Canada Health Infoway and the Electronic Health Record

Canada Health Infoway and the Electronic Health Record Impacts & Opportunities Robert (Bob) Burns AFMC May 8, 2007

Overview • • • Why the EHR? Why & what is Canada Health Infoway? Progress to date Challenges & hurdles Benefits EHRs and Education

The Need – Patient Expectations

Managing Expectations What are the Jones expecting from their healthcare system? • Accurate information moves with them • Various providers communicate with each other • Privacy is protected • Decisions are made in consultation with them • Not exposed to undue risk • Receive timely access/results • Can access their own EHR • Have the ability to learn on their own, with assistance from their healthcare providers

The Need for EHR For Every …. 1000 hospital admissions 1000 patients with an ambulatory encounter 1000 patients discharged from hospital 1000 Laboratory tests performed …. in Canada 75 people will suffer an Adverse Event 20 people will suffer a serious Adverse Drug Event 90 people will suffer a serious Adverse Drug Event with the drugs received on discharge up to 150 will be unnecessary (range 50 -150) 1000 Emergency Department visits 320 patients had an information gap identified, resulting in an average increased stay of 1. 2 hours Study of 168 traditional medical records 81% didn’t have the information required for patient care decisions 1000 women at risk of cervical cancer 1000 Canadians recommended for influenza protection 300 -400 are not screened 370 -430 are not vaccinated

Growing Need for Health Information Management Resource pressures intensifying Resource pressures greater üProviders, managers, Care settings are shifting patients, public are demanding more üIT has potential to enable solutions to address pressures Consumerism is growing Population is aging Source: CIHI; Sanofi-Aventis; Statistics Canada; OECD; WHO; Centre for Chronic Disease Prevention

Yet Canada Invests Less in Healthcare IT than Other Information-intensive Businesses • Canada is underinvesting in IT relative to other healthcare providers and information management industries • Canada’s healthcare system would rank No. 10 in the Fortune 500 and is 3 times the size of the Royal Bank and has limited ability to manage its information Annual IT spend* Percent of total budgets/revenues 5. 4 4. 5 4. 7 4. 0 3. 4 2. 9 2. 0 • Additionally, investments have often been fragmented and one-off leading to duplication of efforts and need for reinvestments 1. 5 Education US HC providers** UK healthcare*** * Operating and capital ** Gartner estimate as %of revenues; assumes providers working on a non-profit basis *** Predicted rise to 4% from 1. 5% in 2004 Sources: Information Technology Association of Canada, 2004; Gartner Calgary Regional Health Authority Professional services US banking/ financial services Range of HC IT spend of Canadian jurisdictions

EHR Defined An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies. 6 9

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EHR and EMR…and convergence • An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies. • An electronic medical record (EMR) is a provider or site specific record of the interactions with a specific patient. By definition it is not complete, although it may be more richly detailed in some aspects than an EHR. It is maintained by providers to meet their fiduciary duties to their patients, as well as the requirements of their regulatory bodies.

The Model/Vehicle to Begin to Address Need: Canada Health Infoway

About Infoway Mission: • To foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis, with tangible benefits to Canadians Approach: • • • Infoway was established by the First Ministers of Canada’s federal, provincial and territorial governments in 2001 Infoway is a not-for-profit corporation Funded by the Government of Canada, funding was allocated to Infoway in 2001 ($500 m), 2003 ($600 m) and 2004 ($100 m) Infoway’s members are Canada’s 14 federal, provincial and territorial Deputy Ministers of Health Independent Board

Infoway Business Strategies • • • Targeted Investment Programs Limited scope - goal Collaboration with health ministries and other partners Co-Invest with public sector partners (75: 25 formula) Leveraged investment Form strategic alliances with the private sector Manage risk and ensure quality solutions Focus on end-user acceptance Measure benefits and adjust

Infoway’s Programs Infoway’s Goal By the end of 2010, some elements of the basic EHR will be in place for all Canadians, while a complete basic EHR will be in place for 50% of Canadians. All Canadians will benefit from better healthcare access, quality and productivity. Innovation and Adoption – $60 million* Innovation and Adoption - $60 million* Telehealth $120 million Chronic Disease Public Health Surveillance $100 million Primary Care Cancer Patient Safety Wait Times Etc. Mental Health Interoperable EHR – $175 million Registries $134 million Drug Systems $185 million Laboratory Systems $150 million Infostructure – $32 million Diagnostic Imaging $310 million Basic Elements of EHR

Focus on Standards and Interoperability EHR Solution (EHRS) • Common architecture largely accepted by jurisdictions • Revised architecture includes privacy and security • Comprehensive standards collaboration process • New Infoway Standards Collaborative EHR Infostructure (EHRI) Ancillary Data & Services Health Information Data warehouse EHR Data & Services Registries Data & Services Longitudinal Record Services HIAL Point of Service Application EHR Viewer EHRS Locator

EHR: Conceptual Architecture JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry PHS Data & Services Outbreak Management EHR Data & Services PHS Reporting Shared Health Record EHR Index Message Structures Drug Information Data Warehouse Diagnostic Imaging Laboratory Health Information Provider Registry Location Registry Business Rules Terminology Registry Normalisation Rules Longitudinal Record Services Security Management Data Privacy Data Configuration Common Services HIAL Communication Bus Public Health Services POINT OF SERVICE Public Health Provider Pharmacy System Pharmacist Radiology Center PACS/RIS Radiologist Lab System (LIS) Lab Clinician Hospital, LTC, CCC, EPR Physician/ Provider Physician Office EMR Physician/ Provider EHR Viewer Physician/ Provider

Electronic Health Records Linked Jurisdiction Networks Distributed, Message-based, Peer-to-Peer Network of EHRS Systems EHRS EHRS

Progress to Date

Program Activity Summary 217 active & 217 completed projects valued at $1, 133 M in all 9 investment programs 12 The 135 projects jointly developed with provinces and territories are shown. In addition, there are 82 active or completed pan-Canadian projects. Legend Registries Diagnostic Imaging Drug Info Systems Lab Info Systems Telehealth Interoperable EHR Public Health Surv. Innovation & Adoption Number of Projects

Significant Progress in 3 Years WEST INVESTMENT PROGRAMS March 2004 = $125 M BC AB ON SK MB QC NB NS TERRITORIES PE NL YK NT NU Telehealth Phase 0/1 Projects Phase 2 Projects i. EHR System in place Laboratory Drug DI Provider Reg. Client Reg. WEST September 2006 = $825 M 2005 -06 BC AB ON ON SK QC QC MB Telehealth i. EHR Laboratory Drug DI DI Provider Reg. Client Reg. EAST NB Public Health INVESTMENT PROGRAMS EAST 9 NS TERRITORIES PE NL YK NT NU

Different Stages of Progress Canada-wide Public Health Surveillance All 14 provincial, territorial and federal governments agreed to adopt a single Public Health Surveillance solution British Columbia: Leveraging Past Investments for an EHR BC will implement an electronic health record across the province. Alberta: net. Care Alberta-bound Alberta is leveraging Capital Health’s net. Care viewer for province-wide use in i. EHR and Lab information systems. Saskatchewan: Checks Med Safety Drug prescribing has become safer, with one of the first provincial systems covering “all drugs, all people. ” Quebec: Networking 62 Hospitals The Mc. Gill - Montreal RUIS repositories for diagnostic imaging system will be the largest in Canada. Manitoba and New Brunswick: Telehealth Calling Newfoundland & Labrador: Province-wide e. Progress Province-wide Drug Information System underway Nova Scotia: Farewell to Film Manitoba has doubled its network providing access to healthcare services to 10 northern First Nations and 7 Franco-Manitoban communities. Almost 100% filmless - medical professionals in Nova Scotia’s hospitals will be able to access patients’ complete lab results, images and patient history by 2006/7. New Brunswick is the national leader in nurse triage call centres and is now planning to expand their telehealth network to provide tele-homecare PEI: Island-Wide i. EHR Ontario: Keeping Tabs on Labs The first of nearly 200 hospitals and community labs are going “live” in 2006, providing on-line viewing of Lab results through links with hospitals and 10, 000 doctors’ offices. By the end of 2007, PEI’s clinicians will be able to see a patient’s lab results, medication and diagnostic images on on-screen,

Leveraging the EHR for Innovative Health Care Quebec MSSS British Columbia Ministry of Health Newfoundland & Labrador’s Eastern Health electronic patient evaluation and service planning solutions. pilots for province-wide adverse events reporting, analysis and management Sherbourne Health Centre remote electronic records for a Health Bus serving the inner city homeless Sault Ste Marie link primary care providers and pharmacists to the EMR/EHR Public Health Patient Safety Primary Health Information & Care Communications Chronic Disease Technologies patient portal will provide access to health information for cancer and renal patients. Alberta Cancer Board EHR-based clinical decision support tools to for Mental Health & Addictions Services Electronic self-entry (by patients) of patient history in emergency department (ED) using touch-screen kiosks extend Alberta's i. EHR and chronic disease management solutions to primary care teams. Grand River Hospital Vancouver Island Health Authority Scarborough Hospital Alberta Capital/Calgary Health Regions Cancer Wait Times synoptic reporting for cancer surgery will improve data collection and quality surgical management of cancer patients. Cancer Care Ontario computerized order entry and clinical decision support to benefit cancer patients.

Infoway Adding Value at Every Step • Joint governance • Joint planning (rolling 3 years) • Predictable funding • Common solutions architecture • Common ICT standards • Accountable spend • • • Common procurement Common solutions National pricing Shared services Knowledge sharing Global leaders- exporting expertise A mid-term independent performance evaluation conducted in 2005 and a recent review commissioned by Health Canada both validated and supported Infoway’s value-added role.

The Global Scene The International Milieu A number of nations have made significant e -health progress, with widespread EMR adoption, electronic communication and data sharing (e. g. lab results). NED DEN NZL NOR CAN US AUS 5 - Canada and the UK lag slightly behind some others in EHR progress – New Zealand, Denmark, Norway and the Netherlands. However, both Canada and the UK have strong focused national strategies and significant resource commitments to provide these nations the momentum to become the global leaders in the next 3 years. UK DEU SGP FRA Momentum 10 - JPN 5 - (EHR Implementation plus Adoption scores) Progress 10 - The US and Australia currently lack momentum towards an EHR. Both have national strategies but currently lack the funding to successfully execute the strategy. With funding both could quickly join the leading nations. (Strategy plus Resources scores) This graphic is based upon analysis prepared by Infoway using publicly available documentation on international EHR initiatives. All findings are subjective in nature.

Before we get too smug… On the road to 2015 …

The Road to 2015 • To develop a Health Infostructure Plan for Canada that confirms the long term vision and details the strategic directions that the country should consider over the next 10 years, including the associated resource requirements. • To provide a roadmap for the complete implementation of the electronic health record across the country as well as the extension of the infostructure to support all aspects of healthcare renewal.

The Vision Foundation Systems • • Electronic Health Record – for 100% of Canadians Electronic Medical Record – for Primary and Ambulatory Care Hospital Information Systems – CPOE and advanced decision support Patient Portals – to permit patients to view their electronic health record Business Systems • • • Public Health – for comprehensive pandemic management Chronic Disease Management – for advanced case management of key chronic diseases such as diabetes, congestive heart failure and cancer Wait Time Management – to allow electronic referrals, enterprise scheduling and wait time monitoring and reporting Patient Selfcare – to support patients and their care givers in their home Performance Management – to ensure sustainable patient care delivery Capital Cost = $10 to $12 billion Benefits = $6. 0 to $7. 6 billion annually

Priorities to 2015 1 Foundational Ensure baseline EHR and public health infostructure is in place across the country 2 Unlock additional quality and safety benefits by enabling decision support and communication across care continuum 3 Additional Elements Additional elements Facilitate improvements in patient self-care 4 Enable public visibility into wait times 5 Trial more advanced functionality to meet high priority system needs Largest investment required

Opportunities

Benefits Evaluation at Infoway

EHR: Overall Benefits & Value • • Improved interpretation of diagnostic and laboratory results Decreased adverse drug events Decreased prescription errors Increased speed and accuracy in detecting infectious disease outbreaks QUALITY • • Reduced wait-times for diagnostic imaging services Improved availability of community based health services Reduced patient travel time and cost to access services Increased patient participation in home care ACCESS • • Increased access to integrated patient information Reduced duplicate tests and prescriptions Reduced physician prescription call-backs Reduced patient and provider travel costs PRODUCTIVITY

Infoway Benefits Evaluation Plan Purpose: • • Assess the impact of Infoway investments in electronic health record solutions on healthcare quality, productivity and access. Impacts identified will be used to: • Demonstrate value of investments • Advance further investments in EHR solutions • Encourage end user adoption • Highlight necessary adjustments in the Infoway investment strategy Principles: • • Evaluate the Canadian experience with sufficient rigor to provide confidence in benefit estimates; don’t try to develop the definitive EHR evaluation framework Focus on evaluating programs that will produce tangible clinical benefits (Lab, Drug, DI, Telehealth, PHS and i. EHR) Not all projects or activities will be evaluated. Identify representative sample and most appropriate methodologies to allow extrapolation. The EHR benefits evaluation will be evaluated and revised on an ongoing basis

Infoway BE Framework The framework articulates the link between the systems in which Infoway invests and the resulting benefits, providing a basis for measurement. NET BENEFITS SYSTEM QUALITY ? Functionality ? Performance ? Security INFORMATION QUALITY ? Content ? Availability SERVICE QUALITY ? Responsiveness QUALITY USE ? Use Behavior/ Pattern ? Self Reported Use ? Intention to Use USER SATISFACTION ? Competency ? User Satisfaction ? Ease of Use ? Patient Safety ? Appropriateness/ Effectiveness ? Health Outcomes ACCESS ? Ability of Patients/Providers to Access Services ? Patient and Caregiver Participation PRODUCTIVITY ? Efficiency ? Care Coordination ? Net Cost O ORGANIZATIONAL and CONTEXT FACTORS: STRATEGY, CULTURE and BUSINESS PROCESS - UT OF SCOPE Based on the Delone & Mc. Lean IS Success Model

Quality, Access and Productivity Indicators § Change in patient safety • Medication errors and Adverse Drug Events § Change in health system outcomes • Readmission rates • Efficiency of recovery • Patient transfers § Change in access to services • Volume of service provision • Access to previously unavailable services • Timeliness of DI services § Change in provider efficiency • Radiology Technologist and Radiologist efficiency • Pharmacists and Lab technician callbacks • Time to take medication history or assess patient • Clinician workflow § Change in provider effectiveness/ appropriateness of care • Access to information • Timeliness of service delivery, pharmacists, public health, referring physicians, radiologists • Vaccination rates, Outbreak detection and intervention § Change in patient and caregiver participation • Patient awareness and adherence § Change in coordination of care • Information sharing among different providers • Management of outbreaks § Change in net costs • Unnecessary events: radiology, lab tests, vaccinations

New tools bring new questions: EHR and secondary uses of data

Secondary Use of Data workshop with CIHI January 2007 • Time to start building and marketing the case for secondary use to build ‘readiness’ by physicians, public and other stakeholders • Need to develop detailed use cases and/or a higher level framework identifying requirements for secondary use • Need to identify experiences, successes and failures, both nationally and internationally and build upon them

EHR: Conceptual Architecture JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry PHS Data & Services Outbreak Management EHR Data & Services PHS Reporting Shared Health Record EHR Index Message Structures Drug Information Data Warehouse Diagnostic Imaging Laboratory Health Information Provider Registry Location Registry Business Rules Terminology Registry Normalisation Rules Longitudinal Record Services Security Management Data Privacy Data Configuration Common Services HIAL Communication Bus Public Health Services POINT OF SERVICE Public Health Provider Pharmacy System Pharmacist Radiology Center PACS/RIS Radiologist Lab System (LIS) Lab Clinician Hospital, LTC, CCC, EPR Physician/ Provider Physician Office EMR Physician/ Provider EHR Viewer Physician/ Provider

Privacy and Security Services (Future State) JURISDICTIONAL INFOSTRUCTURE Registries Data & Services Client Registry Ancillary Data & Services Outbreak Management PHS Reporting EHR Data & Services Shared Health Record Drug Information Diagnostic Imaging Data Warehouse Laboratory Provider Registry Location Registry Terminology Registry HIAL Common Services Business Rules EHR Index Message Structures Normalisation PRIVACY AND SECURITY Rules Identity Protection Services Anonymisation Services Consent Directives Mgmt Services Identity Mgmt Services Encryption Services Longitudinal Record Services User Authentication Access Control Services Security Management Data Secure Auditing Services Common Services General Security Services Communication Bus Clinical POS Viewer System POINT OF SERVICE User Privacy Configuration Data. Digital Signature Services Health Information

White Paper on Information Governance • Early 2007 release - for feedback & comment • Identifies the areas for dialogue • Governance is not new; how information flows with an i. EHR is new • Governance will require variety of approaches • Where will responsibility for governance management reside?

Areas for Dialogue • • • Trust & Accountability Privacy Rights of Patients Assessment & Compliance Quality in Healthcare Technical Safeguards Rights of healthcare providers & communities of interest …with subsequent sections on legal, ethical and professional requirements, the current mechanisms at play, and examples of other industry’s efforts to come to grips with similar issues

Challenges

Journey far from complete Several Hurdles Will Need To Be Overcome To Complete The Existing Mandate Bring key stakeholders – public and clinicians in particular – on board “We need people pounding the table for this. ” – Regional CIO Securing the right mix of leadership at all levels Front-line implementation, Urgency behind building a case for including standards implementation, business ongoing support process redesign, and clinician adoption “We need additional champions beyond Infoway. ” – Deputy Minister “Until you get a reasonable level of critical mass, we are years away from measuring systemic benefits to the system. This is the problem for elected officials, who want to see the benefits quickly. ” – Regional CIO “Clinicians will not be willing to adopt the technology if it makes their life harder. ” – Clinician

Academe as stakeholders • Teaching, research, service delivery - and thought leader • Teaching - UG, PG, CPD • Research: ‘secondary use’ as discussed • Service delivery: as discussed • Thought leader

Academic/Learning Advisory Group SKILLS KNOWLEDGE • Role: provide expert input to one of 4 key elements of the End User Strategy ATTITUDES EXPERIENCE – After D Covvy CPD/KT

Challenges for Teaching Institutions • Technology itself (50% of FP teaching units) • Strategic alliances with institutions (hospitals, LHINs, RHAs) where care is delivered • Theme of ‘EHR solutions as tool’, cross-cutting all training, rather than ‘stand-alone’ or ‘add-on’ to curriculum • ‘Walk the talk’ - clinically, and technologically

The Promise • Increased patient participation in care • Well managed chronic illness • Improved access to care in remote and rural communities • Less adverse drug events • Better therapeutic outcomes • Better prescribing practices • Reduced wait times

Thank You! www. infoway-inforoute. ca