The National EHR Imperative: the Ways to Success


Published on

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

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

The National EHR Imperative: the Ways to Success

  1. 1. The Dangerous decade: Challenges for builders of national health information systems Enrico Coiera
  2. 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. 3. The two core problems we are trying to solve 1. Sustainability 2. Safety and Quality
  4. 4. The Sustainabilty Funnel: when demand for resources and supply diverge
  5. 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. 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. 7. A shortage of health workers today Source: Dean, D; AHA Conference 2001
  8. 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. 9. Average Annual Income Tax Paid, by Age Group WORKERS
  10. 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. 11. Adherence to quality indicators according to condition (McGlynn et al. 2003)
  12. 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. 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. 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. 15. Strategy: How do we make it happen?
  16. 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. 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. 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. 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. 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. 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. 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. 23. The Dangerous Decade
  24. 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. 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. 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. 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. 28. Thank you