Certification of Primary Care Electronic Medical Records

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system funding and certification programs dating back nearly a decade. In addition, in 2001 Canada established a national health information agency, Canada ...

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Trends in Product Certification, Standardization and Interoperability

Certification of Primary Care Electronic Medical Records Lessons Learned from Canada Mark Dermer and Matthew Morgan

Keywords Electronic medical records, Canada, certification, physician adoption, meaningful use.

Abstract Understanding international approaches to certification of electronic medical records (EMRs) in an effort to achieve widespread meaningful use is particularly timely. Canada’s 34,000 primary care doctors cover a population of 33 million in 13 jurisdictions. A recent survey suggested only 14 percent of Canadian doctors are utilizing EMRs in a clinically meaningful way. In order to accelerate EMR adoption, most jurisdictions have initiated EMR programs. The objectives of these programs are to 1.) certify EMRs to ensure they meet needs for high quality care delivery; 2.) provide funding for EMR acquisition, implementation and support; 3.) supply services to assist with EMR purchase and implementation; and 4.) measure adoption and impact of EMR use. In this article we review the impact of certification on the advancement of EMR use in Canada and discuss both the benefits that these programs have provided and the challenges that they have posed.

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he American Recovery and Reinvestment Act, passed into law in February 2009, includes funding for an unprecedented investment in electronic health information systems. Much of this investment will be through federally funded health insurance programs that will introduce financial incentives for physicians and hospitals that implement information systems and sufficiently integrate these systems into care processes to achieve “meaningful use.” To earn the incentives, health providers must meet specific criteria that include the use of certified health information system products. Canada has several provincial electronic health information system funding and certification programs dating back nearly a decade. In addition, in 2001 Canada established a national health information agency, Canada Health Infoway, with a clear mandate to achieve “better care through timely access to secure health information when and where it’s needed.”1 However, despite an early start in initiatives to accelerate the adoption of electronic records in healthcare, Canada ranked last in proportion of primary care doctors who have “advanced electronic health information capacity” in Commonwealth Fund studies from 2006 and 2009.2,3 Given the lack of results, we set out to examine the electronic health information system adoption programs in volume 24 / number 3 SUMMER 2010 jhim n

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small exceptions, healthcare insurance programs are controlled by provinces and territories rather than by the federal government. Second, and despite the primary provincial/territorial jurisdiction, the federal Canada Health Act of 1984 provides a set of five fundamental rules that provinces and territories must adhere to in order to qualify for significant federal contributions to the provincial/territorial programs: public administration, universality (includes all citizens), comprehensiveness, accessibility and portability (within Canada).5 While approximately 30 percent of healthcare services and treatments are funded by individuals and supplemental private insurance, universal public insurance covers virtually all physician and hospital expenses and also covers most medications for persons 65 years and over and persons who require income assistance. While Canadian doctors receive nearly all of their clinical revenues from provincial and territorial insurance plans, the majority of physicians are in private practice. Primary care doctors have historically been paid by a fee-for-service system but increasing numbers participate in “blended” payment plans that combine capitation, fee-for-service, incentives for outcomes and support for continuing education. Payments that doctors receive for their clinical services are gross revenues from which the doctor pays for office staff, rent, supplies and equipment, including information systems. Though a shrinking number of physicians are in solo practice, Canadian group practices are smaller than in the neighboring US. In Canada, groups are considered large when they have more than 10 physicians. There are only a handful of practices in the entire country that are groups of more than 30 doctors. The smaller “mom and pop” size of Canadian practices is at least partly due to the fact that management of billings is extremely simple in its single payer system, which means that there is little need to gain economies of scale in administration. However, the small size of practices is now regarded as a barrier to adoption of EMRs, since the average group practice’s size and collected expertise is not sufficient to efficiently undertake the financial and time investment to implement electronic medical records.

Table 1: High-level overview of provincial and territorial programs.

Canada and specifically the certification of primary care electronic medical records (EMRs) in an attempt to determine what lessons can be learned from the Canadian experience thus far. In a recently published review, Doucette and Ludwig examined a number of international and Canadian provincial programs that certify primary care EMRs.4 Based on a literature review supplemented by communication with key informants within the certification programs, the authors made several recommendations regarding the structure of such programs and the mechanisms that they should use to both evaluate systems and flow funds to physicians. In contrast, this article will examine only Canadian certification programs and will draw upon interviews with a wide variety of stakeholders to get a broad range of viewpoints on the progress and pitfalls of Canada’s initiatives to date.

HEALTHCARE DELIVERY IN CANADA The organization and delivery of Canadian healthcare derives from two essential facts. First, the Canadian constitution defines healthcare as primarily a provincial/territorial jurisdiction, so with some 50

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ELECTRONIC MEDICAL RECORD SYSTEMS IN CANADA Canada Health Infoway is a federal agency whose mandate is to accelerate the adoption of electronic health records in healthcare. www.himss.org

to encourage physicians to adopt EMRs. Though Canada’s overall rate of advanced use lags other nations as highlighted in the Commonwealth Fund surveys of 2006 and 2009, the programs appear to have been successful at increasing the initial rate of EMR adoption. Jurisdictions with such programs have higher adoption rates than those without, and those with the longest-standing programs also have higher rates than provinces that introduced them more recently, see Table 1. There are four elements that are common to all provincial EMR adoption programs: 1. Funding to partially cover the cost of acquiring, implementing and maintaining certified EMRs. 2. Expert support to assist physicians with the transition from paper records to electronic records. 3. Certification of EMRs. 4. Evaluation of the program’s effects. While there is broad agreement on the benefit of funding and expert support, the area of EMR certification has been more controversial. This is because certification involves setting standards for complex information management systems and evaluating EMRs against these standards. Furthermore, the stakeholders that are engaged in the certification process – providers, payers and product vendors—have interests that are not always fully aligned. The result has been considerable variation in how these programs are structured and operate.

Table 2: Two approaches to provincial EMR certification in Canada.

Since 2001 it has received over one billion dollars in funding to distribute as a strategic co-investor with provinces and territories for selected projects in the areas of drug, laboratory, diagnostic imaging, telehealth and client and provider registries. The overall collection of projects is managed with a view to preventing wasteful duplication of pilot initiatives and broadly sharing project findings among the jurisdictions so that they can avoid needlessly spending time and money “reinventing the wheel.” In addition, Infoway also funds and manages the Standards Collaborative, the national body that develops and certifies standards for health information storage and exchange. However, despite the sound mandate and approach, Infoway has had difficulty achieving its goals. This is at least partly due to the fact that the provinces and territories, who are Infoway’s ultimate owners and who appoint its board members, place significant restrictions on Infoway’s powers and authority. In addition to Infoway at the federal level, each provincial and territorial government has its own “eHealth” infrastructure that is either within the ministry of health or under its authority. These provincial and territorial entities work to build information systems capacity within their jurisdiction, particularly in the area of clinical data repositories and registries, often with the assistance of Infoway funding. The provinces and territories are also responsible for any existing EMR funding and certification programs that exist to advance the use of information systems by physicians, particularly primary care doctors. Over the past year, several Canadian eHealth programs have been criticized by independent public audits for both lack of progress and poor organization of their initiatives.6-10 Canadian adoption of EMRs thus far appears to adhere to a recognized “adoption curve”: first are the pioneers, followed by early adopters, then the early majority, the late majority and finally the laggards.11 Nearly all Canadian jurisdictions are in the early adopter or early majority phase of overall EMR use, though advanced, meaningful use lags considerably behind.

CANADIAN PROGRAMS TO ACCELERATE PHYSICIAN ADOPTION OF EMRs To date, several Canadian provinces have developed programs www.himss.org

CANADIAN EMR CERTIFICATION PROGRAMS–TWO APPROACHES EMR Certification programs in Canada follow two distinct approaches, see Table 2. The first, which we’ll refer to as “top of the class” limit the number of certified products to the top scoring EMRs based on functional, technical, usability and interoperability specifications. The second, which we’ll refer to as “passing grade” sets minimum specification criteria which EMRs must meet as a prerequisite for provincial certification. In both approaches EMRs are formally assessed by the provincial certification organization, however in the “top of the class” approach only the highest scorers, usually between two and six EMRs, are invited to enter into contract negotiations for provincial certification. For specification development and minimum criteria definition, several provinces use a version of EMR specifications developed in British Columbia and revised by a Canada Health Infoway working group on Physician Office System Requirements (POSR).12 However, provinces are not mandated to use any national standards; common specification criteria; the same scoring system; or standardized procurement processes. As a result each provincial EMR certification process is unique and vendor products that score high in one province have been eliminated in other provinces. Reasons for this inconsistency include unique provincial volume 24 / number 3 SUMMER 2010 jhim n

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procurement policies, technicalities, variability in vendor performance and possible political interference. The rationale for the “top of the class” approach, which limits EMR choice, was to create a marketplace where vendors can achieve client “critical mass” and thus increase the long-term business viability for those vendors as well as increasing physician purchasing confidence and mitigating future risk of EMR replacement from bankrupt vendors. The top of class approach was also intended to lower total cost of ownership and accelerate EMR adoption through economies of scale (i.e., hardware purchases); fewer interfaces/health information exchange requirements; and lower implementation, training and support costs. The issue of critical mass was particularly important in smaller provinces: While Canada’s four most populous provinces–Ontario, Quebec, British Columbia and Alberta–all have at least 3.7 million residents and 7,000 physicians, Canada’s remaining six provinces and three territories have populations of fewer than 1.1 million residents and 2,200 physicians, markets that are too small to support more than a few EMRs. The rational for the “passing grade” approach was recognition that the marketplace had not yet declared itself, that product innovation was critical to long term success and that market forces should prevail. In order to increase physician purchasing confidence passing grade certification programs provide regularly updated information on vendor market share.13 This information helps guide EMR buyers but does not provide information on business strength or provide details regarding relative performance of certified products on evaluation criteria. Currently the “passing grade” approach is only used in Ontario, Canada’s largest jurisdiction (13 million residents and 23,000 physicians), which offers enough potential clients for several vendors to achieve critical mass. As highlighted in Table 1, funding of certified EMRs in Canadian provinces is not linked to meaningful use. The goal is to provide funding for certified EMRs so that more physicians will take the first step on the EMR journey. As a result more Canadian primary care doctors have computers on their desktops loaded with EMR software accompanied by broadband internet access. But only fourteen percent of Canadian doctors are using EMRs with “advanced electronic health information capacity”, a definition that is functionally similar to meaningful use. Furthermore, no Canadian doctor has been able to practice medicine without relying on many paper-based care processes and no Canadian province has yet quantified the EMR benefits in terms of improved primary care delivery and patient outcomes from a health system perspective. Though physicians, payers and product vendors share common goals in EMR certification—clear ground rules and higher likelihood of successful implementations – there are conflicting perspectives both between and within these groups on the positive and negative effects of each of the two approaches to EMR certification in Canada. The passing grade approach offers the widest range of choice. This is favored by many physicians and vendors as it allows

market forces to pick the winners and losers. Assuming that the process for setting the minimum standard is sound, the available products will compete for business on the basis of their quality and service. However, payers are concerned that the passing grade approach leads to negotiating contracts and health information exchange requirements with too many companies. In addition, payers and a significant number of physicians worry that the passing grade approach leads to an excessively fragmented market that will eventually require consolidation, leading to major disruptions for those physicians who are forced to migrate to a new EMR when their vendor fails re-certification or is acquired by a competitor.

Despite an early start in initiatives to accelerate the adoption of electronic records in healthcare, Canada ranked last in proportion of primary care doctors who have ‘advanced electronic health information capacity.’

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Experience informs this perspective: Canada’s first EMR certification program in Alberta used the passing grade approach and evaluation of that experience led the Alberta government to replace the original program with a top of the class approach. At the same time, in Ontario, the one Canadian province that still uses a passing grade approach, the leading vendor has nearly fifty percent of the market, more than the next six vendors combined, which is taken as evidence that the market is able to effectively pick winners and create a strong consolidating force. In contrast, the top of the class approach is significantly preferred by payers. They maintain that as long as there is choice, even among as few as two or three vendors, there is sufficient competitive drive to continuously improve products and service. It has also provided the opportunity for bulk hardware purchasing, decreased interface and health information exchange requirements; and lowered implementation, training and support costs. However, even the EMR market leaders, who might be expected to favor initiatives that exclude weaker players, are opposed to the top of class approach due to fact that the results of certification assessments have been inconsistent, calling into question the objectivity and rigor of these initiatives across the country. For these same reasons, most physicians are mistrustful of top of the class approaches and some physicians have elected to forgo the funding and support and implement non-certified EMRs. Concerns about the assessment and certification process are common to both approaches. Regardless of the approach, if the program sets a standard for “pass” that is too high it can lead to less choice than intended. There is also experience for this phenomenon: Ontario evaluated several submissions for a top of the class program for Application Service Provider (ASP) EMRs and sought to select three products. However, only a single vendor met the minimum requirement (in a subsequent tender Ontario chose two additional ASP EMR offerings). Even if this particular certification had been one that www.himss.org

most informants voiced that programs currently “certify the wrong things.” At present, nearly all programs focus on the internal functionality of the EMR product. While this does assure that prospective EMR buyers do not purchase a system that is inadequate for running a primary care practice, our informants felt that it does not adequately address at least four other issues: health information exchange (HIE), data codification, usability and ability to contribute to measurably improving patient outcomes. There are ongoing debates about these issues throughout the health informatics community and all jurisdictions in Canada. Regarding HIE, certification programs have included some requirements in their specifications. However, because most jurisdictions have over-promised and under-delivered in their provision including laboratory and drug information systems to which EMRs can exchange information there are few instances where such exchange can be tested and many where there are no final specifications. As such, product vendors complain that they have no target at which they can aim and are committing their resources to HIE specifications that are in constant flux. Furthermore there has been little consideration of provider-to-provider HIE requirements to support common care processes such as specialist referral, hospital discharge planning and provider communication across the continuum of care. This also extends to HIE requirements to enable patients’ access to their own records. Data coding continues to be a challenging issue, independent of the requirements for EMR certification. As in many other countries, conflict exists in Canada regarding this question between clinicians on the one hand and researchers and payers on the other. The latter understandably seek to have the highest possible data quality, something that unstructured narrative, which is still the standard form for recording encounters, cannot provide. However, physicians feel that coding must not become a burden that impedes their workflow during clinical care. This tension between codifiable data and efficient clinical care delivery remains unresolved but negotiating this issue is a crucial step to setting standards that can clearly address data coding, which is a prerequisite to system wide performance measurement, continuous quality improvement and population-based analytics. Usability is another continuing challenge. Most EMR certification programs explicitly avoid usability standards because they are difficult to define. Many feel that there is no clear evidence as to what targets to set for the primary interface between the clinician and the EMR. Some believe that the marketplace is better suited to making this choice. However, there are also those who feel that many physicians are seduced by product demonstrations that emphasize ease of initial learning rather than ease of expert and meaningful use. The ability to improve patient and population outcomes is the true

Table 3: The impact of certification from several perspectives.

used a passing grade, the result would have been the same. Thus, it may be that the debate about the relative merits of the two approaches is less important than a discussion about what should constitute the minimum acceptable requirements. The one remaining stakeholder, the patient, has not been represented in the discussion about the two approaches to EMR certification. This is because from the patient’s perspective, neither approach to EMR certification is visible as no provincial EMR program has assessed patient specific EMR requirements in a meaningful way.

CURRENT PERSPECTIVES ON CANADIAN EMR CERTIFICATION PROGRAMS Beyond the issues surrounding the two distinct approaches to EMR certification is the more significant question of what can be learned from the Canadian experience with EMR certification programs. To inform our discussions we spoke with a wide variety of informants – physicians, product vendors, payers and researchers – to get their opinions on three key questions: To what degree have provincial EMR certification programs in Canada contributed to advancing adoption? What are the current challenges for EMR certification programs? Should we move from provincial to federal certification and if so, why? Many informants believe that provincial certification programs have contributed somewhat to advancing EMR adoption in Canada through the provision of funding and implementation support. That is, if EMR certification is not accompanied by money with which to buy the certified products, physicians will generally not find the “seal of approval” sufficient to overcome any hesitation to acquiring an EMR. Some respondents felt that the certification programs were actually counterproductive at times. According to those with whom we spoke, there are instances where physicians put too much faith in certification, leading them to neglect the necessary due diligence required to choose the best EMR for their practice. In addition, several informants felt that the programs have neither set appropriate standards nor properly executed product assessments, leading to physician skepticism. In response to our question about current challenges for EMR certification programs, three common themes emerged. First, www.himss.org

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endpoint by which any health information system including EMRs should be measured. While some Canadian EMR adoption programs attempt to measure benefits, none have been able to credibly identify improvement thus far. Some argue that outcomes measures should be the basis for additional funding for primary care doctors—pay for performance—rather than funding tied to certified EMR products, particularly since this approach has appeared to work in the United Kingdom with the Quality Outcomes Framework (QOF).14 However, at present there are very few provincial payers that reward outcomes and those that do only measure a few preventive and screening maneuvers. The second theme that was common to most of our responses to the question regarding current EMR certification challenges was the fact that the process is too slow and complex. The result is confusion for physicians who are looking to acquire EMRs and financial stress for product vendors while awaiting the opening of the marketplace. While payers obviously want to be sure that the process is carried out diligently, many feel that certification programs are too prescriptive about how products should meet clinical endpoints, leading to extremely detailed specifications that guarantee functional capability but not usability and improved outcomes. In addition, the significant variation in which products are chosen in competitions that use very similar specifications (derived from Infoway’s POSR) calls into question the process by which products are evaluated. Finally, the third and most common theme that we heard in response to challenges was that there are too many programs and that all parties would be better served by replacing jurisdictional certification with a national program. Though this response preempted the final question about whether or not there should be a federal program, there was some qualitative variations in the answers that merits review. Almost all respondents supported a move to a federal program, in theory, but there were several qualifications. As noted earlier, Canada Health Infoway continues to struggle against limitations placed upon it by provincial/territorial constitutional jurisdiction over health matters. For a federal EMR certification program to be successful, the jurisdictions would have to be prepared to negotiate a framework and agree to abide by it, something that has been historically very challenging for Canada’s public health sector. Some of our informants feared that supporting a federal certification standard might lead to an additional requirement rather than one that replaces the provincial approach. Furthermore, there were concerns expressed about which entities would set standards and perform the evaluations. In particular, some felt that setting standards and certifying products against those standards should be performed by two separate entities. Finally, others wondered whether even properly authorized and structured entities would be able to avoid mistakes that have been observed at the provincial level.

is contingent on using a certified product. The adoption programs also provide local expert support to assist primary care practices with the transition from paper records to electronic records. Criticisms of the certification process focus on the fact that the criteria for certification are focused on functionality for primary care processes without adequate consideration of efficiency, health information exchange with systems beyond the EMR and data codification, In addition, most programs limit the number of products in order to overcome phenomena of small, fragmented markets. In summary, the Canadian provincial programs appear to respond to two concerns: 1.) that physicians can be too easily persuaded to buy products that fail to meet the most basic requirements; and 2.) that the organization of Canadian healthcare cre-

Regardless of what form US certification of EMRs take and how meaningful use is ultimately defined, all who are involved in the process of accelerating the use of EMRs must recognize that …financial incentives for physicians must be sufficient to convince them to take both the big first step and all subsequent steps along the EMR journey.

THE ROLE OF CERTIFICATION PROGRAMS Certification of EMRs in Canada is one of the four components of most EMR adoption programs and available funding for physicians 54

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ates small jurisdictional marketplaces that can ultimately support only very few products and that cannot afford the gradual and painful evolution that an open market would bring. In contrast, the United Kingdom has achieved very high levels of “advanced electronic health information capacity” (meaningful use) without relying on programs dedicated to accelerating adoption of EMRs. Instead, they have used the QOF as the basis for providing substantial additional revenues to primary care doctors. Since the QOF targets can only be efficiently achieved with comprehensive information systems, EMRs have been adopted as a means to an outcomes end. As a result, there is no need for exhaustive certification standards; products either meet clinicians’ needs to efficiently earn outcome-based revenues or they have no future in the marketplace. Although there is interest in outcome-based funding in Canada, it remains elusive, in part because there appears to be a lack of recognition that meaningful use of EMRs is a prerequisite for efficient and affordable population-based health outcomes reporting. Nevertheless, some Canadian provinces tie some EMR funding to rudimentary meaningful use: Ontario offers a small bonus when a certain proportion of charts are converted to electronic, B.C.’s maintenance funding is contingent upon converting all charts to electronic, and in Saskatchewan there is a supplemental fee for each encounter that is recorded in the EMR. In the US, EMR certification will be tied to the requirement that the physician prove meaningful use of the EMR in order to earn funding in the form of reimbursement. From our reading of the proposed US requirements, meaningful use is a concept that www.himss.org

is clinically valid and which places emphasis on EMR capabilities—functional, interoperable and usable—that will improve the efficiency and safety of care delivery and improve both individual patient and population-based outcomes. It also includes key requirements designed to further engage patients as informed decision-makers.

CONCLUSION The current US national dialogue on defining meaningful use criteria and reconsidering initial targets is appropriate and productive. Physicians and health informatics professionals are engaged in this dialogue with payers, policy makers, product vendors, certification agencies, politicians and patients. Both this multi-party and national leadership, and the meaningful use framework are grounded in sensible health outcome-driven goals that hold promise to truly transform the delivery of primary care in the US, a promise that is lacking in Canada’s EMR certification journey so far. In order to benefit from the quality, safety and efficiency improvements that can only be achieved by high rates of meaningful EMR use, we hope that the US EMR certification approach will not make the same mistakes that we have experienced in Canada. In addition, the US must overcome challenges that Canada has not has not even attempted to address. First, it must balance the desire to demonstrate meaningful use in multiple dimensions against the provider work effort required to prove such meaningful use. The burden of meaningful use must not impede the doctor’s desire to transition from paper to electronic health information management nor render them less efficient once the transition is complete. Second, it must enforce a national approach to meaningfully useful health information exchange requirements based on industry standards. Finally, it must deal with the certification of an EMR market that is significantly more crowded and fragmented than Canada’s, though with a critical mass that other nations envy.

References 1. Canada Health Infoway. The Infoway Vision. Available at: http://www.infowayinforoute.ca/lang-en/about-infoway. Accessed on February 23, 2010. 2. Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: primary care doctors’ office systems, experiences, and views in seven countries. Health Affairs. Web Exclusive, November 2006: w555-w571. 3. Schoen C, Osborn R, Doty M, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in 11 countries, 2009: perspectives on care, costs, and experiences. Health Affairs. Web Exclusive, November 2009: w1171–w1183. 4. Ludwick DA, Doucette J. A review of general practice system certification programs in seven countries and five Canadian provinces. Healthcare Quarterly. 2009; 12(3): 111-123.

Regardless of what form US certification of EMRs take and how meaningful use is ultimately defined, all who are involved in the process of accelerating the use of EMRs must recognize that to achieve rapid, broad and sustainable physician adoption, financial incentives for physicians must be sufficient to convince them to take both the big first step and all subsequent steps along the EMR journey. Without a clear business case for meaningfully using EMRs for better care delivery and improved health outcomes, very few doctors will choose to sacrifice the considerable time and effort to make the transition. The US is poised to move forward with the adoption of primary care EMRs in a sensible way that has the potential to be rapid, broad and a means to achieve greater benefits and a faster return on investment than has been achieved in Canada. Meaningful use is not only the primary goal for EMR adoption, it is also essential to health system sustainability and can serve as a powerful inductive force for the other key components of comprehensive nationwide health informatics infrastructure.

ACKNOWLEDGEMENTS Special thanks to Steven Anderson, Allen Ausford, Allan Brookstone, Brendan Byrne, Brian Forster, MaryLyn Fyfe, Andrew Grant, Bill Haver, Karim Keshavjee, Stephen McLaren, Bill Pascal, Morgan Price, Denis Protti, Roy Robb, Nicki Shaw, and Norman Yee for their contribution to this paper. Also special thanks to Cahyee Cheung for project management and editorial support. JHIM Mark Dermer is a family physician, Lead Physician of the Central Ottawa Family Health Organization, Assistant Professor of Family Medicine at the University of Ottawa and an independent management consultant. Matthew Morgan is a Partner at Courtyard Group, Staff Physician at University Health Network and Adjunct Professor, University of Toronto in the Department of Medicine.

8. Office of the Auditor General of Alberta. October 2009: Report of the Auditor General of Alberta. Edmonton, AB: Office of the Auditor General of Alberta; 2009. 9. Office of the Auditor General of Nova Scotia. February 2010: Report of the Auditor General: Chapter 2 – Electronic Health Records. Halifax, NS: Office of the Auditor General of Nova Scotia; 2010. 10. Office of the Auditor General of Canada. Fall 2009: Report of the Auditor General of Canada to the House of Commons: Chapter 4 – Electronic Health Records. Ottawa, ON: Office of the Auditor General of Canada; 2009. 11. Rogers EM. Diffusion of Innovations. New York: Free Press; 1962. 12. Canada Health Infoway. Annual Report 2008/2009: Building a Healthy Legacy Together. Toronto, ON: Canada Health Infoway; 2009.

5. Department of Justice Canada. Canada Health Act (R.S., 1985, c. C-6).

13. Ontario MD. OntarioMD Funding Eligible EMR Offerings. Available at: https:// www.emradvisor.ca/compare. Accessed on February 23, 2010.

6. Office of the Auditor General of Ontario. Special Report October 2009: Ontario’s Electronic Health Records Initiative. Toronto, ON: Office of the Auditor General of Ontario; 2009.

14. Department of Health. Quality and Outcomes Framework. Available at: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/ DH_6618. Accessed on February 23, 2010.

7. Office of the Auditor General of British Columbia. Electronic Health Records Implementation in British Columbia: 2009/2010. Report 9. Victoria, BC: Office of the Auditor General of British Columbia; 2010.

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