On May 28, I keynoted the Canadian eHealth 2012 Conference, focusing on the need to innovate in the areas of EHR usability, frictionless health information exchange, novel analytics, patient/family engagement, and privacy protection.
Here's the presentation I used.
I talked to dozens of people during my 24 hours in Vancouver and I believe there are 5 areas that Canadians should address to enhance their national healthcare IT program.
1. Enable innovation via grant programs, competitive challenges, and high risk/high reward projects for emerging technologies, recognizing that traditional procurement approaches can inhibit innovation. Procurement generally includes complex legal boilerplate plus certification that the technology is already running in referenceable customer sites. No innovative startup is going to agree to these terms and conditions. Customer references for new technologies are likely to be scant because it is evolving so fast. Traditional procurement approaches are likely to acquire technology at the end of its lifecycle.
2. Prioritize Patient and Family engagement - to date, much of the Canadian healthcare IT program has focused on acute care hospitals. Although some patient portals have been created, there is no national priority to engage patient and families. Given the importance of shared decision making, keeping the patient informed, and transparency, encouraging interoperability with patients is key.
3. Consider a Meaningful use type program even thought it may be politically unpopular among clinicians. Canada has encouraged clinicians to acquire technology and has set interoperability standards nationally. However, it has not specified the best practices for using the technology or held clinicians accountable for their IT behaviors. There is a fear that pushing the clinicians too far too fast will result in their leaving Canada to practice elsewhere.
4. Clarify the strategy for healthcare IT at a national level. Canada Health Infoway has done a remarkable job with standards and defining infrastructure for data exchange, but healthcare IT implementation is done on the provincial level. It's not clear that the Canadian Prime Minister thinks about healthcare IT or has set priorities that must be followed by all provinces.
5. Standardize outpatient/ambulatory EHRs with the same vigor that Canada has used for acute care settings. Canada has many advantages over the US to accomplish the interconnection of ambulatory records - 30 million people (1/10 of the US), a publicly funded universal healthcare system, and a provincial level healthcare identifier. It does have a challenge ensuring the connectivity of all providers across its diverse and sometimes remote geography. Creating a certification program for ambulatory EHRs and ensuring they adhere to functional capabilities and interoperability standards will enable data sharing for care coordination and population health.
The Canadians are a warm, enthusiastic, and thoughtful people. I look forward to continued collaboration and learning from each other as we implement new healthcare information technologies.
John,
ReplyDeleteThanks so much for your insights. I could not agree with you more. We are doing many of the things you suggest. The balance are in the next generation of our eHealth strategy which is in development and we hope will be funded. Our CEO, Richard Alvarez, shared that strategy with the audience the day after you spoke.
Here are my responses to each of your numbered points:
1. Procurement does present some challenges, especially since most of health care is in the public sector. On the other hand, we are facilitating many innovation projects. To date, Infoway has approved $25.5M for 27 projects. We have also launched some challenges, with some still underway, to highlight and stimulate innovation. In 2011, Infoway hosted its first public Challenge, called the ImagineNation Ideas Challenge. Canadians were asked for bold new ideas to transform health care using information technology. Through the ImagineNation Outcomes Challenge, Infoway is challenging Canadian health care professionals to demonstrate the use and growth of e-solutions in their practices or organizations through this team-based Challenge. The challenge is focusing on four key areas:
- e-Scheduling
- Patient Access to Information
- Clinical Synoptic Reporting
- Medication Reconciliation
I really liked your mention of agile development and deployment for BIDMC. In my recent talks I have promoted “apps for infostructure”. These are small and more agile deployments over big, monolithic procurements and deployments. These “apps” are solutions or callable services for certain functions. An example: incremental deployment of discrete CPOE services rather than a big, monolithic deployment (including process re-engineering, change management and training).
2. Actually, we have not spent any of our investment on acute care. Rather we have focused our efforts on the interoperable EHR which is designed to share data across the continuum of care. These data include medication orders and dispenses, allergies and intolerances to medications, lab results, DI images and reports, clinical reports (e.g. discharge summary), encounter history and problem lists. Recent investment has focused on EMRs for GPs and community-based specialists, and EMRs in ambulatory care. For all three, emphasis has been on connectivity to the EHR. We do lag in patient portals and engaging families, but that work has started in some of the more advanced provinces like Alberta. The key theme of our new strategy is “Enhancing the Patient Experience” which encompasses everything else you suggest.
3. We do have a concept similar to Meaningful Use, called Clinical Value. Some of our investment dollars are tied to clinicians using their EMRs effectively based on certain features/functions such as access and viewing of lab results and e-prescribing. There is accountability for clinical use, but not as high a percentage of the dollars is tied it as in the US. We envy you for that approach and the legislation backing it up. We don’t have that legislative stick, only the carrots.
4. Infoway does develop national strategies in consultation with our stakeholders. As you point out, health care is a provincial/territorial responsibility. Each is in a different place (i.e. current state) and each has slightly different priorities for their eHealth investment. Thus, Infoway is quite flexible on what they do and when they do it, albeit our interest to invest is within the framework of our Board approved strategies.
5. We do have a certification program and have had for a few years. It is growing now. A percentage of our investment dollars for the outpatient/ambulatory EMRs are tied to the vendor completing certification. Those criteria include functionality and interoperability with the interoperable EHR, along with privacy and security.
Thanks so much for you remarks. We do study and learn from others. I love Doug Fridsma’s view on that: “We know we will make mistakes. We just want to make different ones by learning from others”.
Dennis Giokas
CTO
Canada Health Infoway