I am writing in response to Dr Jack Burak’s excellent article from April 2005 entitled, “BC’s technologically challenged health care system” (BCMJ 2005;47[3]:128). His points are well taken and I could not be more in agreement.

I spent 6 months working in the far north of New Zealand in the winter of 2001. I rotated about small rural Maori communities doing locum work, and upward of 80% of the offices were fully electronic at that time. In the fall of 2002 after 10 years of locum work, I set up my own practice in Penticton, going fully electronic. Suffice to say that it has been quite a ride. Dr Burak’s point about cost of the system, though, has been my least concerning challenge. At the outset, Wolf Medical Systems, the software vendor, assured me that the cost benefit analysis showed that for saving 15 minutes daily in efficiency, I would have the system pay for itself in a very short period of time. I believe this has come to prove itself true. However, I feel that the following few issues are continued barriers to more widespread implementation of EMR systems.

As a physician who does a fairly large volume of addiction medicine, I prescribe enough methadone to use up one triplicate (now duplicate) pad weekly at times. Since opening my practice 32 months ago, I have filled a large legal-size file drawer with used pads. The problem is that I also have my very precise electronic copies of all of these prescriptions filed and backed up on each patient on my server (behind a costly hardware firewall). Why do we have to keep using these duplicate forms these days with electronic records and the PharmaNet system rendering them obsolete? The only purpose that they serve me is to fill one drawer in my office, and another at the pharmacy’s office. The time that I have invested in filling out all of these forms makes me shudder every week when I pull open that drawer and toss another completed pad into it for the mandatory 7 years. I have had numerous discussions with the College of Physicians and Surgeons about obtaining an exemption from using these duplicate forms, but have been told that this is not possible.

Another beast for us is the seemingly very outdated MediTech software system that the Interior Health Authority is continuing to pour millions of dollars into. It is very difficult to work with, generates absolute mountains of unnecessary paper, and is seemingly incapable of providing us with electronic transfer of information. Consequently, every day my staff spends up to one hour scanning and linking all of the hospital-generated paperwork into the system. Then I have to do a final review, labelling, and linking of these files.

My last big beef is with fax machines. Once a person becomes used to the efficiencies of electronic systems, fax machines become a prickly thorn in your side. The confidentiality factor is abhorrent, as a single digit entry error could send whatever document you are transferring to anyone in the world. Many offices have cheap, inefficient systems that are consequently difficult to send to, and some physicians still share a fax and phone line as one. The result of these shortcomings is that you are often forced in your paperless electronic office to receive a piece of paper, scan it, shred it, create a document from it, print it out, and then deliver it by snail mail or hand. I find e-mail to be a vastly superior form of information transfer, and I believe that the sooner we come to terms with this, the better our patients and we will be served.

On the positive side, I very much enjoy my electronic system, and my patients appear to as well. I believe it considerably lessens the stresses of day-to-day practice for me, and is helping my earning power at the same time. The latest versions of medical voice recognition software systems are so slick that typing issues are no longer a barrier to data entry. I would recommend an electronic office system to any of you considering one, and if the government considers following Alberta’s lead in helping out financially, I sure hope they will not leave out those of us doing all of the pioneering at our own expense.

—Lloyd Westby, MD
Penticton

The College responds

The College applauds Dr Westby for having a medical practice that is fully electronic. The majority of physicians in British Columbia do not share the benefits that Dr Westby enjoys by being fully computerized. In fulfilling its mandate under the Medical Practitioner’s Act, the College often reviews medical records to make determinations regarding the quality of medical care provided by physicians in this province. Registrar staff have a sympathetic understanding of what community pharmacists experience in attempting to decipher illegible handwriting and cryptic notations.

However, Dr Westby is still required to use duplicate prescription pads. There are many safeguards to the duplicate prescription pad that cannot be replicated by generating such prescriptions electronically. Duplicate prescription pads are printed on bank-note quality paper that cannot be photocopied. Each pad has a folio number, which in the event of theft can be tracked to prevent the rest of the prescription pad from being used fraudulently. While not foolproof, the back copy of the duplicate prescription affords pharmacists and physicians the opportunity to review the authenticity of the prescription if fraudulent use or forgery is suspected.

Methadone maintenance physicians do generate a significant volume of duplicate prescription pad copies. Maintaining the copy of the duplicate prescription pad is a valuable tool in audit processes where discrepancies exist in the PharmaNet record or with the pharmacy dispensing record. The College would consider acceptable Dr Westby’s scanning the duplicate copy into his record so that the security function of the record is maintained. Just as he scans in copies of records or investigations, so too could the back copy of the duplicate prescription be scanned into his permanent records.

Members may be interested to know that duplicate prescriptions date back to the times of Prohibition when physicians wrote prescriptions for medicinal alcohol and did so with special prescriptions printed on bank-note quality paper.

—Heidi M. Oetter, MD
Deputy Registrar, College of Physicians and Surgeons of BC

Dr Brookstone responds

As someone who has been intimately involved with information technology for physicians, I can sympathize with the frustrations that Dr Westby highlights. It is important to understand the current state of information technology in health care in British Columbia (and the rest of Canada) in order to provide the correct context for a discussion of the issues raised.

To date, Canada Health Infoway (at a federal level) and the provincial ministries of health have focused on the development of high-level infrastructure projects in order to wire-up the hospitals and regional facilities. Other than Alberta and Ontario, there has been little investment in supporting IT and EMR systems for physicians who practise at a community level. Vendors of hospital-based clinical information systems, such as MediTech, have a large base of organizational customers and have focused on meeting the needs of the institutions. Unfortunately, there has not been a similar focus on the needs of physicians in the community. The need to re-digitize documents and scan and attach these into an EMR system is a significant resource issue as it takes up both the time of the physician and staff and, as Dr Westby points out, the time saved in pulling and filing charts has been converted into time taken in scanning, labelling, and linking files in an EMR. As we see more widespread adoption of EMR in physician offices, at some point we will reach critical mass and the needs of physicians in the community will begin to drive the development of interfaces to and from these large hospital systems. However, these interfaces will also need to be context appropriate. Will physicians want to receive every X-ray report, lab test, and communication related to a specific patient’s inpatient episode, or just selected documents and the discharge summary? These questions need to be answered. It is likely that physicians will need to be able to select which documents they would like to receive in their office EMR system or they will face the same deluge of reports and paperwork as currently exists, the only difference being that the documents will be in digital format.

The second point that I would like to discuss is that of fax machines and e-mail communication. While it is true that many physicians use older fax technology or have a shared phone-fax line, it is also true that the majority of physicians in BC do have access to a fax machine, making it a more universal form of communication. Until we have widespread adoption of EMR, a secure communication infrastructure that will allow secure e-mail communication among health care providers and legislative approval of electronic signatures in Canada, it will not be possible to send communications electronically with any level of efficiency. One analogy is that of the first fax machine—why would anyone buy a fax machine if there was no one to receive faxes at the other end? I am sure we will eventually be able to send documents electronically including prescriptions, consultation letters, and reports. However, these documents will need to be tagged automatically, allowing them to seamlessly arrive in your electronic inbox and be filed in the correct patient record without the need to rename or manually attach the record. Much work needs to be done in this regard.

I am enthusiastic about the progress that is being made in healthcare IT in British Columbia and encourage physicians to raise these issues at a local and regional level to ensure that they are viewed as important by decision- and policymakers.

—Alan J. Brookstone, MD
Richmond