Toronto, Canada: June 29 - July 2, 2010
Adopting Personal Learning Environments for Sharing
Electronic Healthcare Records
Jinan Fiaidhi, PhD, ISP, PEng
Sabah Mohammed, PhD, ISP, PEng
David Thomas and Jeff Santarossa
Electronic Health Records…
• Electronic healthcare records (EHRs) have been
proposed as one way to reduce practice variation and
improve quality by improving access to patient data,
efficiency of documentation, prompting of clinicians,
decision support, presentations of data, and access to
educational materials for patients. The estimated
potential savings and costs of widespread adoption of
electronic medical record (EHRs) systems for United
States only to reach more than $81 billion annually
(Girosi 2005). This amount is expected to be doubled
by improving prevention and management of chronic
diseases (Hillestad, 2005).
• Giros, F. et al., (2005) Extrapolating Evidence of Health Information Technology Savings and
Costs, Pub. no. MG-410 (Santa Monica, Calif.: RAND, 2005), sec. 4.2.6.
• Hillestad, R. et al., (2005) Can ElectronicMedical Record Systems Transform Health Care?
Potential Health Benefits, Savings, And Costs, HEALTH AFFAIRS ~ Vol. 2 4 , No. 5, 2005.
$$ Saving using EHRs: Giros, F. et al., (2005)
EHR/EMR for Preventing
• Contrary to popular belief, medical errors are not typically the result of negligent
and/or incompetent health care providers. Instead, experts contend that medical
errors are a direct result of how the health system is organized and how care is
delivered. When a patient enters a hospital for treatment, for example, they are
exposed to an outdated, article-based system that is highly fragmented, highly
variable and error prone.
• Typically, a patient’s medical information is scattered across numerous medical
records kept by different providers in different locations and/or by different
departments even within the same hospital. Even the patient herself does not have in
her possession an up-to-date, comprehensive medical record. Therefore, all relevant
medical information is rarely available in one location in realtime when the patient
requires care. The result is that patients are seen by doctors who generally do not
have access to a patient’s records, which include current treatments, medications and
• Jacquelyn N. Crane and Frederick G. Crane, The adoption of electronic medical
record technology in order to prevent medical errors, Policy Studies Journal, Volume
29, Issue 2 June 2008 , pages 137 - 143
• Improve the quality of care – by giving providers accurate and complete
information about their clients at the point of care, including access to clinical
practice guidelines and care plans.
• Increase the productivity of providers – by providing all relevant health
records in a timely manner.
• Enhance the continuum of care – by providing integrated clinical,
administrative, and decision support data to all practitioners at the point of
care, on a need-to-know basis.
• Empower patients – providing access to their own health information will
enable patients to more responsibility for managing their own health and
And more challenges…
• An aging population,
• increased public expectations
• expensive new medical technologies
• Emerging risks to population health due to communicable and
chronic disease epidemics
• The need for Improved:
– patient safety
– client / patient satisfaction and convenience
– quality and continuity of care
– access to health services and information
– continuity of care and health services integration
• Medical manpower retention, supply & distribution concerns
• Public concern about access and wait times
The Tsunami of EHRs !!!
So Many EHRs, So Little Time:
• Simply amazing that this market can
support so many EMR/EHR companies.
How they all survive or will survive is a
mystery to me and rationalization will
occur. Big potential risk here as providers
look to purchase an EHR as many of these
vendors will go belly-up or be acquired
within the next 5 years. Vendor viability is
going to a major issue in coming years.
How much will EMR
Implementation will Costs?
• CLINICARE is Canada’s leading
provider of applications for electronic
medical records (EMR) and practice
management. It is the number one provider
of such software to physicians in group
practices in both Canada and the United
States. CLINICARE has repeatedly won
the annual ―Best in KLAS‖ award from the
prestigious KLAS health care informatics
Other Canadian Vendors
• Canadian companies offering a wide
range of physician office systems
include ABELSoft, Healthscreen
Solutions Inc., Jonoke Software,
Nightingale Informatix, Optimed
Software, Osler Systems, Practice
Solutions, Wolf Medical Systems
and York-Med Systems Inc.
Frequently Asked Questions...
EHRs System costs only $850 !!!
• Whether you are a general practitioner or a consultant, and work solo or as a small group, you will
find UniCharts™ electronic medical records system sufficient for your clinical documentation and
workflow needs. It is being successfully used in a wide range of medical specialties including Primary
Care, Neurology, Psychiatry, Cardiology, Pulmonology, Urology, Physical Medicine & Rehab and
Pain Management. Incorporating the best of client-server and browser technologies, it is one of the
most advanced EMR software in terms of functionality and user interface design. And starting at just
$850 for a 4-User lifetime license, it is probably the only low-priced emr software that provides its
users the customization capabilities of high-end electronic medical record systems.
– Easy to learn,
– Easy to use,
– Easy to install,
– Easy to customize,
– Easy to maintain,
– Easy to rely on,
– Easy on the budget,
EHRs Software from Wal-Mart!
Choosing the right EHRs System!!!
Purchase the Right EMR
• How to Purchase the Right EMR Software for Your Practice
• September 18, 2009 by Jake Linkowski
l EMR ROI:
l EMR Vendor Selection:
l RFP: Request for Proposal:
l Electronic Medical Record Support:
l Final considerations:
Costly EHR features small family
medicine groups can live without
• Expandability. The ability to transfer the record from one
physician to hundreds, encompassing practices
separated by location.
• Granularity. The ability to limit access of various groups
of physicians, secretaries and nursing staff to specific
areas of the chart.
• Customization. The ability to set up the record (usually
for an added cost) to satisfy specific needs.
• Cross-specialty functionality. The ability to use the
record with multiple specialties across a medical
I can be very clear about my needs…
• Results Reporting (lab, radiology, other)
• Order entry
• Multiple note creation options
• Automated E/M coding advisor
• Software interfaces with internal and outside labs
• Prescription writer and database
• Flow charting
• Referral ordering and tracking
• Patient registration information
• Patient web portal
• Electronic fax reports
• Patient follow-up
• Decision support tools
EHR Adoption in Primary Care
Canada Position on EHR/EMR???
• According to a Commonwealth Fund study
conducted in 2007, only 23 per cent of Canadian
physicians use some form of electronic medical
record. That compares to 98 per cent in the
Netherlands, 92 per cent in New Zealand, 89 per
cent in the U.K. and 79 per cent in Australia.
• Canadians can take some comfort from the fact
that our pitiful adoption rate of EMRs is matched
by one other country in the study: the United
Greater Incentives for EHRs Large
• When asked about problems that resulted from adoption,
focus group participants mentioned that the most
significant issues seemed to revolve around the
conversion of paper records to electronic format. There
seems to be a general consensus that this transition
process was the most difficult obstacle in EHRs adoption.
• Encouraging a policy of paying for transition support
project management and practice management
services. This has helped accelerate uptake of EHR in
• In Ontario, physicians are not able to use their EHR
subsidy funding for project management and practice
management services. This policy prevents physicians
from gaining the full value of their investment. As a
result, many EHR implementations fail, leading to poor
uptake by other physicians who see their colleagues
struggling. For example, the failure rate of EHRs in the
Hamilton area is approximately 35%. This has
effectively halted EHR implementations in the area as
physicians are waiting to see whether their colleagues
can turn their practices around.
The Problem: Missing Key Players
(Ontario): OMA, OCFP and CPSO.
• Three key medical policy players have been left out of the picture.
The Ontario College of Family Practice (OCFP) is the major moral
force for change in clinical practice. The OCFP is the organization
that sets the clinical compass for the primary care physicians of
Ontario, setting the agenda for what are the important clinical
goals to be achieved and what clinical training physicians require
to achieve clinical goals. Where the OMA (Ontario Medical
Association) physicians provide political leadership, OCFP
physicians provide clinical leadership. In Ontario, the clinical
leadership has not been engaged in discussing and promoting
• The other key organization left out is the College of Physicians
and Surgeons of Ontario (CPSO).
• The Ontario College of Family Practice (OCFP) is the major moral
force for change in clinical practice. The CPSO is the physician
self-regulatory body, which enforces the standard of care in
Ontario and sets policies for medical record keeping, and
services that need to be provided to patients.
Good and Bad EHRs?
• Dissatisfaction with electronic health records (EHRs)
is widespread among physicians, but a recent study
has found that physicians do not grade all systems
equally in terms of performance, satisfaction, and
• Good EHRs
– e-MDs, Amazing Charts, and eClinicalWorks
• Not Good EHRs
– PowerChart/PowerWorks, Allscripts MyWay, and MPM Suite
• Edsall R L, Adler K G (2009), The 2009 EHR User Satisfaction Survey:
Responses From 2,012 Family Physicians, Journal of the American
Academy of Family Physicians, November/December 2009 Vol. 16 No. 6
Healthcare Community of Practice
• A community of practice is a network of
individuals with common problems or
interests who get together to:
– explore ways of working securely together.
– identify common solutions.
– share good practice and ideas as well as
repositories (e.g. EHR/EMR).
• Healthcare professionals interact
with peers, mentors and other
healthcare professionals to frame
issues, brainstorm, validate and
share information, make
decisions, and create
management protocols, all of
which contribute to learning in
practice. It is likely that working
together in this way creates the
best environment for learning that
enhances professional practice
and professional judgment.
CoP= Inquiry Learning Process
= Collaborative Learning
Advantages of Collaborative
Develops higher level thinking skills
Promotes P2P interaction and familiarity
Builds self esteem
Enhances satisfaction with the learning experience
Promotes a positive attitude toward the subject matter
Develops social interaction skills
Creates an environment of active, involved, exploratory learning
Uses a team approach to problem solving while maintaining
Encourages diversity understanding
Stimulates critical thinking and helps healthcare users clarify
ideas through discussion
Enhances self management skills
Fits in well with the constructivist approach
Fosters and develops interpersonal relationships
Environments for Collaborative Learning
Shared Computer Resources in Classrooms
Online Collaborative Workspaces
Web Conferencing Software with
Collective Immersive Environments
Collaborative Augmented Reality
Networks for Collaborative Learning
Personal and FOAF Networks
Group Forming Networks
Social Mobile Networks
Peer Sharing and Production Networks
Community Computing Grids
Self-Organizing Mesh Networks
Tools for Collaborative Learning
Collaborative Process Tools
Social Markup Tools - Annotation,
Bookmarking, and Rating
Project and Team Management Software
Community Management Tools
One Way to Accelarate Using EHRs is
to rely on Active EHRs
From Passive to Proactive EHRs !!!
• from Passive: Computer-based Patient
Records (CPRs)… Repositories …
• into proactive, predictive, preventive, and
Proactive EHRs: The Wind of
• People inherently dislike and seek to avoid change.
More than most, busy people are reluctant to move
beyond their tried and true methods of getting the job
• This is not to imply that our physicians and healthcare
professionals are not innovative. Quite to the contrary,
we have some of the most intelligent and creative
people in the world working for improving the health of
individuals receiving care in our system.
• However, they understand the potential cost of
failure of new methods. Any new tool or process
must not only improve their situation, but must do
so by a factor that overcomes the cost of training
and lack of familiarity.
The Roadmap to Proactive
Proactive EHRs = Collaborative
The Two Phases for Proactive
(1) Phase I: Having a Secure Collaborative
Learning Environment that can be
integrated with the normal work of the
(2) Phase II: Having support for active
EHRs as well as other type of contents
Phase I: ACLF
• "Asynchronous collaborative learning forums"
(abbreviated as ACLF) is the generic title given to a
category of internet-based educational technologies that
are widely in a variety of collaborative learning contexts,
and are described using a broad range of terms and
• These systems have been labeled "bulletin boards“,
"learning networks“, “Blogs”, “Semantic Wikis”,
“Social Collaboration and Networking” and
"knowledge forums". They have been understood in
terms of "knowledge construction“, "communities of
inquiry" and "computer-supported collaborative
learning“ to name just a few theoretical frameworks.
Do Electronic Health Records Help or
Hinder Medical Education or
• Peled argued that the EHR can enhance medical
education in three ways. First, the "use of an
EHR can enhance history taking and physical
exam skills." Second, EHR can enhance
physician–patient communication if it is
incorporated into the doctor-patient encounter.
Finally, the EHR "can be an impressive clinical
• Peled et al. Do Electronic Health Records Help or Hinder
Medical Education? PLoS Medicine, 2009; 6 (5):
e1000069 DOI: 10.1371/journal.pmed.1000069
Dr. Nikki Shaw Point of View?
• Are educators in medical schools teaching medical
students sufficiently regarding the use of Electronic
Medical Records or Electronic Health Record Portals?
Not so, according to Dr. Nikki Shaw, Research Chair,
Health Informatics University of Alberta, Edmonton.
But What About Physician Training on EHR:
The Missing Roadmap
• Your family physician has a lot to remember when
he sees you once every few months at best.
• We expect our doctor to have a mind of a
computer. We expect him to remind us that we
need an annual physical, PSA test, colonoscopy,
EKG, etc... These are things that when you go into
the doctor for something like a common cold, he
completely forgets due to the number of patients
s/he has to see and lack of information at his
• In an ideal world, the use of electronic health
records (EHR) system these types of things will
automatically remind the physician based on
several parameter like age and sex when these
procedures are due. This could literally save
someone's life by reminding the patient
that a test is due and possibly might be able to
detect enough to treat and cure.
There are many other issues EHR could infer
and help the physician and healthcare users…..
Good News: College of Family
Physicians Mainpro M1 accreditation
for EMR Training
• Accreditation of Electronic Medical Records (EMR) The training
for use of electronic medical records is eligible for Mainpro M1
accreditation. This training may be given by a vendor, or supplier
of electronic medical records, regardless of whether or not this
person is an MD; it is agreed that these vendors are probably the
most knowledgeable regarding the various programs or
equipment being used
17 CME Accredited Centers in
ACLF need to be more than CME !!
The Core to ACLF is PLE?
PLN: The Connectivity
Collaborative Learning via
Many PLE/PLN Tools and
Formal PLN = Weblogs +…
• Of the many available collaborative learning environments two open source
platforms stood out and deserved further examination; Drupal, Moodle and
Elgg. In order for a collaborative learning environment to meet the
requirements needed to share an EHR within a social network, they need to
have appropriate tools and customization options.
• Drupal has more tools and modules available than Elgg and more
documentation. Drupal has a wide variety of modules ranging from Blogs to
Whiteboards. Drupal also allows profiles to be loaded so all users can have
the same interface or they can choose from a list. But the quantity of the
available tools does not help the citation if they are not the tools needed.
Additionally many of the documentation was incomplete or out of date. After
installing and setting up a Drupal server it became apparent that it did not
have the type of social networking modules required. In retrospect the setup
of Drupal was more difficult, which alone is not that much of an issue but
combined with the lack of social networking tools and documentation made
Elgg a more suitable choice.
PLE Comparison 1
PLE Comparison 2
PLE Comparison 3
• Studying our findings from the previous tables, we can identify two major
and effective PLE tools: Elgg and Moodle.
• Elgg is an open source Web application combining elements of weblogging,
e-portfolios, and social networking to create what its authors term a
"personal learning landscape" . The application promotes learner-centered
expression through "personal web publishing", while facilitating the formation
of peer-to-peer (P2P) learning communities in which knowledge sharing,
conversation, and reflection can take place.
• Moodle, on the other hand, enables geographically and demographically
disparate learners to participate in high quality asynchronous instruction
beyond the physical limitations of time, space, and instructor accessibility.
Moodle facilitates collegiality by enabling subject area experts and master
teachers to share and collaborate in the creation and dissemination of
innovation and best practices including coursewares, which thereafter can
be use further to conduct professional development opportunities.
Elgg + Moodle Architecture
Elgg PLE: One of our
Dave is the administrator and
Creating More Groups and
Bob Vital Signs
Personal and Group
Elgg and Moodle Integration
• Moodle and Elgg should be integrated as
seamlessly as possible—users don't need
to know that they are using two separate
environments, and the switch from one to
the other should be simple.
– Elgg as a social tool
– Moodle as a course tool
• LDAP and CAS are required to enforce
integration and security!
• LDAP is used as a directory to store user information.
• CAS is used for Singe Sign-On between both Moodle
• The idea is to sign on to CAS, which authenticates
against the LDAP service. Once the user is
authenticated, they can browse between Elgg and
Moodle by directing their browsers to the proper URL, or
by following the proper links, without having to enter their
authentication information (ie. username and password)
for the rest of the session. So the user doesn't have to
remember URLs or bookmark pages, the Moodle course
plugins can be created or added. Also, a 'sticky block'
can be used in Moodle to put a link to the user's
dashboard in every Moodle course. So one can browse
both Elgg and Moodle at the same time in a uniform
From Elgg, I can access Moodle
Enrolled and Teaching courses
Based on the developed learning ecosystem, the
healthcare users are able to perform the followings:
• Allow users to create their own blog.
• Create bookmarks so users can recommend content
• Custom index to alter the home page
• Provide default widgets set the tools available to users
• Provide diagnostics for troubleshooting
• Provide embed services to enable images to be embedded in text
• Provide file services to allows users to upload files including EHRs
• Link to Patients and Collaborators enabling the creation of social relationships
• Creating Groups to serve
• Inviting friends so users can expand their social network
• Creating new members so to allow new members to link to all other active members
• Providing message board so users can share messages and chat
• Provide notification services
• Provide Editor to build user profile so that other users can view it.
• Provide tools to create courses where others can use them for training.
Many Other Modifications may
Possible Architecture Supporting EHRs
Cross-Culture Sharing and
Further Enhancements to make
EHR as the Partner