Trends in Global Healthcare Informatics

1. Trends in Global Healthcare Informatics Jonathan Edwards NHS Scotland Conference, Glasgow 11 June 2007

2. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

3. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

4. Cost Source: United Nations, World Population Ageing 1950-2050 (2001) The Triple Healthcare Crisis Quality Source: HealthGrades Third Annual Patient Safety in American Hospitals Study 2006 Access

5. Where Can IT Help, and What Arethe Barriers? Government: • Short-term fixes for long-termproblems • IT is a distracting game • Lack of leadership Citizens keep healthy and report problems early Chronically ill patients actively participate in managing their conditionsfrom home or on the move Clinicians incorporate evidence-based medicine at the point of care Health System: • Unclear ROI • Atomisation • Misalignment of incentives Clinicians have all necessary patient data appropriately organized, with active decision support CDOs consolidate back-office functions CDOs know their cost of care and can ensure efficient resource allocation Technology: • Low Automation • Vendor Immaturity • Difficult to implement Government and private payers use outcomes data to link paymentto effectiveness of care Governments use data to reduce fraud, improve bio-surveillance,and better manage access

6. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

7. POE & Order Management Display/ Dashboard Doc. and Data Capture ClinicalKnowledge Management Clinical Workflow Clinical Decision Support CMV/VOSER Clinical Data Repository Interoperability CPR System Management The Computer-based Patient Record: Gartner’s Definition

8. 1993 1998 2005 2010 2015+ Five Generations of CPRs Full Gartner has identified only two enterprise CPR systems that have reached Generation 3 Generation 5:The Mentor Generation 4:The Colleague Functionality Generation 3:The Helper Generation 2:The Documentor Generation 1:The Collector Minimal Availability of Products

9. Medical informatics committee Knowledge management Clinical documentation Clinical data repository Clinical data warehouse RFID & bar coding Business intelligence Six Sigma Security Workflow Location sensing Lean manufacturing Real time feedback Controlled medical vocabulary Computerised order entry Evidence-based medicine Chief medical informatics officer Medication management Clinical decision support Use the CPR to Optimise your Clinical Performance Generation 3 CPR Demonstrable Clinical Quality and Efficiency  Match Expenses to Income Improved Outcomes Reduced Errors Regulatory Compliance Pay for Performance Care Guidelines Evidence-Based Practice      

10. Localautonomy Lackof clinicianengagement RadicalNHSreforms Poordata qualityand reporting Inadequatevendorperformance Costs ofchange managementand implementation CPR Case Study: NHS National Programme for IT, England CPR

11. CPR: Recommendations for Care Delivery Organisations • CPR products are immature: proceed cautiously • Set both end users' and management’s expectations correctly • Push vendors to ensure they deliver the value promised • To gain maximum value from the CPR, ensure that clinicians are in the lead • Chief medical information officer (CMIO) position • Clinician champions (physician, nurse, pharmacist) • An informatics committee to help with decision support, best practices and evidence-based medicine • Remember that CPR implementation is a dynamic process and not a static event • Successful implementation requires clinical optimisation

12. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

13. Health Information Exchanges: Be Bold but Also Be Cunning Privateand Public Hospitals GPs Lab, Radiology etc. Pharmacies PatientSummary/SharedRecord GovernmentAgencies Patients

14. HIE: Who, What, Where? • Europe • Denmark: MedCom, portal, national databases (in use) • Italy (Lombardy): CRS-SISS Health Portal (in use) • Scotland: Emergency Care Record (in use) • Spain (Balearic Islands): Patient summary (in use) • Sweden: Carelink (in design) • England: NHS National Programme for IT (in design) • France: Dossier Medical Personnel (in design) • Finland: Patient summary (in design) • Netherlands: NICTIZ Out of Hours and Medication Records (in design) • Germany: Health card (in preparation) • United States • Regional Health Information Organizations (RHIOs): two are operational • Four National Health Information Network (NHIN) pilot projects complete • Canada • Canada Health Infoway • Asia-Pacific region: Australia, NZ, Singapore, Hong Kong… “My wheel is betterbecause it’s differentfrom yours”

15. Seven Essential Functions of an HIE • Shared health record: “patient summary” • Identification: Patients, users, organisations • Information security: Role-based access control, authentication of user identities, logging of activity • Support for policies governing patient consent for data sharing • Message routing system • Information standards: Message and document formats, clinical terminology • Support for external information requests

16. Optional Extra HIE Functions: No Substitute for Local Applications • Appropriate use of an HIE • Appointment booking, but beware of the business changes it brings • Patient portal, but beware of letting patients view or alter their own records • Inappropriate use of an HIE • Electronic visits • Databases of drugs and devices • Online medical libraries • Care pathways • These functions must be provided in local applications • CPRs at hospitals, EMRs at GP offices • You need integrated applications, not books on a shelf!

17. What Denmark has Achieved withClinical Information Sharing • 5.3 million people • EDI-XML is used for 80% of all messages in the health system • Discharge letters, referrals, lab requests, lab results, reimbursements, prescriptions • This took them 8 years! • Data repositories for prescriptions and acute clinical records • Healthcare portal: access records, renew prescriptions, book appointments, have e-visits, get quality data • They say that thanks to this, information sharing is • More effective (clear, accurate, complete, consistent) • More efficient (rapid, low-cost) • More widespread • A typical Danish GP saves 30 hours/week of secretarial support • Clear cost benefits, but only anecdotal evidence of clinical benefits • How to measure the clinical value of information-sharing?

18. How Did Denmark Succeed? • Gradual approach with realistic time frames • Met basic needs first, then added • Continual monitoring, evaluation, transparency • Local implementation and training to ensure clinician adoption • Balance between central and local leadership • Aligned incentives of providers, payers and vendors • Created a culture of consensus • None of this is special!

19. Country Name Description Challenges Achievements U.S. National Health Info. Network A Connector of independent networks (no hub) Heterogeneity and viability of networks Prototypes complete; trial implementations Canada Infoway An Investor in self-sustaining projects (9 areas) Consistency across jurisdictions Ongoing implementations across Canada Denmark MedCom A Developer of messaging standards Technology refresh, security Operational;wide use, clear benefits France Dossier Medical Personnel An Incentiviser of electronic patient record usage Politicisation, clinician acceptance Pilots complete; seeking national hosting provider England National Programme for IT A Leader of a comprehensive infrastructure program Relevance, politicisation, scope, perceptions Operational; some projects are complete, some struggling National Health Information Organisations: Divergent Approaches in an Immature Market

20. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

21. Process Monitor Diagnose Triage Consult Procedure Application Home health monitoring Remote ICU Telepathology, Telederm., Telecardiologyetc Call Centers E-visits Video-conferencing Remote surgery User Adoption and Staffing Financial Justification Integration with GP systems Legal and Licensing Telemedicine: Needs a Push From Government Transformational potential, but only tactical usage today How to move from pilots to services? GovernmentRole

22. Telemedicine Case Study: U.S. Veterans Administration How many patients? • Home Telehealth (monitoring): 21,000 patientsGeneral Telehealth (VTC): 17,000 patients • Store and Forward (diagnosis): 7,600 patients How did they do it? • Care coordination program • Enterprisewide CPR system • Telemedicine incorporatedin existing health services • Financially self-sustainingin each local network • Standard processes for implementation and treatment • National contracts for devices and applications • “Federal supremacy” But their total eligible population is 70 million!What if they extended this to well patients? Benefits reported? • Fewer bed days • Fewer outpatient visits • Better access to care in remote areas • Lower travel costs • Better sharing of expertise

23. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

24. Azn Mr Jonathan EdwardsAge 70GenX Insurance O Health Cart Help View My Profile Hip replacementsnear London W3 4NG 1- 3 of 3 items Facility Waiting Time Quality Rating Your Payment Action St Luke's Hospital 21 days 7/10 view full report €2450 3 kilometres distanceDirections 3 safety violationsin past 12 months 3 days New Hip Centre 8/10 view full report €49 27 kilometres distanceDirections 2 safety violationsin past 12 months Select surgeon Book initial visit Book operation Hipsters 15 days 9/10 view full report €139 89 kilometres distanceDirections 0 safety violationsin past 12 months Web 2.0 in Healthcare:Application Integration, not Second Life

25. Agenda • Why does healthcare IT matter, and what are the opportunities and challenges? • What are the most important areas of investment in healthcare IT today? Benefits, case studies, lessons learned • Computer-Based Patient Record systems • Health Information Exchanges • Telemedicine • The future? • Recommendations

26. Recommendations for Governments • Enact bold but sensible reforms enabled by IT • IT is not a solution • Don't try to mandate common CPRs • Establish common standards, then delegate leadership to local clinicians • Take the lead in health information exchanges • But ensure that they offer healthcare providers clear business value • Develop them through specific projects, not grand visions • Promote remote health monitoring and call centers • Help resolve the legal and licensing obstacles to telemedicine • Don't get caught up in the hype of Web 2.0 • Avoid “second lives”; concentrate on application integration • Others can provide inspiration and humour, but forge your own path • Build on your strengths!

27. Trends in Global Healthcare Informatics Jonathan Edwards NHS Scotland Conference, Glasgow 11 June 2007