1. Canada Health Infoway and the Electronic Health Record Impacts & Opportunities Robert (Bob) Burns AFMC May 8, 2007

3. Overview Why the EHR? Why & what is Canada Health Infoway? Progress to date Challenges & hurdles Benefits EHRs and Education

4. The Need – Patient Expectations

5. Managing Expectations What are the Jones expecting from their healthcare system? Accurate information moves with them Various providers communicate with each other Privacy is protected Decisions are made in consultation with them Not exposed to undue risk Receive timely access/results Can access their own EHR Have the ability to learn on their own, with assistance from their healthcare providers

6. The Need for EHR For Every …. …. in Canada 1000 hospital admissions75 people will suffer an Adverse Event 1000 patients with an ambulatory encounter20 people will suffer a serious Adverse Drug Event 1000 patients discharged from hospital 90 people will suffer a serious Adverse Drug Event with the drugs received on discharge 1000 Laboratory tests performed up to 150 will be unnecessary (range 50-150 ) 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 cancer300-400 are not screened 1000 Canadians recommended for influenza protection370-430 are not vaccinated

7. Source: CIHI; Sanofi-Aventis; Statistics Canada; OECD; WHO; Centre for Chronic Disease Prevention Resource pressures intensifying Growing Need for Health Information Management Providers, managers, patients, public are demanding more IT has potential to enable solutions to address pressures Care settings are shifting Population is aging Consumerism is growing Resource pressures greater

8. Yet Canada Invests Less in Healthcare IT than Other Information-intensive Businesses * Operating and capital **Gartner estimate as %of revenues; assumes providers working on a non-profit basis *** Predicted rise to 4% from 1.5% in 2004 Sources: Information Technology Association of Canada, 2004; Gartner Annual IT spend* Percent of total budgets/revenues 2.9 3.4 4.0 4.5 4.7 5.4 1.5 Range of HC IT spend of Canadian jurisdictions 2.0 Canada is underinvesting in IT relative to other healthcare providers and information management industries Canada’s healthcare system would rank No. 10 in the Fortune 500 and is 3 times the size of the Royal Bank and has limited ability to manage its information Additionally, investments have often been fragmented and one-off leading to duplication of efforts and need for reinvestments EducationUS HC providers** UK health- care*** Professional services US banking/ financial services Calgary Regional Health Authority

9. 9 An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies. EHR Defined 6

10. 10

11. EHR and EMR…and convergence An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies. An electronic medical record (EMR) is a provider or site specific record of the interactions with a specific patient. By definition it is not complete, although it may be more richly detailed in some aspects than an EHR. It is maintained by providers to meet their fiduciary duties to their patients, as well as the requirements of their regulatory bodies.

12. The Model/Vehicle to Begin to Address Need: Canada Health Infoway

13. About Infoway 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 Approach: Infoway was established by the First Ministers of Canada’s federal, provincial and territorial governments in 2001 Infoway is a not-for-profit corporation Funded by the Government of Canada, funding was allocated to Infoway in 2001 ($500m), 2003 ($600m) and 2004 ($100m) Infoway’s members are Canada’s 14 federal, provincial and territorial Deputy Ministers of Health Independent Board

14. Infoway Business Strategies Targeted Investment Programs Limited scope - goal Collaboration with health ministries and other partners Co-Invest with public sector partners (75:25 formula) Leveraged investment Form strategic alliances with the private sector Manage risk and ensure quality solutions Focus on end-user acceptance Measure benefits and adjust

15. Infoway’s Goal By the end of 2010, some elements of the basic EHR will be in place for all Canadians, while a complete basic EHR will be in place for 50% of Canadians. All Canadians will benefit from better healthcare access, quality and productivity. Innovation and Adoption - $60 million* Public Health Surveillance $100 million Telehealth $120 million Innovation and Adoption – $60 million* Chronic Disease Primary Care Cancer Patient Safety Wait Times Mental Health Laboratory Systems $150 million Diagnostic Imaging $310 million Interoperable EHR – $175 million Infostructure – $32 million Registries $134 million Drug Systems $185 million Infoway’s Programs Etc. Basic Elements of EHR

16. Focus on Standards and Interoperability Common architecture largely accepted by jurisdictions Revised architecture includes privacy and security Comprehensive standards collaboration process New Infoway Standards Collaborative EHR Solution (EHRS) EHR Infostructure (EHRI) EHR Viewer Point of Service Application Point of Service Application EHRS Locator Registries Data & Services Longitudinal Record Services HIAL Ancillary Data & Services EHR Data & Services Health Information Data warehouse

17. EHR: Conceptual Architecture JURISDICTIONAL INFOSTRUCTURE Pharmacy System EHR Data & Services Pharmacist EHR Viewer Radiology Center PACS/RIS Lab System (LIS) Hospital, LTC, CCC, EPR Physician/ Provider Lab Clinician Radiologist Physician Office EMR Physician/ Provider Public Health Services Public Health Provider PHS Data & Services Outbreak Management PHS Reporting POINT OF SERVICE Registries Data & Services Client Registry Provider Registry Location Registry Terminology Registry Drug Information Diagnostic Imaging Laboratory Shared Health Record Security Management Data Privacy Data Configuration HIAL Communication Bus Common Services Data Warehouse Health Information Longitudinal Record Services Message Structures EHR Index Business Rules Normalisation Rules

18. EHRS Distributed, Message-based, Peer-to-Peer Network of EHRS Systems Electronic Health Records Linked Jurisdiction Networks

19. Progress to Date

20. Legend Registries Diagnostic Imaging Drug Info Systems Lab Info Systems Telehealth Interoperable EHR Public Health Surv. Innovation & Adoption  Number of Projects 217 $1,133 M 217 active & completed projects valued at $1,133 M in all 9 investment programs The 135 projects jointly developed with provinces and territories are shown. In addition, there are 82 active or completed pan-Canadian projects. Program Activity Summary

21. WEST ON QCEASTTERRITORIES iEHR NU Client Reg. DI Drug Laboratory Telehealth NT NSPENLYKMBNBSKABBC INVESTMENT PROGRAMS Provider Reg. Phase 0/1 Projects Phase 2 Projects System in place March 2004 = $125 M Significant Progress in 3 Years 2005-06 WESTONQCEASTTERRITORIES WESTONQCEASTTERRITORIES Telehealth NU Client Reg. DI Drug Laboratory NTNSPENLYKMBNBSKABBC INVESTMENT PROGRAMS Provider Reg. Telehealth iEHR Public Health WESTONQCEASTTERRITORIES 9 September 2006 = $825 M

22. Ontario: Keeping Tabs on Labs The first of nearly 200 hospitals and community labs are going “live” in 2006, providing on-line viewing of Lab results through links with hospitals and 10,000 doctors’ offices. PEI: Island-Wide iEHR By the end of 2007, PEI’s clinicians will be able to see a patient’s lab results, medication and diagnostic images on on-screen, Canada-wide Public Health Surveillance All 14 provincial, territorial and federal governments agreed to adopt a single Public Health Surveillance solution Alberta: netCare Alberta-bound Alberta is leveraging Capital Health’s netCare viewer for province-wide use in iEHR and Lab information systems. Saskatchewan: Checks Med Safety Drug prescribing has become safer, with one of the first provincial systems covering “all drugs, all people.” Quebec: Networking 62 Hospitals The McGill - Montreal RUIS repositories for diagnostic imaging system will be the largest in Canada. Nova Scotia: Farewell to Film Almost 100% filmless - medical professionals in Nova Scotia’s hospitals will be able to access patients’ complete lab results, images and patient history by 2006/7. Manitoba and New Brunswick: Telehealth Calling Manitoba has doubled its network providing access to healthcare services to 10 northern First Nations and 7 Franco-Manitoban communities. New Brunswick is the national leader in nurse triage call centres and is now planning to expand their telehealth network to provide tele-homecare Newfoundland & Labrador: Province-wide eProgress Province-wide Drug Information System underway British Columbia: Leveraging Past Investments for an EHR BC will implement an electronic health record across the province. Different Stages of Progress

23. Scarborough Hospital Electronic self-entry (by patients) of patient history in emergency department (ED) using touch-screen kiosks Sherbourne Health Centre remote electronic records for a Health Bus serving the inner city homeless Vancouver Island Health Authority EHR-based clinical decision support tools to for Mental Health & Addictions Services British Columbia Ministry of Health Newfoundland & Labrador’s Eastern Health pilots for province-wide adverse events reporting, analysis and management Sault Ste Marie link primary care providers and pharmacists to the EMR/EHR Quebec MSSS electronic patient evaluation and service planning solutions. Primary Health Care Public Health Patient Safety Chronic Disease Cancer Wait Times Information & Communications Technologies Alberta Cancer Board synoptic reporting for cancer surgery will improve data collection and quality surgical management of cancer patients. Alberta Capital/Calgary Health Regions extend Alberta's iEHR and chronic disease management solutions to primary care teams. Cancer Care Ontario computerized order entry and clinical decision support to benefit cancer patients. Grand River Hospital patient portal will provide access to health information for cancer and renal patients. Leveraging the EHR for Innovative Health Care

24. Infoway Adding Value at Every Step Joint governance Joint planning (rolling 3 years) Predictable funding Common solutions architecture Common ICT standards Accountable spend Common procurement Common solutions National pricing Shared services Knowledge sharing Global leaders- exporting expertise A mid-term independent performance evaluation conducted in 2005 and a recent review commissioned by Health Canada both validated and supported Infoway’s value-added role.

25. The Global Scene A number of nations have made significant e-health progress, with widespread EMR adoption, electronic communication and data sharing (e.g. lab results). Canada and the UK lag slightly behind some others in EHR progress – New Zealand, Denmark, Norway and the Netherlands. However, both Canada and the UK have strong focused national strategies and significant resource commitments to provide these nations the momentum to become the global leaders in the next 3 years. Momentum (Strategy plus Resources scores) Progress (EHR Implementation plus Adoption scores) DEN NZL NED UK NOR US CAN 5 - 10 - 5 - AUS The US and Australia currently lack momentum towards an EHR. Both have national strategies but currently lack the funding to successfully execute the strategy. With funding both could quickly join the leading nations. This graphic is based upon analysis prepared by Infoway using publicly available documentation on international EHR initiatives. All findings are subjective in nature. The International Milieu DEU SGP FRA JPN

26. Before we get too smug… On the road to 2015 …

27. The Road to 2015 To develop a Health Infostructure Plan for Canada that confirms the long term vision and details the strategic directions that the country should consider over the next 10 years, including the associated resource requirements. To provide a roadmap for the complete implementation of the electronic health record across the country as well as the extension of the infostructure to support all aspects of healthcare renewal.

28. The Vision Foundation Systems Electronic Health Record – for 100% of Canadians Electronic Medical Record – for Primary and Ambulatory Care Hospital Information Systems – CPOE and advanced decision support Patient Portals – to permit patients to view their electronic health record Business Systems Public Health – for comprehensive pandemic management Chronic Disease Management – for advanced case management of key chronic diseases such as diabetes, congestive heart failure and cancer Wait Time Management – to allow electronic referrals, enterprise scheduling and wait time monitoring and reporting Patient Selfcare – to support patients and their care givers in their home Performance Management – to ensure sustainable patient care delivery Capital Cost = $10 to $12 billion Benefits = $6.0 to $7.6 billion annually

29. Unlock additional quality and safety benefits by enabling decision support and communication across care continuum 2 Facilitate improvements in patient self-care 3 Enable public visibility into wait times 4 Trial more advanced functionality to meet high priority system needs 5 Ensure baseline EHR and public health infostructure is in place across the country 1 Largest investment required Priorities to 2015 Foundational Additional elements Additional Elements

30. Opportunities

31. Benefits Evaluation at Infoway

32. EHR: Overall Benefits & Value ACCESS Reduced wait-times for diagnostic imaging services Improved availability of community based health services Reduced patient travel time and cost to access services Increased patient participation in home care QUALITY Improved interpretation of diagnostic and laboratory results Decreased adverse drug events Decreased prescription errors Increased speed and accuracy in detecting infectious disease outbreaks PRODUCTIVITY Increased access to integrated patient information Reduced duplicate tests and prescriptions Reduced physician prescription call-backs Reduced patient and provider travel costs

33. Infoway Benefits Evaluation Plan Purpose: Assess the impact of Infoway investments in electronic health record solutions on healthcare quality, productivity and access. Impacts identified will be used to: Demonstrate value of investments Advance further investments in EHR solutions Encourage end user adoption Highlight necessary adjustments in the Infoway investment strategy Principles: Evaluate the Canadian experience with sufficient rigor to provide confidence in benefit estimates; don’t try to develop the definitive EHR evaluation framework Focus on evaluating programs that will produce tangible clinical benefits (Lab, Drug, DI, Telehealth, PHS and iEHR) Not all projects or activities will be evaluated. Identify representative sample and most appropriate methodologies to allow extrapolation. The EHR benefits evaluation will be evaluated and revised on an ongoing basis

34. Infoway BE Framework The framework articulates the link between the systems in which Infoway invests and the resulting benefits, providing a basis for measurement. NET BENEFITS INFORMATION QUALITY  Content  Availability SERVICE QUALITY  Responsiveness SYSTEM QUALITY  Functionality  Performance  Security USER SATISFACTION  Competency  User Satisfaction  Ease of Use USE  Use Behavior/ Pattern  Self Reported Use  Intention to Use QUALITY  Patient Safety  Appropriateness/ Effectiveness  Health Outcomes ACCESS  Ability of Patients/Providers to Access Services  Patient and Caregiver Participation PRODUCTIVITY  Efficiency  Care Coordination  Net Cost ORGANIZATIONAL and CONTEXT FACTORS: STRATEGY, CULTURE and BUSINESS PROCESS - OUT OF SCOPE Based on the Delone & McLean IS Success Model

35. Quality, Access and Productivity Indicators  Change in provider effectiveness/ appropriateness of care Access to information Timeliness of service delivery, pharmacists, public health, referring physicians, radiologists Vaccination rates, Outbreak detection and intervention  Change in health system outcomes Readmission rates Efficiency of recovery Patient transfers  Change in patient safety Medication errors and Adverse Drug Events  Change in patient and caregiver participation Patient awareness and adherence  Change in access to services Volume of service provision Access to previously unavailable services Timeliness of DI services  Change in provider efficiency Radiology Technologist and Radiologist efficiency Pharmacists and Lab technician callbacks Time to take medication history or assess patient Clinician workflow  Change in coordination of care Information sharing among different providers Management of outbreaks  Change in net costs Unnecessary events: radiology, lab tests, vaccinations

36. New tools bring new questions: EHR and secondary uses of data

37. Secondary Use of Data workshop with CIHI January 2007 Time to start building and marketing the case for secondary use to build ‘readiness’ by physicians, public and other stakeholders Need to develop detailed use cases and/or a higher level framework identifying requirements for secondary use Need to identify experiences, successes and failures, both nationally and internationally and build upon them

38. EHR: Conceptual Architecture JURISDICTIONAL INFOSTRUCTURE Pharmacy System EHR Data & Services Pharmacist EHR Viewer Radiology Center PACS/RIS Lab System (LIS) Hospital, LTC, CCC, EPR Physician/ Provider Lab Clinician Radiologist Physician Office EMR Physician/ Provider Public Health Services Public Health Provider PHS Data & Services Outbreak Management PHS Reporting POINT OF SERVICE Registries Data & Services Client Registry Provider Registry Location Registry Terminology Registry Drug Information Diagnostic Imaging Laboratory Shared Health Record Security Management Data Privacy Data Configuration HIAL Communication Bus Common Services Data Warehouse Health Information Longitudinal Record Services Message Structures EHR Index Business Rules Normalisation Rules

39. Privacy and Security Services (Future State) JURISDICTIONAL INFOSTRUCTURE EHR Data & Services Ancillary Data & Services Outbreak Management PHS Reporting POINT OF SERVICE Registries Data & Services Client Registry Provider Registry Location Registry Terminology Registry Drug Information Diagnostic Imaging Laboratory Shared Health Record Security Management Data Privacy Data Configuration HIAL Communication Bus Common Services Data Warehouse Health Information Longitudinal Record Services Message Structures EHR Index Business Rules Normalisation Rules Common Services PRIVACY AND SECURITY Identity Protection Services User Authentication Services Anonymisation Services Identity Mgmt Services Consent Directives Mgmt Services Encryption Services Secure Auditing Services Access Control Services Digital Signature Services General Security Services User Clinical Viewer POS System

40. White Paper on Information Governance Early 2007 release - for feedback & comment Identifies the areas for dialogue Governance is not new; how information flows with an iEHR is new Governance will require variety of approaches Where will responsibility for governance management reside?

41. Areas for Dialogue Trust & Accountability Privacy Rights of Patients Assessment & Compliance Quality in Healthcare Technical Safeguards Rights of healthcare providers & communities of interest …with subsequent sections on legal, ethical and professional requirements, the current mechanisms at play, and examples of other industry’s efforts to come to grips with similar issues

42. Challenges

43. Several Hurdles Will Need To Be Overcome To Complete The Existing Mandate Front-line implementation, including standards implementation, business process redesign, and clinician adoption Bring key stakeholders – public and clinicians in particular – on board “Clinicians will not be willing to adopt the technology if it makes their life harder.” – Clinician “We need people pounding the table for this.” – Regional CIO Urgency behind building a case for ongoing support “Until you get a reasonable level of critical mass, we are years away from measuring systemic benefits to the system. This is the problem for elected officials, who want to see the benefits quickly.” – Regional CIO Securing the right mix of leadership at all levels “We need additional champions beyond Infoway.” – Deputy Minister Journey far from complete

44. Academe as stakeholders Teaching, research, service delivery - and thought leader Teaching - UG,PG, CPD Research: ‘secondary use’ as discussed Service delivery: as discussed Thought leader

45. Academic/Learning Advisory Group Role: provide expert input to one of 4 key elements of the End User Strategy –After D Covvy SKILLS KNOWLEDGE ATTITUDES EXPERIENCE CPD/KT

46. Challenges for Teaching Institutions Technology itself (50% of FP teaching units) Strategic alliances with institutions (hospitals, LHINs, RHAs) where care is delivered Theme of ‘EHR solutions as tool’, cross-cutting all training, rather than ‘stand-alone’ or ‘add-on’ to curriculum ‘Walk the talk’ - clinically, and technologically

47. The Promise Increased patient participation in care Well managed chronic illness Improved access to care in remote and rural communities Less adverse drug events Better therapeutic outcomes Better prescribing practices Reduced wait times

49. Thank You! www.infoway-inforoute.ca www.infoway-inforoute.ca