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Canadians’ Access to Health Information – Current State Evaluation. Strategies & Planning 19 May 2017. DRAFT. Table of Contents. Purpose Executive Summary Context Set Up Canada’s State of Play Infoway investments Other initiatives International Scan Vendors
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Canadians’ Access to Health Information – Current State Evaluation Strategies & Planning 19 May 2017 DRAFT
Table of Contents • Purpose • Executive Summary • Context • Set Up • Canada’s State of Play • Infoway investments • Other initiatives • International Scan • Vendors • Trends & Leading Practices • Lessons Learned, Challenges, Success Factors • Observations • Appendices
Purpose • To summarize for EMC the current state of patients’ access to their health information by reviewing: • Infoway investments • Other Canadian examples • International examples • Influential reports • To review leading practices and make inferences to the Canadian context • To describe the challenges, barriers and enablers associated with patients’ access to their health information and describe prerequisites and dependencies to such a future state.
Executive Summary • With the exception of Nova Scotia’s and Alberta’s provincial initiatives, existing portals are tethered to a single source system and give Canadians access to data stored in only one location • Canadians cannot see an historic trail of all their visits to regulated health professionals and cannot enter their own information into their health record. • To date, Infoway has invested $36.7m in demonstration projects and challenges. • $17m in ON on tethered portals that provide limited functionalities in one system only • $15.1m in AB, NS and SK on portals that will provide multiple functionalities to all citizens • The patient vendor landscape is highly fragmented with potential for consolidation • Retail pharmacy patient portals appear to be “table stakes” with potential to enable strategic ambitions to expand services • LifeLabs appearing to be pursuing consumer facing Health IT as a strategic adjacent industry more so than Dynacare • Leading countries are viewing delivery of personal health information and catalyzing open innovation as complementary rather than distinct efforts • A credible industry analysis report highlights the need go beyond patient portals with broader and more integrated patient engagement
Context • In Budget 2017, the federal government granted $300 million to Canada Health Infoway so Infoway can continue • “…expanding e-prescribing and virtual care initiatives, supporting the continued adoption and use of electronic medical records, helping patients to access their own health records electronically, and better linking electronic health record systems to improve access by all providers and institutions.” • Minister Philpott regularly and publicly refers to Canadians’ need to be connected to strong primary care and have access their health information • In its 2017 vision document the Canadian Medical Association calls for meaningful use of electronic medical records and recommends “…enabling all Canadians to have ready access to their medical information from any location in Canada”. • In 2016, World Health Assembly approved the Framework on Integrated, People-Centred Health Services. One Way Forward Strategyis to Engage and Empower People and Communities by giving people access to their personal records. • Helping patients electronically access their own health records is one of Infoway’s three current priority areas. Engaging and empowering patients by giving them access to their personal health information is an international strategic priority and focus for Infoway
Set Up • The 2010 Consumer Health Solutions strategy adjusted the strategy for its $45m allocation to: • Co-invest in 1 province-wide jurisdiction portal project as originally defined • Co-invest in a number of smaller regional/local consumer health projects in jurisdictions that want to demonstrate, in part only, how consumer health solutions can be deployed • e.g., provide some of the following services: find provider, facility and service information; communicating with healthcare providers; viewing one’s health record; manage medication refills; book appointments with family physicians; and so on. • Invest in a few pan-Canadian projects that facilitate shared learning and foundation building with a view of supporting future consumer health solutions • e.g., focus groups to understand consumer priorities
CHS Patient Online Solutions – Infoway Investments • Consumer Health Program launched in 2010 • Initial investments in Wave 1 demonstration projects • 10 projects in 5 jurisdictions • Focus on e-visits, e-views, e-booking, e-request for prescription renewal/refill • First jurisdictional portal project approved in AB • E-Booking Initiative – 2014 to 2016 • Approximately 1,100 clinicians (family physicians, specialists, nurse practitioners) in 9 jurisdictions offered more than 110,000 Canadians the opportunity to e-book • Wave 2 Demonstration Projects 2015 – 2017 • 7 projects in 2 jurisdictions • Focus on e-visits, e-views, e-requests for prescription renewal/refill • Patient Online Solutions 2016 and beyond • Focus on spread and scale of prior investments • Priority given to jurisdictional / regional portals • Projects approved in BC, SK, ON, QC, NS
E-Booking Projects 1 This functionality enables individuals to electronically book an appointment by selecting a date and time for the appointment and receive an electronic confirmation of appointment booking, without interacting with another person.
Waves 1 and 2 – Objectives & Outcomes • Established to strategically invest in, and showcase, select initiatives with tangible value for clinicians and Canadians.
DEMO Wave 1 Projects 2 e-View e-Visit e-Booking Spread beyond original scope
DEMO Wave 2 Projects 3 Funded from 2007 “couch cushion” dollars. Original approved investment was revised to $4,607,180. e-View e-Visit e-Booking Spread beyond original scope
Geographical Distribution of Infoway Investments Additional pan-Canadian Initiatives: Better Health Together campaign, faculty / peer networks
Jurisdictional/ Regional Portals - Current State +Targeted Consumers Infoway funded *Achieved Targets for Infoway invested demonstration projects are not shown Infoway funded - planning +100,000 +30,000 +200,000 Not Infoway funded +500,000 +414,000 +109,500 +65,000 as of April 2017
ImagineNation Challenges 4 • 46 eConnect Impact Challenges received $936,015. • 12 addressed e-visits • 5 addressed e-requests for prescription renewals or refills
Targets vs Actuals: Infoway Portals • No targets are set for planning/strategy projects. | Most projects are in implementation phase with adoption scheduled to begin in next 12 months. Exception: NS is in adoption now. QC e-scheduling expected to start summer 2017.
Summary of Infoway Investments Amount Infoway has invested to date in demonstration projects and challenges (CHS and I&A) • $12.8m with jurisdiction governments • $9.1m with health regions/CCACs • $7.1m with hospitals • $5.4m with NGO/disease organizations • $1.3m with community health centres / family health teams • $0.9m with single site challenges $36.7m 35% 25% 19% 15% 4% 2%
Summary of Infoway Investments Of the $36.7m, Infoway invested: • 48% in Ontario • 33% in Alberta • 5% in New Brunswick and Saskatchewan • 4% in Nova Scotia • 2% in British Columbia and Quebec • 1% in Manitoba • <1% for a national project Current provincial portal
Examples of Other Initiatives in British Columbia • Meditech’sMyHealthPortal initially launched at Shuswap Lake Hospital in Salmon Arm. Eventual staged roll-out to all communities. • Excelleris’ my ehealthgives patients access to their lab test results and is available in BC (LifeLabs, BC Biomedical, Vancouver Coastal Health, outpatient only, Providence Health Care, outpatient only, Fraser Health, outpatient only, Valley Medical Lab) and ON (LifeLabs only). (> 1 million users) • Fraser Health has signed a Letter of Intent with Sunnybrook Hospital (ON) to explore using Sunnybrook’s MyChart. • Island Health has a vision to deploy the Cerner patient portal in the future. • Northern Health has been in discussions with Telus, Relay, and NexJ about customizing a portal/PHR offering for that environment. No deployment yet. • PHSA/VCH/Providence have in their vision to include the deployment of the Cerner patient portal at some point when implementation of the CIS is further along. • Intrahealth has a portal for its EMR product (Accession Patient). • Some private clinics e.g. Continuum & Olive Fertility have client portals.
Examples of Other Initiatives in Alberta • MyChart by Epic is the patient portal in e-Clinician installed in Alberta Health Services and a limited number of community sites. Key features: patient access to health information (labs, DI, meds, allergies, problems, etc); appointment management/scheduling; secure messaging with healthcare team; patient-entered (some) • Healthquest EMR by Microquest provides e-booking that allows patient to go online and schedule their own appointments. • Cliniconex is an independent application used with different EMRs and provides patient reminders (voice, email, text) for appointments, recalls, preventive care, patient surveys, booking notifications, broadcast messages, health program promotion. (in AB, integrated with Healthquest, Telus EMRs, Wolf, Med Access, PS Suite) • Dr2dr secure messaging by Microquest is free to all Alberta Medical Association members. (no expansion to patients yet) • QHR Medeo Virtual Care provides secure online booking, virtual care (video visit via computer or smart phone), messaging and file sharing. • Secure Health Exchange by Brightsquid providers secure encrypted messaging between physicians, patients and other health professionals. Key features: secure messaging for appointments, attaching forms, sending appointment reminders; attaching questionnaires to messages; messaging medical advice to patients; e-consults between physicians • Telus created patient portal integrated into Wolf EMR. Key features: access health information (labs, meds, medical summary, reports); appointment view/book; messaging; notifications; print reports
Examples of Initiatives in Ontario • In 2012, McMaster University received $5.8 million from the federal government to create a personal health record, MyOSCAR, a partner to OSCAR, an electronic health record that is used by more than 2,000 physicians in Canada. • The recently rebranded, kindredPHR,is integrated (only) with OSCAR EMR and features the following functionalities: secure messaging, data sharing (immunization, allergy, medications, lab), appointment booking. Documents sent to Kindred are saved as individual documents with the associated meta-data stored in MySQL relational database. • The Digital Health Solutions and Innovation Branch, Ministry of Health and Long-Term Care is proposing to build a Patient HealthCare Browser, based on one provincial authentication scheme (SecureKEY) • The Health Myself Patient Portal extends the functionality of industry leading electronic medical record systems (single providers, family health teams) by providing an integrated web-based interface that allows patients and providers to engage online in a secure and convenient manner.
Ontario – Sunnybrook MyCHART Portal • As Sunnybrook expands MYCHART, those organizations can decide on which functionalities to implement. • This can be considered as a concept of what is possible based on the current technology/solution: Alerts/Notifications Allergies Advance Care Planning Announcements - All or Targeted AODA Compliance Appointment Requests Appointment Requests/Scheduling Appointments Scheduled Audiology Testing Automated Reminders Automated Rheumatology Appointments Batch Enrollment Cardiology Self Monitoring Tools Communication (eReferral, Family, Circle of Care) Content Mgmt (Patient Education) CPSO Directory (lookup) Delegation Capability (granular access) Discharge Summary eCare Customized Care Plans EEG EKG EMR Integration (expand to primary care) FHIR Interfaces Genetics Screening Global Access Hospitals (Connected) to PHR (Ontario) Immunizations Lab Results Life Labs/CML Medic Alert Medical Imaging Appointments Medication History - DHDR Mental Health (module) Mental Health and Addiction Tools Mental Health Assoc (Connected) Mobile OLIS Pathology Patient and Family Engagement - Surveys Personal Diary (symptoms, search, trend) Provincial Asset - DHDR Provincial CHRIS system Integration Quality of Life Survey Questionnaires Radiation Oncology Radiology (reports and images from hospital RIS system) Rheumatology Automated Appointment Reminders Scheduling Secure Messaging - eVisits Secure Messaging - eVisits/Referrals Self Entered/Trending Blood Pressure Monitoring Self Entered/Trending Glucose Monitoring Self Entered/Trending Measurements Self Entered/Trending Weight Tracker Symptom Diary/search/Trend Test Result Upload Transcriptions (Clinical Notes)
Canada’s Patient Portals – Summary Primary Care Physician’s EMR Hospital Specialty Clinic Retail Pharmacy Insurance Company Medical Laboratory Private Clinic With the exception of Nova Scotia’s and Alberta’s provincial initiatives, existing portals are tethered to a single source system and give Canadians access to data stored in one location. Patient Portals in 2017 Canadians cannot see an historic trail of all their visits to regulated health professionals and cannot enter their own information into their health record.
Australia • New Australian Digital Health Agency created in 2016 reset • Recently completed a “National Digital Health Strategy consultation” • Over 4000 people consulted • National Patient Portal - MyHealthRecord • Online summary of health information • Consumers can share their health information with care providers • Consumers can access their children’s and dependent’s records • Claim approximately 20% of Australia’s population is registered • Developer Program facilitates innovation with MyHealthRecord • Based on approaches of Amazon, Google and Apple • Offers data, tools, proactive support, account management and co-design Recent reset and broad national consultation to set future strategy https://www.digitalhealth.gov.au/implementation-resources/digital-health-developer-program
Denmark • National Patient Portal - Sundhed.dk • Sundhed.dk is the official portal for the public Danish Healthcare Services • Provides general health related information to citizens and health care professionals • Displays information, does not store information • Most information is read-only; with a few exceptions, e.g vaccinations, organ donation • History of Sundhed* • Unique citizen personal ID since 1968 • Achieved critical mass by first focusing on common foundational components - referral letters, discharge letters, prescriptions and lab results • Clear and strategic vision delivered by Danish health authorities • Strong engagement across sectors and specialist fields Time and commitment to deliver the basics and build critical mass *Australian National E-Health Transition Authority, Evolution of eHealth in Australia Achievements, lessons, and opportunities, April 2016
NHS England • National Online Access Point - NHS Choices • Multi-channel service for everyone engaging with the NHS and social care • Comprehensive health information service with articles, videos and tools • Directoriesto find and compare health, support and social care services • Published reviews and ratings across health and social care services • Daily analysis of health-related stories • Summary Care Record (SCR) • Store a limited range of data for all patients except those who opt out • GP practices are required to provide an automated upload • Created for over 90% of population • Current overarching strategy is packaged as “Paperless 2020” • Top priorities - “Patient engagement: Self-care and prevention”, “Urgent and emergency care” and “Transforming General Practice” • Other priorities- “Integrated care and social care”, “Digital medicines” (choice in where and when meds are delivered), becoming “Paper free at the point of care” Unified online access point, Summary Care Record, Achieving “paperless” Australian National E-Health Transition Authority, Evolution of eHealth in Australia Achievements, lessons, and opportunities, April 2016
New Zealand • Health IT use considered among the highest in the world • All of the country’s general practices use an electronic medical record • Long-established and universally used unique patient identifier • ~2015 strategy shifted focus from regional to national approaches • Working towards a single EHR that would physically store the information in a consolidated repository • National Patient Portal - ManageMyHealth™ • Access to PHI from any device anytime from anywhere • PHI uploaded from provider practice management systems • Stores other health-related information - other treatments or medications • Delivers health related news, forums, and access to wellness initiatives • More digital services planed Recent shift from regional to a national approach Australian National E-Health Transition Authority, Evolution of eHealth in Australia Achievements, lessons, and opportunities, April 2016
Sweden • Single online access point - 1177 Vårdguiden(care guide) • Swedish residents first point of contact with healthcare • Enablers secure information exchange between patients and care providers • Digital self-service e-services • Online access to electronic health records from the majority of the EHR systems of Sweden’s 21 county councils and 300 municipalities • Appointments e-service has had a linear increase in patient transitions, starting at 25K per year with a current rate of 1.2 million per year • Current efforts are focused on • Delivering telemedicine services through a national platform for remote treatment programs • The ability for the patient to share EHR data with apps and services • A national architecture for personal connected health (home monitoring) … Presentation to UAE eHealth Week, HIMSS Middle East, Johan Eltes, Swedish Association of Local Authorities and Regions, Inera AB, Deputy CTO, November 2016
Scotland • Articulation of “Technology Enabled Care” • “… the convergence of health technology, digital, media and mobile telecommunications and is increasingly seen as an integral part of the solution to many of the challenged facing the health, social care and wellness sectors, especially in enabling more effective integration of care” • A collective term for telecare, telehealth, telemedicine, mHealth, digital health and eHealth services • Published National Action Plan for Technology Enabled Care in 2016 • Vision: Scotland is an international leader in technology enables care • Emphasises shifting to greater self-management and independence • Overarching aim to contribute to preventative and personalized care • Shift in focus from technology, care supported by technology • Change to be service led and outcomes driven A National Action Plan for Technology Enabled Care
General Vendor Landscape • Fragmented market with potential for consolidation • e.g. - United States ONC Certifies 102 Patient Portal products • Large vendors span all market segments • Government and private payersand primary, secondary community and integrated delivery organizations • Smaller vendors typically focus on one or two market niches • Two notable Canadian start ups have consumer pay business models for aggregating personal health records
Tethered vs Stand-alone Portals • Two broad categories of patient portals • Stand-alone portals are often regional or national • e.g. Australia, Denmark, Sweden Gartner, 2016 Hypcycle for Consumer Engagement
Company • Based in Rockville, Maryland in the United States • Established 2001, currently 500+ employees* • Rated best patient engagement solution by Chilmark 2014/2015 • Products • InstantPHR – patient engagement: patients and providers share data, communicate and collaborate • CHBase - data aggregation and development platform: combines clinical and patient generated data • Example deployments • Saskatchewan – solution for provincial patient portal • New York Presbyterian – “portal-of-portals” solution for “MyNYP” • Sweden – solution for combined patient portal and innovation platform • TELUS Partnership • 2011 - TELUS Health becomes InstantPHR partner for Canada • 2013 - TELUS Ventures invests in GetRealHealth • 2016 - TELUS Health becomes CHBase partner for Canada • Dave Wattling on GetRealHealth Board of Directors • Other notable Telus Ventures Investments • SecureKey – authentication and identity mgmt. • PatientSafe- Point-of-care mobile solutions • Sentrian- Remote Patient Intelligence: biosensors and machine learning to prevent hospitalizations • Sprout - Employee Wellness Engagement Platform *according to LinkedIn
Company • Based in Emeryville, California • Subsidiary of McKesson Technology Solutions (10,000 + employees) • Products • Variety of solutions that span clinical integration, connectivity and care coordination, pharmacy claims adjudication, health information exchanges, and web-based learning • Claim new “Fuse” solution to be a healthcare data platform that acquires and aggregates clinical, financial and operational data at scale across settings • Sample Deployments • Nova Scotia – provincial patient portal • US Department of Defense - patient engagement solution (selected April 2016) • Minnesota Community Healthcare Network – enabling interoperability amongst 5 member orgs • CommonWell Health Alliance (RelayHealth is the service provider) • Person Enrollment – registers and uniquely identifies each patient • Record Location – ‘virtual table of contents’ that specifies available locations for patient info • Patient Identification and linking – links individual records across care continuum • Data Query & Retrieval – enable caregivers to search, potential select and receive data
Retail Pharmacy Landscape • The Canadian market is dominated by McKesson & Loblaw • McKesson controls 27 per cent share with 2016 Rexall acquisition: 2012 acquisition of ~1,100 franchised IDA and Guardian locations, 2016 acquisition of ~470 Rexall stores (both from Katz Group) • Loblaws-Shoppers controls 22 per cent with 2013 acquisition of over 1,300 Shoppers Drug Mart & Pharmaprix (Quebec) locations • McKesson is also the largest wholesaler of pharmaceutical products in Canada, supplying approximately 7,100 pharmacies across the country • Other major chains have fewer stores and less geographic coverage • Jean Coutu (417 stores in QC, NB, ON), Pharmasave (550 stores in nine provinces), Uniprix (375 stores in QC), London Drugs (78 stores MB, SK, AB, BC), Lawtons 79 stores in Atlantic Canada) • Retail pharmacies could improve community-based primary care • Some view Canada’s 9,500 retail pharmacies as convenient, ready-made, professionally staffed primary care hubs
Value of patient portals for Retail Pharmacy • Table stakes • There is limited functional variation among large retail pharmacy chains • Patient portals appear to be currently accepted as a competitive requirement more than differentiator • Customer loyalty & insight • Strengthens loyalty with medication profile, transactions, and additional marketing channel • Data gathered provides insights into customer medical profile and associated consumption behaviors • Services expansion • Each of five strategies in the Neighbourhood Pharmacy Association’s “9000 Points of Care Strategy can be, to greater or lesser degrees, enabled and/or enhanced by patient portals
