EMR A non-techie’s overview

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

2. 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?

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

4. 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)

5. 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

6. 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".

7. 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,"

8. 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)

9. 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?

10. 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?

11. 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

12. BCMA Policy PaperGetting 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.

13. BCMA Policy PaperGetting IT Right - 2004 Inappropriate access or misuse of information would undermine the patient-physician 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)

14. Infoways Presentation 2003

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

19. (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.

22. 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 e-Health bureaucracy and for many government e-health strategists and planners” http://aushealthit.blogspot.com/2007/04/why-government-will-never-fund-shared.html

23. 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)

24. 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)

25. 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 . . .

26. 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

27. 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.

28. UK National Data SpineCost 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

29. 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. 

30. 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.

31. 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.

32. Concerns about Core Data Set EHR

33. 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

34. 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

35. 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.

36. Decision Support?

37. 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.

38. Committee on Privacy & Data StewardshipData Stewardship FrameworkBC 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

39. 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.

40. 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.

41. 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)

42. 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.).

43. 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.

44. 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.

45. About the campaignwww.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.

46. 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.

47. 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.

48. 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

49. 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.

50. 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