D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Electronic Records EMR – the electronic record in a physician’s office EPR – the electronic record in a hospital or facility EHR – the longitudinal electronic record of an individual that contains data from multiple EMRs and EPRs 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

Background to the study A Comparison of Information Technology in General Practice in 10 Countries Commissioned by Canada Health Infoway Goal: to identify the governmental, collegial, technological, and other factors contributing to the success of each country in achieving high levels (>90%) of GP office automation in the last ten years. Success stories are intended to inform health care reform efforts in Canada, specifically in the area of primary care. 14-Nov-18 D. Protti - City University London and University of Victoria

Data collected in 2005 about Australia Austria Denmark England Germany Netherlands New Zealand Norway Scotland Sweden http://www.wave.net/upg/immigration/flags.html 14-Nov-18 D. Protti - City University London and University of Victoria

Data was collected from Scientific literature OECD Government, and professional association reports and web sites Personal interviews with GPs, ministerial and vendor representatives 14-Nov-18 D. Protti - City University London and University of Victoria

Health care systems characteristics Methods of hands-on delivery of care are virtually the same in all of the countries studied The way in which the healthcare systems are financed, administered and managed vary widely 14-Nov-18 D. Protti - City University London and University of Victoria

Health care systems governance Regional (Provincial) Australia, Denmark, New Zealand, Norway, Sweden National England, Scotland Insurance - based Austria, Germany, Netherlands 14-Nov-18 D. Protti - City University London and University of Victoria

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. 14-Nov-18 D. Protti - City University London and University of Victoria

Health systems characteristics Practicing physicians per 1,000 (2003) 4.4 in Austria (highest) 2.2 in England and Scotland (lowest) 2.9 average in OECD countries 2.1 in Canada (17th out of 21 countries) 14-Nov-18 D. Protti - City University London and University of Victoria

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 14-Nov-18 D. Protti - City University London and University of Victoria

Health systems characteristics Per capita expenditures (2003 data) $US 3807 in Norway (highest) $US 1886 in New Zealand (lowest) $US 3003 in Canada 14-Nov-18 D. Protti - City University London and University of Victoria

Health systems characteristics % of GDP (2003 OECD data) 11.1% in Germany (highest) 7.6% in Austria (lowest) 9.9% in Canada 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

% GPs with office computers Australia 98% Austria 99% Denmark 99% England 99% Germany 90% Netherlands 97% New Zealand 100% Norway 100% Scotland 95% Sweden 97% 14-Nov-18 D. Protti - City University London and University of Victoria

% GPs with “automated” medication prescriptions Australia 98% Austria 90% Denmark 99% England 95% Germany 90% Netherlands 90% New Zealand 97% Norway 100% Scotland 95% Sweden 99% 14-Nov-18 D. Protti - City University London and University of Victoria

% GPs recording progress notes Australia 64% Austria 25% Denmark 90% England 90% Germany 24% Netherlands 94% New Zealand 80% Norway 95% Scotland 65% Sweden 15% 14-Nov-18 D. Protti - City University London and University of Victoria

% who operate “paper-light” offices Australia Some Austria Few Denmark Most England Some Germany Few Netherlands Few New Zealand Few Norway Most Scotland Few Sweden Few 14-Nov-18 D. Protti - City University London and University of Victoria

National health network in use Australia No Austria No Denmark Yes England Yes Germany No Netherlands No New Zealand Yes Norway Yes Scotland Yes Sweden No All have plans or intentions to have one 14-Nov-18 D. Protti - City University London and University of Victoria

% GPs using electronic data exchange Australia 86% Austria 25% Denmark 99% England 97% Germany 10% Netherlands 50% New Zealand 97% Norway 10% Scotland 90% Sweden 50% 14-Nov-18 D. Protti - City University London and University of Victoria

% GPs receiving laboratory results Australia Many Austria Many Denmark Most England Many Germany Few Netherlands Many New Zealand Most Norway Few Scotland Most Sweden Most 14-Nov-18 D. Protti - City University London and University of Victoria

% receiving discharge summaries Australia Few Austria Few Denmark Most England Few Germany Few Netherlands Few New Zealand Many Norway Few Scotland Many Sweden Few 14-Nov-18 D. Protti - City University London and University of Victoria

Driving Forces for the Evolution of Primary Care Computing 14-Nov-18 D. Protti - City University London and University of Victoria

Government funding support Australia Yes Austria No Denmark No England Yes Germany No Netherlands Yes New Zealand No Norway No Scotland Yes Sweden Yes 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Billing mandate Australia No Austria Yes Denmark No England No Germany Yes Netherlands Yes New Zealand Yes Norway No Scotland No Sweden No 14-Nov-18 D. Protti - City University London and University of Victoria

College or Association leadership Australia Yes Austria No Denmark No England Yes Germany No Netherlands Yes New Zealand No Norway No Scotland Yes Sweden No 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Peer Influence Australia No Austria No Denmark Yes England No Germany No Netherlands Yes New Zealand No Norway Yes Scotland No Sweden Yes 14-Nov-18 D. Protti - City University London and University of Victoria

Accreditation of vendor systems Australia No Austria Yes Denmark Yes England Yes Germany Yes Netherlands Yes New Zealand Yes Norway No Scotland Yes Sweden No In some cases for billing purposes only 14-Nov-18 D. Protti - City University London and University of Victoria

Non-financial support received Australia No Austria No Denmark Yes England No Germany No Netherlands No New Zealand Yes Norway No Scotland No Sweden Yes 14-Nov-18 D. Protti - City University London and University of Victoria

Benefits of technology to GPs 14-Nov-18 D. Protti - City University London and University of Victoria

Benefits of automation in GP practices Simplified Repeat Prescription (2.1) #1 in Scotland and Sweden #2 in all other countries, except Norway (#3) and NZ (#4) Saving time (3.0) #1 in Australia, England, Germany, Netherlands and New Zealand #7 in Austria 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Quicker receipt of results (3.2) – range:1-5 Improved patient management - easier to find records (3.4) – range:1-5 Legibility of records and forms - who wrote what (5.2) – range: 3-7 More timely communication with other clinicians (5.5) – range: 1-8 Availability of clinical data on Internet or Intranet (6.2) – range: 3-8 Data for clinical research (7.3) – range: 5-8 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria England Clinical computer usage has markedly increased since the advent of the new 2003 contract containing the Quality and Outcomes Framework (QOF). As the QOF covers 11 disease areas and practices are financially rewarded for having objective evidence of the quality of care they provide, data entry into GP clinical systems is taking precedence over handwritten records in these areas. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Denmark Virtually all Danish GPs (and by 2006, all specialists as well) send and receive clinical electronic messages. Sixty standardized messages (up from 32 in 2002) have been implemented in 100 computer systems Over 90% of the country’s clinical communications in the primary sector are exchanged over Denmark’s national network. including 16 physician office systems, 9 hospital systems,12 laboratory systems and 4 pharmacy systems. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Denmark In 2005, created a national health portal to provide information about the Danish National Health Service to its citizens and patients. Waiting list information Quality declarations Online scheduling of GP appointments Renewal of prescriptions Email contact with GPs Access to online medication profile It is also beginning to serve as a unified hub for electronic communication between patients and the Health Service. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Email contact with GPs - users can consult their GP using email; similar to telephone consultation but asynchronous Access to online medicine profile - allows users and health care professionals to access a detailed profile of medicines dispensed for each patient 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Austria and Germany Have introduced national health e-cards (smart cards) Denmark has issued cards to 300,000 so far Also issued each physician with their own healthcare provider e-card which is becoming the digital signature by which clinicians will have access to centralized data such as medication profiles. Denmark and England are also introducing healthcare professional e-cards into their systems. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria The Austrian e-card Front = e-card Rear = EHIC 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Outline Definitions Background to the study of 10 countries Study findings Lessons to be learned Conclusion Discussion 14-Nov-18 D. Protti - City University London and University of Victoria

There are however similarities to draw upon There is no one answer or reason why these 10 countries have a high degree of utilization of computer technology by their GPs There are however similarities to draw upon 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Clearly the role of Government health policy played a part in most of the countries. The policies may not have been directly related to primary care computing (e.g. out of office hours or physician collectives) but in many instances, they indirectly stimulated the introduction of technology. Closely related were the financial incentives and rewards which were provided to GPs if they automated though this was clearly not the case in all of the countries. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria It would appear that a single unifying organization of some type played a key role in Denmark and New Zealand Interestingly, Denmark’s organization is non-profit, arms length from government, while New Zealand’s is a private company. The lack of a unifying organization is seen to be a significant limiting factor in a number of countries. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Other important factors include: certification of vendor systems providing support to GPs use of communications standards use of nomenclatures such as the Read codes in England and Scotland and ICPC in Norway. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria What seems clear in all ten countries is the recognition that significant progress towards an Electronic Health Record, with all its associated benefits, is impossible without the full participation of general practitioners. 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria As the Australian Minister for Health and Ageing and Leader of the House of Representatives said on December 8, 2005 “Doctors are at the heart of the health system and there can be no integrated IT-based patient health record while most doctors' case notes remain on cardboard cards.” 14-Nov-18 D. Protti - City University London and University of Victoria

First attempts at a ranking of countries 14-Nov-18 D. Protti - City University London and University of Victoria

Possible scoring dimensions EMR functionality (rating & percentage of physicians involved) Medications & allergies, case notes, problem lists, immunizations, etc Scheduling Decision support (reminders, alerts, care planning, etc.) Knowledge tools (Medline, guidelines, etc) Structured and coded data Research support Electronic messaging Lab results, discharge summaries, medications, consults, etc. Booking Breadth of sectors (community, mental health, etc.) Use of a shared or integrated EHR Medication profiles, laboratory results, imaging reports, etc. Extent of standards in use Communications, identifiers & registries, SNOMED, alerts, etc. EPR functionality (rating & percentage of facilities involved) Telemedicine/health PHR, portals and e-mail with patients Supportive legislation Privacy, secondary uses, digital signatures, etc. Add in handhelds; outcomes (patient safety, reduced errors, etc.) Score actual functionality versus its use Use vendors to get the functionality data Look at other ranking systems first Going to collect data by survey and/or by site visits and/or other means (send my scores to x people in each country) 14-Nov-18 D. Protti - City University London and University of Victoria

Thank you for your attention Denis.Protti.1@city.ac.uk dprotti@uvic.ca 14-Nov-18 D. Protti - City University London and University of Victoria

D. Protti - City University London and University of Victoria Additional materials 14-Nov-18 D. Protti - City University London and University of Victoria

Central servers and central systems In a number of countries GPs are choosing central server solutions to meet their clinical system requirements. More common to provide full functionality across a wide area network, with all data processed on a central server. System and network administration managed by someone else – often a government supported team. 14-Nov-18 D. Protti - City University London and University of Victoria