1. 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

2. 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

3. 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

4. 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

5. 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

6. Data collected in 2005 about
Australia
Austria
Denmark
England
Germany
Netherlands
New Zealand
Norway
Scotland
Sweden
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D. Protti - City University London and University of Victoria

7. 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

8. 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

9. 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

10. 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.
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D. Protti - City University London and University of Victoria

11. 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

12. 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

13. 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

14. 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

15. 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

16. % 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

17. % 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

18. % 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%
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D. Protti - City University London and University of Victoria

19. % 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
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D. Protti - City University London and University of Victoria

20. 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
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D. Protti - City University London and University of Victoria

21. % 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%
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D. Protti - City University London and University of Victoria

22. % 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
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D. Protti - City University London and University of Victoria

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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Benefits of technology to GPs
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D. Protti - City University London and University of Victoria

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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
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

38. D. Protti - City University London and University of Victoria
contact with GPs - users can consult their GP using ; 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

39. 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

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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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, “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

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

49. 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 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

50. Thank you for your attention
14-Nov-18
D. Protti - City University London and University of Victoria

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

52. 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