EMRs & Physicians
EMRs make entering, storing and retrieving patient information faster and more secure. EMRs also help physicians in shared practice environments provide better, safer care because each physician can access each patient’s vital health information quickly and efficiently.
Today, about 80 per cent of all Alberta physicians use EMRs in their practice.
How do you use your EMR and Netcare?
“Fully Deployed” use needed to enable the Integrated Electronic Patient Record (IEPR)
While we know about 80 per cent of Alberta physicians who provide patient care currently use an EMR at least some of the time, we want to know more about how you use it. Starting with the 2018 Renewal Information Form (RIF), we’ll be asking physicians annually to identify their level of use, as defined below.
Why? To fulfill the promise of the IEPR, all physicians need to be using EMR and Netcare at the “fully deployed” level. Your responses to the RIF questions will help us establish a baseline, measure progress, and determine how best to support physicians along the way.
EMR LEVELS OF USE
Level 1 – Front Office Administration
The EMR is used to support administration of the practice, but not the medical record (e.g., electronic billing, patient scheduling)
Level 2 – Basic Electronic Records
The EMR is used to collect some or all patient information, but is essentially an electronic version of a paper chart without the use of advanced features.
- Entries may include notes, scanned documents and reports.
- Prescriptions and diagnostic orders are handwritten.
- Diagnostic result reports are received electronically.
Level 3 – Fully Deployed EMR
The EMR is used to capture all patient data (i.e. no secondary paper chart) and is the principle method of record-keeping. Data collection is standardized and advanced features of the EMR have been enabled.
- Relevant content is consistently entered as discrete data elements (e.g., problem list, allergies, prescriptions, vital signs, etc.).
- Exact copies of prescriptions and diagnostic orders are maintained (i.e the EMR can replicate or reproduce the details of the order – what tests were included on a requisition, what drug and dosage was prescribed, etc.).
- Diagnostic results are consistently imported as discrete data elements.
- Generally accepted charting and coding standards are used.
- Decision support tools are enabled where appropriate.
Level 4 – Proactive Care / Reflective Practice
The data in the EMR is used to drive enhanced practice management standards.
- Data in the EMR is standardized to enable:
- consistent use of registries, recalls, reminders, templates, and flow sheets to measure and support guideline-informed care
- reporting from the EMR
- The EMR actively supports practice reflection and improvement.
Level 5 – Integrated / Shared Care
Prescribed health information* is collected in the required format using a standardized method, enabling the systematic sharing of data from the EMR to Netcare.
- Data transfer enables effective shared care with patients and between GP, specialists and other care providers.
- Shared care plans are used consistently.
- Patient portals are enabled.
*Prescribed health information is defined in Alberta’s Electronic Health Record Regulation, which also mandates the sharing of this information to Netcare. As the technology to enable this sharing is not currently available, inclusion of this category is for awareness only.
NETCARE LEVELS OF USE
N/A – Non-Clinical Practice
No medical services provided to patients.
Level 0 – No Netcare access
Netcare is not accessible at the practice.
Level 1 – Basic Use
Netcare is accessible at the practice.
- Netcare user-ID and network capability are activated.
- Practitioners are aware of the scope of content available in Netcare relevant to the practice.
Level 2 – Fully Deployed Use
Netcare is accessible at the point of care. A routine process or a defined practice management standard articulates:
- circumstances when Netcare should be used, must be used and may be used
- documentation (copies and/or notes) of relevant Netcare use in the EMR (i.e. PIN opiod dispensing history alters the treatment plan)
- management of observed errors and omissions in Netcare
- management of express wishes of the patient
Level 3 – Integrated/Shared Care
Netcare data and EMR data are integrated and rationalized.
- Netcare data can be imported and integrated into the EMR.
- Shared Netcare profiles are reconciled with EMR profiles (i.e. current medications).