EMR A non-techie’s overview The potential benefits, challenges and long-term implications of e-health that we should all understand Part 2

Plugging in to e-health Key Questions: -What are you plugging in to? -What are the implications for you, your patients and the health care system? -Does it matter?

Part 2 Brief Global overview Evidence

And now... a whirlwind global tour of emr and health systems around the world

Excerpts From: A Comparison of Information Technology in General Practice in Ten Countries City University London Centre for Health Informatics Dennis Protti October 4, 2006

Health systems characteristics Percentage of GPs who work alone: –lows of 5% and 10% in Sweden and New Zealand. –highs of 80% and 90% in the Netherlands and Austria.

Health systems characteristics Physician Reimbursement –Fee-for-service the most common model range from 100% to 40% of income –exception is Sweden >90% of GPs are employed by Primary Health Centres

% GPs with office computers Australia98% Austria99% Denmark99% England99% Germany90% Netherlands 97% New Zealand 100% Norway100% Scotland 95% Sweden 97%

% GPs with “automated” medication prescriptions Australia98% Austria90% Denmark99% England95% Germany90% Netherlands 90% New Zealand 97% Norway100% Scotland 95% Sweden 99%

% GPs recording progress notes AustraliaMany AustriaFew DenmarkMany EnglandMany GermanyFew Netherlands Most New Zealand Many Norway Most Scotland Many Sweden Few

% GPs using electronic data exchange AustraliaMany AustriaFew DenmarkMost EnglandMost GermanyFew Netherlands Some New Zealand Most Norway Few Scotland Many Sweden Some

Benefits of automation in GP practices (ranked scale of 1-8) Simplified Repeat Prescription –#1 in Scotland and Sweden –#2 in all other countries, except Norway (#3) and NZ (#4) Saving time –#1 in Australia, England, Germany, Netherlands and New Zealand –#7 in Austria

Quicker receipt of results – range:1-5 Improved patient management - easier to find records – range:1-5 Legibility of records and forms - who wrote what – range: 3-7 More timely communication with other clinicians – range: 1-8 Availability of clinical data on Internet or Intranet – range: 3-8 Data for clinical research – range: 5-8

EVIDENCE? For the proposed benefits 1) In improving Clinical Outcomes

ICE: Informatics- enhancing the Clinical Experience? Objective The aim of this research is to explore the role and impact of primary care based Electronic Medical Records implementation & use, in terms of the therapeutic relationship and health outcomes, in British Columbia’s Health System. (Source CIHR ICE study – lead researcher Dr. N. Shaw – Center for Healthcare Innovation and Improvement. Study )

Ice study Rationale Unique research that has not been undertaken, to this extent, anywhere in the world to date. The evidence base for the use of EMRs in primary care with reference to the impact on care itself is almost nonexistent. Therefore, this study will be a seminal piece of research that will address a large number of outstanding questions

A Meta-analysis of Interventions to Improve Care for Chronic Illnesses Alexander C. Tsai,et al THE AMERICAN JOURNAL OF MANAGED CARE AUGUST 2005 VOL. 11, NO. 8 Tsai and colleagues examined 112 studies involving disease management programs based on the Chronic Care Model for asthma, congestive heart failure, diabetes, and depression. They found mixed effects on quality of life (no benefit for asthma and diabetes), as well as publication bias for congestive heart failure and some asthma studies.

Disease Management Economic Effectiveness of Disease Management Programs: A Meta-Analysis Disease Management. 2005, 8(2): doi: /dis David S. Krause, Ph.D. Department of Finance, College of Business Administration, Marquette University, Milwaukee, Wisconsin. Krause evaluated 67 studies involving more than 32,000 patients with diabetes, concluding that disease management programs are more effective when provided to severely ill enrollees and that even though a small to moderate positive impact was found, further study of comorbidity and costs incurred by enrollees is needed.

Electronic Medical Records Don't Guarantee Improved Care DOC News Aug, 2007 Volume 4 Number 8, 2007 American Diabetes AssociationAmerican Diabetes Association Implementation of an electronic medical record (EMR) system in a medical practice does not assure quality care for people with diabetes, according to a study reported recently in Annals of Family Medicine. A group of researchers audited medical records from 13 practices with EMR systems and 37 practices without them. The medical practices, located in Pennsylvania and New Jersey, were participating in a practice improvement study. For each practice, investigators looked at adherence to guidelines for diabetes processes of care, treatment, and achievement of outcomes such as levels of glygated hemoglobin.

Electronic Medical Records Don't Guarantee Improved Care cont’d Overall, the quality of care in all practices showed room for improvement, according to the researchers. But... They found better care in practices without EMRs. Practices without such systems were 2.25 times more likely to meet process guidelines, 1.6 times more likely to meet treatment standards, and 2.6 times more likely to meet outcome targets. The authors conclude that, "Simply having an EMR does not guarantee higher quality care." Practices that wish to expand use of EMRs should focus not just on adopting the technology, but also on developing methods to integrate the technology into office operations, the researchers suggest.

EVIDENCE? For the proposed benefits 2) In improving decision making

Vancouver Coastal Health – Chronic Disease Management: The Current State May 30, 2007 Prepared for: Director, Chronic High Prevalence Conditions Population Continuums and Director, Population Strategy Decision Support Tools: Virtually all programs and services interviewed are using decision supports such as evidence-based guidelines, clinical pathways, and flow sheets developed internally or by partners (e.g., Ministry of Health, BCMA, The Lung Association, Canadian Thoracic Society, Canadian Diabetes Association, Heart and Stroke Foundation, Kidney Dialysis Outcome Quality Indicators, etc). While there is evidence that using care pathways and protocols improves the “process” of care for both providers and clients, there is inconsistent evidence to show that it improves clinical outcomes (ref Singh). Singh, D. Transforming Chronic Care: Evidence about improving care for people with long-term conditions. NHS, The University of Birmingham, and HSMC

Computer Technology and Clinical Work Still Waiting for Godot PROCESS-SUPPORTING INFORMATION TECHNOLOGY (IT) has been heralded as an important building block in attempts to improve the quality and safety of health care. One component is clinical decision support; that is, information systems designed to improve clinicians’ decision making. In this issue of JAMA, 2 articles report results in these areas. Garg et al provide an updated systematic review evaluating the impact of computerized clinical decision support systems, (Wears and Berg: JAMA, March 9, 2005—Vol 293, No. 10)

Still Waiting... “Summary by Garg et al of 100 trials of clinical decision support systems over a 6-year span: About 2/3 of the studies claimed improved clinician performance, but these assessments were often biased; When the authors were not also the system developers, less than half of the systems showed an improvement. “Grading oneself” was the only factor that was consistently associated with good evaluations” (Wears and Berg: JAMA, March 9, 2005—Vol 293, No. 10)

Still Waiting.. “Clinical decision support systems come in many different forms and can be implemented in many ways, so it is fair to ask if these systems can really be approached as a single intervention Lack of improved performance could have been due to: poorly designed decision technology or poor use of the technology by clinicians poor human computer interface or lack of time or support among colleagues. More research needed...

EVIDENCE? For the proposed benefits 3) In saving time

The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review Time efficiency is one of many benefits targeted by EHR implementers, but, time inefficiency is also recognized as a major barrier to successful EHR implementation. Poissant et al - Journal of the American Medical Informatics Association Volume 12 Number 5 Sep / Oct 2005

Physician time We learned that expectations of EHR implementation projects that documentation time will be decreased are unlikely to be fulfilled, especially with physicians. This suggests that a shift from the user’s efficiency to the organization’s or even the system’s efficiency is needed.

Poissant et al - Journal of the American Medical Informatics Association Volume 12 Number 5 Sep / Oct 2005 Such a shift will require that the EHR be seen as a tool that can transform work processes and support innovation in care delivery. Future research is required to examine whether the capacity of the EHR to improve the overall care delivery process of patients will likely outweigh the barrier associated with the additional time required to use the system. Further research is needed to examine the impact of EHR on system efficiency and how this will influence adoption rates by all users, particularly physicians.

EVIDENCE? For the proposed benefits 4) A Business Case? Who benefits when the GP invests in emr?

Infoways Business case Review Booz Allan Hamilton Cost Benefit Analysis