The Physician in eHealth - The infraNET Project

Waterloo Smarter Health Seminar Series:
eHealth Strategies: Local to Global
The Physician in eHealth:
The Missing Link
Dr. Bill Haver
Family Physician and Managing Partner
Lakeside Medical Clinic, Saskatoon
University of Waterloo
June 21, 2006
Seminar Sponsors:
The Physician in eHealth
The Missing Link
Dr. Bill Haver
Lakeside Medical Clinic, Saskatoon, SK
Disclaimer / Disclosure
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Information has been gathered from multiple
sources …
Public documents, organizations, government,
friends, colleagues, contacts
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l No data manipulation or analysis was done
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l Original authors are acknowledged
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Opinions expressed are my own unless
indicated otherwise.
Disclosure: Board Member – Clinicare Corp.
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Outline …
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What was the original “eHealth” objective?
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Was there a flaw in the concept?
What is the current state of adoption?
Nationally, provincially
Other countries?
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l Is there a pattern?
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How do the Canadian players feel?
Is there a common thread?
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What will it take to succeed?
Conclusions
Discussion
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What was the original objective?
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“eHealth” as a concept …
Electronic Medical Records
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l Electronic Patient Records
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l Electronic Health Record
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Infrastructure
Connectivity, Communications
Standards
Security, Confidentiality, Privacy
Cost containment
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What was the original objective?
l Was
it to link everything to everybody?
l Was it to develop standards?
l Was it to improve security?
l Was it to improve healthcare delivery?
l Was it to improve healthcare decisions?
l Was it to improve chronic disease
management?
l Was it to reduce medical errors?
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Was it any of the above?
… no
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What was the original objective?
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The original objective was simply:
“Efficiency”
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Technology initially offered a means to
eliminate the repetitive tasks
So it was really cost containment …
Quality of care, decision support,
disease management, outcomes
research, etc. – were all afterthoughts.
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Was this wrong?
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NO …
Cost containment is important
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l Healthcare costs consistently increase:
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Annual
Annual increases
increases in
in provincial
provincial budgets
budgets
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l Annual
Annual increases
increases in
in percentage
percentage of
of GNP
GNP
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The “new objectives” (benefits) are
considered more virtuous (i.e.: marketable)
They ALL have a system wide financial benefit.
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l They ALL originate at the point of care
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Direct
Direct effect
effect on
on physician
physician behavior
behavior (clinical
(clinical &
& business)
business)
Intrinsically desirable, inherently complex,
practically impossible
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Where is the flaw?
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“Desirability” & “complexity” often have a cost
“Practicality” implies cost containment
“Impossible” implies loss of cost containment
The concepts of ownership & responsibility
1.
1.
2.
2.
3.
3.
4.
4.
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Who’s
Who’s problem
problem is
is it?
it?
Who
Who can
can fix
fix it?
it?
Who
Who benefits?
benefits?
Who
Who has
has to
to pay?
pay?
Who
Who controls
controls the
the variables
variables &
& operators?
operators?
Is
Is itit the
the same
same as
as in
in #1?
#1?
Is
Is itit #1
#1 or
or #2
#2 or
or someone
someone else?
else?
Should
Should itit be
be #1,
#1, #2,
#2, #3
#3 or
or someone
someone else?
else?
It is not a flaw to recognize the value in efficiency
It is a flaw to fail to appropriately attribute costs to
beneficiaries.
It is a flaw to fail to recognize who controls the variables.
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Background …
l Center
for Information Technology
Leadership (2003
(2003 Survey
Survey -- USA)
USA)
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l Interoperability
and standards for health
care information exchange
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l Net $87 Billion /year
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l Break even in 5 years
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l Estimated the improved patient safety and
quality of care would dwarf the benefits of
reduced redundancy and administrative time
saved.
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Background …
l CITL
also looked at provider order entry
l CPOE predicted to save $44 Billion/year
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l $27
Billion in medications
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l $10.3 Billion in radiology
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l $4.8 Billion in lab costs
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l $1.9 Billion in adverse drug events
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Background …
l Canada
Health Infoway commissioned
similar survey (Booz
(Booz Allen
Allen Hamilton
Hamilton Inc)
Inc)
l 10 year implementation plan
l $9.9 Billion upfront cost
l Total cost $22.7 Billion over 10 years
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l Upfront
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plus recurring costs
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Background …
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Over 20 years it would
Save $48.3 Billion in reduced adverse drug
reaction costs
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l Save $3.6 Billion in reduced radiology costs
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l Save $10.4 Billlion in reduced lab costs
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ROI = Benefit : Investment = 8:1
Net savings over 20 years= $39.8 Billion
Positive cash flow by Year 7
Break even in Year 11; $6.1 Billion/year
thereafter
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Who is in control?
l 80%
of healthcare delivery is at the
community level
l Virtually all of the clinical information
from an acute care stay will end up with
the primary care provider
l Despite this, almost all of the benefits
found in the studies outlined above
accrue to the system and not the
provider.
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The original objective …
“Although the financial benefits are
significant, one could argue that the
qualitative benefits, particularly in lives
saved, create a moral imperative for the
initiative (EHR)”
Dr. Ruth Collins-Nakai
CMA President
nd Quarter, 2006
HCIM&C, 2nd
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So where do the docs stand?
CHII and CMA carried out a survey of
Canadian physicians late 2005
l Described as the most extensive survey
of physicians in Canada
l Intention was to help the CMA & CHII
to better understand physician needs
for transitioning into a digital world
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National survey:
Computer Skill levels
Expert
4%
Not proficient /
don't use
computers
5%
Advanced
36%
Basic
55%
Majority of respondents
considered themselves to
have basic or advanced
skills – very few nonnon users or experts
These results virtually
mirror those in the New
Brunswick Physician
Survey*
* Information and Communications Technology Survey of New Brunswick Physicians
– January 2005, Baseline Market Research Ltd.
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National Survey:
Current use of technology devices
Technology devices currently being used
within main practice for professional purposes
Desktop PC (at office)
87%
High-speed Internet (at office)
73%
Networked environment (at office)
66%
PDA
47%
Laptop PC
47%
Dial-up Internet (at office)
Use of traditional
technology devices and
environments fairly high,
but use of mobile
technology devices low
21%
Two-way handheld pager or textmessaging device
12%
Tablet PC
0%
7%
20% 40%
60% 80%
Percentage of respondents
100%
Base: Total sample [n=1,986]
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National Survey:
Trends in technology use
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Heavier technology users tend to be:
l A little younger
l Specialists
l In hospital settings
l More comfortable with technology
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National Survey:
Trends in common uses of EMR
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Much like the use of technology in general:
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Physicians in solo or group practices
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more likely to use technology for administrative tasks (billing or
booking of patient appointments)
many physicians are still not using technology to contact patients or
pharmacies directly such as by e-mailing patients for administration
or clinical purposes
Physicians in hospitals are more likely to use technology for
more clinical tasks such as the following:
l Receiving status notifications
l Receiving consultation reports
l Receiving lab or diagnostic test results
l Sending lab or diagnostic test orders
l Receiving discharge summaries
Base: Respondents who currently use technology [n=127-1,002]
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Current use of EMR by province
(CMA Survey - 2005)
NWT/YT/N
14%
B.C.
21%
Alberta
26%
Newfoundland
Sask.
12%
33%
Manitoba
Quebec
21%
Ontario
12%
24%
PEI
6%
Nova Scotia
17%
New Brunswick
22%
NPS 2005 Survey
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National Survey:
Practice setting where EMR is used most often
Practice setting where EMR systems currently used most
often
Office or Clinic
58%
Hospital
39%
Home
2%
Other
7%
0%
20%
40%
60%
80%
100%
Percentage of use
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National Survey:
Business issues facing medical practitioners
Rate the following issues from 1 to 10, where 1 is a 'minor issue'
and 10 is a 'major issue'
Quality of patient care
8.0
Patient wait times
7.2
Operational efficiency of my practice
7.1
Patient safety
7.0
Cost pressures on my practice
6.5
Adoption of new technology
6.3
Transformation of healthcare workflow from
manual, paper-based to automated
6.2
Human resources planning
5.9
Aligning my practice with healthcare reform
initiatives
Base: Total sample [n=1,986]
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5.7
1.0
Mean Score
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10.0
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National Survey:
Reasons for adopting EMR (among the users)
Potential motivators for adopting EMRs within main practice setting,
using a scale of 1 to 10 where 1 is not at all a strong motivator and 10 is
a very strong motivator
8.1
Desire for improved quality and efficiency of your practice
Acquiring the EMR system from a proven, credible software
manufacturer
7.7
Proof that all records within EMRs are secure
7.7
Receiving training in the use of the EMR system when purchasing
7.6
Receiving comprehensive installation support
7.5
Receiving service guarantees from the EMR system vendor
6.6
Testimonials from other doctors w/ high satisfaction levels w/EMR
6.5
Assistance with influencing decision-maker(s) within your primary
practice setting
Receiving a subsidy to help cover costs associated w/ implementing
EMRs
5.4
5.3
Legislated action, requiring the adoption of EMR systems within the
medical practice
Base: Respondents currently using EMR systems [n=703]
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5.2
1
Mean Score
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10
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National Survey:
Barriers to adopting EMR (the non-users)
Potential barriers in adopting EMRs in main practice setting using a
scale of 1 to 10, where 1 is not at all a barrier and 10 is a very
significant barrier
Time and effort required to
implement EMR system
7.8
High cost to purchase and
implement technology
7.8
Concerns about data
security/confidentiality
6.2
Lack of information about
EMR systems
5.7
Administrative staff lack skills
to use EMR system
5.5
Lack of internal champion
to lead EMR integration
5.1
1
10
Mean score
Base: Respondents who currently do not use EMR systems [n=1,261]
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National Survey:
Future Use of EMR
Likelihood of having
an EMR system in
place at main
practice within the
next two years
Main Practice Setting
Solo
practice
Group
practice
Solo and
group
combined
Hospitals
Other
All
settings
Extremely likely (10)
4%
10%
7%
12%
4%
8%
Likely (7-9)
7%
14%
11%
20%
9%
14%
Neither (5-6)
8%
13%
11%
13%
16%
12%
Not likely (2-4)
28%
28%
28%
34%
31%
30%
Not at all likely (1)
54%
35%
44%
21%
39%
36%
2.6
4.0
3.4
4.7
3.3
3.8
Mean likelihood
Likelihood highest among those mainly in hospitals and group practices.
Not surprising among those mainly in hospitals, as they are not likely to
have to pay for the EMR system or manage its implementation
Base: n=1,197
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So what is really happening?
l There
is significant discrepancy between
the numbers produced by the CMA, by
Infoway, and by any specific jurisdiction
l There is a dearth of good studies
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l Mostly
surveys
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l Selective response influenced by self interest
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l Poorly worded questions
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l Skewed by depth of knowledge of respondent
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l “Generous” interpretation influenced by
marketing needs of the organization providing it
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British Columbia
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Government website states 9% of physicians
in BC use EMR (2005)
New negotiated settlement with BC doctors
ratified (March 2006)
Significant funding for IT
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l Total of $110 Million for EHR concept
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l
$50
$50 Million
Million for
for ?ASP
?ASP solutions?
solutions?
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l $20
$20 Million
Million for
for change
change management
management
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Regions very active
Chronic disease management project
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l Electronic Medical Summary (e-MS) VIHA project
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Alberta
l POSP
program
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l Joint
initiative AMA and AB government
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l Started in 2001; approximately $7K/yr/MD
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l As of March 31, 2006:
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l 3,369 physicians have signed up
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l 61%
of Alberta’s doctors
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l Funding
up to a maximum of 48 months
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l Levels 1, 1.5 & 2
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l Progressively more EMR use
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Alberta: Physician participation
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As of March/06:
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3,369 active participants (61% of eligible physician
population)
Level
Level 22
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l Level
Level 1.5
1.5
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l Level
Level 11
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l 915
915 clinics
clinics
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l
2,784
2,784 83%
83%
404
12%
404
12%
181
5%
181
5%
844 Level 2 physicians haven’t selected a vendor yet
(25% of POSP population)
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l Physician retention high: 93% to date
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l 85% of physicians meeting program outcomes re: use
of technology (for
(for those
those who
who have
have implemented
implemented systems)
systems)
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Alberta: Evaluation
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External evaluation of clinical outcomes, operational
impact and program delivery completed.
Physicians ARE using office automation:
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Staff are using it too:
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l
l
l
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Scheduling
Scheduling (86%)
(86%)
Charting
Charting (71%)
(71%)
Scheduling
Scheduling (100%)
(100%)
Communicating
Communicating (78%)
(78%)
Communicating
Communicating (76%)
(76%)
Billing
Billing (80%)
(80%)
Billing
Billing (91%)
(91%)
Filing
Filing (94%)
(94%)
Overall physician satisfaction with program is high
First in Canada;
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The
The results
results in
in Alberta
Alberta are
are aa quantum
quantum higher
higher than
than in
in jurisdictions
jurisdictions
without
without aa program
program
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Saskatchewan
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Health Information Solutions Center
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Formerly SHIN
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Advantages of pre-existing pharmacy system
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13% have full-time EMR anyway …
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Utilization and outcome based
Pharmacy Information Program
Laboratory systems integration
No incentives for physician adoption
SMA IT committee proposal
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Utilized
Utilized aa lot
lot of
of Alberta’s
Alberta’s ground
ground work
work
Government approved but …
Problem: funds (existing vs. new)
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SMA Survey – May 2006
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SMA Survey – May 2006
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SMA Survey – May 2006
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SMA Survey – May 2006
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Ontario Physician IT Program
l
l
OntarioMD.ca
OntarioMD.ca (a
(a subsidiary
subsidiary of
of the
the OMA)
OMA)
l
l
l
l
Smart
Smart Systems
Systems for
for Health
Health Agency
Agency (SSHA)
(SSHA)
l
l
l
l
products
products that
that have
have been
been approved
approved as
as meeting
meeting specified
specified security,
security,
technology,
technology, and
and functionality
functionality standards
standards for
for managing
managing electronic
electronic
medical
medical records
records and
and practice
practice management
management information;
information;
Transition
Transition Support
Support Program
Program
l
l
l
l
providing
providing doctors
doctors with
with secure
secure Internet
Internet connections
connections over
over aa secure
secure
network
network which
which will
will connect
connect all
all doctors
doctors in
in the
the province;
province;
Clinical
Clinical Management
Management Systems
Systems (CMS)
(CMS)
l
l
l
l
an
an Internet
Internet portal
portal that
that provides
provides free
free access
access for
for all
all physicians
physicians to
to
products
products and
and services,
services, including
including online
online access
access to
to medical
medical journals,
journals, aa
drug
drug database
database and
and breaking
breaking medical
medical news
news and
and alerts;
alerts;
to
to help
help physicians
physicians acquire
acquire and
and use
use information
information technology,
technology, including
including
access
to
Transition
Specialists
and
workshops
and
tools
such
access to Transition Specialists and workshops and tools such as
as
best
best practice
practice guidelines
guidelines and
and checklists;
checklists;
Primary
Primary Care
Care IT
IT Funding
Funding Plan
Plan
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to
to assist
assist eligible
eligible primary
primary care
care physicians
physicians to
to acquire
acquire IT
IT
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Ontario Physician IT Program
l
l
Groups eligible for funding:
Family Health Teams (FHT)
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l Family Health Networks (FHN)
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l Health Services Organizations (HSO)
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l Primary Care Networks (PCN)
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l Northern Group Funding Plans (NGFP)
l
l Community Sponsored Contracts (CSC)
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l Community Health Centres (CHC)
l
l The Group Health Associates in Sault Ste. Marie
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l The Queen's Family Health Unit
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l
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OntarioMD Inc.
David
David Pattenden
Pattenden (VP,
(VP, Customer
Customer Relations
Relations && Support)
Support) (email
(email May
May 18,
18, 2006)
2006)
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l
Currently managing the PC IT
l
l
l
l
Primary
Primary Care
Care Information
Information Technology
Technology Funding
Funding Program
Program
AA $28,600
$28,600 per/physician
per/physician subsidy
subsidy
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l
l
l
l
l
The
The Comprehensive
Comprehensive Package
Package includes
includes aa one-time
one-time 'Readiness'
'Readiness'
grant
grant of
of $4500
$4500 per
per physician,
physician, aa monthly
monthly subsidy
subsidy of
of $600
$600 per
per
physician
physician per
per month
month for
for 36
36 months,
months, and
and aa one-time
one-time
'Performance
'Performance Recognition'
Recognition' payment
payment of
of $2500
$2500 per
per physician.
physician.
Participating
Participating physicians
physicians within
within an
an eligible
eligible group
group must
must choose
choose the
the
same
same certified
certified CMS
CMS product,
product, and
and all
all monies
monies will
will be
be paid
paid to
to the
the
group.
group.
to
to acquire
acquire and
and implement
implement pre-certified
pre-certified IT
IT solutions
solutions
Since
Since April
April 2005:
2005:
They
They have
have funded
funded 90+
90+ Group
Group Practices
Practices
l
l Represents
Represents approximately
approximately 600-700
600-700 physicians
physicians (2.6%
(2.6% Ont.
Ont. MDs)
MDs)
l
l the
the estimated
estimated total
total funding
funding commitment
commitment over
over aa three
three year
year
period
period is
is now
now up
up to
to ~$20,000,000.
~$20,000,000. ($28.6K
($28.6K xx 700)
700)
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l
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National Initiative
l
l
Canada Health Infoway Inc.
l
l
l
l
Invests with public sector partners across Canada to
implement and reuse compatible health information
systems that support a safer, more efficient healthcare
system.
l
l
l
l
l
l
Arms-length
Arms-length federal
federal corporation
corporation
An
An independent,
independent, not-for-profit
not-for-profit organization
organization whose
whose Members
Members are
are
Canada's
Canada's 14
14 federal,
federal, provincial
provincial and
and territorial
territorial Deputy
Deputy Ministers
Ministers of
of
Health.
Health.
Launched
Launched in
in 2001,
2001, Infoway
Infoway and
and its
its public
public sector
sector partners
partners have
have over
over
100
100 projects,
projects, either
either completed
completed or
or underway,
underway, delivering
delivering electronic
electronic
health
health record
record (EHR)
(EHR) solutions
solutions to
to Canadians
Canadians –– solutions
solutions that
that bring
bring
tangible
tangible value
value to
to patients,
patients, providers
providers and
and the
the healthcare
healthcare system.
system.
No direct incentives to physicians
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Infoway’s Investment Strategy
Infoway’s Role
•
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. To
build on existing initiatives and pursue collaborative relationships in pursuit of
its mission.
Shared Governance Facilitates Collaboration
Canada Health Infoway is an independent not-for-profit organization, whose Members
are Canada’s 14 federal, provincial and territorial deputy ministers of health.
•
•
Vision
– A high-quality, sustainable and effective Canadian health care system
supported by an infostructure that provides residents of Canada and their
healthcare providers timely, appropriate and secure access to the right
information when and where they enter into the healthcare system. Respect
for privacy is fundamental to this vision.
Goal
– Infoway’s plan is to have an interoperable electronic health record in place
across 50 percent of Canada (by population) by the end of 2009.
44
From Barriers to Our Response Specific
Initiatives
Initiatives
ü
Competing priorities for limited funds
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Leverage national
leadership
Shape the
jurisdictional EHR
environment
Engage and support
super users
Stimulate consumer
demand
Promote support for
end users
Build new workflow
models
Demonstrate the EHR
value proposition
ü
Lack of availability of infrastructure technologies
Lack of accepted pan-Canadian standards to support
interoperability
Privacy and data stewardship issues
Lack of a compelling business case
Promote health
professions EHR
training
Support a continuous
learning environment
Understand
engagement
principles and
practices
Major Barriers Identified
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Lack of financial incentives
Insufficient engagement of end users and other relevant
stakeholders
Diversity of physician needs and technology uptake
ü
ü
ü
ü
ü
ü
ü
ü
Usability issues – solutions not meeting needs or expectations
ü
ü
ü
ü
Poor integration of EHR into educational programs
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
45
From Strategy Suggestions to Our Response
Specific Initiatives
Initiatives
Demonstrate the EHR business case
ü
ü
Establish a network of EHR champions
ü
ü
Provide resources and support for change management
ü
ü
Promote usability standards
ü
ü
Develop funding strategies that foster adoption
ü
Promote collaborative practice models
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Establish pilot projects at the local level to build momentum
Promote integration of EHR into the education system
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Leverage national
leadership
ü
ü
Shape the
jurisdictional EHR
environment
ü
ü
Engage and support
super users
ü
Stimulate consumer
demand
ü
Promote support for
end users
Develop EHR marketing and education materials
Support end user engagement in development of EHR
solutions
Develop vendor engagement strategies to promote
conformance standards
Build new workflow
models
ü
Demonstrate the EHR
value proposition
Support a continuous
learning environment
ü
Promote health
professions EHR
training
Understand
engagement
principles and
practices
Share learnings and best practices
Strategy Suggestions
ü
46
End User Acceptance - The Strategic Challenge
•
Obtaining a return on major investments in EHR infrastructure
requires substantial change in the work behaviours of health
professionals across fourteen jurisdictions
•
Change must occur across a complex landscape
– End users work in a wide range of settings from small medical practices
to large hospitals and health regions, and belong to various
professional organizations
•
End user acceptance is a critical enabler of EHR solutions
– Without acceptance, improvements in patient care from EHR will not be
optimized
•
End user acceptance is slow and must be accelerated
47
Infoway End User Acceptance Strategy
How do we
quickly
stimulate and
support
increased,
changeoriented
engagement of
health
professionals,
on a panCanadian
basis, to
accelerate
acceptance,
adoption and
use of EHR?
Manage the Context
#9: Influence the
jurisdictional EHR
environment
#8: Engage and
support super
users
#10: Leverage
national
leadership
#6: Promote support for
end users
Promote
Behavioural
Change
#5: Build new
workflow
models
#7: Stimulate
consumer
demand
#4: Demonstrate the EHR
value proposition
#2: Support a
continuous learning
environment
#3: Promote health
professions EHR training
#1: Understand
engagement principles
and practices
Establish a Foundation for Learning and Socialization
48
Infoway End User Acceptance Strategy
Establish a Foundation for Learning and Socialization
1. Understand Engagement Principles and Practices
• Documented successful engagement projects/stories.
• Engagement principles & practices for different professions, practice
settings/knowledge objects.
• Input for medical nursing and pharmacy curricula.
2. Support a Continuous Learning Environment
• Online infrastructure/learning environment.
3. Promote Health professions EHR Training
• Integrated EHR concepts/expectations into health professions training
curricula and regulatory processes.
49
Infoway End User Acceptance Strategy
Promote Behavioural Change
4. Demonstrate the EHR Value Proposition
• Value proposition/business case demonstration and documentation
and disseminated learnings.
5. Build New Workflow Models
• Demonstrated leading practices in work flow models applicable to
multi-disciplinary team-based care and integration of knowledge into
education curricula.
6. Promote Support for End Users
• Enhanced ability for jurisdictions to provide change management
support for end users through development of tools to train personnel
in jurisdictions and establishment of mechanisms whereby vendors can
provide enhanced support.
7. Stimulate Consumer Demand
• Documented messages on how patients can improve own health and
healthcare and through access to their own health information
50
message to be targeted to market segments.
Infoway End User Acceptance Strategy
Manage the Context
8. Engage and Support Super Users
• Network of accessible super users across Canada to support
acceptance at practice level and further understanding of acceptance.
Online infrastructure key vehicle.
9. Influence the Jurisdictional EHR Environment
• Supported jurisdictions to build EHR agenda, showcase success
stories and obtain political support, partnered with jurisdictions to align
and accelerate acceptance. Provide best practice knowledge for
leaders.
10.Leverage National Leadership
• Increased momentum among national bodies and organizations,
consistent messaging and alignment of EHR acceptance with health
reform including influencing national research agendas.
51
Successful Implementation of End User
Acceptance Projects
•
•
•
Support jurisdictional change efforts and add value to jurisdictional
plans
Co-ordinate with existing related work (e.g. Health Canada EMR
Toolkit development, CNA nursing portal, CMA e-learning portal,
etc.)
Partner with organizations to implement/sustain initiatives
–
–
–
–
–
–
•
Collaboratory
COACH
Canadian Patient Safely Institute
CIHR and other related research bodies
Health Canada
National provider organizations
Exhibit flexibility, risk-taking, creativity in project implementation
52
Project Support
• Physician, Nurse, Pharmacy Advisory Group
• Academic/Learning Advisory Group
• Vendor Advisory Group
• Communications Advisory Group
• National Leadership Advisory Group
• CIO Forum supported Jurisdictional End User Group
53
Role of Infoway’s Clinician Team
• Build bridges with professional organizations toward
accelerated use of electronic health records by health
providers in delivery of healthcare
• Identify existing and emerging barriers/issues
• Develop strategies/tactics to address barriers/issues
• Provide advice/input to Infoway management on health
provider acceptance and use of electronic health
records
54
The Bottom Line
• Status quo methods of engaging end users will not
enable the goal
• It’s time to move to the next level
• By investing in End User Acceptance, Infoway will:
– Take substantial steps with jurisdictions to master the acceptance
challenge through more effective engagement of end users
– Increase pan-Canadian ability to remove barriers related to end user
acceptance
– Transform end user acceptance into a primary enabler of
implementation and value realization for Electronic Health Record
Solutions
55
What is happening elsewhere?
l Have
other countries experienced similar
problems with adoption/implementation?
l USA
l Other countries
l
l Dr.
Denis Protti - University of Victoria
l
l Analysis of EMR Usage in 10 Countries
2006.06.21
University of Waterloo Smarter Health Seminar
56
U.S.A.: 2005 University of Minnesota,
School of Public Health, Center for Research
l
l
11.5%
l
l
l
l
12.7%
l
l
l
l
Implementation within 12 months
19.8%
l
l
l
l
Implementation in Progress
14.2%
l
l
l
l
Fully implemented, all physicians, all locations
Implementation with 24 months
41.8%
l
l
2006.06.21
Not implemented and no plans to implement
University of Waterloo Smarter Health Seminar
57
U.S.A.: 2005 University of Minnesota,
School of Public Health Center for Research
l Cost
was cited as primary barrier to
implementation
l Cost among the adopters
l Average upfront cost:
l$32, 606 per physician
l Average maintenance cost:
l$1,177 per month per physician
2006.06.21
University of Waterloo Smarter Health Seminar
58
U. S. Experience
l
l
Concern over rigidity of early CDS or “expert” systems
(Kamoroff)
(Kamoroff)
l
l
l
l
l
l
“I
“I am
am being
being regimented
regimented ifif you
you give
give algorithms
algorithms to
to me,
me, but
but II am
am
being
being systematic
systematic ifif II develop
develop algorithms
algorithms myself”
myself”
“The recognition that an EMR could improve care quality,
reduce medical errors, and reduce health care costs was
still not sufficient motivation to overcome resistance to
EMR adoption. Without Strong physician demand, hospital
and practice administrators did not see sufficient potential
return to try to overcome this resistance either in the
patient or outpatient setting” (Berner
(Berner et
et al,
al, JAMIA,
JAMIA, 2005)
2005)
2004 – appointment of David Brailer: National Health
Information Technology Co-ordinator
l
l
2006.06.21
“All
“All Americans
Americans to
to have
have EHR
EHR within
within 10
10 years”
years”
University of Waterloo Smarter Health Seminar
59
U. S. Experience
l Lack
of scalable, interoperable EHR
systems
l
l Vendors
fragmenting the market?
l
l Buyer’s lack of interest?
l
l Resistance from payers?
l
l Perception of market advantage lost if
information shared between provider
groups?
2006.06.21
University of Waterloo Smarter Health Seminar
60
U. S. Experience
l NHII
Conference 2003
l
l Government
must become part of the solution
in terms of financial incentives for EHR
adoption
l Although
it is the physician that has to
change his/her practice and make the
investment in EMR systems, most of the
benefits go to the organization, the
payers, or even the patient, and very little
to the physician. (Berner
(Berner et
et al,
al, 2006;
2006; Doolan,
Doolan, 2002)
2002)
2006.06.21
University of Waterloo Smarter Health Seminar
61
Ten Country comparison:
% GPs with office computers
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
98%
99%
99%
99%
90%
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
97%
100%
100%
95%
97%
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
62
% who operate “paper-light”
offices
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
Some
Few
Most
Some
Few
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
Few
Few
Most
Few
Few
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
63
% GPs with “automated” medication
prescriptions
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
98%
90%
99%
95%
90%
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
90%
97%
100%
95%
99%
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
64
% GPs using clinical electronic data
exchange
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
86%
25%
99%
97%
10%
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
50%
97%
10%
90%
50%
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
65
% GPs receiving electronic lab
results
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
Many
Many
Most
Many
Few
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
Many
Most
Few
Most
Most
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
66
Government funding support
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
Yes
No
No
Yes
No
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
Yes
No
No
Yes
Yes
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
67
Accreditation of vendor systems
l
l
l
l
l
l
l
l
l
l
Australia
Austria
Denmark
England
Germany
No
Yes
Yes
Yes
Yes
l
l
l
l
l
l
l
l
l
l
Netherlands
New Zealand
Norway
Scotland
Sweden
Yes
Yes
No
Yes
No
In some cases for billing purposes only
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
68
Other driving forces
l Mandatory
electronic billing
l College and professional associations
l Peer ‘influence’
l Certification of vendor systems
l Etc.
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
69
There is no one answer or reason why these 10 countries have a
high degree of utilization of computer technology by their GPs
… There are however similarities to draw upon
D. Protti, UVic, 2006
Government policy played a part
in most of the countries
l
l
l
l
The policies may not have been directly
related to primary care computing (e.g. out
of office hours or physician collectives) but
in many instances, they indirectly
stimulated the introduction of technology.
Closely related were the financial incentives
and rewards which were provided to GPs if
they automated …though this was clearly
not the case in all of the countries.
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
71
A single unifying organization played a key
role in Denmark and New Zealand
l
l
Denmark’s organization is non-profit,
arms length from government, while
New Zealand’s is a private company.
The lack of a unifying organization is
seen to be a significant limiting factor
in a number of countries.
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
72
Other important factors
included:
l
l
l
l
Providing non-financial support to GPs
Certification of vendor systems
Use of communications standards
Use of nomenclatures (e.g. Read
codes in England & Scotland, and
ICPC in Norway)
D. Protti, UVic, 2006
2006.06.21
University of Waterloo Smarter Health Seminar
73
What seemed evident in all 10 countries was the recognition that
significant progress towards an Electronic Health Record, with all
its associated benefits, was impossible without the full
participation of general practitioners.
D. Protti, UVic, 2006
Concerns identified by
Canadian Physicians …
l Canadian
Physicians and related
decision-makers were surveyed
l Very non-scientific (did
(did they
they answer
answer my
my email?)
email?)
l Leaders (champions) in their own
jurisdictions
l Experienced educators & speakers
l Experienced trainers on many different
systems and in many different
environments
2006.06.21
University of Waterloo Smarter Health Seminar
75
Concerns identified by
Canadian Physicians …
l
l
Feel marginalized
l
l
l
l
Lack of respect for contribution
l
l
l
l
Lack of consultation, involvement
Persistent misconception of greed
Tying incentives to alternate payment structures
No evidence that FFS is the problem
l
l strong evidence that “tying”, in fact, creates a
deterrent to adoption
l
l Benefits of involvement in EHR would far outweigh
cost containment achieved in alternate payment
structure;
l
l
2006.06.21
University of Waterloo Smarter Health Seminar
76
Concerns identified by
Canadian Physicians …
l Cost
factors: dollars and human factors
l
l Purchase,
support, training, evergreen
l
l Change management
l Market
confusion
l
l No
clear “physician centric” objective
appraisal of vendors/software
l
l No truly unbiased physician advocate
l
l Many small vendors with questionable
stability, questionable support abilities
2006.06.21
University of Waterloo Smarter Health Seminar
77
Concerns identified by
Canadian Physicians …
l Increasingly
complex political scene
l
l Infoway,
Projects, Associations
l
l Multiple provincial initiatives
l
l Varied incentives, Varied success
l
l Confusing
numbers
l
l Reasons for success, Reasons for failure
l
l Regional
or hospital bias
l
l The politics of interfaces
l
l Turf protection
2006.06.21
University of Waterloo Smarter Health Seminar
78
Concerns identified by
Canadian Physicians …
l
l
Lack of well articulated business case for front
line providers
Failure of “system” to recognize where the benefits
accrue
l
l Lack of a meritocracy
l
l
l
l
l
l
No unifying force that can effectively and
consistently influence provinces
Frozen by indecision (the “viewer effect”)
l
l
2006.06.21
Wait for next perk to be announced
University of Waterloo Smarter Health Seminar
79
Concerns identified by
Canadian Physicians …
l Lack
of integration with other providers,
hospitals, labs, pharmacy, regions, etc
l Security and privacy concerns
l Fear of steep learning curve
l Effect on workflow, office structure,
practice habits, culture
l Effect on income
l Time (swamp theory)
2006.06.21
University of Waterloo Smarter Health Seminar
80
Conclusions
l
l
l
l
l
l
l
l
l
l
l
l
There is tremendous benefit in EHR
There will be NO effective EHR until primary care
physicians are involved
Physician adoption has been slow but is growing
faster where incentives exist
Meaningful MD involvement in the process is required
An ethical market environment must be enforced.
Infoway:
l
l
l
l
l
l
l
l
2006.06.21
national
national cohesive
cohesive force
force (remove
(remove political
political bias
bias &
& COI)
COI)
protect
protect and
and promote
promote physician
physician involvement
involvement
single
single standards
standards agency
agency
single
single testing
testing (conformance
(conformance agency)
agency)
University of Waterloo Smarter Health Seminar
81
Conclusions
l Adoption
will accelerate with:
l
lA
focus on patient care issues at the
primary care provider interface first
l
l Provide evergreen funding based on both
utilization and outcomes
l
l Start to reward dedication, quality & excellence
l
l Do not penalize initiative, commitment, or hard
work
l
l For
change management, provide direct
financial support with no strings attached.
2006.06.21
University of Waterloo Smarter Health Seminar
82
Thank-you!
…any questions or discussion?
Dr. Bill Haver [email protected]
[email protected]