Canada Health Infoway and the Electronic Health Record

Impacts & OpportunitiesRobert (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 ExpectationsWhat 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 EHRFor Every …. …. in Canada

1000 hospital admissions 75 people will suffer an Adverse Event

1000 patients with an ambulatory encounter 20 people will suffer a serious Adverse Drug Event

1000 patients discharged from hospital 90 people will suffer a serious Adverse Drug Event with the drugs received on discharge

1000 Laboratory tests performed 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 300-400 are not screened

1000 Canadians recommended for influenza protection 370-430 are not vaccinated

Source: CIHI; Sanofi-Aventis; Statistics Canada;

OECD; WHO; Centre for Chronic Disease

Prevention

Resource pressures intensifying Growing Need for Health Information Management

Providers, managers, patients, public are demanding more

IT has potential to enable solutions to address pressures

Care settings areshifting

Population is aging

Consumerism isgrowing

Resource pressures

greater

Yet Canada Invests Less in Healthcare IT than Other Information-intensive Businesses

* 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

Annual IT spend* Percent of total budgets/revenues

2.9

3.4

4.0

4.54.7

5.4

1.5

Range of HC IT spend of Canadian jurisdictions

2.0

• 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

• Additionally, investments have often been fragmented and one-off leading to duplication of efforts and need for reinvestments

Education US HC providers**

UK health-care***

Professional services

US banking/ financial services

Calgary Regional Health Authority

9

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.

EHR Defined

6

10

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 ($500m), 2003 ($600m) and 2004 ($100m)• 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 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.

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*

Public Health Surveillance

$100 million

Telehealth$120 million

Innovation and Adoption – $60 million*

Chronic Disease

Primary Care

Cancer

Patient Safety

Wait Times

Mental Health

Laboratory Systems$150 million

Diagnostic Imaging $310 million

Interoperable EHR – $175 million

Infostructure – $32 million

Registries$134 million

Drug Systems$185 million

Infoway’s Programs

Etc.

Basic

Elements

of EHR

Focus on Standards and Interoperability

•Common architecture largely accepted by jurisdictions•Revised architecture includes privacy and security•Comprehensive standards collaboration process•New Infoway Standards Collaborative

EHR Solution (EHRS)

EHR Infostructure (EHRI)

EHR ViewerPoint ofServiceApplication

Point ofServiceApplication

EHRS Locator

Registries Data &

Services

Longitudinal Record Services

HIAL

AncillaryData &

Services

EHRData &

Services

HealthInformation

Datawarehouse

EHR: Conceptual ArchitectureJURISDICTIONAL INFOSTRUCTURE

Pharmacy System

EHR Data & Services

Pharmacist

EHR Viewer

RadiologyCenterPACS/RIS

LabSystem(LIS)

Hospital,LTC, CCC,EPR

Physician/Provider

Lab ClinicianRadiologist

PhysicianOfficeEMR

Physician/Provider

Physician/Provider

Public HealthServices

Public HealthProvider

PHS Data & Services

OutbreakManagement

PHSReporting

POINT OF SERVICE

Registries Data & Services

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

DrugInformation

DiagnosticImaging

LaboratorySharedHealthRecord

SecurityManagement Data

PrivacyData Configuration

HIALCommunication Bus

Common Services

DataWarehouse

HealthInformation

Longitudinal Record Services

MessageStructures

EHRIndex

BusinessRules

NormalisationRules

EHRS EHRS EHRS EHRS EHRS EHRS EHRS

Distributed, Message-based, Peer-to-Peer Network of EHRS Systems

Electronic Health RecordsLinked Jurisdiction Networks

Progress to Date

Legend Registries Diagnostic Imaging Drug Info Systems Lab Info Systems Telehealth Interoperable EHR Public Health Surv. Innovation & AdoptionNumber of Projects

217217 active & completed projects valued at $1,133 M$1,133 M

in all 9 investment programs

217217 active & completed projects valued at $1,133 M$1,133 M

in all 9 investment programs

The 135 projects jointly developed with provinces and territories are shown. In addition, there are 82 active or completed pan-Canadian projects.

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Program Activity Summary

WEST ON QC EAST TERRITORIES

iEHR

NU

Client Reg.

DI

Drug

Laboratory

Telehealth

NT NS PE NL YKMB NBSKABBC

INV

ES

TM

EN

T P

RO

GR

AM

S

Provider Reg.

Phase 0/1 Projects

Phase 2 Projects

System in place

March 2004 = $125 M

Significant Progress in 3 Years

2005-06WEST ON QC EAST TERRITORIES

Telehealth

NU

Client Reg.

DI

Drug

Laboratory

NTNS PE NL YKMB NBSKABBC

INV

ES

TM

EN

T P

RO

GR

AM

S

Provider Reg.

Telehealth

iEHR

Public Health

WEST ON QC EAST TERRITORIES WEST ON QC EAST TERRITORIES

Telehealth

NU

Client Reg.

DI

Drug

Laboratory

NTNS PE NL YKMB NBSKABBC

INV

ES

TM

EN

T P

RO

GR

AM

S

Provider Reg.

Telehealth

iEHR

Public Health

WEST ON QC EAST TERRITORIES

9

September 2006 = $825 M

Ontario: Keeping Tabs on LabsThe 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.

PEI: Island-Wide iEHR

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,

Canada-wide Public Health Surveillance

All 14 provincial, territorial and federal governments agreed to adopt a single Public Health Surveillance solution

Alberta: netCare Alberta-boundAlberta is leveraging Capital Health’s netCare viewer for province-wide use in iEHR 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 HospitalsThe McGill - Montreal RUIS repositories  for diagnostic imaging system will be the largest in Canada. 

Nova Scotia: Farewell to Film

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.

Manitoba and New Brunswick: Telehealth Calling

Manitoba has doubled its network providing access to healthcare services to 10 northern First Nations and 7 Franco-Manitoban communities.

New Brunswick is the national leader in nurse triage call centres and is now planning to expand their telehealth network to provide tele-homecare

Newfoundland & Labrador: Province-wide eProgress

Province-wide Drug Information System underway

British Columbia: Leveraging Past Investments for an EHRBC will implement an electronic health record across the province.

Different Stages of Progress

Scarborough HospitalElectronic self-entry (by patients) of patient history in emergency department (ED) using touch-screen kiosks

Sherbourne Health Centreremote electronic records for a Health Bus serving the inner city homeless

Vancouver Island Health AuthorityEHR-based clinical decision support tools to for Mental Health & Addictions Services

British Columbia Ministry of HealthNewfoundland & Labrador’s Eastern Healthpilots for province-wide adverse events reporting, analysis and management

Sault Ste Marielink primary care providers and pharmacists to the EMR/EHR

Quebec MSSS electronic patient evaluation and service planning solutions.

Primary Health Care

Public Health Patient

Safety

Chronic Disease

CancerWait

Times

Information &

Communications

Technologies

Alberta Cancer Boardsynoptic reporting for cancer surgery will improve data collection and quality surgical management of cancer patients.

Alberta Capital/Calgary Health Regionsextend Alberta's iEHR and chronic disease management solutions to primary care teams.

Cancer Care Ontariocomputerized order entry and clinical decision support to benefit cancer patients.

Grand River Hospitalpatient portal will provide access to health information for cancer and renal patients.

Leveraging the EHR for Innovative Health Care

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.

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

A number of nations have made significant e-health progress, with widespread EMR adoption, electronic communication and data sharing (e.g. lab results).

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.

Momentum(Strategy plus Resources scores)

Pro

gre

ss(E

HR

Im

ple

me

nta

tion

plu

s A

do

ptio

n s

core

s)

DEN NZLNED

UKNOR

US CAN5

-

10 -

10 -

5 -AUS

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.

This graphic is based upon analysis prepared by Infoway using publicly available documentation on international EHR initiatives. All findings are subjective in nature.

The International Milieu

DEU

SGP

FRA

JPN

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 VisionFoundation 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 billionBenefits = $6.0 to $7.6 billion annually

Unlock additional quality and safety benefits by enabling decision support and communication across care continuum

Unlock additional quality and safety benefits by enabling decision support and communication across care continuum

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Facilitate improvements in patient self-careFacilitate improvements in patient self-care

33

Enable public visibility into wait timesEnable public visibility into wait times

44

Trial more advanced functionality to meet high priority system needsTrial more advanced functionality to meet high priority system needs

55

Ensure baseline EHR and public health infostructure is in place across the countryEnsure baseline EHR and public health infostructure is in place across the country

11

Largest investmentrequired

Priorities to 2015F

ou

nd

ati

on

al

Ad

dit

ion

al e

lem

ents

Ad

dit

ion

al E

lem

en

ts

Opportunities

Benefits Evaluation at Infoway

EHR: Overall Benefits & Value

ACCESS

• 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

QUALITY

• Improved interpretation of diagnostic and laboratory results• Decreased adverse drug events• Decreased prescription errors• Increased speed and accuracy in detecting infectious

disease outbreaks

PRODUCTIVITY

• Increased access to integrated patient information • Reduced duplicate tests and prescriptions• Reduced physician prescription call-backs• Reduced patient and provider travel costs

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 iEHR)• 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 FrameworkThe framework articulates the link between the systems in which Infoway invests and the resulting benefits, providing a basis for measurement.

NET BENEFITS

INFORMATIONQUALITY Content Availability

SERVICEQUALITY Responsiveness

SYSTEMQUALITY Functionality Performance Security

USERSATISFACTION Competency User Satisfaction Ease of Use

USE Use Behavior/

Pattern Self Reported Use Intention to Use

QUALITY Patient Safety Appropriateness/

Effectiveness Health Outcomes

ACCESS Ability of Patients/Providers

to Access Services Patient and Caregiver

Participation

PRODUCTIVITY Efficiency Care Coordination Net Cost

ORGANIZATIONAL and CONTEXT FACTORS: STRATEGY, CULTURE and BUSINESS PROCESS - OUT OF SCOPE

Based on the Delone & McLean IS Success Model

Quality, Access and Productivity Indicators

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 health system outcomes • Readmission rates• Efficiency of recovery• Patient transfers

Change in patient safety• Medication errors and Adverse Drug

Events

Change in patient and caregiver participation

• Patient awareness and adherence

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 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 ArchitectureJURISDICTIONAL INFOSTRUCTURE

Pharmacy System

EHR Data & Services

Pharmacist

EHR Viewer

RadiologyCenterPACS/RIS

LabSystem(LIS)

Hospital,LTC, CCC,EPR

Physician/Provider

Lab ClinicianRadiologist

PhysicianOfficeEMR

Physician/Provider

Physician/Provider

Public HealthServices

Public HealthProvider

PHS Data & Services

OutbreakManagement

PHSReporting

POINT OF SERVICE

Registries Data & Services

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

DrugInformation

DiagnosticImaging

LaboratorySharedHealthRecord

SecurityManagement Data

PrivacyData Configuration

HIALCommunication Bus

Common Services

DataWarehouse

HealthInformation

Longitudinal Record Services

MessageStructures

EHRIndex

BusinessRules

NormalisationRules

Privacy and Security Services (Future State)JURISDICTIONAL INFOSTRUCTURE

EHR Data & ServicesAncillary Data & Services

OutbreakManagement

PHSReporting

POINT OF SERVICE

Registries Data & Services

ClientRegistry

ProviderRegistry

LocationRegistry

TerminologyRegistry

DrugInformation

DiagnosticImaging

LaboratorySharedHealthRecord

SecurityManagement Data

PrivacyData Configuration

HIALCommunication Bus

Common Services

DataWarehouse

HealthInformation

Longitudinal Record Services

MessageStructures

EHRIndex

BusinessRules

NormalisationRules

Common Services

PRIVACY AND SECURITYIdentity Protection

Services

User AuthenticationServices

AnonymisationServices

Identity MgmtServices

Consent DirectivesMgmt Services

EncryptionServices

Secure AuditingServices

Access ControlServices

Digital SignatureServices

General SecurityServices

User

Clinical Viewer

POSSystem

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 iEHR 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

Several Hurdles Will Need To Be Overcome To Complete The Existing Mandate

Front-line implementation, including standards implementation, business process redesign, and clinician adoptionBring key

stakeholders – public and clinicians in particular – on board

“Clinicians will not be willing to adopt the technology if it makes their life harder.”

– Clinician

“Clinicians will not be willing to adopt the technology if it makes their life harder.”

– Clinician

“We need people pounding the table for this.”

– Regional CIO

“We need people pounding the table for this.”

– Regional CIO

Urgency behind building a case for ongoing support

“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

“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

Securing the right mix of leadership at all levels

“We need additional champions beyond Infoway.”

– Deputy Minister

“We need additional champions beyond Infoway.”

– Deputy Minister

Journey far from complete

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

• Role: provide expert input to one of 4 key elements of the End User Strategy

– After D Covvy

TODAYÕS

ROLE

Challenges

Competencies

Curriculum

TOMORROWÕS ROLE

Challenges

Competencies

Curriculum

SKILLS

KNOWLEDGE

ATTITUDES

EXPERIENCE

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