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					                               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
Graduate Students
                  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
                                Medical Errors
•   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    exposed to an outdated, article-based system that is highly fragmented, highly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
                                            Other reasons….

• 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
EHR/EMR Concept
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.
EHRs Vendors??????
      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
  rating services.
          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!!!
 • http://www.ehrscope.com/emr-
EHR/EMR/PHR Venders???
                  Purchase the Right EMR
                              Software !!!
•   How to Purchase the Right EMR Software for Your Practice
•   September 18, 2009 by Jake Linkowski
•   http://www.cataractoutsourcing.com/healthcare-it/purchase-emr-
     l   Planning:
     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
•   Scanning
•   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
•   http://www.commonwealthfund.org/usr_doc/1104_Smith_state_e-hlt_activities_2007_findings_st.pdf
  Greater Incentives for EHRs Large
                     Scale Adoption!
• 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
  vendor support
• 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
                          and EHRs?

• 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 CoP
• 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
individual accountability
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
                         Collaborative Learning
Environments for Collaborative Learning
    Shared Computer Resources in Classrooms
    and Workplaces
    Online Collaborative Workspaces
    Web Conferencing Software with
    Collaboration Features
    Knowledge Collectives
    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
    Communications Tools
    Collaborative Process Tools
    Presence 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
  participatory health...
            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
  theoretical frameworks.

• 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
                     Collaborative Learning?
• 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
  teaching tool.―
• 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.
• http://blog.canadianemr.ca/canadianemr/m_emr_educ
     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
• http://www.cfpc.ca/local/files/CME/Mainpro/Electronic%20Medical
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 +…
                                                Sound PLEs?
•   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
                                                       The Result
•   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
a doctor
Andrew, doctor
John, doctor
Linda, specialist
Elma, specialist
Kathy, nurse
Suzy, nurse
Lynn, nurse
Bob, patient
Joe, patient
Jane, patient
Sue, patient
Add users
Doctor Group
Creating More Groups and
           Posting Feeds
The Dashboard
Bob Vital Signs
Personal and Group
Notification Inbox
Patient Intake
        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
  and Elgg.
• 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
Moodle-Elgg Integration
From Elgg, I can access Moodle
Enrolled and Teaching courses
Moodle 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

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