MyEHR to National eHealth Record Transition Impact Evaluation - - PowerPoint PPT Presentation

National E-Health Transition Authority www.nehta.gov.au

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Prepared for public release

MyEHR to National eHealth Record Transition Impact Evaluation

Prepared for public release June 2015

Presentation of findings from phase 1

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The evaluation team recognises this work would not have been possible without the contribution and collaboration of a wide range of people and organisations. Particular thanks to the following:

• Northern Territory Department of Health
• Aboriginal Medical Services Alliance Northern Territory
• Northern Territory Medicare Local
• Aboriginal Health Council South Australia
• Ms Sally Mainsbridge, formerly of NEHTA

Lastly, and importantly, thank you to the many healthcare providers who sacrificed their time to provide input and insight into their use of the My eHealth Record service.

Acknowledgement

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My eHealth Record (MyEHR), formerly known as the Shared Electronic Health Record, is a way of securely storing and sharing an individual’s health information. The service was designed principally to overcome fragmentation of clinical information by ensuring it could be quickly and easily accessed by participating healthcare providers. The My eHealth Record service is operated by eHealthNT, NT Department of Health. It was developed with financial assistance from the then Department of Health and Ageing as part of HealthConnect, and has been operating since 2004. More information can be found at www.myehealthrecord.com.au

Overview of the MyEHR service

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Screenshots of the MyEHR service (training record)

Kanga icon indicating presence of a record

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• The MyEHR-to-National (‘M2N’) Transition Project is

transitioning the existing MyEHR Service over to the National eHealth Record System (PCEHR)

• At the request of the M2N Project Steering

Committee, NEHTA is conducting an evaluation of the impact of the transition

• A pre- and post-implementation evaluation

approach is being used

• Phase 1 has been completed prior to transition; it

comprised qualitative analysis of n=94 in-depth interviews, and quantitative analysis of close to 15 million system transactions covering 10 years

• This presentation is an overview of phase 1 results

M2N Transition Impact Evaluation project

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View over Ltyenty Apurte (Santa Teresa)

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• Benefits attributable to the MyEHR service provide

strong evidence validating the value proposition of the PCEHR system

• The MyEHR service was able to realise this value

via a gradual evolution towards critical mass, which allowed it to become embedded into workflow

• Lessons learned from this evaluation suggest

specific ways to accelerate achievement of critical mass in the PCEHR system, and emphasise the importance of sustaining effort aligned to a clearly defined long term strategy Overview of key findings

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A description of the benefits attributable to the MyEHR service

Value the MyEHR service provides

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The evaluation provides strong evidence of benefits attributable to the MyEHR service

Increases access to health information Reduces time spent sourcing information Supports clinical decision making Increases provider & consumer confidence Improves continuity

• f care

Increases capacity to deliver population- based primary health care

"I've been obsessive with MeHR since it first came in because of everything I can

• see. It saves you so much

trouble, so much time." GP "Without the MeHR you couldn't have made the same decision" Registered Nurse & Midwife

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The MyEHR service bridges gaps between unconnected clinical information systems

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Sending facility type Viewing facility type

Total document views by sending and viewing facility type

Direction of information flow

MyEHR enables vast flows of information between and within sectors – close to a million document views so far

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2008 2009 2010 2011 2012 2013 2014 2012 sending facility type 2012 viewing facility type, and 2013 sending facility type

Document views by sending and viewing facility type, per year

In recent years, the volume of information exchange between and within sectors has increased exponentially

The MyEHR service reached approximately 50% of NT Indigenous population registered during 2010

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“It's a lot less time consuming because you're not ringing up another clinic down the road.” Registered Nurse "It saves you so much trouble, so much time." GP “You can get a history immediately rather than starting again.” Registered Nurse “Rather than ring the clinic and humbug them, if you look on the shared records it should be all there.” Clinic Manager MyEHR service reduces the amount of time and effort required to source health information

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Improved decision making: “I look up the date and when they were last there or whatever and then I would judge whether that's the latest or whatever they've come in for or when was your last fracture, look at that, see what the doctor said from the hospital.” Aboriginal and Torres Strait Islander Health Practitioner “I think we can approach the whole complex problem a bit better because we're better informed basically… I find I've got the big picture; I've got a better picture.” GP Evidence of improved clinical safety: “We actually looked up on the MeHR and that's where we've seen it, this patient is actually allergic to penicillin. So the patient didn't get the needle and went onto a different medication.” Registered Nurse & Midwife

MyEHR service supports providers’ clinical decision making and clinical safety

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51.3% 17.4% 20.6% 5.7% 4.1% 0.8% 0% 20% 40% 60% 80% 100% 1 2–5 6–9 10–19 20 + Percentage of all records

• No. different providers who have accessed a record in

the last 12 months (Nov 2013 to Nov 2014)

Different providers Almost a third of all MyEHR records have been accessed by 2+ providers in the last 12 months

57.4% 20.3% 11.7% 6.0% 2.8% 1.9% 0% 20% 40% 60% 80% 100% 1 2 3 4 5 + Percentage of all records

• No. different facilities where a record has been accessed

in the last 12 months (Nov 2013 to Nov 2014)

Different facilities

Over 20% of records have been accessed at 2+ facilities in the last 12 months

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87% of all documents viewed are viewed at facilities that are not the person’s HHC

Home Health Centre (HHC): location identified by the consumer as a preferred / main healthcare facility, i.e. their place of usual care.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Outback SA Anangu Pitjantjatjara Yankunytjatjara Queensland Western Australia East Arnhem Katherine Darwin Alice Springs Barkly Percentage of documents viewed Region where the viewing facility is located

Percentage of documents viewed at a facility that is/isn't the consumer’s home health centre (HHC), by viewing facility region

Viewed at a facilty that is NOT the record holder's HHC Viewed at a record holder's HHC

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The MyEHR service enables clinical information to be accessed at a consumer’s non-usual place of care;

• vercoming limitations of point-to-point transfer

5 10 15 20 25 30 35 40 45 2008 2009 2010 2011 2012 2013 2014 Thousands

Total documents sent by NT acute facilities and subsequently viewed at an NGO health centre that isn't the consumer’s HHC, by doc type

ED Discharge Summary Inpatient Hospital Document Other Hospital Document Outpatient Hospital Document

“They might present to ED

• vernight and come here with

nothing, we can have a look in MeHR, if they're registered and see what's happened in that presentation.” Aboriginal and Torres Strait Islander Health Practitioner

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Increased confidence for providers:

"They're here with me now and they expect me to do something so I'll do the best I can under the circumstances, and now a lot of the time you can be a great deal more confident about what you're doing." GP

Reduced anxiety for providers in remote settings:

"But the anxiety of trying to care for people when you know there's something going on and you don't know what, you just look at a nurse's face when someone turns up and she knows they're sick and she gets on there [the MyEHR] - oh, thank God for that!" GP

Increased confidence and empowerment for consumers:

“I think for the patients, us being able to access previous consults makes them feel as though we are actually starting to understand what they're talking about” Registered Nurse “They want to come to the hospital and expect you to know their medications.” Specialist doctor

MyEHR service has increased confidence for both consumers and providers

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• Increased access to information has resulted in

decrease time to source information

• MyEHR service supports clinical decision making

and continuity of care

• Increased provider and consumer confidence and

the capacity to deliver population-based primary health care Review of benefits attributable to MyEHR

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• 1. Gradual evolution towards

critical mass

• 2. Becoming embedded into

routine clinical and administrative workflow

• 3. Critical success factors

How has the MyEHR service been able to realise value?

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• Three prerequisite elements of critical mass:
• 1. Population registration;
• 2. Actively participating providers across all sectors; and
• 3. Sufficient content to make accessing worthwhile.
• No silver bullets that triggered immediate,

sustained increase in sending, accessing and viewing of health information

• Reinforces that critical mass is not a discreet point

in time – the fabled ‘ka-pow!’ moment The MyEHR service evolved gradually towards critical mass

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0% 10% 20% 30% 40% 50% 60% 70% 12 24 36 48 60 72 84 96 Estimated percentage of the population (ABS ERP) registered Months since system launch

Estimated percentage of the population registered, by system

MeHR (NT total popn) PCEHR (Australian popn) MeHR (NT Indigenous popn)

50% registration associated with the tipping point when MyEHR service reached critical mass

“In the beginning because only 20 per cent of the community was signed up, it just wasn't worth it...You had in the end probably 80 per cent plus of the rural community, remote community, signed up, which is a great success.” GP

MyEHR registration was focussed on Indigenous communities, therefore using the Indigenous population of the NT as the denominator is

• appropriate. Total NT population is given for comparative purposes. Note: MyEHR registration data for first 12 months not available.

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0% 20% 40% 60% 80% 100% ≥ 1 sends ≥ 1 accesses ≥ 1 views ≥ 1 sends ≥ 1 accesses ≥ 1 views Last 3 months Last 12 months Percentage of all records

Percentage of records that have been utilised in the last 3/12 months, by type of interaction Currently high levels of utilisation of consumers’ MyEHR records

In the last 12 months, three quarters of all records have had a document uploaded, half have been accessed, and

• ver a third have had a

document viewed

Last 12 months defined as Nov 2013 to Nov 2014, and last 3 months as Sep to Nov 2014.

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50 100 150 200 250 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Thousands

MyEHR service usage per month

Sends Record accesses Document views

Gradual increases, with growth in document viewing preceded by sending

“The amount of information as it built up, built the clinicians' confidence in using it.” Department Director

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Who is sending documents? Nurses send the most

10,000 20,000 30,000 40,000 50,000 60,000 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 2013 2014

Document sends in 2013 and 2014 by sending provider's profession

Aboriginal Health Worker Allied Health Professional Dentist / dental nurse Doctor Health Facility Admin Officer Nurse Other Pharmacist Over 80% of documents sent by nurses come from NTG and NGO health centres

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10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Document sends per month by document type

Antenatal ED Discharge Summary Event Summary Health Profile Inpatient Hospital Document Other Hospital Document Outpatient Hospital Document Pathology Report

Automatically generated documents account for majority of sending

Documents that are automatically generated with each episode of care (event summaries, health profiles, and pathology reports) are sent most frequently; whereas other documents that require deliberate authoring by a provider have lower sending volumes.

Inpatient hospital document = discharge summary; outpatient hospital document = specialist letter

NB suspect this is a data blip, not a real spike in sending

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Pharmacist Doctor Social Worker Health Facility Admin Officer Nurse Aboriginal Health Worker Allied Health Professional Occupational Therapist Dental Nurse Nurse (Student) Physiotherapist Doctor (Student) Dentist Audiologist

50 100 150 200 250 300 350

Average number of unique records accessed*, by profession

Average unique records accessed in last 3 mths Average unique records accessed in last 12 mths

Breadth of providers utilising the MyEHR service frequently

Pharmacists (hospital-based) accessed an average of almost 350 different records during the last 12 months; social workers accessed the third most on average

*For providers who have accessed at least one record in the last 12 months

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Three prerequisite elements of critical mass:

• 1. Consumer registration took 5½ years to reach

50% of the target population

• 2. Provider registration and participation has

continued to increase over time

• 3. Clinical content generation preceded viewing

Review

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• 1. Gradual evolution towards

critical mass

• 2. Becoming embedded into

routine clinical and administrative workflow

• 3. Critical success factors

How has the MyEHR service been able to realise this value?

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• Four distinct approaches evident in how providers

use the MyEHR service

• Interaction between the approach employed and

the clinical scenario The MyEHR service has become embedded into routine workflow

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Variability in frequency of use, with high concentration on a subset of consumers

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Cumulative % of sends/views/accesses in last 12 months Cumulative % of providers who have sent/viewed >0 documents,

• r accessed >0 records during last 12 months, ordered from

lowest to highest count of sends/views/accesses

Concentration in usage of the MyEHR service by providers

Document sends Document views Record accesses 6% 16% 33% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Cumulative % of total views / accesses / sends in last 12 months Cumulative percentage of registered consumers

Concentration of MyEHR usage amongst consumers

Sends Record accesses Document views

20% of consumers account for: 67% (1- 33%) of all sends, 84%

• f all record accesses,

and 94% of all views. Use by healthcare providers is highly concentrated, with 20% of providers account for ~80% of all sends, accesses and views.

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20 40 60 80 100 120 140 160 180 200 2007 2008 2009 2010 2011 2012 2013 2014 Average number of document views per provider* per year

Average document views per year per provider*, by profession

Aboriginal Health Worker Allied Health Professional Dentist / dental nurse Doctor Health Facility Admin Officer Nurse Other Pharmacist

In terms of provider viewing, hospital pharmacists view the most on average

*Providers with at least one view in any given year; analysis excludes some high viewing generic provider logins

Qualitative research indicates pharmacists in particular have embedded use of the MyEHR into their workflow; this is supported by the quantitative data

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Overwhelmingly, hospital pharmacists are viewing health profiles for meds info

17% 33% 35% 35% 40% 38% 50% 79% 21% 23% 20% 27% 21% 19% 15% 9% 13% 17% 13% 11% 13% 17% 22% 2% 32% 13% 18% 13% 11% 11% 7% 4% 14% 8% 9% 6% 8% 8% 4% 3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Other Nurse Aboriginal Health Worker Health Facility Admin Officer Allied Health Professional Doctor Dentist / dental nurse Pharmacist Percentage of documents viewed per profession

Percentage of views by doc type, per viewing provider profession

Health Profile Event Summary Pathology Report ED Discharge Summary Inpatient Hospital Document Other Hospital Document Outpatient Hospital Document Antenatal

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• MyEHR service has become embedded into routine

workflow, particularly at points of handover

• Four distinct approaches evident in how providers

use the MyEHR service

• 1. Investigative
• 2. Targeted
• 3. Supplementary
• 4. Opportunistic
• Use of the MyEHR service highly concentrated

amongst providers and consumers (80:20 rule) Review

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• 1. Gradual evolution towards

critical mass

• 2. Becoming embedded into

routine clinical and administrative workflow

• 3. Critical success factors

How has the MyEHR service been able to realise this value?

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• Success factors identified by the evaluation are either:
• Fixed characteristics of the setting into which the MyEHR was

deployed, which were conducive to success, or

• Enablers that were able to be controlled / influenced by the

implementation program

Value provided by the MyEHR service has emerged from a complex set of circumstances

Fixed characteristics

Consumer characteristics Provider characteristics

Enablers (controllable)

Attitudinal & behavioural Technical & functional Policy & governance

An understanding of these factors can assist in the transition process, and in development and rollout of the PCEHR system, e.g.

Default-to-send Clinical Advisory Committee Intuitive design

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• Consumers
• English as an additional language
• Sensitivity to Indigenous concepts of identity
• Gender propriety
• Multiple care providers
• Pressure to provide timely care
• Providers
• Remuneration model
• Provider mindset
• Wide scope of acuity
• Staffing models and high turnover

Fixed characteristics

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• Policy & governance
• Collaboration and continuity
• Clinical Advisory Committee
• Peer to peer encouragement
• Ongoing consent for access
• Recognisable branding
• Registration drives with

community engagement

• KPIs promote improved data

quality

• Attitudinal & behavioural
• Benefits from engaging are

immediate

• Consumer willingness to

register

• Staff skilled at identification
• Minimal privacy concerns

Enablers

• Functional & technical
• Automated document

generation with default to send

• Intuitive design
• Progress notes and free text

contribution

• Ability to sort
• Capability to extract
• Web portal
• Careplan templates
• Existing recalls facilitate

proactive care

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The evolution of the MyEHR service provides a yardstick against which to track progress of the PCEHR system, and allows us to assess if the PCEHR system is on track to achieve critical mass and realise equivalent value as the MyEHR service

How does the PCEHR system compare?

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0% 10% 20% 30% 40% 50% 60% 70% 12 24 36 48 60 72 84 96 Estimated percentage of the population (ABS ERP) registered Months since system launch

Estimated percentage of the population registered, by system

MeHR (NT total popn) PCEHR (Australian popn) MeHR (NT Indigenous popn) Linear projection (PCEHR)

2½ years post launch, PCEHR and MyEHR registration rates similar, though diverging trends

MyEHR registration was focussed on Indigenous communities, therefore using the Indigenous population of the NT as the denominator is

• appropriate. Total NT population is given for comparative purposes. Note: MyEHR registration data for first 12 months not available.

Based on projected registration trends (assuming current approach maintained), PCEHR will not reach 50% population registration for 12 years (2027)

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Point in time where MeHR registrations reached approximately 50% of Indigenous NT population 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 12 24 36 48 60 72 84 96 108 120 Sends / uploads per month per 1,000 registered people Months since system launch

Document uploads per month per 1,000 records, by system

MeHR Sends PCEHR clinical document uploads PCEHR clinical document uploads (incl. NPDR)

Including NPDR (prescribe and dispense) records, PCEHR uploading rate higher than MyEHR at comparable stage of maturity

Sending rate begins to

• increase. Sustained volume
• f sending is a prerequisite

for critical mass

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Point in time where MeHR registrations reached approximately 50% of Indigenous NT population 500 1,000 1,500 2,000 12 24 36 48 60 72 84 96 108 120 Accesses per month per 1,000 registered people Months since system launch

Record accesses per month per 1,000 records, by system

MeHR Accesses PCEHR Accesses

However, at comparable stage of maturity, normalised rate of PCEHR accessing lower

Evidence of marked growth in rate of accessing years 5 to 7, and also stabilisation

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Point in time where MeHR registrations reached approximately 50% of Indigenous NT population 100 200 300 400 500 600 12 24 36 48 60 72 84 96 108 120 Views per month per 1,000 registered people Months since system launch

Document views per month per 1,000 records, by system

MeHR Document Views PCEHR Document Views

On current trend, normalised PCEHR viewing rates are comparatively lower

Note: Data on MyEHR viewing for first three years not available.

Five-fold increase in viewing rate (100 to 500 views per month per 1,000 records) following critical mass point

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An understanding of the success factors provides an opportunity to apply these lessons to the M2N transition project. In addition, this understanding helps to identify the prerequisite conditions necessary for the PCEHR system to reach critical mass, and also to identify factors that can be directly influenced in order to accelerate benefit realisation.

Implications for the transition and PCEHR

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• Transitioning to the national eHealth record system
• ffers a number of advantages, e.g.
• Cross jurisdictional data exchange
• Additional functionality, with atomised data
• However, there were some issues raised that

require consideration:

• Anxiety about the transition, including re-registration
• Concerns about effect on clinical workflow, e.g. arising

from policy differences relating to identifying individuals and accessing records

• PCEHR system not yet having equivalent breadth and

depth of content

• These issues are capable of being mitigated by

current change management activities Implications for the M2N transition

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• This evaluation provides strong evidence validating

the value proposition of the PCEHR system

• Evaluation findings suggest specific activities to

accelerate achievement of critical mass and benefit realisation, relating to:

• Sustaining consumer and provider registration activities,

e.g. on a region-by-region basis (see next slide)

• Stimulating content generation / utilisation across sectors
• Gradual evolution of the MyEHR service emphasises

the importance of sustaining effort aligned to a clearly defined long term strategy

• Finally, evidence validates potential value, but need

further research into impact on health outcomes Implications for the PCEHR system

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Sending facility region Viewing facility region

Total document views by sending and viewing facility region

Direction of information flow

Majority of information exchange occurs within geographic regions, e.g. between primary and acute facilities within the same region

But note the flow of information into referral centres (Alice Springs and Darwin) from surrounding regions, and back from referral centres to surrounding regions.

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• Benefits attributable to the MyEHR service provide

strong evidence validating the value proposition of the PCEHR system

• The MyEHR service was able to realise this value

via a gradual evolution towards critical mass, which allowed it to become embedded into workflow

• Lessons learned from this evaluation suggest

specific ways to accelerate achievement of critical mass in the PCEHR system, and emphasise the importance of sustaining effort aligned to a clearly defined long term strategy Review of key points

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Thank you!

Any questions?

Please contact Mitch Burger (mitchell.burger@nehta.gov.au | 02 8298 3418)

• r Andrew Ingersoll (andrew.ingersoll@nehta.gov.au | 02 8298 2136)

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Appendix

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0% 2% 4% 6% 8% 10% 12% 14% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Percetnage of total views Hour of the day

Document views by time of day, weekend versus weekday

Weekday Weekend

Marked increase in proportion of viewing

• ccurring outside business hours on the

weekend, compared to weekdays

This supports the qualitative observation that the MyEHR service is saving clinicians time on the weekend, and avoiding the need to interrupt nurses at remote health centres, or call them out of hours or on weekends.

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Majority of registered providers are assigned to (work in) NT acute facilities

2,000 4,000 6,000 8,000 10,000 Acute - Interstate Other - NGO and Interstate Other - NTG Health centre - NTG Health centre - NGO and Interstate Acute - NT Number of registered providers

Number of registered providers by profession, assigned facility type

Nurse Doctor Aboriginal Health Worker Allied Health Professional Health Facility Admin Officer Dentist / dental nurse Pharmacist Other

The MyEHR service has clearly been embraced within the acute sector

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80.6% 80.5% 68.8% 51.8% 38.1% 25.5% 19.4% 5.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Health Profile Event Summary Pathology Report ED Discharge Summary Inpatient Hospital Document Other Hospital Document Outpatient Hospital Document Antenatal Percentage of records with one or more documents of each type

Percentage of records with 1 or more documents, by type

Over 50% of records contain an ED discharge summary

And almost 40% contain an inpatient hospital document (i.e. non-ED discharge summary)

Note that antenatal documents only come from facilities using Communicare CIS (~50% of primary health centres in NT)

In comparison, 2% of people with a PCEHR record have a SHS, as at March 2013