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Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
Sharing EHRs - The Canadian Experience
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Sharing EHRs - The Canadian Experience

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Dr Alan Brookstone …

Dr Alan Brookstone
Canada Health Infoway's Clinical Sub-committee on Standards

Published in: Health & Medicine, Business
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  • 1. The Canadian Experience Prepared by Dr. Alan Brookstone April 22, 2009 The ‘Wicked Problem’ of Whether and How to Share Electronic Health Records?
  • 2. Background
    • Family Physician
    • eHealth consultant
    • Experience in provincial and national eHealth programs in Canada and Singapore
    • Privacy, Data Stewardship, Regional EHR, Physician EMR systems
    • The opinions expressed are my own and do not represent Canada Health Infoway or the Provincial or National Programs
  • 3.  
  • 4. Canada – Health System Structure
    • 10 Provinces & 3 Territories
    • Roles and responsibilities shared between federal and provincial-territorial governments
    • Canada Health Act (CHA) specifies criteria and conditions that must be satisfied by provinces in order to qualify for full share of the federal cash contribution, under the Canada Health Transfer (CHT)
    • Provincial and territorial governments responsible for the management, organization and delivery of health services for their residents
  • 5. New Zealand & Denmark
    • High level of EMR adoption of highly functional systems by primary care physicians (+/- 100%)
    • Health Information Exchange – Millions of messages exchanged between compatible systems monthly using HL7 & EDIFACT/XML
    • Focus has been almost exclusively on GP computing vs. large systems infrastructure
  • 6. Canada’s Approach
    • Top down (Canada Health Infoway)
      • $1.6 Billion in funding for EHR projects
      • Additional $500 Million Jan 28, 2009
      • Significant portion to physician EMRs
    • Bottom up (Provincial Programs)
      • Alberta (POSP), Ontario (OntarioMD), British Columbia (PITO), Nova Scotia (> $300 million to date)
      • Saskatchewan, Manitoba, New Brunswick (in progress)
    • Still have low levels of adoption of EMR < 26%
  • 7. Primary Care Doctors’ Use of Electronic Patient Medical Records, 2006 Percent Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
  • 8. Infoway’s Programs 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 Etc.
    • Basic
    • Elements
    • of EHR
  • 9. eHealth Progress
  • 10. Lessons Learned in Canada
    • Challenges of Federation
    • Data Stewardship example (MDERA)
    • EMR Lessons
    • Collision between Policy & Privacy
    • Stakeholder Engagement – Medical Licensing Authorities
    • Source of Truth Debate
    • Approach to data sharing
  • 11. 1. Challenges of Federation
    • Majority of care (80%) is provided in community in which patient lives. How much information needs to flow inter-provincially?
    • Healthcare is highly political federally and provincially
    • Multiple 2-4 year political cycles – Unable to sustain long term strategies
    • Developing the infrastructure (HIAL – Health Information Access Layer) does NOT equate to trust and use by participating parties
    • Variety of provincial legislations (some health specific & others not) creates additional complexity
      • e.g. British Columbia – PIPA & FOIPA
  • 12. 2. MDERA Background
    • Not for profit association
    • Established to define data stewardship responsibilities and data sharing agreement in terms of physician’s EMR, health region and university
    • Members – Physicians (+/- 130 Specialists). Not employees of the region. Affiliated with University
    • Pooled funding from Physician Office Systems Program
    • Selection of a Single EMR (EMIS)
    • Data sharing agreement with health region
  • 13. MDERA (Medical Doctors Electronic Records Association) Doc Doc Doc (Entity) MDERA University Health Region Agreement Doc Data Sharing Agreement
  • 14. Lessons Learned
    • Established data stewardship role for group of physicians through MDERA (Successful)
    • Response to unclear policy regarding data stewardship roles and responsibilities, information sharing and 2° use of data
    • But, requires Privacy Officer (or designate) plus ethics designate to evaluate requests for data for research purposes
    • Incurred ongoing administrative costs
    • Medical Legal responsibility (Fell between Health Region and Canadian Medical Protective Association)
  • 15. 3. EMR Lessons
    • Approximately 35 EMR vendors in Canada
    • 15 are dominantly sold in the market
    • No single vendor controls > 10% of market
    • Combination of Canadian and International vendors
    • Canadian vendors have limited capability to collect structured data using SNOMED CT
    • Conformance is tested at provincial vs. national level e.g. Ontario, BC, Alberta
    • There is no current national set of EMR requirements utilized by all provincial jurisdictions
    • BC, Ontario, Alberta, Nova Scotia, Saskatchewan are all moving towards ASP models for EMRs
  • 16. 4. Collision between Policy & Privacy
    • Technology has been ahead of policy development
    • Concerns about privacy have significantly slowed development of the provincial EHR
    • Special interest groups have legitimate concerns
    • Development of policy regarding masking of EHR data inconsistent with the technological capabilities
    • Legacy systems unable to conform with new policy
    • Privacy officers and Ministries not in alignment
    • The risks of exposing data through inference
    • Requires strong audit capabilities out the gate
  • 17. 5. Medical Licensing Authorities
    • There has been insufficient engagement of physician licensing authorities (Colleges)
    • Only BC & Alberta Colleges developed Physician Data Stewardship guidelines
    • Extremely important for design of EHR solutions to ensure expectations are understood
    • Will face resistance from end-users if there is a conflict between ethics, licensing body requirements and provincial policy
  • 18. 6. Source of Truth
    • Debate in Canada has just begun
    • Information sharing amplifies these debates particularly with respect to:
      • Allergies
      • Current problem list
      • Current medications
    • Risk - lack of trust in the system
  • 19. 7. Approach to Data Sharing Increasing Risk
  • 20. Examples
    • High Value, Low Risk: e.g. Immunization Data
    • High Value, High Risk: e.g. Reportable Disease Data
  • 21. Observations
    • Must maintain momentum of existing programs
    • Need safe zone(s) (sandboxes) within which to experiment and evaluate solutions and options
    • Must develop trust in the system
    • Recognize the weighting effect of clinical judgment
  • 22. Conclusion
    • What has been done well?
      • Diagnostic imaging/PACS has been a success
      • EMPI has generally been a success
      • Infoway has been able to negotiate better prices for applications and equipment/hardware
    • Areas for improvement
      • Too much dependence on IT as the solution
      • Data quality/inconsistent coding is an ongoing problem especially in legacy systems
      • Inadequate focus on process redesign and social reform at the health delivery level
      • Inter-provincial sharing of information is limited by inconsistent legislation and poor understanding of points of responsibility
  • 23. Questions

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