Health Informatics goes Mainstream: Meeting Public Expectations for - - PowerPoint PPT Presentation

COACH: Canada's Health Informatics Association

1 Health Informatics goes Mainstream: Meeting Public Expectations for a Better Healthcare System

Shelagh Maloney, Lydia Lee, Marion Lyver

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Agenda

About COACH Making the Case for e-Health Consumer Demands & e-Health EMR Adoption and Healthcare Transformation

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About COACH

Canada’s Health Informatics Association

– established 30+ years ago

An association of individuals interested in advancing

the practice of health informatics in Canada

Multidisciplinary membership including representatives

from IT, care providers, vendors, consultants, governments and students

Governed by a volunteer Board of Directors

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COACH Mission and Vision

COACH’s Mission

– To promote the understanding and adoption of

health informatics within the Canadian health system through professional development, advocacy, and a strong and diverse membership

COACH’s Vision

Taking health informatics mainstream

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COACH Strategic Goals

Four Strategic Goals

Strengthen the membership of COACH Enhance the Practice of Health Informatics as a

Profession

Be an advocate for health informatics Ensure COACH has the resource capacity to meet

future challenges and seize opportunities

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Making the Case for e-Health COACH

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From their health system, Canadians expect…..

Timely access to services Care to be provided in a safe and effective manner health providers to communicate with one another To be included care decisions A system that will be there for them, for their children and

their grandchildren

That the confidentiality and security of their personal health

information will not be compromised

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Current pressures on today’s health system

The population is aging

–

Increased burden of chronic disease

Resource pressures are intensifying

–

Health care costs are a growing proportion of provincial budgets

–

Health human resources are becoming more scarce

Care settings are shifting

–

From acute, to ambulatory to home and community services

Technology is changing the way we work and play Consumerism is growing

–

Patients expectations of and demands on the system are changing

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Are we meeting these expectations?

• Up to 24,000 deaths each year result from preventable

adverse events in hospitals

• 37-43% of Canadians recommended for influenza protection

are not vaccinated

• ~ $15 billion worth of prescriptions are written by hand

annually

• ~ 2 million Canadians don’t have access to a primary care

provider (need to confirm # and reference for this statement)

“The most remarkable feature about twenty-first century medicine is that we hold it together with nineteenth century paperwork.” US Secretary Tommy G. Thompson, Washington, D.C., May 6, 2004.

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The Good News

Information Technology is recognized as a significant enabler in

meeting growing expectations of the health system

Most industrialized countries have recognized the need to

implement electronic health record solutions quickly to improve the quality and safety of patient care and system efficiency

It is estimated that the savings to the health system would be

approximately $5B per annum if the benefits of ehealth were realized

In Canada, all levels of government agree about the benefits of e-

health and have committed to moving the agenda forward

• EHR: Overall benefits & value
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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
• Infoway’s members are Canada’s 14 federal, provincial and

territorial Deputy Ministers of Health

• Independent Board of Directors

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• 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

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Infoway Business Plan

Solution deployment projects in each jurisdiction

Project Sizing and Estimation Nine Investment Programs Common Blueprint Program Eligible Costs

Approved Projects for Investment

Program Criteria 1. Registries 2. Diagnostic Imaging Systems 3. Laboratory Information Systems 4. Drug Information Systems 5. Public Health Surveillance 6. Telehealth 7. Interoperable EHR 8. Innovation and Adoption 9. Infostructure

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Consumer Demands & E-Health COACH

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Patient safety

Computerized Provider Order Entry

Rising costs of care Professional shortages

Chronic Disease Management

Need for self-care

Consumer Demands on the Healthcare System are Catalysts for Transformation

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Safety: The Burning Platform for CPOE

Canadian Adverse Events Study

– Estimated 70,000 events/y in Canadian Hospitals – Judicious application of new technologies

Communication Coordination

Baker GR, Norton PG, et. al. CMAJ May 25, 2004.

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Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent (P = 0.0003).

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100% of e-Orders are Legible & Complete

• Source: University Health Network, Shared Information Management Services.

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• !

" # Pre n = 456 Post n = 427 Post Post n = 858

Medication Order Processing Cycle: Total Cycle Time

Source: University Health Network, Shared Information Management Services. * End point occurs when Pharmacist/Nurse Reviews Order, whichever occurs last

From Physician order entry to RX* verification From Physician order entry to RX* verification

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Employers are Driving Safety in Healthcare: Leapfrog’s CPOE Standard

MD input of > 75% of medication orders. Prescribing-error prevention software. Inpatient CPOE system can alert physicians of

at least 50% of common, serious prescribing errors.

MDs must electronically document a reason for

• verriding an interception prior to doing so.

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Patient safety

Computerized Provider Order Entry

Rising costs of care Professional shortages

Chronic Disease Management

Need for self-care

Consumer Demands on the Healthcare System are Catalysts for Transformation

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Healthcare spending in Canada has increased by 5% from 1996 to 2006 annually after inflation.

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

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Health care opinion leaders: Views on controlling rising health care costs

• 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

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Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan. 2007.

Note: Based on a list of 19 options

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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

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The productivity imperative: Aging health human resources, RNs

Source: Canadian Institute for Health Information. Workforce Trends of RNs in Canada, 2005

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Chronic disease management in Edmonton

Source: “Edmonton’s health census a bold example of modern care”, Andre Picard, 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.”

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SIMS Partnership CDM Program Design has 6 Best Practice Innovations with an initial focus on Diabetes

• Employ evidence-based

standards of practice Main Strategic Themes

Create linkages with primary

care and community resources

Identify clients with diabetes

early in disease progression

Share information to improve

client outcomes

Empower clients to be

informed, active members of care team

Shift roles, resources and

processes to ensure “Right service by right provider at the right place at the right time”

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How Can a Client Portal Support CDM?

Patient Portal: – A secure, web-based information system that

supports patient education, patient-provider communication, and the achievement of self- management goals.

Improves the patient experience by providing: – Personalized information and care – Treatment plans – Education – Clinical data – Links to community programs Transforms heath care service delivery: – Empowers patients with 24/7 access to information

and tools

– Enables patient participation in decision-making

processes

– Encourages self-management behaviours that lead to

improved outcomes

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EMR adoption and healthcare transformation

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Drivers of Healthcare Transformation

– Consumer, clinician, industry and governmental

demands for improved safety, quality, effectiveness and efficiency in health care are driving the need for more “connected’ care

– Connected care requires ongoing patient care

information to be communicated between multiple providers at local, and progressively at regional, jurisdictional and national levels.

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2006 Commonwealth Fund International Health Policy Survey of Primary Care Doctors

• Mail and telephone survey of primary care physicians in Australia, Canada,

Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

• Final samples: 1003 Australia, 578 Canada, 1,006 Germany,

931 the Netherlands, 503 New Zealand, 1,063 United Kingdom, and 1,004 United States. (Note: There are approximately 30,000 primary care physicians in Canada.)

• Core Topics: information technology and clinical record systems, access,

care coordination, chronic care/use of teams, quality initiatives, and financial incentives.

• http://www.commonwealthfund.org/surveys/surveys_show.htm?doc_id=419152

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32 Figure 1 EMR Penetration Figures – 2006 Commonwealth Fund Survey (by IT component)

20 40 60 80 100 120 Use EMR e-Lab order e-Rx e-Lab result e-Hospital AUS CAN GER NET NZ UK US

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EMR Penetration Figures – 2006 Commonwealth Fund Survey (by country)

10 20 30 40 50 60 70 80 90 100 AUS CAN GER NET NZ UK US Use EMR e-Lab order e-Rx e-Lab result e-Hospital

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Figure 6. Summary and Implications

(CWF survey)

• Striking differences across the countries in elements of primary care

practice systems that underpin quality and efficiency.

• Physicians in Australia, the Netherlands, New Zealand and the U.K. most

likely to report multitask IT systems; U.S. and Canada lag behind.

• Integration and coordination are a shared challenge.
• Safety tracking systems are rare except in the U.K.

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Cross Country check-up…..Alberta

• EMR penetration in Alberta is 58% of doctors; all health regions and the provincial government

are developing their electronic infrastructure. (83% of 3369 total physicians are in at Level 2 in the POSP i.e. requires use of an EMR)

• Have been through the innovators, early adaptors and middle adopters and are now into the

late adopters. Risk profile for late adopters is different - need to reduce entry barriers (such as complexity of vendor selection) to get these physicians onboard.

• Culture for automation has shifted and the non-automated physicians are starting to feel out-of-
• date. Indications are that most of the rest will come if a clear and simple path is laid out for

them.

• “It is getting very hard to find a physician who is progressive clinically and isn't automated.”
• “Using” is not the same as “using well”. One problem is that a lot of EMRs are serving as

expensive text repositories. This was something you didn't see as much with the innovators but the later adopters don't come with a clear vision of benefits and so don't get the need for discrete data. More work needs to be done on this culture change.”

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Cross Country check-up…..the rest of us

• Most jurisdictions have physician adoption/support programs in place or planned
• ASP model and local models of EMR being supported in most jurisdictions
• 5% up to 15-18% using “real” EMRs; 95%+ billing electronically (CFPC survey of 2200 physicians in 2001

indicated that 26% of physicians believed they would adopt get an EMR in 5 years; 30% said they never would)

• Reasons for low/slow adoption rates – impacts on staff time, revenue and workflow; not so visible/tangible

early benefits; lack of support for implementation; the risk of EMR vendors disappearing after 2 years spent learning and inputting data; lack of a real, shared data model that would allow proper import / export of data so that patients’ records aren’t locked into one product; lack of familiarity with technology in general; privacy and data control concerns; part-time physicians for whom the time investment is proportionately larger.

• Variable degrees of implementation of Infoway Gen 1 and Gen 2/3 EMR technology
• Primary care pilots running in several jurisdictions or completed and evaluation underway
• Some pilot physicians feel they are “islands in a sea of paper” - everything else comes in on paper or fax; no

provincial leadership in guiding their choices; can't get connected to the electronic databases and LIS data - "no end to no end" interoperability. No ePrescribing yet.

• Physicians chart in the EMR the same way they chart on paper - no consistency in the way diagnostic data is

actually captured; billing is coded with ICD-9 and that is what gets captured most often, regardless of whether it truly reflects the “real” diagnosis. Many physicians only know a few (most commonly used) billing codes.

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What is needed to ensure and sustain adoption?

Infoway Report on End User Acceptance Strategy – Current Status - May 2005

• Despite the low adoption rates in most of the country (Alberta excepted),

there is reason to believe that EMR adoption will continue to occur.

• Surveys from Canada and the U.S. suggest a large percentage of the

physician workforce is considering adoption of an EMR and positive response from those early adopters of fully operational, organization wide EMR systems, including increased provider satisfaction, increased patient satisfaction and increased efficiency (in terms of both increased patients seen and reduced cost).

• Understanding of critical success factors
• Building on known successes
• Providing appropriate support tools and strategies i.e. readily available

and accessible; easy to use and understand; supporting information

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Critical Success Factors for End User Adoption

Infoway End User Acceptance Strategy – Current State Assessment, May 2005

• Alignment with workflow. Integration of technology solutions into established

workflow patterns is critically important. “Easy to use” and “easy to learn” mantras

• Demonstrable clinical value.
• Support for change through appropriate incentives. At the very least, providers

must be supported so that adopting a change is not punitive.

• Support for experimentation and continuous learning.
• Engagement of stakeholders as partners - fosters ownership, improves the

design of EHR technologies, and encourages the development of champions to support widespread acceptance among health care providers.

• Building a foundation of trust based on mutual understanding of needs,

expectations and priorities. EHR technologies are implemented in highly complex environments and require the support from a wide range of stakeholders. If stakeholders are unable to see a “win”, the chances for success are very low.

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Critical Success Factors for End User Adoption (cont’d)

VHA Report (2005)

• Innovation Watch: Successful organizations are always on the lookout for new answers and

develop applications to support the answers later on. It is critically important for physicians to be involved in this process.

• Reaching and Teaching: Understanding and matching up to the need for education, training

and ongoing communication is no less important. Communication is the key element not only to the success of a particular project, but to ongoing relationships with the physician community.

• Leveraging Knowledge and Experience: One of the phenomena researchers have noted is

that once an innovation has been adopted by about 15 percent of a population and has begun to be embraced by the “Early Majority,” spread takes place almost inevitably. If healthcare

• rganizations can persuade about one physician in seven to adopt an information technology

program, it becomes possible to take advantage of social networks to accelerate the spread among the others.

• Enabling Environment: refers to the foundation of culture, leadership, technical and
• perational infrastructure and support that make information technology adoption possible.

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EMR Requirements Process (Source: PITO, BC)

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• Privacy & Technical

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Infoway End User Adoption Strategy

– Pan-Canadian Physician Office System

Requirements Committee

– Peer-to-Peer network (physician mentoring)

program

Contact:

Catarina Versaevel Group Director, End User Adoption

Canada Health Infoway/Inforoute Santé du Canada

cversaevel@infoway-inforoute.ca

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42 Tools currently available to support adoption

Canadian EMR

http://emruser.typepad.com/canadianemr/

• Website founded by a Canadian Primary Care physician

who is an EMR user

• Allows Canadian physicians to share information about

EMRs

• Recent articles on Planning, Early Support Keys to EMR

Success

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Health Canada EMR (2006) Toolkit http://www.emrtoolkit.ca/

• A resource manual and website to support Canadian

primary health care practices to adopt EMRs

• Practices that are already using EMRs will find valuable

information on EMR optimization and further benefits.

• Intent is not just to provide support for hardware and

software selection, but to help practices to get the most out

• f their EMR once it is in place.

E.g. data quality, using the EMR to support clinical decision making, and using it to streamline workflow in the practice.

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Health Canada EMR (2006) Toolkit at a glance

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COACH: Canada's Health Informatics Association

45 Aligning EMR and EHR Technologies

• The growing use of EMRs among physicians suggests there is an urgent need to address

alignment between EMR and EHR technologies.

• In the absence of interoperability between EMRs and EHR technologies, the value of

EHR technologies is severely limited.

• The window of opportunity to strengthen and consolidate understanding around these

fundamentally important types of infrastructure is now. Acceleration in acquisition and implementation of systems is occurring in a context of rising cost pressures, and is not likely to slow down.

• If the solutions are not innovative and synergistic, it will be exceedingly difficult to overcome

the interoperability challenges associated with widespread “islands of data”.

• Infoway pan-Canadian standards and EHRi implementations are in use or coming on stream

shortly in many jurisdictions.

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RAND HIT Project (2005)

• Broad adoption of EMR systems and connectivity are necessary but not sufficient

steps toward real health care transformation.

• HIT also should facilitate system integration for broader optimization, and

comparative benchmarking should encourage development of market leading examples of ways to better organize, pay for, and deliver care.

• It is not known what changes should or will take place after widespread EMR

system adoption—for example, increased consumer-directed care, new methods

• f organizing care delivery, and new approaches to financing.
• However, it is increasingly clear that a lengthy, uneven adoption of non-

standardized, non-interoperable EMR systems will only delay the chance to move closer to a transformed health care system. The government and other payers have an important stake in not letting this happen. The time to act is now.

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From there……

“…that it will ever come into general use notwithstanding its value is extremely

doubtful; there is even something ludicrous in the picture of physicians using this device.” The Times (London)

• Given the quote above, one could reasonably conclude there is great deal of

skepticism around health care providers using modern technology to support the delivery of care to patients.

• This quote actually comes from the 1860s and refers to acceptance of the

stethoscope as a new technology.

• There is still a long way to go before Canadians see the benefit of EHR solutions
• n a large scale, but the stethoscope gives us hope!

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To here…..EMRs and Electronic Practice Management - Keys to Healthcare transformation

–

“I think electronic practice management is part of the evolution of health services. It is transforming the way we learn, with medical schools using tools like curriculum information systems. It is transforming the way we store patient information. It is transforming our clinical interactions through electronic prescriptions, e-messaging information/requests, and improved care with guideline templates. And it is transforming

• ur adjunctive patient care through web resources and online patient info.”

–

“It is the medical tool of the 21st century – more important than our stethoscope or

• toscope – and I think it is incumbent on modern physicians to not only embrace this new

integrative and interactive technology, but that we should be competent with it. We are not merely skilled clinical technicians who can perform procedures and techniques on patients, we are personable guides, managers, and guardians of their intimate health information, as well as human portals to the collective resources and experiences of our social health network.”

• Dr. Norman Yee, Family Physician & “Techie” Calgary, Alberta

–

“The transition to EMRs is part of the inevitable evolution of health care. It will only be a matter of time before there is complete integration of various electronic systems to assist in improving overall patient care.”

• Dr. Roger Cho, Orthopedic Surgeon, Calgary, Alberta

–

EHRs will be the norm, not the exception.

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Health Informatics goes Mainstream:

Meeting Public Expectations for a Better Healthcare System

The Case for e-Health Consumer Demands & e-Health EMR Adoption and Healthcare Transformation

Reality is closing in on Expectations – Health Informatics is going Mainstream

COACH: Canada's Health Informatics Association

50 T H A N K Y O U

Shelagh Maloney, Lydia Lee, Marion Lyver