HW 2023-02 I 119 of 144 pages

Jasmina Garlc

From: Kim Knox

sent: Tuesd<ty, November 22, 2022 8:03 PM
To: Dr. Michael Gardam; Marion Dowling; Melanie Walsh; Corinne Kowswell; Andrew
MacDougall; KathP.rine McNally; Everton Mcl.enn; Deborah Bradley; Belinda White
Cc: Karen Mccaffrey
Subject: RE: Missed referral requests in EMR

Follow Up Flag: Follow up

Flag Status: Flagged

Thanks for the quick response.

Answers to your questions:

1. Is there a way for the system to prompt the person entering the referral that there Is another step? This feels
like a human factors gap. Why does it require two steps? When you say "fax", I am hoping you don't mean fax
machine???
For referr;Jls being strn l outslcle the EMR -· thP.re are P.-rifx c:a pabilltics embedded in the solution.
A field h.:i ~ been arldc~d to the rnterral screen tliilt clt'e11ly sl1uws if <i fax was sent (this wlll make it e<isier for clinic
staff to 11\0ni tor rnoving forward).
We are working on a change request for thE.> lMH v.~ndor around adding a fl<ic/imlirni-or.
2. Yes I do think we need to provide mandatory billable education as this has bec:ome a big deal and we need to
stop any further misses (and education needs to be part of the solution)
Great; wr~ Will for.us on r~etting some refre sher l'rnlning established ;incl work with t:he Steering Committee on
how to communicale. I 1noulCI think a r:ommu nicntio!l from lc aderr.hip regc;rdiilg partidp<ltion would be inore
niea11h1gful t han thr.~ EivlH Prograrn tnt>ss;1!5ing it.
3, Happy to support the trainers being able to look at current worl<flows. What do you need from me to help this
along?
I lhlnk having 1-IP EI leader~h l p rnessage that all clinics sho1.1ld utilize this offer to review their workflow~ wottld be
v~I y benefici<.11 for uptake . We are rnorf' than happy ro dr<t ft so11wll1h1g. Another conversation we'll ll~)c~d lo
lrnve soo n Is how hf.st to liandh~ sittw t·ions where users may not he utili zing the ~ofu tio n "appropriately"
(Lraining & peer support is alwciys t.he first step, bL1t if is~; UQ S continue).
4. If you are ready to go with those clinics and they agree, I s~y go ahead, making this issue a central part of the
role out so thal we are not creating more lost referral s.
We will have il conversation witft lht-!m tornorrow.
s. How soo11 do you thlnl1 we will be confident we have this well In hand? We wlll send out a public J
communication at that point with an update on our investigation and tell patients how to contact us for more
lnformatloll. j
We n1et with Linda and Laurcrn today to discus~ th'~ is~ue <111rl an ;1pproach for ha vi ng the c!inir:al r~view
ii
r.ornpletec!. Melanie, I shared wh.11: we discussed this morning a11d Uncla wll! connect with your Learn as well.
.!
r mil not speak to il(IW long I hr. clinical rcvilw1 wfll tal<e - Linda will llavc the required detai!s for fnllow ·up
lomorrov; ancl will start lhr. proce ss fo1· her <lrea. ''

Ft·om: Dr. Michael Gardam <[email protected]>

Sent: Tuesday, November 22, 2022 1:23 PM
To: l<fm l<nox <[email protected]>; Marlon Dowling <MH DOWLI [email protected]>; Melanie Walsh <M<[email protected]>;
Corinne Rowswell <[email protected]>; Andrew MacOougall <ASMACDOUGALL@lh is.org>; Katherine McNally

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 HW 2023-02 I 120 of 144 pages

<l<[email protected]>; Everton Mclean <[email protected]>; Deborah Bradley <[email protected]>; Belinda

White <[email protected]>
Cc: l<aren McCaffrey <l([email protected]>
Subject: RE: Missed referral requests in EMH

Thanks for this J<lm and l(aren. This Is another hump in the EMR road and not unexpected. The l<ey thing Is for us to
jump on It, communicate about it, and fix it moving forward I

My thoughts and answers to your questions:

1. Is there u way for the system to prompt the person entering the referral that there is another step? This feels
llf<c a human facto ts cap. Why does ft require two steps? When you say "fax", I am hoping you don't met1n fax
machine???
2. Yes I do think we need to provide mandatory blllable education as this has become a big deal and we need to
stop any further· misses (and education needs to be part of the solutlon)
3. H<ippy to support the trainers being able to look at current worl<flows. What do you need from me to help this
along?
4. Yes bringing this back to the EMR steering committee for discussion makes sense
5. If you are ready to go with those clinics and they agree, I say go nhead, making this Issue a central part of the
role out so that we are not creating more lost referrals.
6. I would start the process for the new clinics but wait and see re. this Issue In il couple of weeks
7. I agree with the audit system you have set up. I am hopeful that will stop this Issue from continuing (or at least
catching It right away so there Is no patient Impact) while we work through the backlog of possibly missed
referrals.

I would like us to be very confident that we have stopped any more of this occurring, we have identified all the
clrcl.lmstances where this has occurred, and are ready to notify patients where necessary about the delay.

How soon do you thin!< we will be confident we have this well In hand? We wlli send ~ut a public communlcatlotl ot
that point with an update on out• investigation and tell patients how to contact us for more Information.

Michael

From: Kim l<no>< <[email protected] .ca>

Sent! November 21, 2022 10:34 PM
To: Dr. MICt\ael Gardam <[email protected]>; Marlon Dowling <Ml·lOQWLING<@ihis.gJg>; Melanie Walsh
<[email protected]>; Corinne Rowswell <f:.<!.LQW_~well@ihis .qrg>; Andrew MacDougall <f\[email protected]>;
Katherine McNally <Jil'[email protected]>; Everton Mclean <[email protected]>; Deborah Brndley
<MDB8.8Q.~IY@ggy,pe.ca>; Belinda White <[email protected]>
Cc: l<aren Mccaffrey <l<JMCCAFFREY@i!Jls.org>
Subject: RE: Missed referral requests in EMR

HI All,

Sorry for the late response. Karen and I connected loday to discuss this issue, Here is a sumrnuy of the worl< happening
on the EMR side and I have noted a few questions/requests in blue.

Issue Summary:
• This is a separate/different issue related to referrals.

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 HW 2023-02 / 121 of 144 pages

• Sending a referral outside the system Is a 2-step process -create and then fax, It appears that some
cllnlcs/cllnlclans have missed th e flnaf step (fa xing) un some of their refe rral reque sts. One cllniclan, in
particular, had a largfl number.
• An audit report was developed last week which flags any referral that does not have a fa>< date/time stamp
associated with It. The Audit rn!iults will need to be reviewed by the cllnlcs to confirm If the referral was handled
In another way or not meant to go out (eg. printed and sent outside the solution, duplicate referral, or was
started but for some reason was not Intentionally comple ted).

Planned Ne>tt Steps;

1. Generate a listing of all outgoing Referrals (without a fax date/time stamp) by Clinic/Provider. Provide the audit
to each clinic for review - EMR Advisors with follow~up to explaln and provide direction.
2. Clinics/Providers will be asl<ed to go through their list to dAtermlne If the refefl'al should have been faxed out (or
confirm that It Is a duplicate, was sent another way, etc) and then perform any required cfean~up In the solutlon
so we have a clean audit moving forward.
3. Once the clinic review i.s complete - the scope of Impact can be determined.
Note: Lana and I will discuss the approach with Melanie's team tomorrow to ensum r.oordlnated.

Mitigation activities completed to date:

• Updated Referrals user guide recently created and distributed.
o Introduced a newfleld on the referrals screen so MO/\s can quickly review t he outgoing referrals each day
and confirm ttrnt all were faxed (If appllcable).
• High lighted the prnc:ess/issue at the Primary Carn Networl< Managers' meeting.
• Communication was sent out to remind users of the 2 step process for outgoing referrals (and how they can
confirm lt was completed).
• Created an "outgoing referrals not faxed" audit (as mentioned al.love).

Mitigation steps In progress:

• Updating itnplementatlon training for new clinics - stressing the 2 step pror.ess of sending outgoing
referrals and outlining how clinics can effectively ma naBe and monitor referrals.
• Stand-up refresher training sessions on a variety of key topics - Referrals being the first area of
focus. (Request: Would li ke UPF.l l:o endorse this ;,1s manclcitory; approval for use of hilling code fol'
Provider time)
• HPEl/DoHW to look at Immediate (interim) resource needs to support operational support untll operational
positions are flllcd and LIP to speed (eg, Hire Training Lead to coordinate training activities and assessments).
" EMR Program t rainers to reach out to cllnlcs {again) to try and schedule a time to revlew current worl<flows
{fkq ucst: Need support. from HPEI ltH1clershlp for 11ptake ).
o Work with HPEI (and other stal<eholder groups) to bulld QUt a more collaboratlve/r.omprehcnslve support
model for various cllnlc mod els that exist (defining clinic/business area accountablllties, EMR Program
accountabilities, etc). Ht~q1.1e~t: WHI ask EMR Steering CotrHnitt~~e tnC!mbei's to Identify representatlvHs to
parti<:ipate.
• Meeting with the EMR Solution vendor on Tuesday to review the process and look at potentlal solution
Improvements to facilitate the referral process.
• Create a quick reference document on managing referrals so clinics have <1Uicl</clear Instructions on how to
monitor and manage referrals.
o Create Referral qui cl< videos for quicl</easy reference (Internal, external and sender/receiver perspective).
• Continue to run and monitor ourgoing referral audits and send to sites for con tinued review/dean up (until
a well-embedded practice).

Pausing lmpletnentatlons:
• We had already started work on a decision document around slowing implementations until we can collectively
put the required operational supports in place. This would allgn with Dr. Gardam's request.
• We have 3 Implementations planned between now and Christmas:
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 HW 2023-02 / 122 of 144 pages

o Geriatrics Program (next week)

o Dr. Isa (week of Dec 5U1)
o Dr. I< MacDonald (week of Dec 121h)
All would have tline lllocl<ed for training/go-live and a reduced patient load for the followlrlg 2 weeks.
Q: Gi11e.n where they <ire in the process-· should we completely stop ....or reach out to l:hese 3 clinics to
confirm if they want to move forward (with the u1>datcd emr>hasis al'ouncJ rP.fomils .ind a scheduled touch
point within the first 2 weeks of use to confirm they m·e utfll:dng the referral function - as well as other l<ey
functio1ls • ap1wopriately}'? Will need to communicate quickly to Impacted clinics so they can rel.Joo!<patients,
If necessarv.
• As most are aware, each implernentatlon Is a 10-13 week process (from start to finish} for the clinic. We are
supposed to l<lc:k off 4 more Individual physician clinks this week (for implementation In mid to late
January). These 4 are specialists so require a slgniflcant lead time (eg. 10 weelcs) to hook lmplementatlon
activities Into their schedules.
Q: Should we not start worl< with these clinics (if we leave It a few weeks, it will meo11 a l<ick-off in P.arly
January and M<1rr.h irnplemenl:ations} OB do WP- start the process and assess whet'e thing s stand by mld-
Deceinber? (and if necessary, push out the hn t>lementatlon dates at !:hat point).

At this point, thAre are no other clinics with ~cheduled/conflrmed BO·llve dates (outside the ones I have mentioned
above).

Thanl<s - any questions let us know.

Kim

F1·om: Dr. Michael Gardarn <rnMardam@ltils.,9.rg>

Sent: Friday, November 18, 2022 3:43 PM
To: Marion Dowling <[email protected]>; Melanie Walsh <.Maw~lill@ihis . org>; Corinne Rowswell
<I~i:.mvsweliCciilhis . QDPi Andrew MacDougall <[email protected].&J:g>; l<atherlne McNally <[email protected]>;
Everton Mclean <[email protected] .ca>; Karen McCaffrey <KJ.M~_<;;AE.fRE Y@lh ls.om>; l<lm l<nox <llikn.Q.!<[email protected]>;
Deborah Bradley <M [email protected]>; Belinda White <h.'1Yh.l~~@ lhls.org>
Subject: Missed referral requests in EMR

HI Everybody,

Several of the HPF.I team copied on this note had an urgent meeting today to discuss the growing problem we are having
with referrals being rnissed in the Telus EMR. Last week we heard of700+ referral~ to OB/GYN being missed, and as we
continue to investigate, over 1000+ new missed referrals have been Identified this week. They are In more. settings than
jL1st OB/GYN and the drcumstanccs around why they have been missed are also different.

This Is becoming a very significant rcputational risk to HPEI as weli a.~ the EMR project. The opera tional group at HPEI
was trying to manage this when we thought It was a one off with the Mount referrals, but clearly this is a much bigger
deal. At our meeting we discussed:

:I.. All referrals need to be reviewed from all uses of the F.MR to see If any more arc missing.
2. The reasons for the missed referrals need to be Identified and addressed;
3. If human error is involved, there needs to be both training as well as possibly modifications of the EMR from a
human factors perspective to rnal<e It harder to make a mlstal<e
4. HPEI must send out both individual notlf101tions to those patients Impacted by this problem and public
messaging disclosing that this Is an ongoing Issue and thilt as we Investigate, we find more Issues. We also arc
setting up phone llnes so concerned patients can call In for lllformation. Finally, clinically we have to review each
missed referral to see if an urgen1 case was missed that 1nust be expedited.

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 HW 2023-02 I 123 of 144 pages

. ,.
We need urgent help from the EMR team for tasl< #1 and need a point person/project manager who can pull this group
together on a regular basis for updates and decision making.

Karen and IClm, can I ask you to figure that technlcal support piece out?

We also think the roll out will need to be paused again while we sort this out. With more cases being identlfleu I think It
Is risky to continue. ·

I am hopeful we can get to the bottom of this quite quickly <111d resume the roll out-I do understand there are funding
obligations we need to meet

Thrinks

Micha el

..
:J
5/19/23, 10:57 AM Family physician blames inefficient EMR software for departure I The Eastern Graphic I peicanada.com

http s://www. peicanad a. com/ea stern_g rap hi c/fa mi ly-p hysicia n-bIames-inefficient·em r-software-for·departure/ article_48018 b3 6·
ee8a-11ed·b82b-f78d1774062f.html

I TOP STORY I
Family physician blames inefficient EMR software for departure
Rachel Collier
May 10, 2023

Health PEl's chosen electronic medical record system was a major factor pushing Dr Thor Christensen to leave his Montague practice.
Rachel Collier photo

Privacy - Terms

https://www.peicanada.com/easlern_graphic/family-physician-blames-inefficient-emr-soflware-for-departure/article_48018b36-ee8a-1 1ed-b82b-f78d17.. . 1/7

5/ 19/23, 10:57 AM Family physician blames inefficient EMR software for departure I The Eastern Graphic I peicanada.com

Dr Thor Christensen, one of two family physicians to resign from practice in Montague this month, blames Health
PEl's EMR (Electronic Medical Record System) for creating extreme workload expectations.

Dr Christensen was finishing his residency in PEI and looked forward to opening his practice in Kings County in
the spring of 2015.

Eight years later in a candid interview he explained his decision to discontinue working with Health PEI.

"This is still my dream job," he said. "My patients are my friends from high school who have grown up to have
children, their parents, my neighbours.

"I grew up in Upton, went to Dundas School and my son will go to Cardigan. My community has always been what
has mattered to me and it still is."

Dr Christensen explained a combination of factors, not uncommon to doctors in rural areas across the country
led to nearly unsustainable work-life balance. Health PEI-specific issues added to the challenge.

But he coped to one degree or another for more than 7.5 years since taking over Dr David Hambly's aging patient
load.

It was Health PEl's adoption of what Dr Christensen describes as a dysfunctional electronic record system that
forced his work-life balance brutally over the edge. It pushed him to a point he felt was dangerous to his patients,
he said.

Dr Christensen believes electronic medical record is the way to go but the system chosen by the Department of
Health and Wellness has created a system that is exceptionally less efficient than a traditional paper filing
system. The system has yet to achieve the lauded goal of one efficient interconnected electronic medical record
on the Island which would be connected for example between hospitals and family practices. In his experience it
results in more errors, missed information and leaves him feeling like he is drowning in administrative work
rather than spending crucial time with patients.

"I'm 37, I know how to use a computer, I learn systems quickly, that is not the issue," he said.

Writing a prescription on paper used to take Dr Christensen 15 seconds. All issues considered, with the Telus
electronic system in place, this task now takes him four to five minutes of dealing with a clumsy system.

Billing, which was written into his contract wasn't initially his responsibility now it falls in his hands.

https://www.peicanada.com/eastern_gra phic/family-physician-blames-inefficient-emr-software-for-departure/article_ 48018b36-ee8a-11ed-b82b-f78d1 7.. . 217

5/19/23, 10:57 AM Family physician blames inefficient EMR software for departure I The Eastern Graphic I peicanada.com
.
These are just two of many issues Dr Christensen, who is a salaried physician and not fee-for-service, highlights.

Instead of spending time with his family Dr Christensen found himself spending the little spare time he had
between on-call duties at Souris and Montague Hospitals, emergency room shifts some weekends and his family
practice at home on his laptop for hours completing administrative tasks that suddenly fell within his
responsibilities.

He said he raised concerns with Health PEI superiors from day-one and was open to giving the system a chance.

"It's been 18 months and it still can't assist with bloodwork," he said, adding the system is intended to make
doctors work more efficiently and in some applications to be more accurate. The opposite has resulted. He also
suspects the burden will grow as patients' files are recorded for decades. Finding relevant information in the
system will be a disastrous challenge.

When he first brought forward his formal letter of resignation Dr Christensen was open to working in a different
capacity with Health PEI. Somewhere he wouldn't have to deal with the EMR system.

But Health PEI burnt the last plank in a negotiation period.

He said Health PEI asked him if he could possibly work at a walk-in clinic but that would mean he wouldn't have a
day off.

Health PEl's Chief of Medical Affairs also texted him to say he didn't have to use the system, he said. But by that
time it was too late and Dr Christensen had lost hope in accessing a workplace that would support health and
happiness in Health PEI.

Dr Krista Cassell, president of the Medical Society of PEI isn't surprised Dr Christensen cited the EMR system as
a reason for his departure.

In a letter to politicians during this spring election campaign period, the Medical Society named actions that
could prevent a health care system collapse as the result of worn out, frustrated health care workers leaving
practice on PEI.

The letter explicitly calls on government to ensure electronic medical records do not add administrative burdens
to physicians.

https :l/www.peicanada.com/eastern_graphic/fa mily-physician-blames-inefficient-emr-software-for-departure/article_ 48018b36-ee8a-11ed-b82b-f78d17... 3/7

5/ 19/23, 10:57 A M Family physician blames inefficient EMR software for departure I The Eastern Graphic I peicanada.com

Since January 2022 a total of 27 physicians have left their Island practice. Fifteen of those resigned for various
reasons, 12 retired and six have stayed on to work in other Health PEI positions.

Health PEI is working on gathering data from a more extensive survey process recently implemented, however
was not able to comment about when data will be available to the public.

Dr Christensen had approximately 1,300 patients.

https ://www.peicanada.com/eastern_g raphic/family-physician-blames-inefficient-emr-soflware-for-departure/article_48018 b36-ee8a-1 1ed-b82b-f78d17. .. 417