Transcript Canada Health Infoway and the Electronic Health Record

Canada Health Infoway and the Electronic
Health Record
Impacts & Opportunities
Robert (Bob) Burns
AFMC
May 8, 2007
Overview
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Why the EHR?
Why & what is Canada Health Infoway?
Progress to date
Challenges & hurdles
Benefits
EHRs and Education
The Need – Patient Expectations
Managing Expectations
What 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 EHR
For Every ….
1000 hospital admissions
1000 patients with an ambulatory encounter
1000 patients discharged from hospital
1000 Laboratory tests performed
1000 Emergency Department visits
Study of 168 traditional medical records
1000 women at risk of cervical cancer
1000 Canadians recommended for influenza protection
…. in Canada
75 people will suffer an Adverse Event
20 people will suffer a serious Adverse Drug Event
90 people will suffer a serious Adverse Drug Event with the
drugs received on discharge
up to 150 will be unnecessary (range 50-150)
320 patients had an information gap identified, resulting in an
average increased stay of 1.2 hours
81% didn’t have the information required for patient care
decisions
300-400 are not screened
370-430 are not vaccinated
Growing Need for Health Information Management
Resource pressures intensifying
Resource
pressures
greater
Providers, managers,
Care settings are
shifting
patients, public are
demanding more
IT has potential to
enable solutions to
address pressures
Consumerism is
growing
Population is aging
Source: CIHI; Sanofi-Aventis; Statistics Canada;
OECD; WHO; Centre for Chronic Disease
Prevention
Yet Canada Invests Less in Healthcare IT than
Other Information-intensive Businesses
• 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
Annual IT spend*
Percent of total budgets/revenues
5.4
4.7
4.5
4.0
3.4
2.9
2.0
• Additionally, investments
have often been
fragmented and one-off
leading to duplication of
efforts and need for
reinvestments
1.5
Education
US HC
providers**
UK healthcare***
* 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
Calgary
Regional
Health
Authority
Professional
services
US banking/
financial
services
Range of HC
IT spend of
Canadian
jurisdictions
EHR Defined
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.
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EHR and EMR…and convergence
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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.
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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.
The Model/Vehicle to Begin to
Address Need: Canada Health
Infoway
About Infoway
Mission:
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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:
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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
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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 Programs
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
Innovation
and
Adoption
- $60million*
million*
Telehealth
$120 million
Public Health
Surveillance
$100 million
Chronic
Disease
Cancer
Wait
Times
Primary
Care
Patient
Safety
Mental
Health
Etc.
Interoperable EHR – $175 million
Registries
$134 million
Drug
Systems
$185 million
Laboratory
Systems
$150 million
Infostructure – $32 million
Diagnostic
Imaging
$310 million
Basic
Elements
of EHR
Focus on Standards and Interoperability
EHR Solution (EHRS)
•Common architecture largely
accepted by jurisdictions
•Revised architecture includes
privacy and security
•Comprehensive standards
collaboration process
•New Infoway Standards
Collaborative
EHR Infostructure (EHRI)
Ancillary
Data &
Services
Health
Information
Data
warehouse
EHR
Data &
Services
Registries
Data &
Services
Longitudinal Record Services
HIAL
Point of
Service
Application
Point of
Service
Application
EHR Viewer
EHRS
Locator
EHR: Conceptual Architecture
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
PHS Data & Services
Outbreak
Management
EHR Data & Services
PHS
Reporting
Shared
Health
Record
EHR
Index
Message
Structures
Drug
Information
Data
Warehouse
Diagnostic
Imaging
Laboratory
Health
Information
Provider
Registry
Location
Registry
Business
Rules
Terminology
Registry
Normalisation
Rules
Longitudinal Record Services
Security
Management Data
Privacy
Data
Configuration
Common Services
HIAL
Communication Bus
POINT OF SERVICE
Public
Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Public Health
Provider
Pharmacist
Radiologist
Lab
System
(LIS)
Lab Clinician
Hospital,
LTC, CCC,
EPR
Physician/
Provider
Physician
Office
EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
Electronic Health Records
Linked Jurisdiction Networks
Distributed, Message-based, Peer-to-Peer
Network of EHRS Systems
EHRS
EHRS
EHRS
EHRS
EHRS
EHRS
EHRS
Progress to Date
Program Activity Summary
217 active &
completed projects
valued at $1,133 M
in all 9 investment
programs
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The 135 projects jointly developed with provinces and territories are shown.
In addition, there are 82 active or completed pan-Canadian projects.
Legend
 Registries
 Diagnostic Imaging
 Drug Info Systems
 Lab Info Systems
 Telehealth
 Interoperable EHR
 Public Health Surv.
 Innovation & Adoption
Number of Projects
Significant Progress in 3 Years
WEST
INVESTMENT PROGRAMS
March 2004 = $125 M
BC
AB
ON
SK
QC
MB
NB
NS
TERRITORIES
PE
NL
YK
NT
NU
Telehealth
Phase 0/1 Projects
Phase 2 Projects
iEHR
System in place
Laboratory
Drug
DI
Provider Reg.
Client Reg.
WEST
WEST
September 2006 = $825 M
2005-06
BC
AB
ON
ON
SK
QC
QC
MB
Telehealth
Telehealth
Telehealth
Telehealth
iEHR
iEHR
Laboratory
Laboratory
Drug
Drug
DI
DI
ProviderReg.
Reg.
Provider
Client
Client Reg.
Reg.
EAST
EAST
NB
PublicHealth
Health
Public
INVESTMENT PROGRAMS
EAST
9
NS
TERRITORIES
TERRITORIES
PE
NL
YK
NT
NU
Different Stages of Progress
Canada-wide Public Health Surveillance
All 14 provincial, territorial and federal governments agreed to adopt a single Public Health Surveillance solution
British Columbia: Leveraging
Past Investments for an EHR
BC will implement an electronic health
record across the province.
Alberta: netCare Alberta-bound
Alberta 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 Hospitals
The McGill - Montreal RUIS
repositories for diagnostic imaging system will
be the largest in Canada.
Newfoundland & Labrador:
Province-wide eProgress
Province-wide Drug Information System
underway
Manitoba and New Brunswick:
Telehealth Calling
Nova Scotia: Farewell to Film
Manitoba has doubled its network providing
access to healthcare services to 10 northern First
Nations and 7 Franco-Manitoban communities.
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.
New Brunswick is the national leader in nurse
triage call centres and is now planning to expand
their telehealth network to provide tele-homecare
PEI: Island-Wide iEHR
Ontario: Keeping Tabs on Labs
The 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.
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,
Leveraging the EHR for Innovative Health Care
Quebec MSSS
electronic patient evaluation and service planning
solutions.
British Columbia Ministry of Health
Newfoundland & Labrador’s Eastern Health
pilots for province-wide adverse events reporting, analysis and
management
Sherbourne Health Centre
remote electronic records for a Health Bus
serving the inner city homeless
Sault Ste Marie
link primary care providers and
pharmacists to the EMR/EHR
Public
Health
Primary
Health
Care
Alberta Capital/Calgary Health
Regions
Patient
Safety
Information &
Communications
Technologies
extend Alberta's iEHR and chronic disease
management solutions to primary care teams.
Grand River Hospital
Chronic
Disease
patient portal will provide access to
health information for cancer and renal
patients.
Vancouver Island Health Authority
Alberta Cancer Board
EHR-based clinical decision support tools to
for Mental Health & Addictions Services
synoptic reporting for cancer surgery will
improve data collection and quality surgical
management of cancer patients.
Scarborough Hospital
Electronic self-entry (by patients) of patient history in
emergency department (ED) using touch-screen kiosks
Cancer
Wait
Times
Cancer Care Ontario
computerized order entry and clinical decision support to
benefit cancer patients.
Infoway Adding Value at Every Step
• Joint governance
• Joint planning (rolling 3
years)
• Predictable funding
• Common solutions
architecture
• Common ICT standards
• Accountable spend
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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.
The Global Scene
The International Milieu
A number of nations have made significant
e-health progress, with widespread EMR
adoption, electronic communication and data
sharing (e.g. lab results).
NED DEN
NZL
NOR
CAN
US
AUS
5-
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.
UK
DEU SGP
FRA
Momentum
10 -
JPN
5-
(EHR Implementation plus Adoption scores)
Progress
10 -
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.
(Strategy plus Resources scores)
This graphic is based upon analysis prepared by Infoway using publicly available
documentation on international EHR initiatives. All findings are subjective in nature.
Before we get too smug…
On the road to 2015 …
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 Vision
Foundation Systems
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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
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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 billion
Benefits = $6.0 to $7.6 billion annually
Priorities to 2015
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Foundational
Ensure baseline EHR and public health infostructure is
in place across the country
2
Unlock additional quality and safety benefits by
enabling decision support and communication across
care continuum
3
Additional Elements
Additional elements
Facilitate improvements in patient self-care
4
Enable public visibility into wait times
5
Trial more advanced functionality to meet high priority
system needs
Largest investment
required
Opportunities
Benefits Evaluation at Infoway
EHR: Overall Benefits & Value
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Improved interpretation of diagnostic and laboratory results
Decreased adverse drug events
Decreased prescription errors
Increased speed and accuracy in detecting infectious
disease outbreaks
QUALITY
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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
ACCESS
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Increased access to integrated patient information
Reduced duplicate tests and prescriptions
Reduced physician prescription call-backs
Reduced patient and provider travel costs
PRODUCTIVITY
Infoway Benefits Evaluation Plan
Purpose:
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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:
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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 Framework
The framework articulates the link between the systems in which Infoway invests and the
resulting benefits, providing a basis for measurement.
NET BENEFITS
SYSTEM
QUALITY
? Functionality
? Performance
? Security
QUALITY
USE
? Use Behavior/
Pattern
? Self Reported Use
? Intention to Use
INFORMATION
QUALITY
? Content
? Availability
SERVICE
QUALITY
? Responsiveness
USER
SATISFACTION
? Competency
? User Satisfaction
? Ease of Use
? 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 patient safety
• Medication errors and Adverse Drug
Events
 Change in health system outcomes
• Readmission rates
• Efficiency of recovery
• Patient transfers
 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 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 patient and caregiver
participation
• Patient awareness and adherence
 Change in coordination of care
• Information sharing among different
providers
• Management of outbreaks
 Change in net costs
• Unnecessary events: radiology, lab
tests, vaccinations
New tools bring new questions: EHR and
secondary uses of data
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 Architecture
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
PHS Data & Services
Outbreak
Management
EHR Data & Services
PHS
Reporting
Shared
Health
Record
EHR
Index
Message
Structures
Drug
Information
Data
Warehouse
Diagnostic
Imaging
Laboratory
Health
Information
Provider
Registry
Location
Registry
Business
Rules
Terminology
Registry
Normalisation
Rules
Longitudinal Record Services
Security
Management Data
Privacy
Data
Configuration
Common Services
HIAL
Communication Bus
POINT OF SERVICE
Public
Health
Services
Pharmacy
System
Radiology
Center
PACS/RIS
Public Health
Provider
Pharmacist
Radiologist
Lab
System
(LIS)
Lab Clinician
Hospital,
LTC, CCC,
EPR
Physician/
Provider
Physician
Office
EMR
Physician/
Provider
EHR Viewer
Physician/
Provider
Privacy and Security Services (Future State)
JURISDICTIONAL INFOSTRUCTURE
Registries Data
& Services
Client
Registry
Ancillary Data &
Services
Outbreak
Management
PHS
Reporting
EHR Data & Services
Shared
Health
Record
Drug
Information
Diagnostic
Imaging
Data
Warehouse
Laboratory
Provider
Registry
Common Services
Location
Registry
Terminology
Registry
HIAL
Business
Rules
EHR
Index
Message
Structures
Normalisation
PRIVACY
Rules
AND SECURITY
Identity Protection
Services
Anonymisation
Services
Consent Directives
Mgmt Services
Identity Mgmt
Services
User Authentication
Services
Encryption
Services
Access Control
Services
Services
Longitudinal Record Services
Security
Management
Data
Secure Auditing
Common Services
General Security
CommunicationServices
Bus
Clinical
Viewer
POS
System
POINT OF SERVICE
User
Privacy
Configuration
DataDigital Signature
Services
Health
Information
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
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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
Challenges
Journey far from complete
Several Hurdles Will Need To Be Overcome
To Complete The Existing Mandate
Bring key
stakeholders –
public and
clinicians in
particular – on
board
“We need people
pounding the table
for this.”
– Regional CIO
Securing
the right
mix of
leadership
at all levels
Front-line implementation,
including standards
implementation, business
process redesign, and
clinician adoption
“We need
additional
champions beyond
Infoway.”
– Deputy Minister
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
“Clinicians will not be
willing to adopt the
technology if it makes
their life harder.”
– Clinician
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
SKILLS
KNOWLEDGE
•
Role: provide expert input to one
of 4 key elements of the End User
Strategy
ATTITUDES
EXPERIENCE
– After D Covvy
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
Thank You!
www.infoway-inforoute.ca