Lynn M. Nagle, RN, PhD April 24, 2009

 Up to now…  A few of the challenges  Some of the strategies  Thinking about the future

“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison…” Nightingale, 1863 “There is a lack of a uniform and integrated system for maintaining health records of individuals……essential data are scattered in many locations: in physicians’ offices, hospital records, clinics, etc.” Lalonde, 1974

“Electronic health records are one of the keys to modernizing Canada’s health system and improving access and outcomes for Canadians.” “The Committee strongly believes that electronic health care records and the evaluation of quality, performance, and outcomes are the three areas of Canadian health care infrastructure that must be given priority by the federal government” Romanow, 2002 Kirby, 2002

“The 2007 Canadian National Physician Survey revealed that 26.1% of physicians use a combination of Electronic and Paper charts as their record keeping system. Only 9.8% of physicians use Electronic Charts instead of Paper Charts” Canadian EMR

Generation 1 The Foundation Infrastructure, Registration, Departmental Systems Generation 2 The Documenter Results Review, Order Entry, Clinical Documentation Generation 3 The Helper Integrated Decision Support Generation 4 The Partner Knowledge Management Generation 5 The Mentor Knowledge Generation Nagle & Catford, Adapted from Gartner 2003 EHR Evolution

In many instances, we are still some way from having basic information digitized within hospitals, let alone having the ability to transmit data among groups of hospitals and across the country. There is still a need to boost IT budgets in hospitals and health regions. Source: Irving, R. (2005) Report on I.T. in Canadian Hospitals: Current capabilities and upcoming acquisitions. Canadian Healthcare Technology: Thornhill, ON.

Healthcare In Canada – The Statistics For Every …. …. in Canada 1000 hospital admissions75 people will suffer an Adverse Event 1000 patients with an ambulatory encounter20 people will suffer a serious ADE 1000 patients discharged from hospital 90 people will suffer a serious ADE with the drugs received on discharge 1000 Laboratory tests performed up to 150 will be unnecessary (range ) 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 are not screened 1000 Canadians recommended for influenza protection are not vaccinated

So why is it taking so long?!

Healthcare is More Complex than Other Industries

I’m just not into change…

I haven’t asked for IT yet…

700 Hospitals 40,000 General Practitioners 315,000 Nurses 29,000 Specialists 26,000 Pharmacists 1,600 Long-term Care Facilities Homecare Emergency Services Pharmacy LaboratoryDiagnosticHospital Emergency Hospice Community Care Centre Clinic

 Investments – National, Regional, Local  Development & Adoption of Standards ◦ Technical ◦ Data ◦ Clinical  Engagement of users  Setting expectations of vendors  Demonstrating the value of systems integration

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.

Getting there…  Effective & empowered leadership  Increase clinical IT spend  Align national, jurisdictional, organizational, & provider strategies  Engage clinical users  Align vendor solutions with clinical practice needs  Establish IT/Clinical partnerships  Raise the bar for safety & quality  Develop & adopt standards

Articulating the value proposition…

From: Zielstorff et. al (1993). Next Generation Nursing Information Systems, ANA. Atomic Level Data – Collected Once, Used by Many

Evidence-based clinical outcomes being collected systematically by nurses across sectors of care ◦ Function –ADL and continence ◦ Therapeutic self-care – “Readiness for Discharge” ◦ Symptoms  Pain  Fatigue  Dyspnea  Nausea ◦ Safety outcomes: Falls & pressure ulcers

 Integrate outcomes capture with existing nursing assessments - avoid duplication of documentation  Maximize electronic capture through existing systems  Provide access to information for nurses, healthcare managers, researchers and ministry planners  Provide scalability for future parameters such as nursing interventions and additional measurable outcomes

Challenges  Current clinical information systems do not provide outcomes information to clinicians in ‘real time’  Information is focused on one sector and does not follow the patient across the system Opportunities  Shift the nursing profession from ‘task focused care’ to ‘outcomes focused care’  Standardized information that is patient-centred and can follow the patient over sectors and be available over time

 Promotes and enhances the nurse-patient relationship  Improves each nurse’s: ◦ Documentation ◦ Discharge planning ◦ Patient teaching ◦ Awareness of patients’ symptoms and needs

◦ Electronic data capture of HOBIC measures leverages the core competency of informatics  creates information for clinical practice, management, education and research  provides decision support information at the POC that compels a new way of thinking  i.e.., shift from task oriented care to outcome based care  provides clinical trends

 Having access to common, consistently measured outcome data across the continuum of care, across the country…  Capability to analyze health service outcomes on the basis of: ◦ Diagnoses ◦ Age ◦ Region – Sector - Provider ◦ Cost of care ◦ Skill mix, staff ratios ◦ Access to resources  Research potential

(HOBIC Ontario – HI Next, 2009) Value of HOBIC

Results and images Patient information Medical alerts Medication history Interactions ImmunizationProblem list

 Improved client/family experience  Continuity of information;  Improved quality, safety, clinical outcomes  Consistent, evidence-based practice  Improved continuity of care  Improved system & operational efficiency;  Provider, organizational, regional, provincial, & national healthcare information that informs health policy & funding

 Capitalize on existing clinical data sets  Add value and inform practice  Align with clinical workflows  Are scalable and open to future integration

Shifting Power Differentials…