Integrated Care Records: An international perspective

1. Integrated Care Records:An international perspective Marc Berg Integrated Care Records: Problems and Solutions Workshop December 11-12, 2003 Edinburgh

2. Overview • State of the Art: optimism or pessimism? • Why has the Holy Grail been so difficult to find? • Some solutions solve many issues, but not the problem… • How to make the next step? • Example: Integrated Medication Management

3. EPRs in Integrated Care • EPR for GP’s? • Some progress in UK, Scandinavian countries, the Netherlands, Australia • Integrated EPR? • No; but: • Much data exchange • GP – pharmacy • GP - hospital • GP – laboratory • But systems remain very loosely or non-integrated

4. EPRs in Integrated Care • The promise: truly redesigning care paths across institutional borders through ICT • Stroke care • Integrated Diabetic Care • Heartfailure Care • …. • In US? • Not through ICT as much but through institutional mergers • In HMO’s, integrated primary care is at least a theoretical possibility

5. EPRs in Integrated Care • In Europe? • No, but many local experiments • Integrated Diabetic Care Record • Nurse doing retinal imaging, physicians checking at a distance • ‘Software guided nurse’ for Heart Failure and Cardiovascular Prevention • Dermatology clinics (telemedicine supported) etc. • Etc...

6. EPRs in Integrated Care • EPR for GP’s • Integrated Primary Care EPR • Integrated Primary Care Redesign using IMIT • Optimism or Pessimism ... • ... But progress is slow! • Many projects fail • Many projects that initially succeed subsequently come to a standstill • ‘Diffusion’ very slow

7. Medication Management • State of the art:(GP, pharmacy, specialist, hospital pharmacy) • Paper-based (often still handwritten) medication order is standard

8. Medication Management • State of the art:(GP, pharmacy, specialist, hospital pharmacy) • No single care professional has routine, integrated access to complete medication record of patient

9. Medication Management • Research in Western countries: • Between 5 – 15% of medication orders contains mistakes • ... 10 – 25% of these result in adverse drug events

11. IT supported medication management: the dreams • Electronically available pharmaceutical protocols • Electronic storage and retrieval of medication information in (virtual) medication record • Electronic transmission of medication orders / Ordercommunication • Decision support • Computer-based medication evaluation & review • Automated medication distribution systems • Barcode medication administration systems

12. IT supported medication management: the reality • Many local initiatives; e.g. local GP – pharmacy links and data exchange • Hospital pharmacies often have electronic medication record, sometimes available throughout the hospital, sometimes with computer-based medication evaluation & review

13. IT supported medication management: the reality • GP’s may prescribe electronically – but patient takes printed medication order to pharmacy • Island automation; infrastructure of hospitals, GPs and pharmacies too often operate independently • No single care professional has routine, integrated access to complete medication record of patient

14. Why this discrepancy between ‘dream’ and ‘reality’? • Technical limitations? • No: all dreams are technically feasible • (all the different aspects have been realized somewhere, sometime) • Limited standardization? • No: standardization is not self-evident, but there is enough of a basis to realize the different dreams

15. Why this discrepancy between ‘dream’ and ‘reality’? • In Europe, problems are hardly felt by those professionals that are most central (GP’s, Specialists): • Many prescription mistakes are solved ‘later on’ in the medication chain • By nurses • By pharmacy assistants • By GPs (when specialist-generated) • By patients • Problems due to ‘breaks’ in the medication chain emerge elsewhere in the chain • (contrast US: liability claim-problems result in large investment and core attention to ‘safety culture’)

16. GP Pharmacist Efficiency Specialist Hospital Pharmacist Safety Politics of Medication Systems

17. Why this discrepancy between ‘dream’ and ‘reality’? • There were the problems are prioritized… • … and the possibilities of ICT are seen … • … one too often aims to build a Porsche to drive the muddy roads that constitute the health care ‘information highways’

18. Porsche I: • Decision Support for physicians during prescription process: • Is often turned of or ignored • ‘Government on my desk’ • To give relevant, clear and not too many or repetive advices/reminders is not an easy task • In many situations, it is not the end-responsible care giver that enters the medication! • Is the ICT infrastructure available???

19. Porsche II: • Electronically available pharmaceutical guidelines • Are very labour-intensive to create, and require much inter-professional and inter-organizational cooperation • Yet electronic versions have little added value over paper versions: • … a common set of pharmaceutical guidelines will only be truly useful as part and parcel of a common medication management system… • … and such systems are as yet far from common

20. Porsche or Pick-up Truck? • Porsches will hardly be able to function on the muddy roads. Nor will they solve the core problem of primary care medication management: No single care professional has routine, integrated access to complete medication record of patient • This results in communication errors, confused patients • This results in errors in prescription, diffusion and administration • Without such a basis, added functionality cannot give added value

21. Porsche or Pick-up Truck? • This results in communication errors, confused patients • This results in errors in prescription, diffusion and administration • Without such a basis, added functionality cannot give added value In such a situation, aiming for a sturdy, simple Pick-up Truck to carry basic information back and forth is a better strategy than attempting to build a Porsche for an infrastructure that is as yet non-existent

22. What’s the strategy? • Search for the most urgent problem from a quality of care perspective • No insight in total medication profile • Find a problem definition that is shared (as much as possible) between parties • Medication management discontinuities (‘breaks’ in the chain) • Bring political issues out in the open! • ‘Merely technical’ solutions often contain hidden agenda’s

23. What’s the strategy? • Search for the most urgent problem from a quality of care perspective • Find a problem definition that is shared (as much as possible) between parties • Bring political issues out in the open! • Build upon already started, promising initiatives (motivation, ‘champions’, organizational structures) • Search for low-tech, robust and cost-effective solutions • Local IT networks vs National database? • Make one, result-oriented step at a time, and let the health care field and the technology evolve together

24. Example: from Pick-up Truck to Porsche? 1) (Electronic) overview of patient medication at point of care Simple, proven technology is to be preferred 2) Electronic order communication for GP and Specialist (separately developed) Electronic medication order messaging between physician and pharmacy 3) Build in selected protocols in the order communication system E.g. for patients treated by GP and specialist, diabetes, etc. 4) Active decision support Optimal integration of decision support functionalities with health care work still requires much research

25. Towards multidisciplinary electronic records: beware of the Porsche fans! • Final benefits are to be found in measured redesign and standardization of care delivery processes, made possible by IT. • Reaping these benefits is not self-evident: truly multi-disciplinary (medication) records will require a substantial cultural – and organizational transformation. • IT can stimulate organizations to get there • Through the Pick-up Truck, drivers realize the benefits of fast transportation • Through the common, sturdy design and the lack of specialized functions or specifications, other parties can join easily. • .... Yet it can also prevent organizations from doing so • The Porsche won’t work or will get stuck in the first muddy or dusty through-road