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The National EHR Imperative: the Ways to Success


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The National EHR Imperative: the Ways to Success. Coiera E. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

The National EHR Imperative: the Ways to Success. Coiera E. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

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  • 1. The Dangerous decade: Challenges for builders of national health information systems Enrico Coiera
  • 2. Setting the scene - a dangerous decade • Over the next 10 years we will build and deploy more ICT in the health system than ever before in history. • These systems will be larger, more complex, and see a shift from local/regional to national/supranational scale. • The costs and benefits of such systems have major implications for national GDP and accounts. • The demands for health system modernization are so compelling that we have no choice but implement nation- scale health IT (NHIT). • Yet we are at the same place in industry maturity as aviation in the 1950s. • The risks of failed or delayed implementation, cost over- runs, and safety risks are still too real.
  • 3. The two core problems we are trying to solve 1. Sustainability 2. Safety and Quality
  • 4. The Sustainabilty Funnel: when demand for resources and supply diverge
  • 5. Australian Population Growth and Aging •In 2007, 13.4% +65, and 2047, >25% [87% increase] •Very old (+85) rises from 1.7% to 5.6 % 85+ [329%] 65-84 Budget Papers 2002/03: Intergenerational Report
  • 6. Projected Australian Commonwealth Health Spending •In 2007, 3.8% GDP •In 2047 7.3% [92% increase] Ageing -> 25% growth, rest is new technology and drugs Budget Papers 2002/03: Intergenerational Report
  • 7. A shortage of health workers today Source: Dean, D; AHA Conference 2001
  • 8. Dependents as % working age population In 2007 5 people of working age support every person aged >65. By 2047, will only be 2.4 people. Combined Aged Child Budget Papers 2002/03: Intergenerational Report
  • 9. Average Annual Income Tax Paid, by Age Group WORKERS
  • 10. Safety and quality • 10% of admissions to acute care hospitals are associated with an adverse event (ACSQHC 2001). • About 2% of separations associated with serious adverse events causing major disability (1.7%) or death (0.3%) (Runciman et al. 2000). • 1 million general practice encounters each year in Australia involve an adverse event (AIHW 2008) • Adults receive recommended care just over half the time (55%) and children just under half the time (46%) (McGlynn et al., 2003)
  • 11. Adherence to quality indicators according to condition (McGlynn et al. 2003)
  • 12. In 2020 the health system will have to • … treat proportionately more people • … with proportionately more illness • … to a higher standard of safety and quality • … in a more evidence-based way • ... with relatively fewer tax dollars • … and proportionately fewer workers MAKING THIS HAPPEN IS THE PROBLEM WE NEED TO SOLVE
  • 13. How will we do this? • In 2020, each clinician cares for more patients than today, more effectively, because: – Some burden of care shifts to the consumer (new tools, new skills, new norms) – Some burden of care shifts to new clinical roles – Some burden of care shifts to smart machines – Our services and systems are safer and more effective because they are purpose „designed‟, not inherited and patched up – Many of the innovations are unimagined today (remember Gaudi!)
  • 14. E-health can help improve system sustainabilty and patient safety • Gartner (2009) report provides many examples where E-health: – Improves patient safety (eg reduce prescription, medication errors, avoid ADEs) – Improve clinical efficiency (eg reduce duplicate tests, or admissions via home monitoring) – Help clinicians care for more patients (e.g. EMR, CPOE reduce length of stay) – Helps burden of care shift to the consumer (e.g. electronic messaging reduces GP visits by 10%)
  • 15. Strategy: How do we make it happen?
  • 16. Case study 1: English NHS NPfIT • World‟s largest civil IT project, £13 billion over 10 years to improve services and quality of patient care • NHS is a nation-scale, single-payer health system • Adopted a top-down strategy for system architecture, standards compliance, and procurement • Many notable wins but also plenty of setbacks, clinical unrest, delays, cost overruns, paring back of promised functionality. Hospitals a problem. • Demands from political quarters to shut it down : “Conservatives pledged to cancel the programme … Liberal Democrats described it as "a disaster … from the start.” BMJ 28 Jan 2009
  • 17. Problems with top-down strategies • One size doesn‟t fit all. • No easy migration plan. Non compliant systems shut down and replaced even better fit local needs. • Imposed redesign is expensive, wasteful, generates disaffection. Staff retraining/workflow adjustment can introducing errors. • Long delay until ROI means „stuck‟ with ageing systems and technology despite significant changes, i.e. more brittle to change. • To meet emerging needs service providers will build work-arounds, adding “unwanted” local variation to singular national design.
  • 18. Case study 2: US HIEs • Pre American Recovery and Reinvestment Act (ARRA), US embarked on a bottom-up strategy to NHIS development. • Service providers form coalitions to interconnect existing systems into regional health information exchanges (HIEs). • Preserves existing systems. New technologies, system designs can be adopted locally where is need and capacity • Standards not mandated but adopted on a business needs basis. Little central intervention. • Does not create a single central record, but allows remote view of local records, perhaps abstracted or aggregated regionally. • Expectation that Regional HIEs eventually aggregate into a nation-scale system.
  • 19. Variable HIE success • Indiana HIE - – Based on Regenstrief Institute EHR – Connects 39 hospitals, 10,000 physicians and > 6 million patients – 85 primary care providers, 20 locations – securely aggregates and delivers lab > 5 million results, reports, medication histories, and treatment histories regardless of system or location • Other successes e.g. Massachusetts (, Spokane ( • Less e.g Santa Barbara County: combination of technical, leadership, and funding (Miller,2007; Brailer, 2007), NE Pennsylvania (Robinson, 2007), Oregon (Conn, 2007).
  • 20. Problems with bottom-up strategies • Cannot predict how expensive or feasible it is for a local system to interface with an HIE. • Cannot predict how much information is available to other providers. • Incompatible data models may make reconciling information across different systems arbitrarily complex. • Unlikely to be aligned with national policy goals. • The price for preservation of local systems is a weaker national system, which may have data holes, and data quality problems. • Business model unclear
  • 21. Middle-out: A third way • Need to acknowledge government, providers have different starting points, goals and resources. • All come together to agree on common NHIT functions, standards, strategy. • Providers then bring existing systems up to national standards e.g. customized interfaces or make new purchases standard compliant. • End product has rich capability for information sharing, resilient over time, preserves what works. • Allows government to pursue policy goals. J Am Med Inform Assoc. 2009;16:271-273.
  • 22. Middle-out: Government‟s role • Define policy framework to converge public and private, local and central systems into a functionally national system. • Fund public sector to join the NHIS. • Incentives for private sector where the business case is weak but national interest is strong. • Develop public goods e.g. standards, broadband, health informatics workforce, evaluation of progress. • Legislation to protect privacy and interests of citizens. • Avoid as far as possible what it is not good at, like designing, buying or running IT.
  • 23. The Dangerous Decade
  • 24. Strategic Risks (1) • HIT safety: – Emerging data about risks associated with rushed implementation, poor training, software performance. – We are yet to experience our first HIT ‘air crash’ – Safety is a systems issue and software is just one component of the socio-technical system – Standards needed not just for technology (e.g. HL7) , but at services level (system functions), implementation quality (certification of process quality) and for the hands of users (certification of competence) – Routine monitoring of IT related safety incidents should be mandatory as should rapid response to incidents
  • 25. Strategic Risks (2) • Expectations: “Past performance (in one setting) does not predict future performance (in another): – HIT Centers of excellence often used as benchmarks for outcomes, but often have home-grown solutions, developed incrementally over decades, with large resource including academic informaticians and IT staff (e.g. >200 at Partners) – Industry solutions are usually implemented entirely differently, from generic packages, with little local expertise available, and ongoing monitoring and modification. – Need to base expectations upon robust outcomes at the bottom, not the top!
  • 26. Strategic risks (3) • Solving the wrong problem: – An "EHR first" strategy will miss easy wins to demonstrate success, keep political momentum, preserve end-user buy-in, build public confidence. – What is ROI for a fully shareable national record vs regional systems, viewable nationally? – Easy wins? Web-based knowledge services, decision support (e-psychiatry), electronic prescribing, home monitoring, online bookings, discharge summaries, personal health records.
  • 27. Summary • We are in the exciting, but not risk free, decade of heath IT • The two core problems we are trying to solve are health system sustainability, and safety and quality • Top down and bottom up strategies for building national health information systems have had mixed success • There is a third way, middle out, bringing together jurisdictions, consumers, health service providers and clinicians, to agree on „meaningful use‟ and each contributes what they are most expert at.
  • 28. Thank you