GUIDING PRINCIPLES FOR PHYSICIAN ELECTRONIC MEDICAL RECORDS (EMR) ADOPTION IN AMBULATORY CLINICAL PRACTICE
The following principles outline what is important to physicians and why as they make the decision to adopt electronic medical record systems (EMRs) in ambulatory clinical practice.
Physician adoption of the EMR has the potential to transform patient care and the quality of health statistics and health research in Canada, as long as the right conditions are met and the guiding principles outlined here are adhered to. Adoption of EMRs in clinical ambulatory practices will lead to significant improvements in data comprehensiveness, clinical relevance and quality — and this, in turn, will lead to improved clinical decision support, core data sets and health statistics that meet the primary goal of enhancing health care delivery, treatment and outcomes.
Privacy. A physician’s ethical and legal responsibility as data steward of the patient’s medical information must be protected and enhanced.1
Choice. There must be appropriate independence of choice that respects physicians’ professional and business autonomy. Physicians must be free to choose the EMR product that best meets the needs of their practice model, type and size.
Voluntary. Physician adoption of EMRs must be voluntary, not mandated or coerced.
Non-discriminatory. Programs designed to offset physicians’ costs or encourage them to adopt EMRs must be non-discriminatory (i.e., not tied to a single EMR product or health care practice model). While such restrictions may be attractive to some payors and administrators, they discriminate against physicians who do not meet their criteria and risk creating two “classes” of physicians and patients.
Outcome-related incentives. Incentives for EMR adoption should be tied to clinical benefits and outcomes, not driven by cost containment. Financial incentives or bonuses that are tied to clinical outcomes may encourage EMR utilization and optimize the use of these systems in ambulatory clinical practices.
1 For more detail on the physician’s ethical responsibilities as data steward of patient information please refer to the CMA Code of Ethics and Professionalism, Guiding Principles for the Optimal Use of Data Analytics by Physicians at the Point of Care, and Guiding Principles for Physicians Recommending Mobile Health Applications to Patients.
Unrestricted. Funding for EMRs in physician offices must be equally available to all physicians, and not restricted to a single EMR product or physician practice model.
Funding. Cost analyses have determined that the majority of the benefits from EMRs accrue to the health care system (i.e., payors and patients) and not to individual physicians. It is only reasonable that those who benefit most should assume the costs.
Comprehensive. The cost of implementing an EMR system goes beyond acquisition of hardware and software. Funding for physician adoption of EMRs must be comprehensive and include costs associated with the initial purchase, as well as implementation, change management, ongoing operation, and evergreening of the system.
Save harmless. Early adoptors who need to update or replace their existing systems, as well as physicians whose EMR vendor goes out of business, must not be disadvantaged. These physicians must not be penalized or excluded from funding programs, and should be provided with the necessary transition support.
Vendor sustainability. Vendor stability is critical to EMR adoption by physicians. This can be achieved through vendor compliance with technical and business requirements that address fiscal sustainability as well as EMR product quality, technical standards and capabilities.
Due diligence. Because physician practices vary in type, size and needs, there is no “one-size-fits-all” EMR solution. Physicians must assess the needs of their individual practice to determine the best product.
Workflow re-engineering. Implementation of EMRs in ambulatory clinical practice may require workflow adjustment or re-engineering. Assessments of workflow and practice needs must be part of EMR change management programs.
HR impact. Adoption of EMRs in ambulatory clinical practices will have an impact on human resources. Provision should be made for physician and office staff retraining, retention and turnover.
Support and service agreements. Physician use of EMRs in ambulatory clinical practice requires appropriate support and service agreements not only to provide the necessary infrastructure and connectivity, but also to guarantee ongoing, accessible and reliable technical support. Physicians must be able to access patient records in their EMR system at all times, regardless of where the records are physically stored (e.g., off-site with an alternate service provider, or onsite in a local client server).
Risk management strategies (liability and insurance) tied to EMR adoption must address the privacy, security, business continuity and professional liability requirements of physician practice in an electronic environment.
Change management and transition
Critical to success. To fully realize the benefits from EMR adoption, the move from paper to electronic records requires change management support and services geared specifically to physician EMR adoption.
Ongoing. Change management is a key success factor in driving both uptake and optimal utilization of EMRs in ambulatory clinical practice. To realize the full benefits of EMR adoption on health care outcomes, physician change management programs must be ongoing, not one-time.
Comprehensive. Comprehensive change management for physicians who adopt EMRs must include the tools and services to assist with system needs assessment, EMR selection, implementation, workflow adjustment, and training for physicians and staff, as well as suggestions to maximize use of the EMR.
Physician driven and designed. Change management must meet the real and individual needs of physicians as they move to an EMR-based practice. This requires flexibility (not one-size-fits-all), “just in time” capacity and delivery, and a mechanism for evaluating the program.
Payor funded and delivered. Delivery and costs of these programs should be borne by payors as part of any physician EMR funding programs or agreements.
Usability and human factors
User interface and usability. User interface and usability of EMR systems are critical success factors for physician acceptance and optimal utilization of EMRs in clinical practice.
Workflow. EMR adoption requires changes to physician workflow, such as history-taking and charting. Done properly, workflow changes related to EMRs should result in administrative efficiencies and improved clinical outcomes.
Core principles of practice must be respected. The EMR must allow the physician to practice comprehensive care, efficiently manage patients with multiple problems and respect the doctor-patient relationship where the patient’s values, wishes, advance directives and physical and social function are integral to medical care.
Training and education. Training in the use, benefits, shortcomings and opportunities of an EMR must become part of the medical education curricula in all stages of physician practice: undergraduate, postgraduate and continuing medical education.
Standardized data. Large data sets that record every observation are unworkable in practice. The EMR must allow the physician to record and access data in a standardized way.
Data quality. Data quality is critical to patient care. Physicians require access to accurate, clinically relevant data. Inaccurately recorded and unfiltered data does not benefit patient care.
Clinical patient care
Management of patient records. EMR systems allow physicians to quickly access and manage patient data in an organized fashion (e.g., search, sort and retrieve data, spot trends, or flag charts). This leads to more efficient practices and enhances care delivery.
Referrals and patient summaries. The ability to transmit referral requests and reports electronically using an EMR greatly facilitates the consultation process. Core clinical data sets generated from the EMR can be used to share or hand off patient care among providers, facilitating both continuity of care and emergency access to relevant data.
Drugs and lab reports. Physician use of an EMR permits drug and lab data to be recorded and shared more accurately and efficiently. Benefits to patient care include automated prescription renewals, quick identification of patients affected by drug alerts, and collation of lab data to show trends.
Decision support. EMR adoption in ambulatory clinical practice makes clinical decision support (i.e., access to timely, appropriate, evidence-based information) possible at the point of care. This has the potential to enhance patient safety, care delivery and health outcomes.
Patient values and autonomy. Patient values and autonomy cannot become secondary to the "data management" requirements of the EMR. An EMR must provide the same (or better) standards of patient confidentiality as traditional paper-based records.
Accessibility. Patient data must always be collected and stored in an EMR with the primary goal of improving individual patient care. Data accessibility for clinical care is more important than compiling a large common data set.
Standardized data. Primary care is driven by symptoms, not diagnoses, and both must be recorded in the EMR in a standardized way.
Clinical coding. Primary care disorders are low-prevalence and will require a high degree of precision when data are coded.
Evidence-based care models. The episode-of-care data model demonstrates how symptoms and symptom clusters evolve over time. It is possible to derive the sensitivity and specificity of symptoms and symptom clusters to improve pre-test likelihood and avoid unproductive testing.
Core and aggregate data. Standardized data means that core data sets can be combined, and their aggregation allows identification and analysis of rarer conditions.
Principles concerning physician information (CMA policy – approved June 2002)
In an environment in which the capacity to capture, link and transmit information is growing and the need for fuller accountability is being created, the demand for physician information, and the number of people and organizations seeking to collect it, is increasing.
Physician information, that is, information that includes personal health information about and information that relates or may relate to the professional activity of an identifiable physician or group of physicians, is valuable for a variety of purposes. The legitimacy and importance of these purposes varies a great deal, and therefore the rationale and rules related to the collection, use, access and disclosure of physician information also varies. The Canadian Medical Association (CMA) developed this policy to provide guiding principles to those who collect, use, have access to or disclose physician information. Such people are termed “custodians,” and they should be held publicly accountable. These principles complement and act in concert with the CMA Health Information Privacy Code (1), which holds patient health information sacrosanct.
Physicians have legitimate interests in what information about them is collected, on what authority, by whom and for what purposes it is collected, and what safeguards and controls are in place. These interests include privacy and the right to exercise some control over the information; protection from the possibility that information will cause unwarranted harm, either at the individual or the group level; and assurance that interpretation of the information is accurate and unbiased. These legitimate interests extend to information about physicians that has been rendered in non-identifiable or aggregate format (e.g., to protect against the possibility of individual physicians being identified or of physician groups being unjustly stigmatized). Information in these formats, however, may be less sensitive than information from which an individual physician can be readily identified and, therefore, may warrant less protection.
The purposes for the use of physician information may be more or less compelling. One compelling use is related to the fact that physicians, as members of a self-regulating profession, are professionally accountable to their patients, their profession and society. Physicians support this professional accountability purpose through the legislated mandate of their regulatory colleges. Physicians also recognize the importance of peer review in the context of professional development and maintenance of competence.
The CMA supports the collection, use, access and disclosure of physician information subject to the conditions outlined below.
Purpose(s): The purpose(s) for the collection of physician information, and any other purpose(s) for which physician information may be subsequently used, accessed or disclosed, should be precisely specified at or before the collection. There should be a reasonable expectation that the information will achieve the stated purpose(s). The policy does not prevent the use of information for purposes that were not intended and not reasonably anticipated if principles 3 and 4 of this policy are met.
Consent: As a rule, information should be collected directly from the physician. Subject to principle 4, consent should be sought from the physician for the collection, use, access or disclosure of physician information. The physician should be informed about all intended and anticipated uses, accesses or disclosures of the information.
Conditions for collection, use, access and disclosure: The information should:
be limited to the minimum necessary to carry out the stated purpose(s),
be in the least intrusive format required for the stated purpose(s), and its collection, use, access and disclosure should not infringe on the physician’s duty of confidentiality with respect to that information.
Use of information without consent: There may be justification for the collection, use, access or disclosure of physician information without the physician’s consent if, in addition to the conditions in principle 3 being met, the custodian publicly demonstrates with respect to the purpose(s), generically construed, that:
the stated purpose(s) could not be met or would be seriously compromised if consent were required,
the stated purpose(s) is(are) of sufficient importance that the public interest outweighs to a substantial degree the physician’s right to privacy and right of consent in a free and democratic society, and
that the collection, use, access or disclosure of physician information with respect to the stated purpose(s) always ensures justice and fairness to the physician by being consistent with principle 6 of this policy.
Physician’s access to his or her own information: Physicians have a right to view and ensure, in a timely manner, the accuracy of the information collected about them. This principle does not apply if there is reason to believe that the disclosure to the physician will cause substantial adverse effect to others. The onus is on the custodian to justify a denial of access.
6. Information quality and interpretation: Custodians must take reasonable steps to ensure that the information they collect, use, gain access to or disclose is accurate, complete and correct. Custodians must use valid and reliable collection methods and, as appropriate, involve physicians to interpret the information; these physicians must have practice characteristics and credentials similar to those of the physician whose information is being interpreted.
7. Security: Physical and human safeguards must exist to ensure the integrity and reliability of physician information and to protect against unauthorized collection, use, access or disclosure of physician information.
8. Retention and destruction: Physician information should be retained only for the length of time necessary to fulfill the specified purpose(s), after which time it should be destroyed.
9. Inquiries and complaints: Custodians must have in place a process whereby inquiries and complaints can be received, processed and adjudicated in a fair and timely way. The complaint process, including how to initiate a complaint, must be made known to physicians.
10. Openness and transparency: Custodians must have transparent and explicit record-keeping or database management policies, practices and systems that are open to public scrutiny, including the purpose(s) for the collection, use, access and disclosure of physician information. The existence of any physician information record-keeping systems or database systems must be made known and available upon request to physicians.
11. Accountability: Custodians of physician information must ensure that they have proper authority and mandate to collect, use, gain access to or disclose physician information. Custodians must have policies and procedures in place that give effect to the principles in this document. Custodians must have a designated person who is responsible for monitoring practices and ensuring compliance with the policies and procedures.
(1) Canadian Medical Association. Health Information Privacy Code. CMAJ 1998;159(8):997-1016.
SCOPES OF PRACTICE
This policy outlines the principles and criteria that are important for physicians to consider when they are involved in the determination of the scopes of practice of physicians and other health care providers, whether regulated or unregulated, in all settings.
The primary purposes of scopes of practice determinations are to meet the health care needs and to serve the interests of patients and the public safely, efficiently, and competently.
There are many factors impacting the scopes of practice of health providers: broadening definition of health, emerging use of alternative therapies, increasing patient consumerism, advances in technology and in treatment and diagnostic modalities, information technology, legislation, changing demographics, increasing health care costs, and the shortage of physicians, nurses and other providers. Scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities. These factors and related issues (e.g., access, availability and cost) are influencing
governments and other stakeholders to consider new roles and expanded scopes of practice for health care providers.
There is a need to define principles and criteria for understanding and articulating scopes of practice that ensure public safety and appropriate utilization of provider skills.
Principles for determining scopes of practice
Focus: Scopes of practice statements should promote safe, ethical, high-quality care that responds to the needs of patients and the public in a timely manner, is affordable and is provided by competent health care providers.
Flexibility: A flexible approach is required that enables providers to practise to the extent of their education, training, skills, knowledge, experience, competence and judgment while being responsive to the needs of patients and the public.
Collaboration and cooperation: In order to support interdisciplinary approaches to patient care and good health outcomes, physicians engage in collaborative and cooperative practice with other health care providers who are qualified and appropriately trained and who use, wherever possible, an evidence-based approach. Good communication is essential to collaboration and cooperation.
Coordination: A qualified health care provider should coordinate individual patient care.
Patient choice: Scopes of practice should take into account patients' choice of health care provider.
Criteria for determining scopes of practice
Accountability: Scopes of practice should reflect the degree of accountability, responsibility and authority that the health care provider assumes for the outcome of his or her practice.
Education: Scopes of practice should reflect the breadth, depth and relevance of the training and education of the health care provider. This includes consideration of the extent of the accredited or approved educational program(s), certification of the provider and maintenance of competency.
Competencies and practice standards: Scopes of practice should reflect the degree of knowledge, values, attitudes and skills (i.e., clinical expertise and judgment, critical thinking, analysis, problem solving, decision making, leadership) of the provider group.
Quality assurance and improvement: Scopes of practice should reflect measures of quality assurance and improvement that have been implemented for the protection of patients and the public.
Risk assessment: Scopes of practice should take into consideration risk to patients.
Evidence-based practices: Scopes of practice should reflect the degree to which the provider group practices are based on valid scientific evidence where available.
Setting and culture: Scopes of practice should be sensitive to the place, context and culture in which the practice occurs.
Legal liability and insurance: Scopes of practice should reflect case law and the legal liability assumed by the health care provider including mutual professional malpractice protection or liability insurance coverage.
Regulation: Scopes of practice should reflect the legislative and regulatory authority, where applicable, of the health care provider.
Principles and criteria to ensure safe, competent and ethical patient care should guide the development of scopes of practice of health care providers. To this end, the CMA has developed these principles and criteria to assist physicians and medical organizations when they are involved in the determination of scopes of practice.
The CMA welcomes opportunities to dialogue with others on how scopes of practice can be improved for the benefit of patients and society in general.