Five months ago I decided to try an experiment – see if it would be possible to set up an Electronic Medical Record (EMR) on a limited budget. OntarioMD provides government funding to physicians who are looking to switch from paper to electronic records but the amount of funding is limited. (I applied in August 2013 and I got approved almost a year later). My question, therefore, was whether it is possible for a physician to set up an EMR independently of government funding. If EMR is the way of the future, why should it need to be heavily incentivized in order to get people to make the switch? If it really is better, then shouldn’t it be faster than paper, easy to maintain, and competitive with paper charts in terms of operating costs?

There are other reasons why I thought this experiment would have social value. Besides physicians who are new into practice, there are other professionals (e.g. naturopathic doctors, independent psychotherapists and counselors) who could use an EMR but who do not have access to funding.

In this series on EMRs, I’ll write about my experience trying to set up an EMR system keeping those three points in mind:

1. Efficiency
2. Operating costs
3. Maintenance

Efficiency is relevant because if the EMR, subsidized or not, is slower to operate than keeping paper charts in a filing cabinet, it does not make sense for the average doctor to make the switch. Yes, there are future visions of big medicine – connecting all of the EMRs in a network that would allow for information sharing and data mining (and government snooping, perhaps?) In the long term that may contribute to better care from a systems / population perspective, but from the perspective of most doctors I would argue that we care primarily about whether it helps us provide better care to the patient in front of us right now. If the record-keeping system slows us down or does not add any short-term benefit, it is not very attractive. If one spends a little bit of time on the online self-help forums or talking to colleagues it does not take long to hear stories about the physician who stays a couple of extra hours at the end of the day to finish typing paperwork, whose appointments run over time because of the extra time it takes to figure out how the prescription module of the software is supposed to work, or who (worst-case scenario) is not able to function at all because the computer is down.

Operating cost is also very important – a doctor could apply for the government funding and wait until it goes through before switching over, but the funding is only for a number of years and after that, the burden of maintenance goes back to the physician. In my mind, that means the EMR had better be easy and cost-effective to maintain after funding runs out, or else we would be foolish to jump on the bandwagon only to be saddled with the burden of maintaining aging computer hardware and continuing to pay service fees that mostly benefit the proprietary software companies and service providers that sprung up when the subsidy gravy was flowing.

Ease of maintenance is closely related to operating cost, but not exactly the same thing. Even if a doctor contracts out the maintenance of the EMR to a third party, the doctor is ultimately responsible for whether or not it works, because we are the ones who bear the consequences if it doesn’t. There are also factors to consider that a third-party service provider is not directly responsible for – the physician’s client computers (the ones used to access the server), the Internet connection, the physician’s time to learn how to use the software and ensure that staff know how to use it. Also, for a solo or small group practice that does not have in-house IT staff, the physician is more than likely going to be the one troubleshooting when there are small problems and therefore (in my opinion) should know how the system works. Consider, as an analogy, commuting to work on a bicycle. Of course, you can take your bike to a shop every time you want it tuned up. Even so, if it breaks down on the road, the rider’s tools and mechanical knowledge make the difference between calling a taxi or walking to work and getting up and riding again.

Next up, we’ll look at the first step in constructing the EMR – selecting the software – keeping the three above points in mind.