Transcript Slide 1

EMR
A non-techie’s overview
The potential benefits,
challenges and long-term
implications of e-health that we
should all understand
Plugging in to e-health
Key Questions:
- What are you
plugging in to?
- What are the
implications for you,
your patients and the
health care system?
- Does it matter?
What is the definition of e- Health
in BC?:
CAUTION
Admin-speak
Ahead . ..
In BC e- Health is defined as:
An integrated set of information and
communication technologies, together with
related health delivery process enhancements,
that:
• enables the efficient delivery of health care
services over the full continuum of care through
the provision of integrated, interoperable health
information systems, tools and processes;
(British Columbia Electronic Health Steering Committee, “Terms of Reference”,
January 2005)
In BC e- Health is defined as:
• transforms the health sector decision-making
culture into one that is firmly supported by
accurate, timely and relevant information in a
manner that protects individual privacy, respects
clinical practice requirements and sustains the
long-term viability of the health care system; and
• encompasses the interoperable Electronic
Health Record (EHR) and
Telehealth.
Chair of e-health steering committee: Danderfer
Definitions
Electronic medical record (EMR)
An electronic medical record (EMR) is a patient medical
record that is generated and maintained by one care
provider (physician) or institution (clinic or hospital).
(although it will contain some information from other
accessible sources.)
Electronic health record (EHR)
The electronic health record (EHR) includes patient
medical information from multiple sources, including
components of the EMR.
Is accessible from any location. This is sometimes referred
to as a "dataspine".
Medical Post May 15, 2007
Alan Brookstone, founder of Canadian EMR
website notes:
"B.C. is the only place in the world to be
introducing the EHR and EMR more or
less simultaneously. It will be coming at
physicians from every level at work, and
from many quarters . . .“
"This is an enormously complicated and
ambitious undertaking,"
Key Benefits of e-Health?
The Ministry’s proposed “key benefits” to be
achieved through e-Health are:
• Improved health care quality, safety and
outcomes;
• Increased service efficiency, productivity and cost
effectiveness; and
• Enhanced service availability and satisfaction for
citizens, patients and providers.
(Source: MOH e-Health Strategic Framework Nov 2005)
Benefits?
• Evidence is far from bullet proof that these
benefits can or will be achieved . . .
• More later on evidence if time permits . . .
• But there is no doubt about the POTENTIAL for
benefit
• Also potential for spending a lot of $ to make
things worse . . . For patients, docs and health
systems . .
• Many physician colleagues have compared risk
of large scale waste... of public funds (around
EHR) to gun registry debacle
• How do we ensure benefits maximized and
potential harms, costs and risks minimized?
If you use PITO funds
What are you buying into?
(as defined in appendix C and RFP)
1) EHR – Canada Infoways version
2) ASP data storage – functionality and readiness
question to be addressed
3) CDM Toolkit: Ministry’s Electronic CDM Toolkit –.
4) Functionally tri-lateral contract:
Between Vendor and Ministry and you
Vendor’s prime customer = Ministry?
Primary payor = you?
Primary benefit accrues to -> Ministry?
If you use PITO funds
What are you buying/plugging into?
1) EHR
The Infoways vision . . .
Review:
 BCMA 2004 position on EHR/Repository
 Canada Health Infoways definition of
EHR
Appendix C of LOA
 College Position on EHR
BCMA Policy Paper
Getting IT Right - 2004
Although the BCMA supports the integration
of health IT systems, it opposes the
concept of a central repository where
identifiable patient information generated
in physicians’ offices would be stored, and
potentially accessed by third parties such
as Health Authorities and government.
BCMA Policy Paper
Getting IT Right - 2004
Inappropriate access or misuse of
information would undermine the patientphysician relationship. The Office of the
Privacy Commissioner of Canada has
stated that having all health information
including doctor and hospital visits,
prescription, and lab tests in a central
repository would significantly undermine
privacy rights.
(p. 43)
Infoways Presentation 2003
Putting it all together
Note HIAL and EHR viewer in next slide
(HIAL) is a term defined in Canada Health
Infoway’s Electronic Health Record (EHR)
Blueprint Architecture.
The main purpose of this component is to leverage
the value of existing heterogeneous medical
applications and integrate them into networked
EHRs.
EHR = Holy Grail?
Thoughts from Australia: Might a simpler vision achieve the
same goals without the same high risks and costs?
The “National Shared Electronic Health Record
has been some form of Holy Grail for the eHealth bureaucracy and for many
government e-health strategists and
planners”
http://aushealthit.blogspot.com/2007/04/why-government-will-never-fund-shared.html
Why The Government will Never Fund a
Shared EHR – And Probably Shouldn’t
“Can I say that the whole plan has a total air
of un-reality and fantastic wishful thinking
about it.”
From: 'Australian Health
InformationTechnology'.
EMR Blog - Dr. David More
(Cited by Alan Brookstone on
Canadian EMR Blog)
Thoughts from Australia cont’d
• Among the realities that need to be faced
are the following:
. . . large scale top down complex IT
projects – in mixed health sector funding
environments – are likely to be very
problematic.” (Dr. More cont’d)
Bottom-up vs Top-down
Implementation
• “Successes at a national scale have been
in countries like Denmark and the
Netherland where a messaging based
bottom up relatively simple, standards
based and incremental strategy has been
successful.”
• . . . as opposed to large scale top down
projects . . .
What should be done instead?
a national strategy based on locally based health
information sharing initiatives on a background
of proven Standards and compliance
certification has the highest probability of
success –
A top down strategy is almost certain to fail in the
Australian environment and we would be better
to go down a path that involves the
determination of client functionality required,
development of appropriate certification
processes and standards and have the private
sector develop and support appropriate systems
Final thoughts from Australia
• A Government funded Open Source alternative could be
developed, supported and provided at low (but
reasonable) cost and maintained as an exemplar of what
is required. This strategy could provide an incentive for
commercial system developers to ‘out develop’ the basic
system to demonstrate the additional value provided by
their offering.
• Current EHR plans, seem ‘courageous’ in the extreme.
• Cooler heads need to prevail and a strategy suitable for
Australia in 2008 to 2018 and beyond needs to be
developed free from the unsuitable large scale
dominating current thinking.
UK National Data Spine
Cost to date = 12 Billion Pounds
• A large scale top-down
project
• Things are not going well.
• Huge costs
• Benefits/Risks (more later)
• Compared to other countries
docs in UK most likely to
have to re-order lab test for
result not being available
• (Schoen et al Commonwealth
fund
Appendix C of the LOA 2006:
-The EMR shall include a core data set which
shall be a key tool in providing patient
care. The core data set shall be available to
health care providers, other than the primary
physician
- The core data set may reside in a number of
locations, including with a local or regional ASP,
in order to facilitate direct patient care
and/or system health planning.
More Definitions
ASP
An application service provider is a company
that delivers software programs and other
services over a network instead of being
located on the physician’s own computers
or servers in their office.
Appendix C of the LOA 2006
Physicians shall participate in the establishment and operation of
core data set projects.
The core data set shall include the following:
a)
demographic information;
b)
current conditions;
c)
past medical and surgical history;
d)
allergies/alerts;
e)
current medications;
f)
immunizations;
g)
advance directives; and
h)
most recent and critical diagnostic data.
Concerns about Core Data Set
EHR
Core Data set = GP piece of EHR
“If the "Core Data Set", including a list of
current diagnoses is implemented as
planned, we are going to see many examples
of clinical errors because treating physicians
have mindlessly accepted incorrect
diagnoses made by others.
“Nonphysicians don't understand how much
subjectivity goes into the diagnostic
process--how often diagnoses are, by their
nature, tentative, pending the further
evolution of the clinical syndrome.”
- Galt Wilson Past President College of Physicians
and Surgeons
EHR potential Hazards
“Too much forward feeding will be
hazardous to some patients.”
- Galt Wilson
Past President College of Physicians and Surgeons
Clinical Professor
Year III/IV Clerkship Director, Northern Medical Program
Universities of British Columbia and Northern BC
Jerome Groopman
Professor of medicine at Harvard
Staff writer for The New Yorker
Author of “ How Doctors Think”
Diagnosis momentum as source of error
• Once the diagnosis is made, it is passed
on to other doctors with ever-increasing
conviction. Contradictory evidence is
brushed aside.
Decision Support?
Groopman re Decision Support
Electronic decision aids—devices that supposedly
help doctors to arrive at the correct diagnosis—
are unlikely to help, even though many
extravagant claims are made for the impact of
information technology on health. Groopman
believes such electronic fixes might actually
encourage more mistakes. They are a
distraction. They promote a reductive and
unthinking kind of checklist behavior. And they
divert the doctor away from what should be his
primary focus: the patient's own story.
Committee on Privacy & Data Stewardship
Data Stewardship Framework
BC College of Physicians and Surgeons August 22, 2007
Data Stewardship
• The management of health information including
the collection, use, access, disclosure and
retention; and the legal, ethical and fiduciary
responsibilities of a physician in such
management.
Consent
• The autonomous authorization of an information
access or disclosure by individual patients.
Consent has three components: disclosure,
capacity, and voluntariness
BC College of Physicians and Surgeons
Data Stewardship Framework cont’d
Posting to an Electronic Health Record
There may be multiple EHRs that physicians have the
opportunity to
access and post information to. . . e.g.
-BC PharmaNet
- PathNet
are EHRs that exist today, and there may be other EHRs
developed in the future such as the Electronic Medical
Summary.
BC College of Physicians and Surgeons
Data Stewardship Framework cont’d
These EHR applications have independent
governance and management, and while a
physician may view them as a collective whole as
an external medical record, they are unique
sources and as a result have explicit and different
disclosures.
BC College of Physicians and Surgeons
Data Stewardship Framework Cont’d
This model introduces the role of an Information Service Provider who
acts as a custodian in the collective interest of the participating
organizations to manage the circumstances in which personal health
information may be disclosed, including limitations and conditions.
In an evaluation of an EHR, physicians should evaluate the level and
breadth of support for the governance structure
(i.e. consider if the CPSBC has endorsed the governance structure
in place)
BC College of Physicians and Surgeons
Data Stewardship Framework Cont’d
The decision to disclose patient information collected by a physician to
an EHR needs to be a thoughtful one.
As the stewards of very sensitive information, physicians need to take
care in the level of disclosure as well as the potential impacts of that
disclosure.
The decision should be evaluated for each instance of an EHR:
• For benefits and risks to the patient,
• For the ability to manage patients’ wishes in the management of their
information,
• And the rules and processes which govern the actions of information
service provider.
These conditions need to be re-evaluated when the parameters for the EHR
Are materially changed (e.g. when additional data elements are added, when
The approved uses or access to information is extended, etc.).
Headlines from the UK
GPs revolt over patient files privacy
Tuesday November 21 2006 – John Carvel - The Guardian
• Poll shows doctors fear national database will be at risk
from hackers
• About 50% of family doctors are threatening to defy
government instructions to automatically put patient
records on a new national database because of fears
that they will not be safe, a Guardian poll reveals today.
It shows that GPs are expressing grave doubts about
access to the "Spine" - an electronic warehouse being
built to store information on about 50 million patients and how information on it could be vulnerable to
hackers, bribery and blackmail.
UK Headlines Contd
• The survey reveals that 4/5 doctors think the
confidentiality of their patients' medical records will be at
risk if the government proceeds with plans to load them
on to the new database.
• More than 60% of family doctors in England also said
they feared records would be vulnerable to hackers and
unauthorised access by public officials from outside the
NHS and social care.
• Ministers have committed a large slice of the NHS's
£12bn IT upgrade to developing the Spine. They acted
on the assumption that doctors would provide the
information without asking their patients' permission first.
About the campaign
www.TheBigOptOut.org
Founder: Ross Anderson - Chair of the Foundation for Information
PolicyResearch, and professor of security engineering at Cambridge
The NHS Confidentiality campaign was set up to protect patient
confidentiality and to provide a focus for patient-led opposition to the
government’s NHS Care Records System. This system is designed to
be a huge national database of patient medical records and personal
information (sometimes referred to as the NHS ’spine’) with no opt-out
mechanism for patients at all.
If you use PITO funds
What are you buying into?
1) EHR – Infoways vision and core data set
2) ASP data storage
3) Ministry CDM Toolkit
4) Functionally Trilateral contract
ASP
An application service provider is a company that delivers
software programs and other services over a network instead of
being located on the physician’s own computers or servers in their
office. i.e. your data resides elsewhere and you are working over
the internet.
As per Appendix C of the 2006 Agreement
Funding will only be provided for ASP-hosted
EMRs, although PITO will evaluate the
practicality of this requirement in certain very
remote areas where network reliability may be
uncharacteristically low and may identify
alternatives that still maintain the spirit of the
2006 Agreement. Further, the Ministry of Health
is currently negotiating a contract with a vendor
for the Private Physician Network to ensure that
BC physicians can be confident accessing their
EMR through a secure, high speed, high
availability network.
From PITO FAQs
It is important to note that the PITO vendor
selection process provides PITO with the
opportunity to put mechanisms in place to lessen
many prior pitfalls and potential issues.
For example, through its master standing
agreement with vendors, PITO can bind them to
key province-wide conditions related to privacy,
system reliability, response time, etc
More From PITO FAQs
• While there are understandably concerns regarding
privacy, in many ways an ASP solution enhances the
confidentiality of patient records.
It moves the computer server which stores the patient
records into a highly secure data centre run by the
physician’s EMR vendor, rather than being vulnerable to
theft in an empty physician office overnight.
• The vendor will be clearly accountable to the physician
for the secure storage of their patients’ files.
What are the challenges of using an ASP?
(More From PITO FAQs)
The ASP model does come with challenges, each of which is being
carefully addressed by PITO:
When an EMR is hosted at an off-site ASP data centre, the network
connection becomes critical for reliability. PITO will be working with
the physician-based Clinical Advisory Group (CAG) and technical
groups to define network solutions with high degrees of reliability to
reduce this risk.
Emphasis is on ensuring the EMR is consistently available, and the
physician practice is unaffected by technical issues.
PITO is also designing solutions to have a local encrypted backup of
key patient data in the physician’s office in the rare case of the EMR
being unavailable. This solution will allow physicians to continue
seeing patients with access to their most important data in almost
any situation
ASP benefits and challenges
Benefits
Not responsible for database
Easier for vendor to service
Challenges/ Concerns
Functionality issues resolved?
Responsibility for millions of patient charts in
hands of 6 emr vendor companies
Aggregation of mass amounts of data
increases black market value to third
parties (risk for both EHR and ASP)
Third Party Value of Aggregated Data
Health Data for Sale
September 12, 2006
• The transfer and sale of personal health information is proceeding
largely unregulated, according to an expert panel assembled by the
American Medical Informatics Association in a newly issued report.
• Despite the requirements of HIPAA (Health Insurance Portability and
Accountability Act) health care information is routinely being
exchanged that is not anonymous, according to a report from the
AMIA.
• Another even more problematic privacy violation is the "ongoing
buying and selling of non-anonymized patient and provider data by
the medical industry without explicit consent of either patients or
physicians."
• "Patients do not know who has access to their data and for what
purposes. The expert panel learned of financial incentives for
sharing of patient data that raises ethical questions," said AMIA
chairman Paul Tang.
If you use PITO funds
What are you buying into?
1) EHR – Infoways vision and
core data set
2) ASP data storage
3) Ministry CDM Toolkit
4) Functionally Trilateral
contract
Ministry’s electronic CDM Toolkit:
Many concerns
Ministry’s toolkit is a mandated part of PITO funding . . .
Increasing concern among physicians about the toolkit.
While an electronic flowsheet helpful . Ministry’s Toolkit is
much more . . . (flowsheet with an opinion.)
Designed as a hardwired template for “judging and
rewarding quality” in primary care . .
Stepping stone to P4P . . .
Guidelines should inform not compel . . .
Doing it right isn’t always about following guideline . . .
EBM is about incorporating co-morbidities and patient’s
values and customizing care. . . .
Significant potential for negative impacts on patients,
profession and health system with Ministry’s e-toolkit
Concerns from UK over
CDM-toolkit type initiative: QOF
The Quality and Outcomes Framework: what have you done to
yourselves?
Br J Gen Pract, Mangin et al June 2007
By following a medicine-by-numbers path under the QOF, the
profession cannot lay claim to its own knowledge base and
priorities. At what point do we switch from educated professional to
technician? Patient centredness is still (we think) a core value of
primary care for GPs and for patients.
It beggars belief how we could have arrived at a point where the very
nature and content of the doctor–patient encounter is prescribed by
the state. This loss of professionalism has profound implications
and may result in a change in professional values. . .
The focus has shifted from patients and the diseases that make them
suffer, to the diseases themselves and their measurement within the
patient.
The Quality and Outcomes Framework: what
have you done to yourselves? Cont’d
QOF by its nature promotes simplicity over complexity and
measurability over meaningfulness
We do have an alternative. Most GPs wish to do a good job. Most
recognize that where there is clear evidence that a particular course
of action or inaction will result in benefit or harm, then their role as
advocate for their patients is to make them aware of those options.
We can advocate for a system which promotes evidence-informed
care . . . and provides options (with attendant uncertainties) for
GPs and patients to interpret for themselves”
(i.e. In BC - That means not entering data into Ministry’s CDM toolkit or
accepting PITO funding. PITO funds are contractually connected to
toolkit.)
If you use PITO funds
What are you buying into?
1) EHR – Infoways vision and core data set
2) ASP data storage
3) Ministry CDM Toolkit
4) Functionally Trilateral contract
Between Vendor and Ministry and you
Vendor’s prime customer = Ministry?
Primary payor = you?
Primary benefit accrues to -> Ministry?
If you take Regional Funding:
What are your buying into?
• Sharing office patient data with Health
Region . . . Privacy implications unclear
• Details unclear due to non-disclosure
agreements (Does it seem right to
fragment us all in this way and undermine
our ability to learn from one another’s
experiences)
PITO “Early Adopter” Program
PITO has established the PITO “Early
Adopter” Program for physicians who
implemented EMRs prior to June 28,
2006. The Early Adopter Program helps
offset the ongoing monthly costs of using
their existing EMR at the standard 70%
reimbursement rate for up to 18 months,
contingent upon conversion to a PITOqualified EMR within those 18 months.
What happens at the end of the six year PITO
mandate, would I inherit all future costs?
The funding for this agreement expires in
2012. Prior to then, the BCMA and
Government will determine the availability
of ongoing funding through the negotiation
process.
Overview of PITO Systems
-
Clinicare
EMIS
Intrahealth
Med Access
Osler
Wolf
Open Source
- OSCAR – developed at MacMaster
- MOIS – developed in Northern Health
Non-PITO
Open Source:
As per Ken Kizer – former CEO of VA
Testimony to house ways and means committee of US Senate
Make Selection of Open Source Software the Default Mode for
Federal Funds
For the past twenty years open source software has been building
momentum in the technical cultures that built the Internet and the
World Wide Web. Open source has now established its viability in
the commercial sector, and a major shift toward open source
software is underway throughout the world.
When using the term open source software I refer to software that is
nonproprietary, available at no or minimal cost, allows different IT
systems to operate compatibly, and facilitates collaboration in order
to improve and enhance the freely accessible source code.
A critical milestone in the history of open source was the creation of the
Linux operating system in the 1990s. Linux demonstrated that open
source development methodologies could deliver commercially
viable technology to the market.
Kizer on Open Source cont’d
• In open source, the basic software is viewed as a
commodity and its development is collaborative and
shared by the community of users.
• Because contributions to enhancing the code come from
many sources in an environment of collaboration,
innovation is more rapid.
• Open source is much more consistent with a true free
market approach than proprietary products that entail the
infamous “vendor lock.”
• I am confidant that the federal government would save
billions of dollars in licensing fees alone over the next 10
years by preferentially pursuing open source solutions.
Dutch government adopts
open source software – Dec 2007
• The Dutch government has set a soft deadline of April 2008 for its
agencies to start using open-source software — freely distributed
programs that anyone can modify
• Government organizations will still be able to use proprietary software
and formats but will have to justify it under the new policy, ministry
spokesman Edwin van Scherrenburg said.
• Many governments worldwide have begun testing open-source software
to cut costs and eliminate dependency on individual companies such as
Microsoft Corp. The government estimates it would save $8.8 million a
year on city housing registers alone after switching to open source.
• Microsoft has raced to achieve "open source" certification for its Open
Office XML standard, but has so far failed to receive endorsement from
the International Standards Organization, the certifying authority
recognized by the Dutch government.
• The Dutch policy directs government organizations at the national level to
be ready to use the Open Document Format to save documents by April,
and at the state and local level by 2009.
http://ap.google.com/article/ALeqM5gKeb7SFzG8QLvOOlfdt_cPMnFmwD8TGNLJ80
A Cautionary College Tale
EMR contributed to child's death
Excerpt from BC College Review
"A young child was playing when he began to feel
unwell, and shortly thereafter collapsed. Despite
resuscitative efforts, he went into full cardiac
arrest prior to transport to hospital. . . At
postmortem, it was determined that this child
had developed a fatal arrhythmia as a result of a
congenital heart defect known as “idiopathic
asymmetric hypertrophic cardiomyopathy.”
BC College Review cont’d
“The College’s review of this event found that the
child had received his medical care from a group
of family physicians who used an electronic
medical record.
In reviewing that record, it was noted that in the
three years prior to the death, numerous
physicians had seen the child for minor
illnesses.
On several occasions, the child had attended a
clinic where physicians had heard a heart
murmur, which was appropriately recorded.”
College Review cont’d
• “Unfortunately, the clinic’s electronic medical record used a template
that would “auto fill” systems as being normal, unless contrary
information was entered. Therefore on other visits, when no
physician entry was made under Cardiovascular System Review,
the “auto fill” would result in the notation, “no history of murmurs or
hypertension.” This denied previous clinical findings .”
• “Moreover, a chest X-ray performed while investigating the
possibility of pneumonia stated that the child had cardiomegaly and
suggested a specialist consultation. The report was noted by the
physician concerned who arranged for a patient recall.
Unfortunately, the electronic medical record could not flag the recall.
Consequently, the family doctor thought that the recall was for a
pneumonia re-examination.”
• “Physicians from this clinic also noted that navigating the electronic
medical record was difficult, and allowed only for one small screen
to be seen at a time. This made scrolling through the medical record
awkward and time consuming.”
The Quality of Medical Performance
Committee Conclusions
Important to advise members that while the electronic
medical record has many virtues, it also has the potential
for some pitfalls worthy of attention:
• It is important to ensure that the electronic medical record
has the ability to flag appropriate follow-up concerns.
• The system must be easy to navigate and allow for
multiple screen options.
• The physician must never allow for an automatic template
to fill in options stating “normal” when no such exam is
performed.”
Also? – a CONTINUITY failure
The child saw many different physicians
No clear MRP or information flow through
MRP
EMR is not a substitute for the continuity of
a central patient-provider partnership.
An EMR or EHR cannot KNOW a patient or
which things in an e-deluge of information
MATTER
Building IT to support human
partnerships
Putnam on alloys of silicon and flesh wrt
system architecture
Building Electronic Connections to support
and enhance human partnerships – IT
systems cannot replace them or
substitute for CONTINUITY of a
relationship
Closing Questions
What are you plugging into?
What will be future costs?
What shape would you like to see EHR
take?
What will implications of your choices today
– be for you and your patients in the
future?