Annual Review of IM/IT in Healthcare · 4 WTIS-EMPI implementation status – adoption statistics,...

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



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



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


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


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


11

90% MRI scans completed within


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


Total = 5,139

17

User activity is tracked to focus improvements onpriority areas


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

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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


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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


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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

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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

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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

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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)

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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.

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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

*

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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.

Annual Review of IM/IT in Healthcare · 4 WTIS-EMPI implementation status – adoption statistics,...

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