International Leaders of the EHR journey ASSIST and NHS NorthWest October 9, 2007 From what perspective I come from – it’s a tool 16-Feb-19 Denis Protti - University of Victoria & City University London

Evidence of progress from around the world We are making an impact 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London Denmark 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London Denmark Virtually all Danish GPs (and as of 2007, almost 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 in 4,000 organizations. 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. 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London Denmark In 2005, a national health portal provided information about the Danish National Health Service to its citizens and patients. Waiting list information Online scheduling of GP appointments Access to online medication profile Renewal of prescriptions Email contact with GPs Quality declarations It is also beginning to serve as a unified hub for electronic communication between patients and the Health Service. 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London New Zealand 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London AGPAL ACCREDITED 2,200 New Zealand sites 1,200 Australian sites 1-800 support across Australasia 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London KIWI SCORECARD 85% use of GP clinical systems (in consultation) 90% use clinical messaging 95% receive electronic pathology reports 95% can receive electronic discharge summaries and send referrals 60% of hospitals (and growing) send electronic discharge summaries 16-Feb-19 Denis Protti - University of Victoria & City University London

Denis Protti - University of Victoria & City University London Hong Kong 16-Feb-19 Denis Protti - University of Victoria & City University London

Hospital Authority Services 43 Hospitals 46 Specialist clinics 74 General clinics 8M Patient Records Annually: 1M Admissions 2M A&E visits 11M Outpatient visits 52,000 Staff 4,500 Doctors 20,000 Nurses

Clinical Systems Comprehensive functionality developed in-house since early 90’s High utilization by clinicians Mission critical systems Increasing strategic importance Source: Dr. NT Cheung The Hospital Authority adopted a centralized approach in developing its IT system for clinical care, the clinical management system (CMS). This has reduced IT cost per hospital. High mobility of both patients and doctors are characteristics in Hong Kong. Therefore, inter-operability between different hospitals is one of the forefront initiative in developing the clinical management system. A familiar user interface is important in enhancing the efficiency in a busy clinic setting. The Hospital Authority CMS has very high user acceptance and is in use in everyday care delivery.

Electronic Patient Record (ePR) Web-based lifelong longitudinal record of all healthcare transactions for all Hong Kong citizens Patient privacy protected with access controls and full audit logs Available at all 162 facilities in the HA Many data formats (textual, numerical and digital images) Now extending to external providers

Impressive statistics 7.6 million patients 57 million episodes of care 540 million laboratory results 34 million radiology results 230 million drug items 1 million image studies Sub-second response time 7x24 >99.99% uptime

Denis Protti - University of Victoria & City University London USA 16-Feb-19 Denis Protti - University of Victoria & City University London

US – Veteran’s Administration Every VA Medical Center has Electronic Health Records and Computerized Provider Order Entry! 16-Feb-19 Denis Protti - University of Victoria & City University London

Veterans Health Administration Department of Veterans Affairs (VA) Provides benefits and services to our nation’s veterans and selected family members Veterans Health Administration (VHA) The branch of VA that provides healthcare benefits to some 5 million veterans and their families Locations & Affiliations ~ 1,400 Sites-of-Care Including 154 medical centers, ~ 875 clinics, 207 counseling centers, plus long-term care, domiciliaries, home-care programs Affiliations with 107 Academic Health Systems Additional 25,000 affiliated physicians Additional 35,000 residents & fellows (in 14,000 slots) ~90,000 trainees each year in all disciplines 1,500 Health Professions Training Affiliations Nearly half US health professionals (>65% physicians) have some training in VA

Scope of Use Scope of use Single patient record immediately available real time, supports both continuity and longitudinal patient-centric care across continuum Inpatient: Wards, critical care, specialty care, Bone Marrow Transplant Unit, surgery Outpatient: Primary Care, Specialty Care, Allied health, Community Based Outpatient Clinic Emergency room Nursing Home Home Care Home Telemonitoring

10 Year Cumulative % Change in Costs - VA, Medicare, CPI -20% -10% 0% 10% 20% 30% 40% 50% VHA Cost Per Patient Avg. Medicare Payment/Enrollee Medical CPI - -0.3% 0.8% -6.2% -8.6% -6.5% -7.3% -9.1% -4.6% 6.4% 14.9% 12.8% 25.5% 31.9% 40.4% 44.7% 3.3% 5.9% 9.8% 13.5% 18.4% 23.7% 29.5% 34.7% 39.4% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 VHA Cost per Patient– Total Medical Care Obligations per Total Unique Patients (inc non Veterans) Average Medicare Payment per (www.cms.hhs.gov/researchers/pubs/datacompendium) Medical Consumer Price Index-- Bureau of Labor Statistics

Performance Measurement Setting the U. S Performance Measurement Setting the U.S. Benchmark for 18 Comparable Indicators Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002) Beta Blocker after MI 98 93 94 (NCQA 2002) Breast Cancer Screening 84 75 (NCQA 2002) Cervical Cancer Screening 90 81 (NCQA 2002) Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001) Cholesterol Screening (post MI) 94 78 79 (NCQA 2002) LDL Cholesterol <130 post MI 61 (NCQA 2002) Colorectal Cancer Screening 67 49 (BRFSS 2002) Diabetes Hgb A1c checked past year 85 83 (NCQA 2002) Diabetes Hgb A1c > 9.5 (lower is better) 15 34 (NCQA 2002) Diabetes LDL Measured 95 88 85 (NCQA 2002) Diabetes LDL < 130 77 63 55 (NCQA 2002) Diabetes Eye Exam 68 52 (NCQA 2002) Diabetes Kidney Function 70 57 Hypertension: BP < 140/90 58 (NCQA 2002) Influenza Immunization 76 P 68 (BRFSS 2002) Pneumocooccal Immunization 63 (BRFSS 2002) Mental Health F/U 30 D post D/C 61 74 (NCQA 2002)

Denis Protti - University of Victoria & City University London Spain (Andalucia) 16-Feb-19 Denis Protti - University of Victoria & City University London

Health Care Information and Management Integrated System Andalusian Health Service

Andalusian Public Health System Primary Care Specialized Care 37 hospitals 64,000 professionals Outpatient Admissions Emergency room services Diagnostic tests 1,500 health centres 19,000 professionals System gateway General practitioner Paediatrician Nurse Other services: Dentist, Rx...

Diraya´s objective Integrate the healthcare information of every citizen A SINGLE HEALTH RECORD

1 2 3 4 A SINGLE Health record for each citizen Diraya’s key elements 1 A SINGLE Health record for each citizen KEYS 2 Unified access to all services 3 All relevant information structured Developed by the practitioners/users 4

Diraya. Building blocks DATA WAREHOUSE ELECTRONIC PRESCRIPTION CENTRALISED APPOINTMENT HEALTH RECORD CITIZEN REGISTER STRUCTURE (resources) OPERATORS MANAGEMENT

Diraya. Implementation in Primary Care 2002 < 25 % 25 - 50 % 50 - 75 % 75 - 90 % > 90 % Population coverage

2007 Implementation in Primary Care 521 Health centres With clinical data: 5.2 million (79 %) Monthly: Consultation forms: 1.9 million Prescriptions: 5.6 million 2007 < 25 % 25 - 50 % 50 - 75 % 75 - 90 % > 90 % Population coverage 521 Health centres 6,700, 000 inhabitants

2007 Diraya. Implementation in Specialized Care Monthly: Emergencies: 76,000 episodes Consultations: 4,000 episodes

Diraya. Appointments Primary Care Salud Responde Specialized Care 902 505 060 Primary Care Specialized Care Diagnostics tests

Make haste slowly Denis.Protti.1@city.ac.uk dprotti@uvic.ca Festina Lente Make haste slowly Denis.Protti.1@city.ac.uk dprotti@uvic.ca 16-Feb-19 Denis Protti - University of Victoria & City University London