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National eHealth Initiatives Effecting Change for Better Outcomes

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HINZ | Presentation by Trevor Hodge | Senior Vice President, Canada Health Infoway | October 30, 2007

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National eHealth Initiatives Effecting Change for Better Outcomes

  1. 1. National eHealth Initiatives Effecting Change for Better Outcomes HINZ | Presentation by Trevor Hodge | Senior Vice President, Canada Health Infoway | October 30, 2007
  2. 2. Agenda <ul><li>National eHealth Initiatives </li></ul><ul><li>The Change Equation </li></ul><ul><li>The Canadian Experience </li></ul><ul><li>Effecting Change for Better Outcomes </li></ul>
  3. 3. National eHealth Initiatives Where are they Happening <ul><li>Europe </li></ul><ul><li>Austria </li></ul><ul><li>Belgium </li></ul><ul><li>Denmark </li></ul><ul><li>Finland </li></ul><ul><li>France </li></ul><ul><li>Germany </li></ul><ul><li>Netherlands </li></ul><ul><li>Norway </li></ul><ul><li>Sweden </li></ul><ul><li>United Kingdom </li></ul><ul><li>Asia Pacific </li></ul><ul><li>Australia </li></ul><ul><li>New Zealand </li></ul><ul><li>Singapore </li></ul><ul><li>South America </li></ul><ul><li>Brazil </li></ul><ul><li>North America </li></ul><ul><li>Canada </li></ul><ul><li>USA </li></ul><ul><li>Mexico </li></ul><ul><li>Middle East </li></ul><ul><li>UAE </li></ul>… . In addition there are 40 more countries ramping up national ehealth initiatives. We see momentum building significantly over the next 5 years! [1] .   Kay M, Olesen-Gratama van Andel M, Klint K, Tristam C.  Building Foundations for e-Health: progress of member states.  ISBN 92 4 159504 3  WHO 2006.  339p. [2] .   The logframe handbook: a logical framework approach to project cycle management. Washington DC, World Bank, 2000. [3] .   E-Strategies monitoring and evaluation toolkit. Washington DC, World Bank, 2005 (INF/GICT V6.1B).  http://siteresources.worldbank.org/INTEDEVELOPMENT/Resources/estrategiesToolkit_Jan2005.pdf.  
  4. 4. National eHealth Initiatives Who are the Leaders On the world stage both New Zealand and Canada are definitely seen as leaders in ehealth!
  5. 5. National eHealth Initiatives Providing Leadership is more Relevant <ul><li>Sharing Knowledge and Expertise </li></ul><ul><li>National models for health and ehealth; architecture and standards; approaches used to deploy ehealth solutions; outcomes achieved </li></ul><ul><li>Private Sector Leadership </li></ul><ul><li>Specific solutions: ex. Orion, HealthLink, IntraHealth, HealthPhone </li></ul><ul><li>New product development: ex. middleware (HIAL), chronic disease management, wait times, home monitoring, patient solutions </li></ul><ul><li>Global eHealth Collaboration </li></ul><ul><li>public, private and NGO sectors </li></ul><ul><li>the Commonwealth </li></ul><ul><li>Globally </li></ul>For us, leadership is about …. learning from each other…. and b ringing together developing and developed nations to strengthen and accelerate the ehealth agenda worldwide
  6. 6. National eHealth Initiatives Two Basic Flavours <ul><li>Telehealth (Telemedicine) </li></ul><ul><ul><li>Has been in play for about 15 years </li></ul></ul><ul><ul><li>Affordable; mature technology; easy to implement; but, poor interoperability </li></ul></ul><ul><ul><li>Currently a focus in developing nations </li></ul></ul><ul><ul><li>For example, India is rapidly deploying telemedicine services both within the country and also to African nations. Within the next 5 years they will likely have the largest telemedicine network in the world </li></ul></ul>1
  7. 7. National eHealth Initiatives Two Basic Flavours <ul><ul><li>Electronic health record </li></ul></ul><ul><ul><li>Has been in play for about 10 years; major increase in activity in the last 5 years </li></ul></ul><ul><ul><li>Expensive; less mature technologies; difficult to implement; good (not excellent) interoperability </li></ul></ul><ul><ul><li>Currently a focus in developed nations </li></ul></ul><ul><ul><li>For example, the NHS in England is implementing an electronic health record for its 52 million residents </li></ul></ul>2
  8. 8. National eHealth Initiatives Electronic Health Records – the Vision An electronic health record is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. … . To date the global focus has been on automating paper records, a first step in modernizing healthcare
  9. 9. National eHealth Initiatives Electronic Health Records – the Promise <ul><li>Increased patient participation in care </li></ul><ul><li>Well-managed chronic illness </li></ul><ul><li>Improved access to care in remote and rural communities </li></ul><ul><li>Fewer adverse drug events </li></ul><ul><li>Better prescribing practices </li></ul><ul><li>Reduction in duplicate or unnecessary tests </li></ul><ul><li>Reduced wait times </li></ul><ul><li>Saving lives </li></ul>… . A utomating paper records, with a “Generation 2 EHR” …. is a long way from fulfilling the promise
  10. 10. National eHealth Initiatives Electronic Health Records – the Technologies Enablers The Foundation Generation 1 Functionality and Value Chain Optimization Includes investments to support project management, user-adoption, change management, knowledge transfer, standards and benefits evaluation, representing 30% of program investments overall GARTNER Generation Model The Documenter Generation 2 The Helper Generation 3 The Mentor Generation 4
  11. 11. Gartner “Hype” Cycle Visibility Technology Trigger Peak of Inflated Expectation Trough of Disillusionment Slope of Enlightenment Plateau of Productivity Maturity
  12. 12. National eHealth Initiatives Electronic Health Records – 2 Starting Points <ul><li>Physician Office Centric </li></ul><ul><ul><li>Leverage a high level of physician office system automation </li></ul></ul><ul><ul><li>Provide electronic diagnostic data (e.g. laboratory) to physicians through their EMR </li></ul></ul><ul><ul><li>Through point to point custom interfaces </li></ul></ul><ul><ul><li>Examples – Denmark, Netherlands, New Zealand </li></ul></ul>1 Lab Radiology Hospital GP Specialist
  13. 13. National eHealth Initiatives Electronic Health Records – 2 Starting Points <ul><li>Hospital Centric </li></ul><ul><ul><li>Leverage a high level of hospital system automation </li></ul></ul><ul><ul><li>Provide electronic diagnostic data to clinicians through their hospital information system </li></ul></ul><ul><ul><li>Point to point custom interfaces </li></ul></ul><ul><ul><li>Examples – USA, Canada </li></ul></ul>2 Lab GP Pharmacy Hospital Hospital
  14. 14. National eHealth Initiatives Electronic Health Records – Why was North America Different?
  15. 15. National eHealth Initiatives Electronic Health Records – The Evolution From Data Exchange To Data Sharing … . Data exchange works well up to a point, then it becomes too expensive to maintain and impossible to scale nationally
  16. 16. National eHealth Initiatives Electronic Health Records – The Evolution … . Regardless of the starting point or the path being currently taken we are all striving to reach the same end point …… an interoperable electronic health record
  17. 17. National eHealth Initiatives Electronic Health Records – the Evolution … . The evolution to an interoperable electronic health record is a major exercise in CHANGE
  18. 18. National eHealth Initiatives The Steps to Manage Change Kotter “ Leading Change ” Harvard Business Review
  19. 19. National eHealth Initiatives The Change Tools Christensen et al “ Tools of Cooperation and Change ” Harvard Business Review <ul><li>Power Tools </li></ul><ul><li>No agreement on what is required or how to do it - financial incentives, nurturing, persuasion, coercion, threat, controls </li></ul><ul><li>Leadership Tools </li></ul><ul><li>Agreement on what’s wanted, but not on how to do it - common vision, charisma, salesmanship, role modeling, negotiation </li></ul><ul><li>Management Tools </li></ul><ul><li>Agreement on how to do things but not on what is needed – governance, planning, training, standard operating procedures and measurement systems </li></ul><ul><li>Culture Tools </li></ul><ul><li>Agreement on both what is needed and how to do it – strategic planning, democracy, tradition, strong culture, self management </li></ul>
  20. 20. Advancing eHealth in Canada has been all about CHANGE
  21. 21. A Quick Snapshot Of Canada
  22. 39. Canada is a Large Country <ul><li>Geographic Size </li></ul><ul><li>2 nd largest country in the world – 10M km 2 </li></ul><ul><li>Six time zones </li></ul><ul><li>7% of worlds renewable fresh water supply </li></ul><ul><li>Governance </li></ul><ul><li>Federal, 10 provincial and 3 territorial governments </li></ul><ul><li>British Parliamentary system </li></ul><ul><li>A Commonwealth nation </li></ul>
  23. 40. Canada has a Small Population <ul><li>Population Size and Location </li></ul><ul><li>32.6 million people - 3.3/km 2 - among the lowest population densities in world </li></ul><ul><li>76% urban; 24% rural </li></ul><ul><li>Most live within 400km of the US border </li></ul><ul><li>Ethnically Diverse </li></ul><ul><li>British Isles: 28% </li></ul><ul><li>French: 23% </li></ul><ul><li>Other European:15% </li></ul><ul><li>Non-European: 6% </li></ul><ul><li>Mixed heritage: 25% </li></ul><ul><li>Aboriginal: 3% </li></ul>
  24. 41. Canada is Connected <ul><li>Internet Usage </li></ul><ul><li>68% of Canadians use the internet (2005) </li></ul><ul><ul><li>91% for email </li></ul></ul><ul><ul><li>65% weather, travel </li></ul></ul><ul><ul><li>62% news, sports </li></ul></ul><ul><ul><li>55% banking, pay bills </li></ul></ul><ul><li>Broadband Availability </li></ul><ul><li>Greatest broadband penetration in G7 </li></ul><ul><li>76% of households using the internet in Canada have high speed connectivity and 24% use low speed dial-up options (2005) </li></ul>
  25. 42. Healthcare in Canada is Universally Available <ul><li>Cost </li></ul><ul><li>$148 Billion business </li></ul><ul><li>10.4% of GDP </li></ul><ul><li>65% of costs for hospitals, physicians and drugs </li></ul><ul><li>Financing </li></ul><ul><li>70% public funding </li></ul><ul><li>30% private funding, primarily for drugs, dental and co-pay services </li></ul><ul><li>Most privately provided healthcare services (e.g. physicians, laboratories, diagnostic imaging) are publicly funded </li></ul>
  26. 43. Governance through Shared Accountability <ul><li>Governance </li></ul><ul><li>Federal government sets and administers national principles </li></ul><ul><li>13 provincial/territorial governments plan, finance, manage, evaluate health services </li></ul><ul><li>100+ health regions coordinate care delivery over a set geographical area </li></ul><ul><li>900+ hospitals manage care </li></ul><ul><li>Approximately 400,000 healthcare professionals deliver care </li></ul>
  27. 44. Healthcare Drivers <ul><li>Pressure on the Health System </li></ul><ul><li>Canada's population is aging fast </li></ul><ul><li>By 2011, an estimated 1.3 million Canadians will be over the age of 80 </li></ul><ul><li>Senior citizens will outnumber children in about a decade </li></ul><ul><li>Health of baby boomers is declining </li></ul><ul><li>Healthcare spending is increasing </li></ul><ul><li>Wait times are a major issue </li></ul><ul><li>Political debates over private sector role in healthcare delivery </li></ul>
  28. 45. Managing Information in This Complexity
  29. 46. … .. Is All About Change Our Model for Applying Change to eHealth … . In Canada we have undergone a major change in the way that ehealth initiatives are implemented across the country Change Model & Tools LEADERSHIP <ul><li>Commitment </li></ul><ul><li>Policy </li></ul><ul><li>Funding </li></ul><ul><li>Governance </li></ul><ul><li>Vision </li></ul><ul><li>Goal </li></ul>APPROACH <ul><li>Engagement approach </li></ul><ul><li>Investment model </li></ul><ul><li>Priorities and Plans </li></ul><ul><li>Architecture </li></ul><ul><li>Standards </li></ul>MANAGEMENT <ul><li>Project management </li></ul><ul><li>Procurement </li></ul><ul><li>Human resources </li></ul><ul><li>Solution deployment </li></ul><ul><li>Change management </li></ul><ul><li>Privacy </li></ul><ul><li>Communication </li></ul>OUTCOMES <ul><li>System quality </li></ul><ul><li>Information quality </li></ul><ul><li>Service quality </li></ul><ul><li>Clinician use </li></ul><ul><li>Clinician satisfaction </li></ul><ul><li>Net benefits </li></ul>
  30. 47. Leadership
  31. 48. Leadership – Building Commitment <ul><li>1990’s – “ everyone was doing their own thing ” </li></ul><ul><li>1997 - Alberta we//net the first provincial ehealth network </li></ul><ul><li>1998 – Federal Minister of Health Canada Health Infoway Report </li></ul><ul><li>2000 – Pan-Canadian Health Infostructure Tactical Plan </li></ul><ul><li>2000 – National Health Accord </li></ul><ul><ul><ul><ul><li>$500 million for electronic health records </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Canada Health Infoway </li></ul></ul></ul></ul>… . acceleration of the ehealth agenda in Canada did not occur until all the 14 Governments agreed that it was a national priority
  32. 49. Leadership – Policy <ul><li>The 2000 Health Accord made health information technology a joint government policy direction </li></ul><ul><li>Provinces made ehealth a formal policy imperative </li></ul><ul><ul><ul><li>By 2008 every Albertan will have an electronic health record – then Premier Hon. Ralph Klein </li></ul></ul></ul><ul><li>The Federal Government has linked increases in ehealth funding to major policy initiatives over the past 7 years </li></ul>… . An explicit link to government policy has been critical to trigger the continued flow of funding for ehealth initiatives
  33. 50. Leadership - Funding <ul><li>Since 2001 the Federal Government has provided $1.6 B in capitalization </li></ul><ul><ul><li>$500M: Electronic Health Records (2001) </li></ul></ul><ul><ul><li>$600M: Electronic Health Records and Telehealth (2003) </li></ul></ul><ul><ul><li>$100M: Health Surveillance Systems (2004) </li></ul></ul><ul><ul><li>$400M: Electronic Health Records and Wait Time Systems (2007) </li></ul></ul><ul><li>Spans two different federal government regimes </li></ul><ul><li>The funding commitment from the provincial and territorial governments in a co-investment model took longer </li></ul><ul><li>The total spend today by all governments is over $3 B </li></ul>… . Without $1.6 B in new federal government funding everyone would have continued to do their own thing
  34. 51. Leadership – Governance <ul><li>The Federal Government = accountable spend </li></ul><ul><li>Provinces and Territories = shared governance </li></ul><ul><li>… . the result was …. </li></ul><ul><li>Canada Health Infoway </li></ul><ul><li>Independent, not-for-profit corporation </li></ul><ul><li>Equally accountable to 14 F/P/T governments; the Members </li></ul><ul><li>Independent Board of Directors appointed by the Members </li></ul><ul><ul><li>mix of public and private sector representatives </li></ul></ul><ul><ul><li>public sector representatives are regionally focused </li></ul></ul><ul><ul><li>private sector representatives are from finance, information technology and clinical backgrounds </li></ul></ul>… . The shared governance model has been key to ensuring the ongoing agreement and collaboration among all 14 governments “ If you’re looking for a template for an extremely successful national initiative, you’d look to Infoway .” Deputy Minister of Health
  35. 52. Leadership – Vision and Goal <ul><li>Vision </li></ul><ul><li>A high-quality, sustainable and effective Canadian healthcare 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 </li></ul><ul><li>Goal </li></ul><ul><li>By 2010 every province and territory will benefit from new ehealth systems that will modernize their healthcare system. </li></ul><ul><li>By 2010, 50 percent of Canadians will have an electronic health record </li></ul>… . The 50% goal statement has been the call to action for the country and continues to “focus the effort”
  36. 53. Approach
  37. 54. Approach – Investment Model Funder Intervener Developer <ul><li>Invests with Partners </li></ul><ul><li>Involved in project planning </li></ul><ul><li>Monitors progress of projects and quality of deliverables </li></ul><ul><ul><li>► Gated funding approach allows management of risk </li></ul></ul>“ Work alongside & take over if needed” <ul><li>Invests with partner </li></ul><ul><li>Involved with partner in planning, and execution </li></ul><ul><li>Ensures success through ongoing, active participation or intervention when something goes wrong </li></ul>“ Fund & ignore” <ul><li>Grants funding </li></ul><ul><li>Is uninvolved in project execution </li></ul><ul><li>Checks on status of phase-based deliverables </li></ul>Strategic Investor Infoway also provides leadership, expertise and pan Canadian services to support EHR deployment across Canada .…. The strategic investor model is at the heart of ensuring an accountable health IT spend – a very different funding approach “ Lead, invest, advise & monitor” “ Write code & build modules” <ul><li>Invests independently </li></ul><ul><li>Engages potential partners in needs analysis and testing </li></ul><ul><li>Aims for speed and success by working without a partner or on behalf of a future partner </li></ul>
  38. 55. Approach – Investment Model
  39. 56. Approach – Investment Model
  40. 57. Approach – Investment Model $1,2 B in approved projects to date; 150 active projects with 20% in planning and 80% in implementation/adoption .…. A standard investment model reduced any debate about the total cost of a project and which costs were eligible for reimbursement
  41. 58. Approach – Investment Model .…. Gated Funding and 50% of the investment for system adoption introduced a new level of accountability for health IT projects Implementation Adoption 30% on Implementation gates 20% on contract signing 50% on adoption gates Approved Project Completed Project Infoway co-invests with jurisdictions at 75:25 of eligible project capital costs. Jurisdictions pay for the operating costs
  42. 59. Approach – Engagement Approach Partnership built on Collaboration <ul><li>Shared governance – represented by the federal, provincial and territorial governments </li></ul><ul><li>Pan-Canadian approach – a common national direction, leveraging investments and replicating solutions but with local flexibility </li></ul><ul><li>Collaboration – working together with jurisdictions to plan and implement a pan-Canadian health infostructure </li></ul><ul><li>Sharing of cost and risk – co-investing with jurisdictions in the successful modernization of health information technology across Canada </li></ul><ul><li>Benefits driven – clearly demonstrating what was achieved for the investment </li></ul>.…. The collaboration model we deployed was founded on strong working relationships built up over 20 years
  43. 60. Approach – Engagement Approach The Infoway Team .…. The culture of collaboration requires continual interaction and communication directed toward achieving a successful outcome ….. spiced with a little bit of humour
  44. 61. Approach – Engagement Approach …. But We Found it was a Rough World out There! Show me the money!! Why is it taking so long?!? What are you doing?!
  45. 62. .…. When we realized they weren’t really up on Monty Python we turned to football …. The North American variety Approach – Engagement Approach The Infoway Team
  46. 63. .…. So now its all about scoring touchdowns and celebrating success - together! Approach – Engagement Approach A Collaborative Culture
  47. 64. Approach – Priorities & Plans <ul><li>3-Year Jurisdiction Plans </li></ul><ul><li>Infoway wanted a commitment to the national ehealth agenda </li></ul><ul><li>The jurisdictions wanted an Infoway commitment to future funding, knowing that Infoway did not have all the $ to complete the job </li></ul><ul><li>Rolling 3-year plans resulted in </li></ul><ul><ul><li>Agreement on a high-level plan to implement an EHR </li></ul></ul><ul><ul><li>Commitment of “notional funding” if plan is implemented </li></ul></ul><ul><ul><li>Identification of the jurisdictions share of total funding to get approved from their Treasury </li></ul></ul>.…. Three-Year planning focused the priorities, reduced financing uncertainty and placed a competitive pressure on Treasury Boards to finance their share – “ Snooze you Lose! ”
  48. 65. Approach – Priorities & Plans <ul><li>Vision 2015 </li></ul><ul><li>The country wanted to agree on priorities beyond just the implementation of an electronic health record </li></ul>.…. The 2015 Vision has bought agreement as to what the next steps will be in Canada, beyond electronic health records
  49. 66. Approach – Architecture <ul><li>Common architecture accepted by jurisdictions and vendors </li></ul><ul><li>links local clinical systems with jurisdiction and regional registries and repositories using a data sharing approach </li></ul><ul><li>serves as a reference model for Infoway investments </li></ul><ul><li>Freely available on the Infoway website </li></ul><ul><li>http://www.infoway-inforoute.ca </li></ul>.…. A single architecture for the country was the first “rallying point” that Infoway used to get all the jurisdictions to agree on implementing a pan-Canadian health infostructure
  50. 67. JURISDICTIONAL INFOSTRUCTURE POINT OF SERVICE Terminology Repository Ancillary Data & Services Registries Data & Services EHR Data & Services Data Warehouse Immunization Management PHS Reporting Shared Health Record Drug Information Diagnostic Imaging Laboratory Health Information Hospital, LTC, CCC, EPR Physician Office EMR EHR Viewer Physician/ Provider Business Rules EHR Index Message Structures Normalization Rules Security Mgmt Data Privacy Data Configuration Physician/ Provider Physician/ Provider Lab System (LIS) Lab Clinician Radiology Center PACS/RIS Radiologist Pharmacy System Pharmacist Public Health Services Public Health Provider Longitudinal Record Services HIAL Communication Bus Common Services Client Registry Provider Registry Location Registry Approach - Architecture
  51. 68. Approach – Architecture EHRS EHRS EHRS EHRS EHRS EHRS EHRS EHRS EHRS EHRS .…. Linked jurisdiction networks – a distributed, message-based, peer-to-peer network of ehealth systems across Caanda
  52. 69. <ul><li>Infoway Standards Collaborative ; a single national group for standards development, support and maintenance </li></ul><ul><li>Standards necessary to allow data and document sharing – for example, HL7 CCOW, HL7 v2.4, HL7 v3, HL7 CDA </li></ul><ul><li>International propagation of the standards developed in Canada </li></ul><ul><li>Infoway investments require standards compliance </li></ul>Messaging HL7 and DICOM are the primary standards for the electronic exchange of clinical and administrative data Terminologies LOINC and SNOMED CT are the primary terminologies for coding of clinical information Interoperability Profiles Define functional behaviours of components of the EHR system .…. Consolidating the ehealth standards function into a single organization involving all stakeholders has accelerated this agenda Approach – Standards Ensuring Interoperability and Privacy
  53. 70. Approach – Standards The Global Standoff .…. The Standards Challenge …. how do we get the USA and the major POS vendors to support the standards being implemented in the rest of the world … the next item on our Change Agenda HL7 v3 HL7 v2.x
  54. 71. Management
  55. 72.   Registries  Diagnostic Imaging  Drug Info Systems  Lab Info Systems  Telehealth  Interoperable EHR  Public Health Surveillance  Innovation & Adoption  Number of Projects                                                                                Management – Program Activity Results = Momentum  1 1
  56. 73. Management - Progress Across Canada .…. Public accountability regarding progress toward the national goal has placed pressure on jurisdictions to accelerate their efforts Forecasted Jurisdictional progress to March 31, 2008
  57. 74. Management – Project Management <ul><li>Large, Complex, Interdependent Projects </li></ul><ul><li>Project sizing and costing </li></ul><ul><li>Project management discipline </li></ul><ul><li>Collaborative Risk Management </li></ul><ul><li>Standard risk assessment approach </li></ul><ul><li>Project, jurisdiction and national risk </li></ul><ul><li>Instil a culture of risk reporting/mitigation </li></ul><ul><li>Quality Management </li></ul><ul><li>Processes, Tools -> Consistent deliverables best practices and lessons learned </li></ul><ul><li>Conformance testing and certification </li></ul>.…. Instilling a best practice project management discipline is a major and ongoing challenge through implementation
  58. 75. Management – Procurement Aggregated Demand and Preferred Pricing Agreements .…. A major change in the way ehealth procurements were conducted in Canada resulting in significant financial benefits
  59. 76. Management – Human Resources <ul><li>Capacity </li></ul><ul><li>2006 Conference Board of Canada study - 17,000 new IT jobs </li></ul><ul><li>Tightening for some key resources – project managers. architects, change personnel </li></ul><ul><li>Tightening in some geographies </li></ul><ul><li>Increased use of near-shore and off-shore resources starting to occur </li></ul><ul><li>Capability </li></ul><ul><li>Increased use of private sector resources </li></ul><ul><li>Experience and capability of some resource types is mixed </li></ul>.…. Implementing multiple, large, complex, interdependent ehealth projects in a fairly short time frame is challenging most jurisdictions’ capability to deliver successfully
  60. 77. Management – EHR Solution Deployment Prime Vendors <ul><li>24 product and services vendors are dominating the investments to date </li></ul><ul><li>54% (13) are US vendors; 25% (6) Canadian; the remainder 21% (5) are from Belgium, Bermuda, Japan, Netherlands and New Zealand </li></ul><ul><li>75% publicly traded companies and 25% are privately held </li></ul>.…. Creating a culture that supports replicated COTS solutions as a way to reduce risk and cost has been a major change
  61. 78. Management – Change Management Primary Care Practices with Advanced Information Capacity * Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care. Percent reporting seven or more out of 14 functions* Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. 72 8 32 59 87 83 19 0 25 50 75 100 AUS CAN GER NETH NZ UK US
  62. 79. Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Management – Change Management The Use of Teams and non-Physicians for the Chronically Ill 50 29 81 30 49 32 32 Yes Practice routinely uses clinicians other than doctors to: Practice routinely uses multidisciplinary teams: 39 70 51 33 56 22 38 Provide primary care services 73 UK 62 GER 57 NZ 36 46 25 38 Help manage patients with multiple chronic diseases US NETH CAN AUS
  63. 80. Management – Change Management Availability of Outcomes or Performance Data Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. .…. Canada lags significantly in primary care …. this requires a major transformation effort, both clinical and administrative, that cannot be solved simply by implementing information technology 43 78 54 37 71 24 36 Patients’ clinical outcomes 89 UK 27 GER 33 NZ 48 16 11 29 Surveys of patient satisfaction and experiences US NETH CAN AUS Percent reporting yes:
  64. 81. Management – Change Management At a National and Jurisdiction Level … . Clinician leadership is now happening with excellent support from the professional associations …. but we have a long way to go <ul><li>Clinician Leadership </li></ul><ul><li>The active engagement of colleges and professionals associations in promoting the ehealth agenda </li></ul><ul><li>Funding regional peer to peer networks to champion and support electronic health record implementation </li></ul><ul><li>Invest in up to 75 demonstration sites, including documented case studies across Canada where users can see the electronic health record in use and interact with the clinicians using it </li></ul><ul><li>Education and Training </li></ul><ul><li>Work with universities and colleges to develop new curricula to advance the education and training of clinicians in ehealth </li></ul>
  65. 82. Management – Change Management At the Local Level within a Project … . In general, c hange management knowhow, experience, best practices and learnings are currently not at a level that can support the amount of change required – more focus needed <ul><li>15% to 30% of a project cost </li></ul><ul><li>Clinician led </li></ul><ul><ul><li>Understand clinician motivations </li></ul></ul><ul><ul><li>Manage expectations </li></ul></ul><ul><ul><li>Support workflow enhancements </li></ul></ul><ul><ul><li>Different training approaches </li></ul></ul><ul><ul><li>1:1 peer support </li></ul></ul><ul><ul><li>Open, transparent communication </li></ul></ul><ul><li>Coordinated Change Management directed at providing change management services to clinicians across projects </li></ul>
  66. 83. Management – Privacy Canadians’ Views of the Electronic Health Record <ul><li>85 per cent support electronic records </li></ul><ul><li>Canadians believe electronic health records will enable healthcare providers to deliver better quality care </li></ul>* EKOS survey <ul><li>Increase effectiveness for doctors 85 per cent </li></ul><ul><li>Increase effectiveness for pharmacists 83 per cent </li></ul><ul><li>Increase effectiveness for nurses, patients 81 per cent </li></ul><ul><li>and the healthcare system in general </li></ul>.…. We regularly survey public attitudes towards electronic health records and privacy
  67. 84. Management – Privacy Canadians’ Views of the Electronic Health Record <ul><li>Canadians want it to be a serious criminal offence for anyone to access the record without proper authorization </li></ul><ul><li>Canadians want to be able to access, verify and report corrections to their record at any time </li></ul><ul><li>Canadians want there to be a clear and accessible privacy policy </li></ul><ul><li>Canadians feel it is important that the system is supported by their doctor </li></ul>* EKOS survey 66 per cent 57 per cent 59 per cent 57 per cent .…. Public concerns about privacy and electronic health records have decreased significantly over the past 10 years
  69. 86. Management – Privacy Infoway’s Approach to Privacy <ul><li>Require every project that involves personal health information to conduct a privacy impact assessment (PIA) </li></ul><ul><li>PIA to be approved by jurisdiction privacy commissioners </li></ul><ul><li>Provided a privacy and security architecture </li></ul><ul><li>Contribute to legislative reviews </li></ul><ul><li>Encourage action in relation to governance of health records </li></ul><ul><li>Continue to monitor public attitudes </li></ul><ul><li>Be transparent with privacy commissioners and the public </li></ul>.…. Having trusted parties like the privacy commissioners actively involved has been extremely helpful
  70. 87. <ul><li>Multi-faceted audience segments </li></ul><ul><li>Within the health care industry </li></ul><ul><li>The general public </li></ul><ul><ul><li>Until recently, our focus was on first group (trade journals, conferences, ehealth showcase, website, e-newsletters) </li></ul></ul><ul><ul><li>As implementation occurs, promoting success stories takes on increasing prominence </li></ul></ul><ul><ul><li>This facilitates greater pursuit of mainstream audiences who ultimately influence first group (newspaper, radio, TV) </li></ul></ul><ul><li>Media momentum </li></ul>Management – Communication 2005 100 media mentions (predominantly health media) 2006 300 media mentions (50-50 split health/ mainstream media) 2007 (Q1) 400+ media mentions (incr. national print media and radio 1 every 3 days 1 every day 4 every day
  71. 88. Outcomes
  72. 89. What Constitutes Success The Infoway Mission
  73. 90. Outcomes Framework User satisfaction Competency User satisfaction Ease of use Use Use Behavior/Pattern Self reported use Intention to use Net benefits <ul><li>Access </li></ul><ul><li>Ability of patients/providers to access services </li></ul><ul><li>Patient and caregiver participation </li></ul><ul><li>Productivity </li></ul><ul><li>Efficiency </li></ul><ul><li>Care coordination </li></ul><ul><li>Net cost </li></ul>ORGANIZATIONAL & CONTEXT FACTORS: STRATEGY, CULTURE & BUSINESS PROCESS – OUT OF SCOPE <ul><li>Quality </li></ul><ul><li>Patient safety </li></ul><ul><li>Appropriateness/effectiveness </li></ul><ul><li>Health outcomes </li></ul>Service quality Responsiveness Information quality Content Availability System quality Functionality Performance Security Based on the Delone & McLean IS Success Model
  74. 91. Outcomes – Top Down View <ul><li>Booz Allen Hamilton (March 2005) </li></ul><ul><li>Used the CITL costing model </li></ul><ul><li>Cost of a pan-Canadian EHR = $10 Billion </li></ul><ul><ul><li>Include physician office systems, hospital CPOE, long term care, public health and mental health point of service systems, as well as the Infoway EHR infostructure </li></ul></ul><ul><li>Benefits are realized from 3 major sources = $3 Billion/year </li></ul><ul><ul><li>Reduction in adverse drug events </li></ul></ul><ul><ul><li>Reduction in duplicate laboratory tests </li></ul></ul><ul><ul><li>Reduction in duplicate radiology tests </li></ul></ul><ul><li>The Return on Investment is $40 Billion over 20 years </li></ul>.…. The Booz Allen study provided a great starting point for understanding the total cost and the benefits to be realized
  75. 92. Outcomes – Bottom-up View <ul><li>Process </li></ul><ul><li>Framework developed & validated by an Expert Panel </li></ul><ul><li>Set of 27 indicators developed by Subject Matter Experts </li></ul><ul><li>Measure each of the 27 indicators across 2-4 projects each </li></ul><ul><li>Evaluations initiated and will increase over next 24 months </li></ul><ul><li>Evaluations Completed to Date </li></ul><ul><li>Drug Information Systems </li></ul><ul><ul><li>ON - Drug Profile Viewer System survey </li></ul></ul><ul><li>Diagnostic Imaging </li></ul><ul><ul><li>BC - Report Turnaround Time study </li></ul></ul><ul><ul><li>ON, NS and BC - PACS Opinion survey </li></ul></ul><ul><ul><li>ON and BC - Cost per Exam (pre vs. post-PACS) </li></ul></ul><ul><ul><li>BC - Impact of PACS on neurosurgical diagnoses in the ER of a community hospital </li></ul></ul>.…. Infoway has partnered with the Canadian Institutes for Health Research to assist with the benefit evaluation studies
  76. 93. Outcomes – Bottom-up View <ul><li>Indicator Examples </li></ul><ul><li>Diagnostic Imaging Systems </li></ul><ul><li>Efficiency improvements for staff (radiologists and technologists) </li></ul><ul><li>Quality benefits of timely service delivery (with improved turnaround time) </li></ul><ul><li>Availability of previous DI results decreasing duplicate exams </li></ul><ul><li>Sharing test results with offsite specialists to reduce patient transfers </li></ul><ul><li>Drug Information Systems </li></ul><ul><li>Efficiency improvement for patient assessment </li></ul><ul><li>Efficiency improvement for pharmacists & prescribing physicians </li></ul><ul><li>Medication error avoidance by identifying duplications/interactions </li></ul><ul><li>Medication error avoidance with e-prescribing completeness/legibility </li></ul><ul><li>Medication error avoidance with physician alerts when e-prescribing </li></ul><ul><li>Reduction in adverse drug events (ADEs) </li></ul>.…. See Canada Health Infoway “ Benefits Evaluation Indicators Technical Report ” at http://www.infoway-inforoute.ca
  77. 94. Key Findings: PACS Evaluations <ul><li>Improvement in productivity </li></ul><ul><li>After one year of implementation, BC’s Fraser Health Authority had a 17% reduction in operating cost per exam in a PACS environment in comparison to a pure film environment, ($37/exam vs $44/exam) </li></ul><ul><li>87% of Radiologists and 73% of Referring Physicians indicated that PACS has increased their reporting and consultation efficiency </li></ul><ul><li>Across BC’s Interior Health Authority project sites (n=22), average Report Turn Around Time decreased by 41% </li></ul>
  78. 95. Key Findings: ON Drug Viewer Evaluation Improvements in Quality, Productivity and Satisfaction
  79. 96. Challenges
  80. 97. Tough times are ahead
  81. 98. Planning implementation <ul><li>Possible consequences: </li></ul><ul><ul><li>Blown budgets </li></ul></ul><ul><ul><li>Extended timelines </li></ul></ul><ul><ul><li>Scope creep </li></ul></ul><ul><ul><li>Build and no one shows up </li></ul></ul><ul><ul><li>Solutions not interoperable </li></ul></ul><ul><ul><li>Quality and benefits not realized </li></ul></ul>
  82. 99. Other Hurdles to Overcome <ul><li>“ If you think that an electronic health record is an essential backbone of any modern health care system, then [2015 is] far too long to wait.” Steven Lewis, Health Council of Canada, October 7, 2007 </li></ul><ul><li>Physician office automation </li></ul><ul><li>Remote and first nations communities </li></ul><ul><li>Jurisdictional capacity </li></ul><ul><li>Standards </li></ul><ul><li>Interoperability and vendors </li></ul><ul><li>Clinician adoption </li></ul><ul><li>Patient engagement </li></ul><ul><li>Further capitalization </li></ul><ul><li>Public impatience </li></ul>
  83. 100. And the change will continue as we increasingly try to effect bette r health outcomes
  84. 101. HINZ | Presentation by Trevor Hodge | Senior Vice President, Canada Health Infoway | October 30, 2007 [email_address] http://www.infoway-inforoute.ca/ Thank you!