Post on 22-Mar-2020
1
Annual Review ofAnnual Review of
IM/IT in HealthcareIM/IT in Healthcare
Breakfast with the Chiefs
March 6, 2007
2
Agenda
• Notable successes and disappointments
• Principals for eHealth investments
• Rising health expenditures
• Colorectal cancer in Ontario
• Update on Health Human Resources
• International perspective: Primary care
• Diabetes care in Canada
• Concluding thoughts
3
Notable successes and disappointments
Successes:
• Ontario Wait time information system (and eMPI)
• Capital Health netCare
Disappointments:
• Smart Systems for Health Agency
• Ontario Lab Information System
• Alberta Pharmacy Information Network
4
WTIS-EMPI implementation status – adoptionstatistics, by surgeon offices
1400
1700
300
0
200
400
600
800
1000
1200
1400
1600
1800
March 2006 Nov. 2006 Projected June 2007
Source: Ontario Cancer Plan: 2006-07 Annual Progress Report
5
WTIS-EMPI implementation status – adoptionstatistics, by hospitals connected
5
55
77
0
10
20
30
40
50
60
70
80
90
March 2006 Nov. 2006 Projected June 2007
Source: Ontario Cancer Plan: 2006-07 Annual Progress Report
6
WTIS-EMPI implementation status – adoptionstatistics, by volume of surgical cases
255,000
235,000
36,000
0
50,000
100,000
150,000
200,000
250,000
300,000
March 2006 Nov. 2006 Projected June 2007
Source: Ontario Cancer Plan: 2006-07 Annual Progress Report
7
90% of cataract surgeries completed within
0
50
100
150
200
250
300
350Aug/S
ept 05
Oct/Nov 0
5
Dec 05/Ja
n 06
Feb/Mar 0
6Apr/M
ay 06
June/Ju
ly 06
Aug/Sep 0
6Oct/
Nov 06
Dec 06/Ja
n 07
Feb/Mar 0
7
Apr 07
Day
s
Trend-line
Source: Alan Hudson’s Empire Club of Canada address, Jan. 25th, 2007
8
90% Hip replacement surgeries completed within
0
50
100
150
200
250
300
350
400Aug/S
ept 05
Oct/Nov 0
5
Dec 05/Ja
n 06
Feb/Mar 0
6Apr/M
ay 06
June/Ju
ly 06
Aug/Sep 0
6Oct/
Nov 06
Dec 06/Ja
n 07
Feb/Mar 0
7
Apr 07
Day
s
Trend-line
Target-line
Source: Alan Hudson’s Empire Club of Canada address, Jan. 25th, 2007
9
90% Knee replacement surgeries completed within
0
50
100
150
200
250
300
350
400
450Aug/S
ept 05
Oct/Nov 0
5
Dec 05/Ja
n 06
Feb/Mar 0
6Apr/M
ay 06
June/Ju
ly 06
Aug/Sep 0
6Oct/
Nov 06
Dec 06/Ja
n 07
Feb/Mar 0
7
Apr 07
Day
s
Trend-line
Target-line
Source: Alan Hudson’s Empire Club of Canada address, Jan. 25th, 2007
10
90% Cancer surgeries completed within
0
10
20
30
40
50
60
70
80
90Aug/S
ept 05
Oct/Nov 0
5
Dec 05/Ja
n 06
Feb/Mar 0
6Apr/M
ay 06
June/Ju
ly 06
Aug/Sep 0
6Oct/
Nov 06
Dec 06/Ja
n 07
Feb/Mar 0
7
Apr 07
Day
s
Trend-line
Source: Alan Hudson’s Empire Club of Canada address, Jan. 25th, 2007
11
90% MRI scans completed within
Source: Alan Hudson’s Empire Club of Canada address, Jan. 25th, 2007
0
20
40
60
80
100
120Aug/S
ept 05
Oct/Nov 0
5
Dec 05/Jan 0
6Feb/M
ar 06
Apr/May 0
6Ju
ne/July
06Aug/S
ep 06
Oct/Nov 0
6
Dec 06/Jan 0
7Feb/M
ar 07
Apr 07
Day
s
Trend-line
Target-line
12
Current overall gap - % cases completed withintarget
71%
43%
66%
78%
87%
100%
91%
0%
100%
Cancer Surgery
Bypass Surgery
Cataract Surgery
Hip ReplacementKnee Replacement
MRI
CT
Target
Actual (Oct/Nov 06)
Source: Interim wait times database & WTIS, Wait Times Information Office
13
WTIS-eMPI Success
• Motivated by a clear operational objective everyonecan understand (reduce wait times)
• The system was a means to an end, not an end initself
• Incentives for adoption understood by all (access tofunds for expanded procedure volume)
• Implementation occurred in rapidly expanding waves(a few pilot sites, followed by successive waves ofadoption)
• Data publicly available to all (close scrutiny onaccuracy)
• Excellent, proven project leadership
• Focus on immediate operational needs that could beaccomplished in <18 months
14
Capital Health Edmonton - NetCARE
• Canada's first major regional electronic healthrecord
• Edmonton and surrounding area
• Available 24 hours a day, seven days a week
• netCARE is accessed by physicians, nurses, alliedprofessionals, unit clerks, and management
• Implementation started in April 2004
• System provides detailed month by month usagestatistics
15
netCARE utilization continues to increase
Source: “Capital Health Electronic Health Record: Utilization update,September 15, 2006”
netCARE Active Users per Month
16
Active user professions – August, 2006
Source: “Capital Health Electronic Health Record: Utilization update,September 15, 2006”
Total = 5,139
17
User activity is tracked to focus improvements onpriority areas
Source: “Capital Health Electronic Health Record: Utilization update,September 15, 2006”
netC
ARE S
cre
ens A
ccessed
18
netCare Success
• Clear value proposition from first day (completeclinical content)
• Short development window before release toclinicians
• Successive waves of implementation after a shortinitial pilot
• Rapid releases of new versions that added newclinical content (ECGs, PACs, reports, etc.)
• Careful tracking of user activity to focus improvementefforts
• Excellent, proven leadership
19
Operational Review of Smart Systems
• Ministry of Health and Long-Term Care and the SSHABoard Chair commissioned Deloitte to conduct anoperational review
• The final report was dated November 6, 2006 andreleased January 2007
• The review involved:
– over 800 SSHA internal documents
– 56 interviews with SSHA executives and staff
– 16 interviews with MOHLTC executives and staff
– 13 external stakeholder interviews; and
– research and interviews for 8 jurisdictions
Source: “Smart Systems for Health Agency” , Operational Review Final Report,Deloitte Consulting, November 6th, 2006
20
Findings of the Operational Review
1. Lack of strategic direction from the Ministry
2. SSHA brand is not well regarded as it tried to be “all things toall people”
3. Failed to demonstrate its value proposition to clients
4. Operates more as a Ministry division than an independentoperating entity
5. Questions about value obtained from significant investments -failed to measure performance therefore cost/benefit could notbe assessed
6. Financial management inadequate to ensure cost-effectivedeployment of $145M in FY 06/07
7. Lack of rigorous operational and financial planning, weakproject management, unnecessarily complex structure
Source: “Smart Systems for Health Agency” , Operational Review Final Report,Deloitte Consulting, November 6th, 2006
21
Value for money?
“without clearly defined targets in each area, it isdifficult to assess SSHA’s progress and value formoney against the cumulative investment of $458million since its inception”
• Seven priority areas:– Manage private network
– Secure messaging service
– Security infrastructure
– Data centres
– Voluntary emergency health record
– Data and technology standards
– Portals
22
Recommendations
• 32 recommendations under the headings:
– Strategy, governance and accountability
– Client service
– Operational processes
– Financial management
– Organization and HR
• Recommendation #1 is to finalize and approve theeHealth Strategy for Ontario
• The Ministry needs to own the eHealth program andbe engaged at the level of making strategy, policy,and program decisions, and work with the Agency toimplement appropriate solutions
Source: “Smart Systems for Health Agency” , Operational Review Final Report,Deloitte Consulting, November 6th, 2006
23
SSHA model has not worked
• Infrastructure free of clinical content
• Remote governance and management disconnectedfrom front line clinical needs
• Design phase tries to anticipate all future needs andissues – makes for large, complex projects that takea long time to implement. No rapid prototyping thatengages stakeholders in the design process.
• No focus on customer needs – the funding is providedwithout accountability for achieving results –manifests itself as repeated preaching about whathealth users should want
• Business or clinical objectives are vague andsecondary to the systems architecture
• Legacy systems have largely been ignored
24
Ontario Lab Information System
• A single information system allowing all laboratorytest information to be electronically exchangedamongst authorized practitioners and lab serviceproviders in Ontario.
• A source of system and program managementinformation for the ongoing enhancement of labservices
• A key component of Ontario’s electronic health recordstrategy
• OLIS Clinical Repository ready to receive informationMarch 31st, 2006
Source: SSHA presentation
25
Yet OLIS has had no impact
• Long build time prior to engaging end users – largespend (>$40 million) before any feedback from a liveclinical environment
• No well defined clinical or business objective
• No clinical content at inception
• User engagement has not occurred
• Major challenges integrating lab data from manylegacy systems
• It is not possible to design the end state workflow upfront – changes in operations must evolve withsuccessive versions of the software
26
The Alberta Pharmacy Information Network hadsimilar problems
• Spending >$50 million
• Expensive, long term build before use in a clinicalsetting
• No clinical content at inception
• Suffered from the “fax machine adoption problem”
• No well defined business objective
• Lack of incentives for clinical users
• Major integration problems with legacy systems
27
Principles for eHealth investments
• Use experienced teams lead by leaders with a trackrecord of success
• Build time should be short – get the application into alive clinical environment rapidly (<18 months)
• Implement using a short pilot phase followed rapidlyby 2-3 waves of additional users
• Learn from the successes and failures of others
• Put users in the driver’s seat (monitor utilizationcarefully)
• Make sure the users have a strong value proposition(incentives or benefits)
• Build on legacy investments (don’t ignore them!)
• Establish clear business or clinical objectives (the ITsystem is the means to an end)
28
0.00
20.00
40.00
60.00
80.00
100.00
120.00
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
f
Current Dollars
Constant Dollars (1997)
F O
R E
C A
S T
Government health expenditures in Canada(1975 to 2006)
($ billions)
Year
Source: CIHI. National Health Expenditure Trends1975-2006. 2006
*Note: 2005 and 2006 total expenditures have been forecasted.
29
Healthcare spending in Canada has increased by 5%from 1996 to 2006 annually after inflation.
Per Capita Health Spending in Canada
in Constant Dollars 1997
Source: CIHI. National Health Expenditure Trends 1975-2005
Real growth is expected to have been 3.7% in 2005 and 2006.
$2,000
$2,500
$3,000
$3,500
$4,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
f
2006
f
F O
R E
C A
S T
Source: CIHI. National Health Expenditure Trends1975-2006. 2006
30
20.0
25.0
30.0
35.0
40.0
45.0
50.0
1975-1976 1979-1980 1983-1984 1987-1988 1991-1992 1995-1996 1999-2000 2003-2004
Ontario
Canadian Average
Alberta
F O
R E
C A
S T
Provincial health expenditures, as a percent of total provincialprogram spending (1975-1976 to 2005-2006)
(percent)
Year
Source: CIHI. Preliminary Provincial and Territorial Government HealthExpenditure Estimates 1974-1975 to 2006-2007. November 2006
Health care opinion leaders:views on controlling rising health care costs
50%
51%
54%
54%
57%
61%
65%
66%
70%
75%
Consolidate purchasing power by public, private
insurers working together to moderate rising costs of
Have all payers, including private insurers, Medicare,
and Medicaid, adopt common payment methods or rates
Establish a public/private mechanism to produce,
disseminate information of effectiveness, best practices
Reduce administrative costs of insurers, providers
Allow Medicare to negotiate drug prices
Reward providers who are more efficient and provide
higher quality care
Increase the use of disease and care management
strategies for the chronically ill
Increased and more effective use of IT
Use evidence-based guidelines to determine if a test,
procedure should be done
Reduce inappropriate medical care
“How effective do you think each of these approaches would be
to control rising costs and improve the quality of care?”
Percent saying “extremely/very effective”
Source: The Commonwealth Fund Health Care Opinion Leaders Survey,
Jan. 2007.
Note: Based on a list of 19options
32
Cancer cases in Ontario: 2006
New cases Deaths
Lung 7,600 6,600
Breast 8,400 2,000
Prostate 8,400 1,550
Colorectal 7,500 3,100
Source: Canadian Cancer Statistics
* Colorectal cancer has a 90% chance to be treated and cured, ifdetected in its early stages
*
33
Screening for colorectal cancer
Average risk individuals:
• Canadian Cancer Society recommends that men andwomen age 50+ have a fecal occult blood test (FOBT)at least every 2 years.
At risk individuals:
• Canadian Cancer Society recommends a colonoscopy,every 5 years
More precise recommendation is presently beingdeveloped by MOHLTC. The announcement offunding support was made January 23rd, 2007
Source: Canadian Cancer Society & Cancer Care Ontario
34
Percent of screen-eligible men & women (ages 50-74) who received fecal occult blood test (FOBT)
FOBT: by LHIN 2001-2004
0%
20%
40%
60%
80%
100%
Ont
ario
Erie S
t. Clair
South
Wes
t
Wat
erloo
Wellin
gton
Hm
ltn-N
gr-H
ldm
nd-B
rnt
Cen
tral W
est
Mississ
auga
Halto
n
Toron
to C
entra
lCen
tral
Cen
tral E
ast
South
Eas
tCha
mplain
Nor
th S
imco
e M
usko
kaNor
th E
ast
Nor
th W
est
LHIN/Regional Cancer Programs
2001
2002
2003
2004
Target 90%
Sources: Ontario Health Insurance Plan database; Registered Persons Database; Statistics Canadapopulation estimates
Sources: Ontario Health Insurance Plan database; Registered PersonsDatabase; Statistics Canada population estimates
35
Percent of pathology lab reports meeting provincialstandard
Colorectal cancer resections: by LHIN, April 1 - September 30,
2005
0%
20%
40%
60%
80%
100%
Ont
ario
Erie S
t. Clair
Sou
th W
est
Wat
erloo
Wellin
gton
Hm
ltn-N
gr-H
ldm
nd-B
rnt
Cen
tral W
est
Mississ
auga
Halto
n
Toron
to C
entra
lCen
tral
Cen
tral E
ast
Sou
th E
ast
Cha
mplain
Nor
th S
imco
e M
usko
kaNor
th E
ast
Nor
th W
est
LHIN/Regional Cancer Programs
Target 90%
Sources: Ontario Health Insurance Plan database; Registered PersonsDatabase; Statistics Canada population estimates
36
Many surgical procedures do not meet practicestandards
Sources: Cancer Care Ontario, Pathology Information Management system(PIMS). Based on a sample of pathology reports for 1,404 colorectal cancerresections
Percent of Colorectal cancer resections with 12 or more lymph
nodes collected and examined
60%
69%
0%
20%
40%
60%
80%
100%
2004 2005
37
Trends in cervical cancer incidence and mortality inCanada, 1950-2000
Source: Cervical Cancer in Canada, Public Health Agency of Canada,2003
38
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
<30 30-34 35-39 40-44 45-49 50-54 55-59 60+
1999
2000
2001
2002
2003
2004
2005
Age Group
Pro
po
rti
on
of
To
tal
Nu
rses
(percent)
The productivity imperative:Aging health human resources, RNs
Source: Canadian Institute for Health Information. Workforce Trends ofRNs in Canada, 2005
39
Total number of RNs in the workforce 1999-2005
256,544 254,628 252,913 254,752 258,393 263,356251,675
0
50,000
100,000
150,000
200,000
250,000
300,000
1999 2000 2001 2002 2003 2004 2005
Source: Canadian Institute for Health Information. Workforce Trends ofRNs in Canada, 1999-2005
40
Another productivity imperative:Aging health human resources, MDs
0
5,000
10,000
15,000
20,000
25,000
<30 30-39 40-49 50-59 60-69 70-79 80+
1999
2001
2002
2003
2004
2005
Age Group
Nu
mb
er o
f P
hysic
ian
s
Source: Supply, Distribution and Migration of Canadian Physicians,Canadian Institute for Health Information
41
Physician graduate numbers are increasing
Source: Canadian Medical Education Statistics, 2006, Association ofFaculties of Medicine of Canada (www.afmc.ca)
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2200
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006*
Males
Females
Total
Year
Nu
mb
er o
f G
rad
uate
s
F O
R E
C A
S T
42
1.1
1.3
1.5
1.7
1.9
2.1
19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021
1999 estimates
2001 estimates
2005 estimates
Source: CMA Physician Resource Evaluation Template
Estimates of future physician supply in CanadaP
hysic
ian
s p
er 1
,00
0 p
op
ula
tio
n
Year
43
Primary care doctors use of electronic patientmedical records in 2006
98
9289
79
42
28
23
0
25
50
75
100
NET NZ UK AUS GER US CAN
Percent
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary
Care Physicians.
44
Primary care doctors’ reports of any financialincentives targeted on quality of care
95
79
72
58
43 41
30
0
25
50
75
100
UK NZ AUS NET GER CAN US
Percent reporting any financial incentive*
* Have potential to receive payment for: clinical care targets, high patient ratings, managing chronic
disease/complex needs, preventive care, or QI activities
Source: 2006 Commonwealth Fund International Health Policy Survey ofPrimary Care Physicians.
45
Why health care renewal matters: Lessons fromDiabetes
• Health outcomes report by Health Council of Canada
• Released March 5th, 2007
• Funded by Health Canada
• The report, the first in a series on health outcomes,shows how the health care system needed renewal,where there are care gaps and positive outcomes inthe quality of life of Canadians with chronic healthconditions such as type 2 diabetes.
• Measuring and monitoring health outcomes helps usunderstand where the country needs to act and how.
Source: “Why health care renewal matters: Lessons from Diabetes” , Healthoutcomes report by Health Council of Canada, March 5th, 2007
46
Diabetes care
959292879391Cholesterolchecked in last
year
555658404138All 4 servicesreceived in last
yr.
856983667373Eye exam inlast yr.
657075665752Feet exam inlast yr.
919085798690A1C in last 6mos.
GER
%
US
%
UK
%
NZ
%
AUS
%
CAN*
%
Indicator
*Source: Schoen et al. “Taking the pulse of health care systems: experiences ofpatients with health problems in six countries.” Health Affairs , Nov. 3, 2005
Patients with chronic diseases often do not receive the recommended care
Statistics Canada Canadian CommunityHealth Survey (Cycle 3.1), 2005.
Data not available.
Data not available.
61% had an eye check-up in the past 2 years.
48% had a professional foot exam in the last year. 65% hadchecked their own feet (part of recommended self-care) inthe past year.
74% had an A1C test at least once in the past 12 months. Onaverage, these people were tested 3.4 times during theyear, or about every 3 to 4 months.
47
Chronic disease management in Edmonton
Source: “Edmontonʼs health census a bold example of modern care” , AndrePicard, The Globe and Mail, February, 22nd, 2007
“Capital Health in Edmonton … announced recently
that it plans to identify 100 per cent of people in its
territory who suffer from diabetes. Then it plans to
ensure that every single one of them achieves his or
her treatment goals. Deadline: 2009.”
“That we are doing so little to prevent this kind of
suffering and expense speaks volumes about how our
health system has gone astray in the setting of priorities.”
“It begins with using electronic databases to check every
blood glucose test and flag abnormal results -- an
indication a person is diabetic or at risk of developing
diabetes. These tests are done routinely, but far too
often there is no follow-up by the patient or his doctor.”
48
Chronic disease management in Edmonton
Source: “Edmontonʼs health census a bold example of modern care” , AndrePicard, The Globe and Mail, February, 22nd, 2007
“But the real story here is hidden in some seemingly
mundane bureaucratic details. The health region can
identify diabetics because it has superb electronic
health records that include relevant information right
down to the results of lab tests.”
“Studies have shown that for every dollar invested in
diabetes prevention, between $3 and $20 can be saved
in treatment costs.”
“The result is better care, not only for diabetics, but for
all those who will face the challenge of living with a
chronic condition.”
“We should all be so lucky.”
49
Concluding Thoughts
• Chronic Disease Management and Cancer Screeningoffer a fantastic opportunity to:– Reduce the rate of escalating healthcare costs
– Improve the productivity of providers
– Motivate the adoption of electronic health records
– Improve the quality of care
– Improve our health
• Initiatives focused on clinical objectives have a muchhigher likelihood of success
• There may be a good reason why an “eHealthstrategy” has never been embraced in Ontario.