CPOE:WHY IS CANADA LOSING THE RACE, BUT POISED FOR A COMEBACK?Jeremy Theal, CMIO, North York General Hospital

eHealth Conference, Ottawa • May 28, 2013

FACULTY/PRESENTER DISCLOSURE

• Faculty: Jeremy Theal MD FRCPC

• Relationships with commercial interests:• Grants/Research Support: Canada Health Infoway

• Speaker Honoraria: Cerner CanadaOntario Hospital Association

Provincial Health Services Authority

Vancouver Island Health Authority

• Consulting: Provincial Health Services Authority

DISCLOSURE OF NO CONFLICT OF INTEREST

• The Canadian CPOE Toolkit/NYGH has received financial support from Canada Health Infoway in the form of development funding.

• No conflict of interest to declare:• The Canadian CPOE Toolkit is a service available free of

charge to any publicly-funded Canadian healthcare institution• North York General Hospital, as the host organization for the

Canadian CPOE Toolkit, does not receive any financial support or financial gain from the Toolkit aside from the initial development funding it received from Canada Health Infoway

• No products other than the Canadian CPOE Toolkit will be discussed in this presentation

CANADA: LOSING THE CPOE RACE

• US has 12x the proportion of sites at HIMSS Stage 4 and above compared with Canada (38.3% vs 3.1%)

• Progression to HIMSS EMRAM Stage 4 and above is associated with improved quality and safety outcomes

- Amarasingham R et al. Arch Intern Med 2009 169(2):108-14- 2006 HIMSS EMR Sophistication Correlates to Hospital Quality Data

- 2012 HIMSS Analytics Report: Quality and Safety Linked to Advanced IT-Enabled Processes

WHY IS CANADA FALLING BEHIND?

• Differences in funding, incentives and penalties

• Misunderstanding of definition of CPOE and its benefitsAmarasingham R et al. Arch Intern Med 2009 169(2):108-14

• Heterogeneity of implementation approaches• Risk of negative patient and provider outcomes

• High quoted failure rate of CPOE projects (>30%)

• Lack of “critical mass” of successful projects in Canada

• Large amount of evidence-based content required for both go-live and ongoing maintenance

• Limited sharing of content and expertise within the public system, without incurring extra cost

WHY DO WE NEED TO SUCCEED?

• Patients deserve better quality and safety of care

Baker GR, Norton PG. Canadian Adverse Events Study. CMAJ 2004 170(11): 1678-86

Berwick DM et al. The 100,000 Lives Campaign. JAMA 2006 295(3): 324-7

• Government expects evidence-based care,

and hospitals need to report detailed quality outcome data

Excellent Care for All Act, Leg Assemb Ontario 2010

Quality-Based Procedures, MOHLTC, Ontario 2012

• Healthcare providers need systems that provide evidence built

into clinical workflows, to improve quality and safety of care

Kawamoto K et al. Systematic review of clinical decision support system success factors. BMJ 2005

0

40

8017

65 5084 96

% Appropriate VTE Prophylaxis

CPOE + CDS + EVIDENCE = IMPROVED OUTCOMES

CPOE + CDS + EVIDENCE = IMPROVED

OUTCOMESStudy population of all Medicine patients at NYGH with primary discharge diagnosis of COPD or Pneumonia:

• Pre-CPOE (Jan-Sep 2010) n=520

• Post-CPOE (Jan-Sep 2011) n=511

Outcome Comparison Odds Ratio

95% Confidence Interval p-value

Death adjusted for Probability of Death and CrCU Admission .

CPOE vs Paper 0.547 0.36-0.83 0.005

Diagnosis-appropriate order set 0.437 0.21-0.90 0.024

Order set close to, but not matching

diagnosis1.821 0.78-4.23 0.163

A POTENTIAL SOLUTION:CANADA MAKES A COMEBACK

• Canada compared with United States:• Healthcare based on single-payer (govt/taxpayer)• Not based on competition (challenge is accommodation)!• No competitive barriers to open information resource

sharing• Can benefit from economies of scale

• Significant proportion of cost and time required for CPOE implementation is due to:• Development of evidence-based standardized clinical

content (order sets, clinical decision support)• Workflow review, refinement and integration• Adoption of content, workflows and system by clinicians These factors are VENDOR-INDEPENDENT and MANDATORY FOR SUCCESS

Leverages the non-competitive structureof Canadian healthcare to create a no-cost sharing platform for Canadian CPOE development resources

• CPOE Implementation guide (>500 pages)

• Evidence-based CPOE order sets:• Searchable library with >500 order sets

(over 50% no license restrictions)• Specialties include:

Medicine, Surgery, Critical Care, Paediatrics• Coming soon: Maternal-Newborn, Mental Health

• Multi-publisher sharing model:• Each contributing organization shares content at no cost,

retains full ownership of all contributions• Contributions pending from multiple organizations

TOOLKIT-AFFILIATED ORGANIZATIONS

• North York General Hospital

• Alberta Health Services

• Brant Community Health Services

• Centre for Addiction and Mental Health (CAMH)

• Fraser Health Authority

• Humber River Regional Hospital

• London Health Sciences Centre

• North Bay Regional Health Centre

• Sunnybrook Health Sciences Centre

• St. Joseph’s Hospital, Toronto

• Provincial Health Services Authority

• Mackenzie Health Richmond Hill

• Ontario Hospital Association

• Canada Health Infoway

• St. Michael’s Hospital (pending)

• Ontario Shores Centre for Mental Health Sciences (pending)

• Vancouver Island Health Authority (pending)

14

organizations

and over 220

users in first

five months

THANK YOU

Join today at:http://www.cpoe-toolkit.ca