EMR A non-techie’s overview The potential benefits, challenges

EMR A non-techie’s overview The potential benefits, challenges and long-term implications of e-health that we should all understand

Plugging in to e-health Key Questions: - What are you plugging in to? - What are the implications for you, your patients and the health care system? - Does it matter?

What is the definition of e- Health in BC?: CAUTION Admin-speak Ahead . .

In BC e- Health is defined as: An integrated set of information and communication technologies, together with related health delivery process enhancements, that: enables the efficient delivery of health care services over the full continuum of care through the provision of integrated, interoperable health information systems, tools and processes; (British Columbia Electronic Health Steering Committee, “Terms of Reference”, January 2005)

In BC e- Health is defined as: transforms the health sector decision-making culture into one that is firmly supported by accurate, timely and relevant information in a manner that protects individual privacy, respects clinical practice requirements and sustains the long-term viability of the health care system; and encompasses the interoperable Electronic Health Record (EHR) and Telehealth. Chair of e-health steering committee: Danderfer

Definitions Electronic medical record (EMR) An electronic medical record (EMR) is a patient medical record that is generated and maintained by one care provider (physician) or institution (clinic or hospital). (although it will contain some information from other accessible sources.) Electronic health record (EHR) The electronic health record (EHR) includes patient medical information from multiple sources, including components of the EMR. Is accessible from any location. This is sometimes referred to as a "dataspine".

Medical Post May 15, 2007 Alan Brookstone, founder of Canadian EMR website notes: "B.C. is the only place in the world to be introducing the EHR and EMR more or less simultaneously. It will be coming at physicians from every level at work, and from many quarters . . .“ "This is an enormously complicated and ambitious undertaking,"

Key Benefits of e-Health? The Ministry’s proposed “key benefits” to be achieved through e-Health are: Improved health care quality, safety and outcomes; Increased service efficiency, productivity and cost effectiveness; and Enhanced service availability and satisfaction for citizens, patients and providers. (Source: MOH e-Health Strategic Framework Nov 2005)

Benefits? Evidence is far from bullet proof that these benefits can or will be achieved . . . More later on evidence if time permits . . . But there is no doubt about the POTENTIAL for benefit Also potential for spending a lot of to make things worse . . . For patients, docs and health systems . . Many physician colleagues have compared risk of large scale waste. of public funds (around EHR) to gun registry debacle How do we ensure benefits maximized and potential harms, costs and risks minimized?

If you use PITO funds What are you buying into? (as defined in appendix C and RFP) 1) EHR – Canada Infoways version 2) ASP data storage – functionality and readiness question to be addressed 3) CDM Toolkit: Ministry’s Electronic CDM Toolkit –. 4) Functionally tri-lateral contract: Between Vendor and Ministry and you Vendor’s prime customer Ministry? Primary payor you? Primary benefit accrues to - Ministry?

If you use PITO funds What are you buying/plugging into? 1) EHR The Infoways vision . . . Review: BCMA 2004 position on EHR/Repository Canada Health Infoways definition of EHR Appendix C of LOA College Position on EHR

BCMA Policy Paper Getting IT Right - 2004 Although the BCMA supports the integration of health IT systems, it opposes the concept of a central repository where identifiable patient information generated in physicians’ offices would be stored, and potentially accessed by third parties such as Health Authorities and government.

BCMA Policy Paper Getting IT Right - 2004 Inappropriate access or misuse of information would undermine the patientphysician relationship. The Office of the Privacy Commissioner of Canada has stated that having all health information including doctor and hospital visits, prescription, and lab tests in a central repository would significantly undermine privacy rights. (p. 43)

Infoways Presentation 2003

Putting it all together Note HIAL and EHR viewer in next slide

(HIAL) is a term defined in Canada Health Infoway’s Electronic Health Record (EHR) Blueprint Architecture. The main purpose of this component is to leverage the value of existing heterogeneous medical applications and integrate them into networked EHRs.

EHR Holy Grail? Thoughts from Australia: Might a simpler vision achieve the same goals without the same high risks and costs? The “National Shared Electronic Health Record has been some form of Holy Grail for the eHealth bureaucracy and for many government e-health strategists and planners” http://aushealthit.blogspot.com/2007/04/why-government-will-never-fund-shared.html

Why The Government will Never Fund a Shared EHR – And Probably Shouldn’t “Can I say that the whole plan has a total air of un-reality and fantastic wishful thinking about it.” From: 'Australian Health InformationTechnology'. EMR Blog - Dr. David More (Cited by Alan Brookstone on Canadian EMR Blog)

Thoughts from Australia cont’d Among the realities that need to be faced are the following: . . . large scale top down complex IT projects – in mixed health sector funding environments – are likely to be very problematic.” (Dr. More cont’d)

Bottom-up vs Top-down Implementation “Successes at a national scale have been in countries like Denmark and the Netherland where a messaging based bottom up relatively simple, standards based and incremental strategy has been successful.” . . . as opposed to large scale top down projects . . .

What should be done instead? a national strategy based on locally based health information sharing initiatives on a background of proven Standards and compliance certification has the highest probability of success – A top down strategy is almost certain to fail in the Australian environment and we would be better to go down a path that involves the determination of client functionality required, development of appropriate certification processes and standards and have the private sector develop and support appropriate systems

Final thoughts from Australia A Government funded Open Source alternative could be developed, supported and provided at low (but reasonable) cost and maintained as an exemplar of what is required. This strategy could provide an incentive for commercial system developers to ‘out develop’ the basic system to demonstrate the additional value provided by their offering. Current EHR plans, seem ‘courageous’ in the extreme. Cooler heads need to prevail and a strategy suitable for Australia in 2008 to 2018 and beyond needs to be developed free from the unsuitable large scale dominating current thinking.

UK National Data Spine Cost to date 12 Billion Pounds A large scale top-down project Things are not going well. Huge costs Benefits/Risks (more later) Compared to other countries docs in UK most likely to have to re-order lab test for result not being available (Schoen et al Commonwealth fund

Appendix C of the LOA 2006: -The EMR shall include a core data set which shall be a key tool in providing patient care. The core data set shall be available to health care providers, other than the primary physician - The core data set may reside in a number of locations, including with a local or regional ASP, in order to facilitate direct patient care and/or system health planning.

More Definitions ASP An application service provider is a company that delivers software programs and other services over a network instead of being located on the physician’s own computers or servers in their office.

Appendix C of the LOA 2006 Physicians shall participate in the establishment and operation of core data set projects. The core data set shall include the following: a) demographic information; b) current conditions; c) past medical and surgical history; d) allergies/alerts; e) current medications; f) immunizations; g) advance directives; and h) most recent and critical diagnostic data.

Concerns about Core Data Set EHR

Core Data set GP piece of EHR “If the "Core Data Set", including a list of current diagnoses is implemented as planned, we are going to see many examples of clinical errors because treating physicians have mindlessly accepted incorrect diagnoses made by others. “Nonphysicians don't understand how much subjectivity goes into the diagnostic process--how often diagnoses are, by their nature, tentative, pending the further evolution of the clinical syndrome.” - Galt Wilson Past President College of Physicians and Surgeons

EHR potential Hazards “Too much forward feeding will be hazardous to some patients.” - Galt Wilson Past President College of Physicians and Surgeons Clinical Professor Year III/IV Clerkship Director, Northern Medical Program Universities of British Columbia and Northern BC

Jerome Groopman Professor of medicine at Harvard Staff writer for The New Yorker Author of “ How Doctors Think” Diagnosis momentum as source of error Once the diagnosis is made, it is passed on to other doctors with ever-increasing conviction. Contradictory evidence is brushed aside.

Decision Support?

Groopman re Decision Support Electronic decision aids—devices that supposedly help doctors to arrive at the correct diagnosis— are unlikely to help, even though many extravagant claims are made for the impact of information technology on health. Groopman believes such electronic fixes might actually encourage more mistakes. They are a distraction. They promote a reductive and unthinking kind of checklist behavior. And they divert the doctor away from what should be his primary focus: the patient's own story.

Committee on Privacy & Data Stewardship Data Stewardship Framework BC College of Physicians and Surgeons August 22, 2007 Data Stewardship The management of health information including the collection, use, access, disclosure and retention; and the legal, ethical and fiduciary responsibilities of a physician in such management. Consent The autonomous authorization of an information access or disclosure by individual patients. Consent has three components: disclosure, capacity, and voluntariness

BC College of Physicians and Surgeons Data Stewardship Framework cont’d Posting to an Electronic Health Record There may be multiple EHRs that physicians have the opportunity to access and post information to. . . e.g. -BC PharmaNet - PathNet are EHRs that exist today, and there may be other EHRs developed in the future such as the Electronic Medical Summary.

BC College of Physicians and Surgeons Data Stewardship Framework cont’d These EHR applications have independent governance and management, and while a physician may view them as a collective whole as an external medical record, they are unique sources and as a result have explicit and different disclosures.

BC College of Physicians and Surgeons Data Stewardship Framework Cont’d This model introduces the role of an Information Service Provider who acts as a custodian in the collective interest of the participating organizations to manage the circumstances in which personal health information may be disclosed, including limitations and conditions. In an evaluation of an EHR, physicians should evaluate the level and breadth of support for the governance structure (i.e. consider if the CPSBC has endorsed the governance structure in place)

BC College of Physicians and Surgeons Data Stewardship Framework Cont’d The decision to disclose patient information collected by a physician to an EHR needs to be a thoughtful one. As the stewards of very sensitive information, physicians need to take care in the level of disclosure as well as the potential impacts of that disclosure. The decision should be evaluated for each instance of an EHR: For benefits and risks to the patient, For the ability to manage patients’ wishes in the management of their information, And the rules and processes which govern the actions of information service provider. These conditions need to be re-evaluated when the parameters for the EHR Are materially changed (e.g. when additional data elements are added, when The approved uses or access to information is extended, etc.).

Headlines from the UK GPs revolt over patient files privacy Tuesday November 21 2006 – John Carvel - The Guardian Poll shows doctors fear national database will be at risk from hackers About 50% of family doctors are threatening to defy government instructions to automatically put patient records on a new national database because of fears that they will not be safe, a Guardian poll reveals today. It shows that GPs are expressing grave doubts about access to the "Spine" - an electronic warehouse being built to store information on about 50 million patients and how information on it could be vulnerable to hackers, bribery and blackmail.

UK Headlines Contd The survey reveals that 4/5 doctors think the confidentiality of their patients' medical records will be at risk if the government proceeds with plans to load them on to the new database. More than 60% of family doctors in England also said they feared records would be vulnerable to hackers and unauthorised access by public officials from outside the NHS and social care. Ministers have committed a large slice of the NHS's 12bn IT upgrade to developing the Spine. They acted on the assumption that doctors would provide the information without asking their patients' permission first.

About the campaign www.TheBigOptOut.org Founder: Ross Anderson - Chair of the Foundation for Information PolicyResearch, and professor of security engineering at Cambridge The NHS Confidentiality campaign was set up to protect patient confidentiality and to provide a focus for patient-led opposition to the government’s NHS Care Records System. This system is designed to be a huge national database of patient medical records and personal information (sometimes referred to as the NHS ’spine’) with no opt-out mechanism for patients at all.

If you use PITO funds What are you buying into? 1) EHR – Infoways vision and core data set 2) ASP data storage 3) Ministry CDM Toolkit 4) Functionally Trilateral contract ASP An application service provider is a company that delivers software programs and other services over a network instead of being located on the physician’s own computers or servers in their office. i.e. your data resides elsewhere and you are working over the internet.

As per Appendix C of the 2006 Agreement Funding will only be provided for ASP-hosted EMRs, although PITO will evaluate the practicality of this requirement in certain very remote areas where network reliability may be uncharacteristically low and may identify alternatives that still maintain the spirit of the 2006 Agreement. Further, the Ministry of Health is currently negotiating a contract with a vendor for the Private Physician Network to ensure that BC physicians can be confident accessing their EMR through a secure, high speed, high availability network.

From PITO FAQs It is important to note that the PITO vendor selection process provides PITO with the opportunity to put mechanisms in place to lessen many prior pitfalls and potential issues. For example, through its master standing agreement with vendors, PITO can bind them to key province-wide conditions related to privacy, system reliability, response time, etc

More From PITO FAQs While there are understandably concerns regarding privacy, in many ways an ASP solution enhances the confidentiality of patient records. It moves the computer server which stores the patient records into a highly secure data centre run by the physician’s EMR vendor, rather than being vulnerable to theft in an empty physician office overnight. The vendor will be clearly accountable to the physician for the secure storage of their patients’ files.

What are the challenges of using an ASP? (More From PITO FAQs) The ASP model does come with challenges, each of which is being carefully addressed by PITO: When an EMR is hosted at an off-site ASP data centre, the network connection becomes critical for reliability. PITO will be working with the physician-based Clinical Advisory Group (CAG) and technical groups to define network solutions with high degrees of reliability to reduce this risk. Emphasis is on ensuring the EMR is consistently available, and the physician practice is unaffected by technical issues. PITO is also designing solutions to have a local encrypted backup of key patient data in the physician’s office in the rare case of the EMR being unavailable. This solution will allow physicians to continue seeing patients with access to their most important data in almost any situation

ASP benefits and challenges Benefits Not responsible for database Easier for vendor to service Challenges/ Concerns Functionality issues resolved? Responsibility for millions of patient charts in hands of 6 emr vendor companies Aggregation of mass amounts of data increases black market value to third parties (risk for both EHR and ASP)

Third Party Value of Aggregated Data Health Data for Sale September 12, 2006 The transfer and sale of personal health information is proceeding largely unregulated, according to an expert panel assembled by the American Medical Informatics Association in a newly issued report. Despite the requirements of HIPAA (Health Insurance Portability and Accountability Act) health care information is routinely being exchanged that is not anonymous, according to a report from the AMIA. Another even more problematic privacy violation is the "ongoing buying and selling of non-anonymized patient and provider data by the medical industry without explicit consent of either patients or physicians." "Patients do not know who has access to their data and for what purposes. The expert panel learned of financial incentives for sharing of patient data that raises ethical questions," said AMIA chairman Paul Tang.

If you use PITO funds What are you buying into? 1) EHR – Infoways vision and core data set 2) ASP data storage 3) Ministry CDM Toolkit 4) Functionally Trilateral contract

Ministry’s electronic CDM Toolkit: Many concerns Ministry’s toolkit is a mandated part of PITO funding . . . Increasing concern among physicians about the toolkit. While an electronic flowsheet helpful . Ministry’s Toolkit is much more . . . (flowsheet with an opinion.) Designed as a hardwired template for “judging and rewarding quality” in primary care . . Stepping stone to P4P . . . Guidelines should inform not compel . . . Doing it right isn’t always about following guideline . . . EBM is about incorporating co-morbidities and patient’s values and customizing care. . . . Significant potential for negative impacts on patients, profession and health system with Ministry’s e-toolkit

Concerns from UK over CDM-toolkit type initiative: QOF The Quality and Outcomes Framework: what have you done to yourselves? Br J Gen Pract, Mangin et al June 2007 By following a medicine-by-numbers path under the QOF, the profession cannot lay claim to its own knowledge base and priorities. At what point do we switch from educated professional to technician? Patient centredness is still (we think) a core value of primary care for GPs and for patients. It beggars belief how we could have arrived at a point where the very nature and content of the doctor–patient encounter is prescribed by the state. This loss of professionalism has profound implications and may result in a change in professional values. . . The focus has shifted from patients and the diseases that make them suffer, to the diseases themselves and their measurement within the patient.

The Quality and Outcomes Framework: what have you done to yourselves? Cont’d QOF by its nature promotes simplicity over complexity and measurability over meaningfulness We do have an alternative. Most GPs wish to do a good job. Most recognize that where there is clear evidence that a particular course of action or inaction will result in benefit or harm, then their role as advocate for their patients is to make them aware of those options. We can advocate for a system which promotes evidence-informed care . . . and provides options (with attendant uncertainties) for GPs and patients to interpret for themselves” (i.e. In BC - That means not entering data into Ministry’s CDM toolkit or accepting PITO funding. PITO funds are contractually connected to toolkit.)

If you use PITO funds What are you buying into? 1) EHR – Infoways vision and core data set 2) ASP data storage 3) Ministry CDM Toolkit 4) Functionally Trilateral contract Between Vendor and Ministry and you Vendor’s prime customer Ministry? Primary payor you? Primary benefit accrues to - Ministry?

If you take Regional Funding: What are your buying into? Sharing office patient data with Health Region . . . Privacy implications unclear Details unclear due to non-disclosure agreements (Does it seem right to fragment us all in this way and undermine our ability to learn from one another’s experiences)

PITO “Early Adopter” Program PITO has established the PITO “Early Adopter” Program for physicians who implemented EMRs prior to June 28, 2006. The Early Adopter Program helps offset the ongoing monthly costs of using their existing EMR at the standard 70% reimbursement rate for up to 18 months, contingent upon conversion to a PITOqualified EMR within those 18 months.

What happens at the end of the six year PITO mandate, would I inherit all future costs? The funding for this agreement expires in 2012. Prior to then, the BCMA and Government will determine the availability of ongoing funding through the negotiation process.

Overview of PITO Systems - Clinicare EMIS Intrahealth Med Access Osler Wolf

Open Source - OSCAR – developed at MacMaster - MOIS – developed in Northern Health Non-PITO

Open Source: As per Ken Kizer – former CEO of VA Testimony to house ways and means committee of US Senate Make Selection of Open Source Software the Default Mode for Federal Funds For the past twenty years open source software has been building momentum in the technical cultures that built the Internet and the World Wide Web. Open source has now established its viability in the commercial sector, and a major shift toward open source software is underway throughout the world. When using the term open source software I refer to software that is nonproprietary, available at no or minimal cost, allows different IT systems to operate compatibly, and facilitates collaboration in order to improve and enhance the freely accessible source code. A critical milestone in the history of open source was the creation of the Linux operating system in the 1990s. Linux demonstrated that open source development methodologies could deliver commercially viable technology to the market.

Kizer on Open Source cont’d In open source, the basic software is viewed as a commodity and its development is collaborative and shared by the community of users. Because contributions to enhancing the code come from many sources in an environment of collaboration, innovation is more rapid. Open source is much more consistent with a true free market approach than proprietary products that entail the infamous “vendor lock.” I am confidant that the federal government would save billions of dollars in licensing fees alone over the next 10 years by preferentially pursuing open source solutions.

Dutch government adopts open source software – Dec 2007 The Dutch government has set a soft deadline of April 2008 for its agencies to start using open-source software — freely distributed programs that anyone can modify Government organizations will still be able to use proprietary software and formats but will have to justify it under the new policy, ministry spokesman Edwin van Scherrenburg said. Many governments worldwide have begun testing open-source software to cut costs and eliminate dependency on individual companies such as Microsoft Corp. The government estimates it would save 8.8 million a year on city housing registers alone after switching to open source. Microsoft has raced to achieve "open source" certification for its Open Office XML standard, but has so far failed to receive endorsement from the International Standards Organization, the certifying authority recognized by the Dutch government. The Dutch policy directs government organizations at the national level to be ready to use the Open Document Format to save documents by April, and at the state and local level by 2009. http://ap.google.com/article/ALeqM5gKeb7SFzG8QLvOOlfdt cPMnFmwD8TGNLJ80

A Cautionary College Tale EMR contributed to child's death Excerpt from BC College Review "A young child was playing when he began to feel unwell, and shortly thereafter collapsed. Despite resuscitative efforts, he went into full cardiac arrest prior to transport to hospital. . . At postmortem, it was determined that this child had developed a fatal arrhythmia as a result of a congenital heart defect known as “idiopathic asymmetric hypertrophic cardiomyopathy.”

BC College Review cont’d “The College’s review of this event found that the child had received his medical care from a group of family physicians who used an electronic medical record. In reviewing that record, it was noted that in the three years prior to the death, numerous physicians had seen the child for minor illnesses. On several occasions, the child had attended a clinic where physicians had heard a heart murmur, which was appropriately recorded.”

College Review cont’d “Unfortunately, the clinic’s electronic medical record used a template that would “auto fill” systems as being normal, unless contrary information was entered. Therefore on other visits, when no physician entry was made under Cardiovascular System Review, the “auto fill” would result in the notation, “no history of murmurs or hypertension.” This denied previous clinical findings .” “Moreover, a chest X-ray performed while investigating the possibility of pneumonia stated that the child had cardiomegaly and suggested a specialist consultation. The report was noted by the physician concerned who arranged for a patient recall. Unfortunately, the electronic medical record could not flag the recall. Consequently, the family doctor thought that the recall was for a pneumonia re-examination.” “Physicians from this clinic also noted that navigating the electronic medical record was difficult, and allowed only for one small screen to be seen at a time. This made scrolling through the medical record awkward and time consuming.”

The Quality of Medical Performance Committee Conclusions Important to advise members that while the electronic medical record has many virtues, it also has the potential for some pitfalls worthy of attention: It is important to ensure that the electronic medical record has the ability to flag appropriate follow-up concerns. The system must be easy to navigate and allow for multiple screen options. The physician must never allow for an automatic template to fill in options stating “normal” when no such exam is performed.”

Also? – a CONTINUITY failure The child saw many different physicians No clear MRP or information flow through MRP EMR is not a substitute for the continuity of a central patient-provider partnership. An EMR or EHR cannot KNOW a patient or which things in an e-deluge of information MATTER

Building IT to support human partnerships Putnam on alloys of silicon and flesh wrt system architecture Building Electronic Connections to support and enhance human partnerships – IT systems cannot replace them or substitute for CONTINUITY of a relationship

Closing Questions What are you plugging into? What will be future costs? What shape would you like to see EHR take? What will implications of your choices today – be for you and your patients in the future?