K'jipuktuk (Halifax) – Electronic Medical Records (EMR), the software programming that your doctor's office uses to keep your files in order, and from time to time receives or sends information about you to other clinics, laboratories, and the like, is an industry on the upswing.

The days of paper files are drawing to a close, and in the United States, for example, digital record keeping will be mandatory by 2014.

Medical data is more sensitive than your average set of figures and numbers, and security needs to be a priority, especially in terms of transmitting and storing information. Capital Health, for example, reported yesterday that it had dealt with over 1 million attempts to access it's electronic patient records. Typically, in terms of regulation, this would mean a stringent set of guidelines to which software producers would need to adhere.

If allowed to simply follow the rules of the free market, the regulatory body would also need to ensure that the competing software packages could seamlessly interact and share data among the different clinics and offices. It's a tall order, but not one that hasn't been done before in a variety of industries, such as the airline and banking systems.

In Nova Scotia, however, the Department of Health and Wellness (DHW) has taken a different approach. In 2004 the DWH sent out a Request For Proposal (RFP) for an 'exclusive applications service provider', as well as an RFP for 'local client server solutions'.

With these RFPs, the DHW appears to have been looking to accomplish two things; First, to gather clinicians' data under one roof – its own. And second, to regulate the EMR industry by limiting the number of players who could compete.

Whoever won these RFPs – and especially whoever won the designation as the DHW's 'exclusive service provider' – would have a big leg up on the competition. Looking only a little farther down the road, the 'exclusive service provider' at this juncture would have an even higher leg up on the competition in any future RFPs dealing with DHW medical software, as it would be the company already aligned with governmental databases and the like.

It was a key moment in EMR history in Nova Scotia – the birth of a private monopoly situated under the comfortable wing of a public regulator.

In August 2005, the exclusive service provider designation went to Ontario-based Nightingale Informatix Corporation, as did one of the two local client server designations.

The decision, understandably, didn't sit well with existing competitors in the Nova Scotia EMR market.

Suddenly they found themselves trying to compete in a marketplace in which they were unequally situated.

The decision to put all their clients' files into a central DWH location, passed as it was from on high, also didn't sit well with the province's doctors. Clinician uptake to EMR has been noticeably slow in Nova Scotia in comparison with countries like New Zealand, where upwards of 95% of physicians are electronically connected. In New Zealand, a free market model with the government as facilitator has proved highly successful.

Bob Brown, Vice President of Dymaxion Research Limted, has been selling EMR software in Nova Scotia under the label 'Practimax', since 1999.

“[In 2004] we applied for the multiple vendor RFP,” Brown tells The Halifax Media Co-op. “This was the one that made sense, because we knew that clinics were not keen on sending all data to the [the DHW]. In 2005 [the DHW] announced that we were one of the winners. But [the DHW] then told us 'You will not be able to sell to anybody who has high speed internet (for potential security risks).' So we were virtually shut out."

In 2007, the Nova Scotia Co-operative Council also entered the EMR market, creating a software system called HealthConnex. Dianne Kelderman, president of the Council, notes that HealthConnex is among the most popular software program in the province, and mentions that of the 2200 doctors in province who use EMR software, 1453 doctors are using the HealthConnex system, while 575 are using the Nightingale clinic software.

“One of the things we saw was needed was a way to connect doctors and patients, so we created a platform for [electronic] consultation, filing prescriptions on-line, and booking appointments on-line,” says Keldermann.

“It wasn't intended to replace the system, it was intended to enhance service. Physicians were telling us 'If we had a new way to communicate with patients, we wouldn't have wait lines.' But one thing we could not do without approval from the Department of Health is provide doctors with lab results. We needed special approval from [the DWH]. They would not give it to us. They told us: 'We have chosen one provider. We want every clinician using the same electronic system.'”

The Nightingale software has, apparently, been unpopular enough with Nova Scotia physicians that the DHW has been offering a $10,000 incentive to make the switch to Nightingale. The same CBC article notes that the system is, according to doctors, prone to crashes. According to Kelderman and Brown, this isn't just a case of the DWH offering the money to doctors currently not using EMR software (Brown estimates that under 40% of Nova Scotia physicians are using EMR software); the DWH is using taxpayer money to pinch their clients.

Brown notes that so far none of Practimax's clients have switched, while Keldermann notes she has lost about “100 clients”.

“The Department of Health with pay for all the computer equipment, all the back-end architecture, plus money, to anyone who will accept their product,” says Bob Brown. “They're just interfering in a private market is what they're doing. They're offering incentives to one vendor. From an economic point of view it's kind of strange, and the fact they're able to do it shows just how out of whack their policy is.

“They've already tied their horse to Nightingale, so they don't have much choice do they?”

Nightingale's pole position in the EMR market in Nova Scotia appears secure. In 2012, another RFP was put forward for a pilot project dealing with Personal Health Records (PHR). This pilot project, awarded to medical giant McKesson Canada (an arm of McKesson, one of the largest companies in the United States), will allow patients to “manage their records online,” according to the government of Nova Scotia website. Now almost a foregone conclusion, one of the key parameters of the RFP was the ability to connect with the Nightingale software.

McKesson's PHR software system, known as 'RelayHealth', is well-tested in the industry. But with all this sensitive information concerning people's health now floating around the internet, especially now in the hands of a company whose American parent company has been involved in major cases of fraud, it does raise the question: Why not establish an in-house data management system and avoid the entire conundrum?

“We have to be very conscious of how the storage of the records and the usage of the records [is undertaken],” says Ian Johnson, the Servicing Coordinator/Policy Analyst for the Nova Scotia Government and General Employees Union. Johnson also sits on the board of directors of the Nova Scotia Citizens' Health Care Network. “The whole debate over the Patriot Act and whether having US companies or foreign companies control databases and programs, or the contracting out of those services, is a serious issue and has major implications as well.

“I'd rather see it owned and operated within the public system if it's at all possible to do that. To allow that to be operated and contracted out is a potential problem. It could create big problems down the road for sure...We're troubled when any external, foreign-based company is involved in a health service, including the storage of health information.”

As for Brown and Kelderman, the sentiment would appear to be that if private service delivery is going to be the model being used, then the DWH has failed to allow for free market competition in the industry, and that has instead chosen to reward only a few large companies, which are still very much private, for-profit enterprises.

“[The DHW] seem[s] to want to model this after the long-gun registry, which is how can you do something the most expensive way that will be guaranteed not to work,” says Bob Brown. “And that is, you come up with a single model and you tell all users that this is what you're going to be using, no matter what seems to be right for you at the time. … There's no indication that Nightingale is the best software or the worst software, or anything else; it's just that doctors, like everybody else, don't like to be told what to do.”