Canada Health Infoway and the Electronic Health Record Impacts & Opportunities Robert (Bob) Burns...
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Transcript of Canada Health Infoway and the Electronic Health Record Impacts & Opportunities Robert (Bob) Burns...
Canada Health Infoway and the Electronic Health Record
Impacts & OpportunitiesRobert (Bob) Burns
AFMC
May 8, 2007
Overview
• Why the EHR?• Why & what is Canada Health Infoway?• Progress to date• Challenges & hurdles• Benefits• EHRs and Education
Managing ExpectationsWhat are the Jones expecting from their healthcare system?
• Accurate information moves with them
• Various providers communicate with each other
• Privacy is protected
• Decisions are made in consultation with them
• Not exposed to undue risk
• Receive timely access/results
• Can access their own EHR
• Have the ability to learn on their own, with assistance from their healthcare providers
The Need for EHRFor Every …. …. in Canada
1000 hospital admissions 75 people will suffer an Adverse Event
1000 patients with an ambulatory encounter 20 people will suffer a serious Adverse Drug Event
1000 patients discharged from hospital 90 people will suffer a serious Adverse Drug Event with the drugs received on discharge
1000 Laboratory tests performed up to 150 will be unnecessary (range 50-150)
1000 Emergency Department visits 320 patients had an information gap identified, resulting in an average increased stay of 1.2 hours
Study of 168 traditional medical records 81% didn’t have the information required for patient care decisions
1000 women at risk of cervical cancer 300-400 are not screened
1000 Canadians recommended for influenza protection 370-430 are not vaccinated
Source: CIHI; Sanofi-Aventis; Statistics Canada;
OECD; WHO; Centre for Chronic Disease
Prevention
Resource pressures intensifying Growing Need for Health Information Management
Providers, managers, patients, public are demanding more
IT has potential to enable solutions to address pressures
Care settings areshifting
Population is aging
Consumerism isgrowing
Resource pressures
greater
Yet Canada Invests Less in Healthcare IT than Other Information-intensive Businesses
* Operating and capital
** Gartner estimate as %of revenues; assumes providers working on a non-profit basis
*** Predicted rise to 4% from 1.5% in 2004
Sources: Information Technology Association of Canada, 2004; Gartner
Annual IT spend* Percent of total budgets/revenues
2.9
3.4
4.0
4.54.7
5.4
1.5
Range of HC IT spend of Canadian jurisdictions
2.0
• Canada is underinvesting in IT relative to other healthcare providers and information management industries
• Canada’s healthcare system would rank No. 10 in the Fortune 500 and is 3 times the size of the Royal Bank and has limited ability to manage its information
• Additionally, investments have often been fragmented and one-off leading to duplication of efforts and need for reinvestments
Education US HC providers**
UK health-care***
Professional services
US banking/ financial services
Calgary Regional Health Authority
9
An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies.
EHR Defined
6
EHR and EMR…and convergence
• An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies.
• An electronic medical record (EMR) is a provider or site specific record of the interactions with a specific patient. By definition it is not complete, although it may be more richly detailed in some aspects than an EHR. It is maintained by providers to meet their fiduciary duties to their patients, as well as the requirements of their regulatory bodies.
About Infoway
Mission:• To foster and accelerate the development and adoption of electronic health
information systems with compatible standards and communications technologies on a pan-Canadian basis, with tangible benefits to Canadians
Approach:• Infoway was established by the First Ministers of Canada’s federal,
provincial and territorial governments in 2001• Infoway is a not-for-profit corporation• Funded by the Government of Canada, funding was allocated to Infoway in
2001 ($500m), 2003 ($600m) and 2004 ($100m)• Infoway’s members are Canada’s 14 federal, provincial and territorial
Deputy Ministers of Health• Independent Board
Infoway Business Strategies
• Targeted Investment Programs• Limited scope - goal• Collaboration with health ministries and other partners • Co-Invest with public sector partners (75:25 formula)• Leveraged investment • Form strategic alliances with the private sector• Manage risk and ensure quality solutions • Focus on end-user acceptance• Measure benefits and adjust
Infoway’s Goal
By the end of 2010, some elements of the basic EHR will be in place for all Canadians, while a complete basic EHR will be in place for 50% of Canadians. All Canadians will benefit from better healthcare access, quality and productivity.
Infoway’s Goal
By the end of 2010, some elements of the basic EHR will be in place for all Canadians, while a complete basic EHR will be in place for 50% of Canadians. All Canadians will benefit from better healthcare access, quality and productivity.
Innovation and Adoption - $60 million*
Public Health Surveillance
$100 million
Telehealth$120 million
Innovation and Adoption – $60 million*
Chronic Disease
Primary Care
Cancer
Patient Safety
Wait Times
Mental Health
Laboratory Systems$150 million
Diagnostic Imaging $310 million
Interoperable EHR – $175 million
Infostructure – $32 million
Registries$134 million
Drug Systems$185 million
Infoway’s Programs
Etc.
Basic
Elements
of EHR
Focus on Standards and Interoperability
•Common architecture largely accepted by jurisdictions•Revised architecture includes privacy and security•Comprehensive standards collaboration process•New Infoway Standards Collaborative
EHR Solution (EHRS)
EHR Infostructure (EHRI)
EHR ViewerPoint ofServiceApplication
Point ofServiceApplication
EHRS Locator
Registries Data &
Services
Longitudinal Record Services
HIAL
AncillaryData &
Services
EHRData &
Services
HealthInformation
Datawarehouse
EHR: Conceptual ArchitectureJURISDICTIONAL INFOSTRUCTURE
Pharmacy System
EHR Data & Services
Pharmacist
EHR Viewer
RadiologyCenterPACS/RIS
LabSystem(LIS)
Hospital,LTC, CCC,EPR
Physician/Provider
Lab ClinicianRadiologist
PhysicianOfficeEMR
Physician/Provider
Physician/Provider
Public HealthServices
Public HealthProvider
PHS Data & Services
OutbreakManagement
PHSReporting
POINT OF SERVICE
Registries Data & Services
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
DrugInformation
DiagnosticImaging
LaboratorySharedHealthRecord
SecurityManagement Data
PrivacyData Configuration
HIALCommunication Bus
Common Services
DataWarehouse
HealthInformation
Longitudinal Record Services
MessageStructures
EHRIndex
BusinessRules
NormalisationRules
EHRS EHRS EHRS EHRS EHRS EHRS EHRS
Distributed, Message-based, Peer-to-Peer Network of EHRS Systems
Electronic Health RecordsLinked Jurisdiction Networks
Legend Registries Diagnostic Imaging Drug Info Systems Lab Info Systems Telehealth Interoperable EHR Public Health Surv. Innovation & AdoptionNumber of Projects
217217 active & completed projects valued at $1,133 M$1,133 M
in all 9 investment programs
217217 active & completed projects valued at $1,133 M$1,133 M
in all 9 investment programs
The 135 projects jointly developed with provinces and territories are shown. In addition, there are 82 active or completed pan-Canadian projects.
12
Program Activity Summary
WEST ON QC EAST TERRITORIES
iEHR
NU
Client Reg.
DI
Drug
Laboratory
Telehealth
NT NS PE NL YKMB NBSKABBC
INV
ES
TM
EN
T P
RO
GR
AM
S
Provider Reg.
Phase 0/1 Projects
Phase 2 Projects
System in place
March 2004 = $125 M
Significant Progress in 3 Years
2005-06WEST ON QC EAST TERRITORIES
Telehealth
NU
Client Reg.
DI
Drug
Laboratory
NTNS PE NL YKMB NBSKABBC
INV
ES
TM
EN
T P
RO
GR
AM
S
Provider Reg.
Telehealth
iEHR
Public Health
WEST ON QC EAST TERRITORIES WEST ON QC EAST TERRITORIES
Telehealth
NU
Client Reg.
DI
Drug
Laboratory
NTNS PE NL YKMB NBSKABBC
INV
ES
TM
EN
T P
RO
GR
AM
S
Provider Reg.
Telehealth
iEHR
Public Health
WEST ON QC EAST TERRITORIES
9
September 2006 = $825 M
Ontario: Keeping Tabs on LabsThe first of nearly 200 hospitals and community labs are going “live” in 2006, providing on-line viewing of Lab results through links with hospitals and 10,000 doctors’ offices.
PEI: Island-Wide iEHR
By the end of 2007, PEI’s clinicians will be able to see a patient’s lab results, medication and diagnostic images on on-screen,
Canada-wide Public Health Surveillance
All 14 provincial, territorial and federal governments agreed to adopt a single Public Health Surveillance solution
Alberta: netCare Alberta-boundAlberta is leveraging Capital Health’s netCare viewer for province-wide use in iEHR and Lab information systems.
Saskatchewan: Checks Med Safety
Drug prescribing has become safer, with one of the first provincial systems covering “all drugs, all people.”
Quebec: Networking 62 HospitalsThe McGill - Montreal RUIS repositories for diagnostic imaging system will be the largest in Canada.
Nova Scotia: Farewell to Film
Almost 100% filmless - medical professionals in Nova Scotia’s hospitals will be able to access patients’ complete lab results, images and patient history by 2006/7.
Manitoba and New Brunswick: Telehealth Calling
Manitoba has doubled its network providing access to healthcare services to 10 northern First Nations and 7 Franco-Manitoban communities.
New Brunswick is the national leader in nurse triage call centres and is now planning to expand their telehealth network to provide tele-homecare
Newfoundland & Labrador: Province-wide eProgress
Province-wide Drug Information System underway
British Columbia: Leveraging Past Investments for an EHRBC will implement an electronic health record across the province.
Different Stages of Progress
Scarborough HospitalElectronic self-entry (by patients) of patient history in emergency department (ED) using touch-screen kiosks
Sherbourne Health Centreremote electronic records for a Health Bus serving the inner city homeless
Vancouver Island Health AuthorityEHR-based clinical decision support tools to for Mental Health & Addictions Services
British Columbia Ministry of HealthNewfoundland & Labrador’s Eastern Healthpilots for province-wide adverse events reporting, analysis and management
Sault Ste Marielink primary care providers and pharmacists to the EMR/EHR
Quebec MSSS electronic patient evaluation and service planning solutions.
Primary Health Care
Public Health Patient
Safety
Chronic Disease
CancerWait
Times
Information &
Communications
Technologies
Alberta Cancer Boardsynoptic reporting for cancer surgery will improve data collection and quality surgical management of cancer patients.
Alberta Capital/Calgary Health Regionsextend Alberta's iEHR and chronic disease management solutions to primary care teams.
Cancer Care Ontariocomputerized order entry and clinical decision support to benefit cancer patients.
Grand River Hospitalpatient portal will provide access to health information for cancer and renal patients.
Leveraging the EHR for Innovative Health Care
Infoway Adding Value at Every Step
• Joint governance • Joint planning (rolling 3
years)• Predictable funding• Common solutions
architecture• Common ICT standards• Accountable spend
• Common procurement• Common solutions• National pricing• Shared services• Knowledge sharing• Global leaders- exporting
expertise
A mid-term independent performance evaluation conducted in 2005 and a recent review commissioned by Health Canada both validated and
supported Infoway’s value-added role.
A mid-term independent performance evaluation conducted in 2005 and a recent review commissioned by Health Canada both validated and
supported Infoway’s value-added role.
The Global Scene
A number of nations have made significant e-health progress, with widespread EMR adoption, electronic communication and data sharing (e.g. lab results).
Canada and the UK lag slightly behind some others in EHR progress – New Zealand, Denmark, Norway and the Netherlands. However, both Canada and the UK have strong focused national strategies and significant resource commitments to provide these nations the momentum to become the global leaders in the next 3 years.
Momentum(Strategy plus Resources scores)
Pro
gre
ss(E
HR
Im
ple
me
nta
tion
plu
s A
do
ptio
n s
core
s)
DEN NZLNED
UKNOR
US CAN5
-
10 -
10 -
5 -AUS
The US and Australia currently lack momentum towards an EHR. Both have national strategies but currently lack the funding to successfully execute the strategy. With funding both could quickly join the leading nations.
This graphic is based upon analysis prepared by Infoway using publicly available documentation on international EHR initiatives. All findings are subjective in nature.
The International Milieu
DEU
SGP
FRA
JPN
The Road to 2015
• To develop a Health Infostructure Plan for Canada that confirms the long term vision and details the strategic directions that the country should consider over the next 10 years, including the associated resource requirements.
• To provide a roadmap for the complete implementation of the electronic health record across the country as well as the extension of the infostructure to support all aspects of healthcare renewal.
The VisionFoundation Systems• Electronic Health Record – for 100% of Canadians• Electronic Medical Record – for Primary and Ambulatory Care • Hospital Information Systems – CPOE and advanced decision support• Patient Portals – to permit patients to view their electronic health record
Business Systems• Public Health – for comprehensive pandemic management• Chronic Disease Management – for advanced case management of key
chronic diseases such as diabetes, congestive heart failure and cancer• Wait Time Management – to allow electronic referrals, enterprise scheduling
and wait time monitoring and reporting• Patient Selfcare – to support patients and their care givers in their home• Performance Management – to ensure sustainable patient care delivery
Capital Cost = $10 to $12 billionBenefits = $6.0 to $7.6 billion annually
Unlock additional quality and safety benefits by enabling decision support and communication across care continuum
Unlock additional quality and safety benefits by enabling decision support and communication across care continuum
22
Facilitate improvements in patient self-careFacilitate improvements in patient self-care
33
Enable public visibility into wait timesEnable public visibility into wait times
44
Trial more advanced functionality to meet high priority system needsTrial more advanced functionality to meet high priority system needs
55
Ensure baseline EHR and public health infostructure is in place across the countryEnsure baseline EHR and public health infostructure is in place across the country
11
Largest investmentrequired
Priorities to 2015F
ou
nd
ati
on
al
Ad
dit
ion
al e
lem
ents
Ad
dit
ion
al E
lem
en
ts
EHR: Overall Benefits & Value
ACCESS
• Reduced wait-times for diagnostic imaging services• Improved availability of community based health services• Reduced patient travel time and cost to access services• Increased patient participation in home care
QUALITY
• Improved interpretation of diagnostic and laboratory results• Decreased adverse drug events• Decreased prescription errors• Increased speed and accuracy in detecting infectious
disease outbreaks
PRODUCTIVITY
• Increased access to integrated patient information • Reduced duplicate tests and prescriptions• Reduced physician prescription call-backs• Reduced patient and provider travel costs
Infoway Benefits Evaluation Plan
Purpose:• Assess the impact of Infoway investments in electronic health record solutions on healthcare
quality, productivity and access. • Impacts identified will be used to:
• Demonstrate value of investments• Advance further investments in EHR solutions• Encourage end user adoption• Highlight necessary adjustments in the Infoway investment strategy
Principles:• Evaluate the Canadian experience with sufficient rigor to provide confidence in benefit estimates;
don’t try to develop the definitive EHR evaluation framework• Focus on evaluating programs that will produce tangible clinical benefits (Lab, Drug, DI,
Telehealth, PHS and iEHR)• Not all projects or activities will be evaluated. Identify representative sample and most
appropriate methodologies to allow extrapolation.• The EHR benefits evaluation will be evaluated and revised on an ongoing basis
Infoway BE FrameworkThe framework articulates the link between the systems in which Infoway invests and the resulting benefits, providing a basis for measurement.
NET BENEFITS
INFORMATIONQUALITY Content Availability
SERVICEQUALITY Responsiveness
SYSTEMQUALITY Functionality Performance Security
USERSATISFACTION Competency User Satisfaction Ease of Use
USE Use Behavior/
Pattern Self Reported Use Intention to Use
QUALITY Patient Safety Appropriateness/
Effectiveness Health Outcomes
ACCESS Ability of Patients/Providers
to Access Services Patient and Caregiver
Participation
PRODUCTIVITY Efficiency Care Coordination Net Cost
ORGANIZATIONAL and CONTEXT FACTORS: STRATEGY, CULTURE and BUSINESS PROCESS - OUT OF SCOPE
Based on the Delone & McLean IS Success Model
Quality, Access and Productivity Indicators
Change in provider effectiveness/ appropriateness of care
• Access to information • Timeliness of service delivery,
pharmacists, public health, referring physicians, radiologists
• Vaccination rates, Outbreak detection and intervention
Change in health system outcomes • Readmission rates• Efficiency of recovery• Patient transfers
Change in patient safety• Medication errors and Adverse Drug
Events
Change in patient and caregiver participation
• Patient awareness and adherence
Change in access to services• Volume of service provision• Access to previously unavailable services• Timeliness of DI services
Change in provider efficiency• Radiology Technologist and Radiologist
efficiency • Pharmacists and Lab technician callbacks • Time to take medication history or assess
patient• Clinician workflow
Change in coordination of care• Information sharing among different providers• Management of outbreaks
Change in net costs• Unnecessary events: radiology, lab tests,
vaccinations
Secondary Use of Data workshop with CIHI January 2007
• Time to start building and marketing the case for secondary use to build ‘readiness’ by physicians, public and other stakeholders
• Need to develop detailed use cases and/or a higher level framework identifying requirements for secondary use
• Need to identify experiences, successes and failures, both nationally and internationally and build upon them
EHR: Conceptual ArchitectureJURISDICTIONAL INFOSTRUCTURE
Pharmacy System
EHR Data & Services
Pharmacist
EHR Viewer
RadiologyCenterPACS/RIS
LabSystem(LIS)
Hospital,LTC, CCC,EPR
Physician/Provider
Lab ClinicianRadiologist
PhysicianOfficeEMR
Physician/Provider
Physician/Provider
Public HealthServices
Public HealthProvider
PHS Data & Services
OutbreakManagement
PHSReporting
POINT OF SERVICE
Registries Data & Services
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
DrugInformation
DiagnosticImaging
LaboratorySharedHealthRecord
SecurityManagement Data
PrivacyData Configuration
HIALCommunication Bus
Common Services
DataWarehouse
HealthInformation
Longitudinal Record Services
MessageStructures
EHRIndex
BusinessRules
NormalisationRules
Privacy and Security Services (Future State)JURISDICTIONAL INFOSTRUCTURE
EHR Data & ServicesAncillary Data & Services
OutbreakManagement
PHSReporting
POINT OF SERVICE
Registries Data & Services
ClientRegistry
ProviderRegistry
LocationRegistry
TerminologyRegistry
DrugInformation
DiagnosticImaging
LaboratorySharedHealthRecord
SecurityManagement Data
PrivacyData Configuration
HIALCommunication Bus
Common Services
DataWarehouse
HealthInformation
Longitudinal Record Services
MessageStructures
EHRIndex
BusinessRules
NormalisationRules
Common Services
PRIVACY AND SECURITYIdentity Protection
Services
User AuthenticationServices
AnonymisationServices
Identity MgmtServices
Consent DirectivesMgmt Services
EncryptionServices
Secure AuditingServices
Access ControlServices
Digital SignatureServices
General SecurityServices
User
Clinical Viewer
POSSystem
White Paper on Information Governance
• Early 2007 release - for feedback & comment• Identifies the areas for dialogue
• Governance is not new; how information flows with an iEHR is new
• Governance will require variety of approaches
• Where will responsibility for governance management reside?
Areas for Dialogue
• Trust & Accountability• Privacy Rights of Patients• Assessment & Compliance• Quality in Healthcare• Technical Safeguards• Rights of healthcare providers & communities of interest
…with subsequent sections on legal, ethical and professional requirements, the current mechanisms at play, and examples of other industry’s efforts to come to grips with similar issues
Several Hurdles Will Need To Be Overcome To Complete The Existing Mandate
Front-line implementation, including standards implementation, business process redesign, and clinician adoptionBring key
stakeholders – public and clinicians in particular – on board
“Clinicians will not be willing to adopt the technology if it makes their life harder.”
– Clinician
“Clinicians will not be willing to adopt the technology if it makes their life harder.”
– Clinician
“We need people pounding the table for this.”
– Regional CIO
“We need people pounding the table for this.”
– Regional CIO
Urgency behind building a case for ongoing support
“Until you get a reasonable level of critical mass, we are years away from measuring systemic benefits to the system. This is the problem for elected officials, who want to see the benefits quickly.”
– Regional CIO
“Until you get a reasonable level of critical mass, we are years away from measuring systemic benefits to the system. This is the problem for elected officials, who want to see the benefits quickly.”
– Regional CIO
Securing the right mix of leadership at all levels
“We need additional champions beyond Infoway.”
– Deputy Minister
“We need additional champions beyond Infoway.”
– Deputy Minister
Journey far from complete
Academe as stakeholders
• Teaching, research, service delivery - and thought leader
• Teaching - UG,PG, CPD
• Research: ‘secondary use’ as discussed
• Service delivery: as discussed
• Thought leader
Academic/Learning Advisory Group
• Role: provide expert input to one of 4 key elements of the End User Strategy
– After D Covvy
TODAYÕS
ROLE
Challenges
Competencies
Curriculum
TOMORROWÕS ROLE
Challenges
Competencies
Curriculum
SKILLS
KNOWLEDGE
ATTITUDES
EXPERIENCE
CPD/KT
Challenges for Teaching Institutions
• Technology itself (50% of FP teaching units)• Strategic alliances with institutions (hospitals, LHINs,
RHAs) where care is delivered• Theme of ‘EHR solutions as tool’, cross-cutting all
training, rather than ‘stand-alone’ or ‘add-on’ to curriculum
• ‘Walk the talk’ - clinically, and technologically
The Promise• Increased patient
participation in care• Well managed chronic
illness• Improved access to care
in remote and rural communities
• Less adverse drug events• Better therapeutic
outcomes• Better prescribing
practices• Reduced wait times