The first line of helpdesk support for practices when they are having trouble accessing their EMR application, PPN network and its related services, is their EMR vendor’s helpdesk. This is known as the ‘Tier 1 support’ helpdesk. Your EMR vendor will provide your practice with their helpdesk phone number, its hours of availability and protocols for using it. If the problem you are experiencing is with the PPN network or its related services, the EMR helpdesk will contact the TELUS “Tier 2” helpdesk on your behalf to resolve the problem. The Tier 1 helpdesk is to respond to your practice’s support call according to service levels outlined in your vendor agreement. The service levels set response time targets based on how your support call is made: phone call with analyst, email or voicemail. NOTE: For problems that occur within 5 days of the TELUS router equipment installation, your practice should directly call the TELUS coordinator with whom they have arranged for the router installation. The coordinator will engage the TELUS installation team to expedite problem resolution. Once the five days interval has passed, the problem must be reported to the EMR Tier 1 help desk as per standard procedures.
The EMR Tier 1 helpdesk will triage the technical problem received from your practice and will take the following actions: o If the problem is with the TELUS router equipment at the practice, the PPN Core network, its gateway to the public Internet, or its VPN service, the EMR Tier 1 helpdesk will: o Open a ‘problem ticket’ directly with TELUS Tier 2 support; o Monitor progress on the ticket, and where required, initiate escalation actions; o On resolution, contact the person who logged the problem to ensure it is resolved to their satisfaction, and then inform the TELUS Tier 2 helpdesk their ticket can be closed; o If the problem is with the EMR data centre or application, the EMR Tier 1 helpdesk will open an internal “problem ticket” and resolve it within their support organization; or o If the problem appears to be originating in the practice’s computer environment, the EMR Tier 1 helpdesk will advise the practice to further investigate and resolve the problem with their designated computer support contact. Note that all support calls by your practice to the Tier 1 helpdesk will be counted towards the call limit outlined in your agreement with your vendor. Charges to the practice may apply if the limit is exceeded.
Practices are responsible for organizing the technical support services they require for their local computers, printers and LAN up to the TELUS-provided router equipment. Specifically, this includes: o Local practice computers, laptops, LAN equipment and software, including computer security software (ex. firewall, anti-virus); o Clinical reference tools available on the public Internet or available clinical applications from Health Authorities. The organization managing the tool or application would need to be contacted directly for support; o Laptops or computers outside of the practice (e.g. home) and their Internet connections (e.g. Shaw, TELUS) when used by physicians and staff to remotely connect to the VPN; and o 3rd party email services (e.g. Shaw, Yahoo, Gmail) including configuring laptops or computers to initially access the email service, or other ongoing usage issues. It is recommended that practices contract with a computer support vendor or their EMR vendor for technical support services for their local computer environment. A further breakdown of PPN related support responsibilities is provided in a separate document titled, “EMR and PPN Support Responsibility Matrix” available on the PITO website at www.pito.bc.ca. For questions regarding this support model, please contact your PITO local relationship manager or EMR vendor.
PITO is the Physician Information Technology Office of British Columbia. PITO was set up by the BCMA and BC Government as part of the 2006 Agreement.
PITO's primary responsibility is to support the implementation of electronic medical records in physician offices across BC. PITO will assist physicians during pre-implementation planning, implementation, and will coordinate the disbursement of IT funds to physicians as defined in the Agreement.
There is an additional $20 million in one-time funding to be paid out over the term of the Agreement.
PITO is governed by a six person steering committee, with three practicing physicians appointed by the BCMA and three members appointed by Government. The PITO Steering Committee is responsible for the PITO policies, annual budget, and overseeing the overall delivery of the program. The committee is supported by the PITO Program Director who is responsible for the day-to-day delivery of the program.
PITO considers the privacy and security of patients' personal information to be the utmost priority and will work to achieve the highest possible level of security. PITO is working closely with practicing physicians, the College of Physicians and Surgeons, the BCMA, and the Ministry of Health's privacy office. Both the BC Office of the Information and Privacy Commissioner and the College of Physicians and Surgeons of BC are providing input and oversight to ensure that sound privacy principles and practices are embedded throughout the PITO program, from hardware and software requirements to legal agreements and technical architecture.
Data stored for a practice in a hosted (ASP) EMR will be controlled by the physician following BC privacy legislation and requirements of professional practice.
which includes practising physicians, College representatives, BCMA staff, and Ministry privacy experts, to thoroughly examine all related privacy issues.
Appendix C of the 2006 Agreement included the notion of a "Core Data Set". The concept of the Core Data Set stemmed from the successful Electronic Medical Summary (eMS) pilot project conducted in 2004/5 which facilitated the electronic sending of relevant patient data from one physician to another (e.g. for referral to specialty care) to enhance continuity of care.
The Core Data Set will not be pursued under the 2006 Agreement and reference to it has been removed from the PITO Policies.
ASP stands for "Application Service Provider". An ASP is a company that hosts a client's information system on its computer servers so the client (in this case a doctor) doesn't have to manage the computer servers themselves. This happens regularly in our everyday lives with everything from email (e.g. Hotmail) to online banking records (e.g. online bill payments).
In a physician practice environment, ASP-hosted EMRs are set up in shared data centres and each physician practice has their own secured patient database (as required by Appendix C of the 2006 Agreement). The physician accesses the EMR and their patient files over the secure physician network. This model is in contrast to the "locally hosted" approach in which each physician maintains computer servers in their office to run a separate EMR.
In an ASP model, the physician continues to look after the patient records as the custodian of the record. The physician enters into a contract with the EMR vendor to store the records on the physician's behalf, similar to how physicians do today with companies who maintain their old paper records off site to save space in the office.
EMRs hosted externally on an ASP basis seek to resolve or mitigate many concerns regarding privacy, difficulty of integrating external data on a local EMR, and system maintenance. A few of the key benefits include:
Many physicians need to access their EMR from their home, vacation, hospitals, etc. For technical reasons, access from within hospitals has proven the most complex and frustrating for physicians.
Secure access to an ASP EMR from the hospital environment and elsewhere can be achieved much more reliably than an office-based locally-hosted EMR.
Regardless of where physicians access their EMR, it will retain the same look and feel that they see in their office.
While there are understandably concerns regarding privacy, in many ways an ASP solution enhances the confidentiality of patient records.
The ASP model moves the computer server which stores the patient records into a highly secure data centre run by the physician's EMR vendor, rather than being vulnerable to theft in an empty physician office overnight.
An ASP also hosts the databases in environments which have 24/7 security monitoring, including sophisticated intrusion detection and prevention, compared to the data stored on a less closely monitored server in a physician office.
The ASP model does come with challenges, each of which is being carefully addressed by PITO:
There is a common concern that having records stored off site affects a physician's control over their patient records. Some physicians may not be comfortable with this. However, this is common practice today in both electronic and paper environments and has been reviewed with the College of Physicians and Surgeons.
Paper records are often stored off site to save space in the office, and physicians have been storing their EMRs on ASP servers for several years in other jurisdictions. Many physicians do so today even within B.C.
Across Canada, it is very common for hospitals to store their patient records on 3rd party commercial servers in the equivalent of an ASP model.
The legal contract (licensing & services agreement) for use of the EMR will be solely between the physician and their vendor to ensure that the physician clearly remains the custodian of their patient records. The BCMA and government will not be parties in that legal agreement. The vendor will be clearly accountable to the physician for the secure storage of their patients' files.
Physicians are strongly encouraged to apply to PITO and wait for acceptance into the PITO Implementation & Transition Support Program (ITSP) before proceeding with an EMR implementation. Currently there is no queue for PITO acceptance and in most cases new applications are accepted into the program in less than 1 month. Once a clinic applies to the PITO program, any Hardware purchases are eligible for reimbursement once the new PITO-approved EMR system is live. If there is a delay in acceptance a clinic may implement a PITO Qualified EMR system on their own. Once accepted, PITO will reimburse for the cost of implementation and will start reimbursements for monthly maintenance costs. NOTE: PITO will not reimburse monthly amounts for the time between the Go Live of the new EMR system and acceptance to the PITO program.
Physicians can apply online any time during the year. There are two "enrollment periods" each year:
If space is available, new applicants will be enrolled prior to the next semi-annual enrolment.
All applications are online on the PITO website. See the "apply online" page for more details. You can apply any time.
All independently practising physicians in BC are eligible for the PITO program. This includes GPs and specialists in solo or group practice. The following basic criteria must be met:
*Note: Physicians in alternative payment situations (e.g. salaried, service contracts) will be addressed on an exceptions basis in consultation with the physician and local health authority and can be approved by the PITO Steering Committee.
**Note: For example, some physicians who practice only in a hospital setting will only chart on the hospital record and therefore do not need a separate, ambulatory care EMR)
PITO will provide reimbursement at 70% of actual costs incurred up to the following limits listed below.
In addition, PITO provides an Implementation & Transition Support Program (ITSP) to support physicians at all key steps from when they apply until post-implementation review.
The Request for Proposals process for identifying the PITO-approved EMR products is now complete. Please see the EMR Products page on the PITO website for more information. Funding is also available through the PITO Early Adopter Program for up to 18 months of continued use of an existing EMR, contingent on conversion to a PITO-qualified EMR. The Early Adopter Program is available whether the physician's existing EMR is on the PITO-qualified list or not.
The PITO Steering Committee decided to seek up to six vendors in order to balance, on the one hand, the ability to offer physicians choice of software vendors, and on the other hand, the need to manage the complexity and ongoing viability of the program. In its research of EMR programs in other jurisdictions, the Steering Committee learned from the Alberta experience that approving a large number of vendors to participate in the Physician Office System Program (POSP) introduced significant complexity and risks. For example, interoperability capabilities, such as interfacing with lab results and electronic prescribing, become increasingly difficult with each additional vendor.
Physicians who adopted an electronic medical record system (EMR) prior to the PITO project will have access to ongoing funding on the same 70/30 split basis (70% PITO government, 30% physician) according the the Early Adopter Program guidelines. The Early Adopter Program provides bridge funding for up to 18 months of ongoing use of an existing full clinical use EMR, contingent upon conversion to a PITO-approved EMR by the end of that period.
Physicians are strongly encouraged to apply to PITO and wait for acceptance into the PITO Implementation & Transition Support Program (ITSP) before proceeding with an EMR implementation. Currently there is no queue for PITO acceptance and in most cases new applications are accepted into the program in less than 1 month. Once a clinic applies to the PITO program, any Hardware purchases are eligible for reimbursement once the new PITO qualified EMR system is live. If there is a delay in acceptance a clinic may implement a PITO Qualified EMR system on their own. Once accepted, PITO will reimburse for the cost of implementation and will start reimbursements for monthly maintenance costs. NOTE: PITO will not reimburse monthly amounts for the time between the Go Live of the new EMR system and acceptance to the PITO program.
Clinics needing immediate Hardware purchase, should apply to the PITO program prior to purchase. Your clinic will then be eligible for reimbursement when you receive acceptance to the PITO program and implement a PITO-approved EMR.
PITO has caught up with the initial pent-up demand, currently there is no queue waiting for PITO program acceptance. New applications are reviewed as they are received and in most cases clinics applying to PITO are accepted within one month of their application data. If applications exceed the available funding in any given period, the PITO Steering Committee will prioritize the applications based on objective criteria defined and made available in advance. If a physician is not selected for two enrolments in a row, they will be the first to be selected in the subsequent enrolment(s).
The funding assigned through PITO expires in 2012. Prior to then, the BCMA and Government will determine the availability of ongoing funding through the negotiation process or other mechanisms.
PITO was established in 2006. Since that time, similar programs have been set up across Canada and the pre-existing programs in Alberta and Ontario have been extended.
In addition, Canada Health Infoway recently announced additional EMR funding through recent federal government funding which will further support provincial EMR programs such as PITO. According to the CMA website, "Within two years, half of all physicians in Canada will be enrolled in an electronic Medical record (EMR) program".
The BCMA's Information Management and Technology (IM/IT) Policy Statement states that "Health IM/IT funding must be stable and on-going to secure the participation of the majority of physicians in Health IM/IT initiatives".
The Electronic Medical Record (EMR) can increasingly be considered as a technological tool used for direct health care purposes (such as clinical decision support tools) and thus it is important that it passes similar rigorous reviews for factors such as safety, quality, confidentiality and robustness as are used for pharmaceutical products and medical devices. The review processes for EMRs have been slow to develop both in Canada and internationally, but are becoming increasingly common. Alberta has been an international leader in this area, and PITO is learning from their successes and challenges.
A rigorous and transparent process. The Request for Proposals (RFP) for the Electronic Medical Records Project (EMR) has been facilitated by the government's Strategic Acquisitions and Technology Procurement (SATP) branch on behalf of the Ministry of Health. The publicly available RFP document can be found at www.bcbid.bc.ca, document #SATP-219) or follow the following URL in the "supplier attachments" folder: www.bcbid.gov.bc.ca/open.dll/submitLogin?disID=9800486.
A mechanism to ensure vendor accountability. The RFP process results in a contract between the Ministry of Health and the suppliers. That contract holds the suppliers accountable to their commitments. The contract resulting from the EMR RFP allows the Ministry, on behalf of PITO and BC physicians, to establish and manage contractual obligations with the PITO-qualified vendors on issues such as:
The publicly available RFP document sets out all of the requirements and the evaluation process that was followed. The RFP is available at: www.bcbid.ca - document #SATP-219, or www.bcbid.gov.bc.ca/open.dll/submitLogin?disID=9800486 (in the supplier attachments folder). Section 3 provides an overview of the requirements and Section 4 on the Selection and Qualification Process includes the key steps of Written Proposal Evaluation, Validation Testing, and Usability Testing.
Almost 40 practicing BC physicians were involved in the RFP process. The Clinical Advisory Group (CAG), a group of approximately 25 GPs and specialists from across BC, was established to provide input and review of the requirements. Physicians were then involved in the evaluation of the written proposals and the usability evaluation.
Physician members for the Clinical Advisory Group were nominated by a group of their peers from all areas of the province, aiming to provide a cross-section of BC physicians: urban and rural/remote, GPs and specialists, older and younger, and those with and without experience using EMRs and technology in practice.
In addition to physicians, several experts in key areas such as technology, privacy and security were involved in the development of the requirements and the evaluation process.