for five doctors. The installation was easy and took less than a day, the cost for support is about $100 month per doctor and I estimated that our 5 year cost for the clinic will be about $30 000. Had we signed up for the Intrahealth system, in the same time frame we would have paid $40 000 upfront, $120 000 in monthly fees and the government would have put up $80 000 for a total of $240 000 or 8 times the price of our current, more open and more compatible and in my opinion more future proof system.  You can clearly see the effect that competition amongst multiple companies has on price.

Sure you can find vendors charging high prices but that is usually because they already have a large user base locked-in their legacy system and they wouldn’t want to set a lower price precedent for these users.

Here are some important questions that need answers:

Has NBMS properly evaluated the risk of letting a single private company’s closed software, Intrahealth, control every New-Brunswicker’s medical record?

If the exclusivity contract was necessary to lower prices, why is the price 8 times that of a competing, leading edge system? Shouldn’t the price be lower not higher?

If it is so difficult and costly to make multiple systems connect to hospital data, why did Velante have to contractually forbid others from this connectivity to prevent it? I personally talked to developers and got very reasonable prices to do the work, a few tens of thousands of dollars, lower than the price difference between just a few installation of Intrahealth and Oscar. It’s not as if you have to provide different connection protocols for each system. You only need to provide a single type of connection based on the secure standards defined by Canada Health Infoway and make it the responsibility of the different EMRs to adhere to this standard. The standardization work on this communication channel has already been performed by other provinces.

Why has Velante been trying to push our small clinic into a $240 000 system when we were able to get a better one for $30 000?

Used and abused…

Image

I had a bit of an epiphany the other day as I drove along one of New Brunswick’s back roads.   An epiphany that was every bit as much as a jolt as hitting one of our famous wheel-swallowing potholes.

What if I have got it all wrong?

What if the CEO of the NBMS is not a conniving, self-serving, duplicitous pawn of I.T. profiteers?

What if the Minster of Health really is as heartless and mean-spirited as the leadership of the NBMS implied last year?

What if I, and others like me who are shut out by New Brunswick’s asinine EMR monopoly, am simply a pawn in a vicious game designed to weaken the province’s doctors and bankrupt their professional society?

It could be, and here’s why.

The New Brunswick Medical Society, like all provincial medical societies, has professed an interest in developing a provincial electronic medical program for years.    They have seen how others in other jurisdictions have failed, running up enormous costs with very little to show for it.  Accordingly, until recently they had proceeded slowly and with appropriate caution.

Other provincial health departments have been stung with the heavy cost of implementing a universal EMR program, while simultaneously deriving little benefit in terms of lower health care costs.

What if the Minister of Health, recognizing that there is federal money available from the Canada Health Infoway, decided to use that money to bait a trap for the hated NBMS?   Having seen the disasters that had befallen provincial governments in places like Ontario, if he could somehow convince the NBMS that they should lead the way in the implementation of a provincial EMR program, then sweeten the deal with federal bucks, convince naive doctors that they should select a sole EMR vendor whose product is almost guaranteed to be unpopular with the bulk of NB doctors, then encourage the NBMS to buy a nice new office building to house all the sales, support, and marketing folk, and take out a huge bank loan to support it all… well, you can see where this is going to end up.

This is precisely what has happened.   The NBMS selected an EMR vendor which not a single New Brunswick doctor was using, and simultaneously slammed the door in the faces of early adopters of systems like Practice Solutions, Nightengale, Oscar, Wolf, and other popular choices.    They bought the new palace on Alison Blvd (then couldn’t sell the old place on York St), took out a huge bank loan, and now are scrambling to find a way to pay off their debts.

NBMS member fees have gone up substantially in the past two years to fund this folly.

As an unexpected bonus, in the mind of the minister, are people like me.   Ostracized by our own professional organization.  Shunned and ignored by the leadership.    Now forced into a role we did not want, fifth columnists fighting those who should be providing wise leadership.   I would be surprised if the Minister can sleep at night, snorting and chuckling gleefully at the prospect of doctors infighting.

This is a perfect storm for the Minister of Health.   The NBMS took the bait and now are saddled with a multimillion dollar boondoggle which is going to bankrupt the Society.    A monopoly EMR, which if it survives, will bleed doctors to feed Accreon corporate profits for years to come in a never-ending web of servitude from which there can be no escape.

I have to hand it to Ted Flemming.   I didn’t think he was this smart.  But he is.  He is a master puppeteer, and he has NBMS CEO Anthony Knight dancing at the end of his strings like a drunken Pinocchio.

Now, having exhausted all reasonable means to achieve justice for early adopters of EMR technology, having sent letters to the president of the NBMS which have gone unanswered, having been lied to by the CEO of the New Brunswick Medical Society, having been manipulated by the Minister of Health to undermine my colleagues, having, in short, been used and abused by almost everyone involved in this sad, sad state of affairs, I am saying now, enough.   I am done.

Let the NBMS carry on with their failed, ill-conceived EMR monopoly.   Let those doctors who wish, sign on to the new program.  I will continue with my EMR of choice.  NBMS fees will continue for rise and there will be great gnashing of teeth when people realize what a terrible mistake the Velante program has been.   But by then it will be too late.    Accreon will buy out the NBMS share in Velante and save the Society from bankruptcy, but leave it crippled and weak.   Doctors who have bought into the Velante solution will be enslaved by it.   User fees will rise and technical support will all but vanish.

And there won’t be a damn thing anyone can do about it.

In closing I will say to the leadership of the New Brunswick Medical Society, Velante, Accreon, and the Minister of Health, it has been a slice.   The combination of duplicity, ignorance, greed, and callousness has been truly mind boggling.   You deserve each other.

The real losers in this debacle are the people of New Brunswick.    Handled properly and honestly, a provincial EMR system could have been a thing of beauty, something which would improve patient care and reduce health care costs.

Sadly, in New Brunswick, it ain’t gonna happen.