1 annual review of im/it in healthcare the unvarnished version february 21, 2005

1

Annual Review of Annual Review of IM/IT in HealthcareIM/IT in Healthcare

The Unvarnished Version February 21, 2005

2

What Has Happened Since November 2003?What Has Happened Since November 2003?

• The service gap with other industries is wider• Evidence of quality problems is growing• Evidence that eHealth improves quality is growing• Fiscal challenges continue to mount• The business case for eHealth is being quantified• Professional demographic trends are challenging• Good information on IM/IT development in Canada is

hard to find• Some providers have made major strides• Public awareness about Health IM/IT has increased

3

• The teller writes your transactions into a paper ledger

• You are told that you can get your money at only one branch because that’s where your records are

• You can use your bank card only in bank machines at your own bank (if at all)

• Your balance is incorrect because the teller’s handwriting is illegible

• You are told to wait for two hours while your money is sent by taxi from head office

• You have to receive a paper pay cheque every two weeks which you then you have to deposit in person

Imagine: A Bank managed by a Health AdministratorImagine: A Bank managed by a Health AdministratorImagine: A Bank managed by a Health AdministratorImagine: A Bank managed by a Health Administrator

4

• Each flight has its own booking agent that you can contact only by phone

• Connecting flights cannot be booked in advance – once you arrive at a stopover point, you wait until there is a seat available on a connecting flight

• No confirmed seating – you can be cancelled at any time before the flight

• Being handed a ticket that says

AC429 yyz-yeg dec10 Y 17:45 19:45 with no further explanation

• Told that you cannot have access to your flight itinerary without the pilot’s permission

• The public is not given information about in-flight mishaps because the pilot might be unfairly maligned

Imagine: An Airline managed by a Health AdministratorImagine: An Airline managed by a Health AdministratorImagine: An Airline managed by a Health AdministratorImagine: An Airline managed by a Health Administrator

5

Imagine:Imagine:

• $15 billion in annual purchases hand-written on slips of paper

– The Canadian prescription drug industry• 1 billion service events scheduled manually over the

phone– Annual diagnostic test events in Canada

• An industry that does not increase productivity– The healthcare industry in Canada, 9.5% of

the economy• A service industry that injured 2.5% of its customers

through preventable errors (30% of injuries resulting in permanent impairment, 5% resulting in death)

– Hospital care in Canada

6

Quality problems abound:– Gaps in care– Poor coordination between primary care and specialty care– Increasing evidence of treatment errors– Need for evidence-based practice– Little incentive to preserve health

“To Err is Human, Building a Safer Health System” (Report from U.S. Institute of Medicine, 2000)– Up to 98,000 deaths each year in U.S. due to medical errors

National Steering Committee on Patient Safety - Royal

College of Physicians and Surgeons – Federal government allocated $10M per year for five years to

create and operate a Patient Safety Institute – Research Study recently published by Ross Baker and Peter

Norton

Patient Safety: An old issue now recognizedPatient Safety: An old issue now recognizedPatient Safety: An old issue now recognizedPatient Safety: An old issue now recognized

7

• Conducted by Ross Baker, Peter G. Norton et al.

• Published in CMAJ. May 25, 2004; 170 (11)

• Reviewed 1527 charts of non psychiatric, non obstetric patients who were admitted to 20 hospitals throughout Canada within year 2000.

“… in 2000, between 141,250 and 232,250 of 2.5 million similar admissions to acute care hospitals in Canada were associated with an Adverse Event (AE) and that 9,250 to 23,750 deaths could have been prevented…”

Quality of care in Canada:

Canadian Adverse Events StudyCanadian Adverse Events Study – May 2004

Quality of care in Canada:

Canadian Adverse Events StudyCanadian Adverse Events Study – May 2004

Adverse Event – Unintended injury or complication that resulted in disability, death or prolonged hospital stay and was caused by health care management rather than by the underlying disease process.

8

Quality of Care in Canada:Canadian Adverse Events StudyCanadian Adverse Events Study – May 2004

• 46.7% resulted in death or disability at the time of discharge or prolonged stay

• 64.4% resulted in no physical impairment• Adverse events resulted in 6.2 extra days in hospital

per patient affected• 34.1% of AEs were related to surgical procedures• 23.6% of AEs were related to Drug or Fluid-related

Event

9

Managing Transportation SafetyManaging Transportation Safety

• NHTSA– responsible for reducing deaths, injuries and economic

losses resulting from motor vehicle – investigates crashes that kill over 43,000 people and

injure close to three million people

• Detected an initial cluster of 62 deaths and determine that the cause was related to defects in Firestone tires used on certain sports utility vehicles. (0.0014 event rate)

• How?– Excellent information systems– Safety culture– Data driven thinking (not political)

10

Quality of Care: US DataQuality of Care: US Data

The Quality of Health Care Delivered to Adults in the US

• Rand Corporation study, by Elizabeth A. McGlynn Ph.D. et al.

• New England Journal of Medicine 2003;348:2635-45

• Methodology:– Random sample of 6,712 adults from 12 metropolitan areas of

US– Performance on 439 indicators of quality of care for 30 acute

and chronic conditions and preventive care

11

Adherence to Quality Indicators, according to Type of Care and Function

56.1

53.5

54.9

0 25 50 75 100

Chronic

Acute

Preventive

TYPE OF CARE

58.5

57.5

55.7

52.2

0 25 50 75 100

Follow-up

Treatment

Diagnosis

Screening

FUNCTION

% of Recommended Care Received

Quality of care: US DataQuality of care: US DataQuality of care: US DataQuality of care: US Data

12

10.5

45.4

48.6

58

64.7

68

73

75.7

0 25 50 75 100

Alcohol Dependence

Diabetes Mellitus

Hyperlipidemia

COPD

Hypertension

Coronary ArteryDisease

Prenatal Care

Breast Cancer

Adherence to Quality Indicators, according to condition

% of Recommended Care Received


13

CONDITION SHORTFALL IN CARE AVOIDABLE TOLL

Diabetes Average blood sugar not measured for 24%

29,000 kidney failures 2,600 blind

Colorectal cancer 62% not screened 9,600 deaths

Pneumonia 36% of elderly didn't receive vaccine

10,000 deaths

Heart attack 39% to 55% didn't receive needed medications

37,000 deaths

Hypertension Less than 65% received indicated care

68,000 deaths


The toll is high:

14

Quality of Care: US DataQuality of Care: US Data“The Quality of Health Care Delivered to Adults in the US”

• Participants received only 54.9% of the recommended care

• “Deficits in adherence to recommended processes for basic care pose serious threats to the health of the American public”

• Strategies to reduce deficits:– Availability of information on performance at all levels– Focus on automating entry and retrieval of key data for clinical

decision making and for the measurement and reporting of quality

15

Comparison of Quality of Care for Patients in the Veterans’ Health Administration and Patients in a National Sample

Steven Asch, Elizabeth McGlynn et al

Annals of Internal Medicine 2004; 141:939-945


16

Comparison of Quality of Care for VA PatientsComparison of Quality of Care for VA Patients

• VA patients scored significantly higher for:– Adjusted overall quality (67% vs 51%)– Chronic disease care (72% vs 59%)– Preventive care (64% vs 44%)

• No difference noted for acute care• The VA advantage was most prominent in areas

where the VA has established performance measures and active performance monitoring

• Other studies suggest contributions from:– EHR, clinician reminders, structured templates, standing orders,

improved inter-provider communication, facility performance profiling, accountability for performance and more integrated delivery systems

18

www.mtpc.org

Poor Quality is Costly: Massachusetts

19

F O

R E

C A

S T

0

10

20

30

40

50

60

70

80

90

1975-76 1979-80 1983-84 1987-88 1991-92 1995-96 1999-00 2003-04

Cur r ent Dol lar s

Constant Dol lar s (1997)

($ billions)

Gov’t Health Expenditure in Canada (1975-2004)Gov’t Health Expenditure in Canada (1975-2004)

YearSource: Canadian Institute for Health Information; Statistics Canada

20

F O

R E

C A

S T

$ 1,000

$ 1,200

$ 1,400

$ 1,600

$ 1,800

$ 2,000

$ 2,200

$ 2,400

1975-76 1979-80 1983-84 1987-88 1991-92 1995-96 1999-00 2003-04

Health E xpenditur e per Capita

Year

Source: Canadian Institute for Health Information; Statistics Canada

Govt. Health Expenditure per Capita in Canada (1975-2004)Govt. Health Expenditure per Capita in Canada (1975-2004)

In constant 1997 Dollars

Linear Trend before

1993-94

21

Health Care Spending: Canada and selected OECD countries as % of GDP

United States (1st)

Canada (5th)

OECD Average

United Kingdom (17th)P

erce

nt

Na

tio

nal

GD

P

Source: OECD Health Data, 2004, 1st Edition

22

Per Capita Health Care Spending in Canada

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

$ p

er c

apit

a (i

n C

urr

ent

do

llars

)

Canadian Average

Canadian Median

Source: CIHI, Statistics Canada

23

Number of Physicians per 1,000 Population in OntarioNumber of Physicians per 1,000 Population in Ontario

1.711.57

1.45 1.34

1.22 1.14

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1998 2003 2008 2013 2018 2021

33% decrease

in 25 years

24

Canada has less Physicians than most OECD countries

Physicians per 1,000 Population (2002)

4.54.4

3.9

3.6 3.6 3.63.5

3.43.3 3.3 3.3 3.3

3.2 3.23.1 3.1

32.9 2.9

2.62.5

2.4 2.42.3

2.1 2.1 2.12

1.5 1.51.3

0

1

1

2

2

3

3

4

4

5

5

Greec

eIta

ly

Belgium

Switzer

land

Slovak R

epub

lic

Icela

nd

Czech

Rep

ublic

Norway

Germ

any

Franc

e

Denmar

k

Austri

a

Portu

gal

Hungar

y

Nether

lands

Finlan

d

Sweden

OECD aver

age

Spain

Luxe

mbo

urg

Austra

lia

United S

tate

s

Irelan

d

Poland

United K

ingdom

New Zea

land

Canada

Japa

n

Mex

icoKor

ea

Turke

y

Source: OECD

25

Canada RNs per Capita vs OECD countries

Nurses per 1,000 Population (2002)

15.3

14

12.8

10.8 10.7 10.4 10.49.9 9.7 9.4 9.4 9.4 9.3 9.2 9 8.8 8.5 8.2 8.1 7.9

7.2 7.1 7.1

5.6 5.44.8

4 3.8

2.21.7 1.7

0

2

4

6

8

10

12

14

16

18

Irelan

d

Icela

nd

Nether

lands

Luxe

mbo

urg

Switzer

land

Norway

Austra

lia

Germ

any

Denmar

k

New Zea

land

Czech

Rep

ublic

Canada

Austri

a

United K

ingdom

Finlan

d

Sweden

Hungar

y

Japa

n

OECD aver

age

United S

tate

s

Franc

e

Spain

Slovak R

epub

lic

Belgium Ita

ly

Poland

Greec

e

Portu

gal

Mex

ico

Turke

y

Korea

Source: OECD

26

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

<25 25-29 30-34 35-39 40-44 45-49 50-54 55+

1993

1998

2000

2001

2002

2003

Registered Nurses Employed in Canada – by Age GroupRegistered Nurses Employed in Canada – by Age Group

Age Group

Pro

port

ion o

f Tota

l N

urs

es

27

-120,000

-80,000

-40,000

0

Sh

ort

ag

e o

f N

urs

es

Low Growth Med Growth High Growth

Demand for Nursing Services

Nursing Deficit in Canada – Projected to 2011Nursing Deficit in Canada – Projected to 2011

28

Canada is below the OECD average for MRI Scanners

Source: Medical Imaging in Canada 2004, CIHI

29

Efficiency of care delivery varies widely across Canada

Hospital Days per 1,000 (2001)

675

941

1,012

837

970

740

552

1,045

804

667 655

0

200

400

600

800

1,000

1,200

Canada Nfld PEI NS NB QC ON MB SK AB BC

Source: CIHI

30

More of the same is not the answer

National Pharmacare? • 30% of seniors’ hospitalizations result from medication

toxicity related to drug interactions. Patients arrive every day in emergency rooms unable to speak or remember which medications they take

More CTs, MRIs, PETs? • 10% of prescribed tests are estimated to be wasteful

duplications because previous results are lost, unavailable or the provider doesn’t even know they exist

More health professionals? • Health professionals spend too much unproductive,

frustrating time chasing paper, trading phone calls, trying to piece together incomplete information

More Homecare? • Visiting nurses often lack background information and e-

tools to provide effective follow-up. Even patients do not have access to their own health information

31

The Potential of Health IT

In the recent issue of Healthcare Papers, Dr. Matthew Morgan estimates the potential impact of three technologies:

1. e-Prescribing2. In-patient physician order entry3. Diabetes home disease management

His business cases are based on published studies, but use:

• conservative approach to benefits• generous approach to costs

32

E-prescribing

• Assume 75% of Canadian family physicians (22,500)• Initial costs $174m, Annual costs $25m• Net Benefits $236m / yr• Savings

– Efficient operations– Increased use of generics and formularies– Malpractice insurance reductions

• No assumption of improved quality - 30% of seniors’ hospitalizations result from medication toxicity related to drug interactions

33

In-patient physician order entry

• Assume 75% of all hospital admissions• Initial costs $3 billion, annual costs $0.5 billion• Net Benefits $1.2 billion/yr• Savings

– Decreased adverse drug events and medical errors– Improved utilization of inpatient resources

34

Diabetes home disease management

• Assume 2 million Canadians• Care costs for this cohort total $13 billion annually

(2002)• Electronic implementation of the Canadian Diabetes

Association Clinical Practice Guidelines• Initial Costs $125m, Annual Costs $360m• Net Benefits $387m / yr

– Decreased emergency visits and inpatient admissions

35

Healthcare spends less on IM/IT than other information-intensive industries

Source: Infoway Pan-Canadian EHR Survey Phase I: Results and Analysis January 2003 from Gartner Group 2002

36

13.8%

7.3%

0 20 40 60 80 100 120

Approved toimplement

Operational

Number of hospitals

Availability of Computerized Physician Order Entry Systems (CPOE)(of all respondents n=123 )

Out of 9 hospitals with operational CPOE systems

• 3 were interfaced with pharmacy information systems

• 3 were integrated with computerized clinical decision support systems

CPOE in Canada: Hospital Pharmacy in Canada Survey (2001-02)CPOE in Canada: Hospital Pharmacy in Canada Survey (2001-02)

37

Danes spend ~$20 Billion per year (8.4% of their GDP) on health services

Has ~3500 GPs, 800 full time specialists, 250 part time specialists, 65 hospitals and 332 pharmacies.

Over 90% of GP offices are computerized and use EMRs. Almost 90% use computers to transmit EDI messages

• Discharge messages• Lab requests/results• Referrals• Prescriptions and reimbursements

40-90% of specialists use computers. 15-70% of them use EDI clinical messages (varies by county)

75% of the health care sector (>2,500 different organizations) now participate in electronic communication via Health Care Data Network

Danish ExperienceDanish Experience

38


39

What are the driving forces to the physician uptake of computers

– Participation is voluntary

– Communication benefits• Test results – use to take 5 days, now received immediately• Discharge summaries – use to take 4+ weeks, now received

within 1-3 days

– Simplified repeat medication prescribing (save time!)

– Peer influence

– Provider registries and other information

– Required computer use for participation in FFS after hours primary care program

– Adequate support and training

– Patient perception


40

Yellowhead

County (East)Edmonton

Sturgeon

County

Strathcona

County

Leduc County

Parkland County

Fort Saskatchewan

Stony Plain

St Albert

Devon

Leduc

Capital

Health

Region

Boundary as ofApril 1, 2003

Redwater

Capital Health is using similar monitoring techniquesCapital Health is using similar monitoring techniques

41

netCARE Adoption: Files Accessed

Daily netCARE Patient Files Accessed Since April 1, 2004

0

200

400

600

800

1000

1200

1400

1600

1800

2000

4/1/

2004

4/15

/200

4

4/29

/200

4

5/13

/200

4

5/27

/200

4

6/10

/200

4

6/24

/200

4

7/8/

2004

7/22

/200

4

8/5/

2004

8/19

/200

4

9/2/

2004

9/16

/200

4

Date of Access

# o

f Files A

ccessed

42

netCARE Adoption

netCARE Patient File Accesses and Active Users Weekly Totals

0

2000

4000

6000

8000

10000

12000

14000

0

200

400

600

800

1000

1200

1400

1600

1800

2000

# Patient Files Accessed # of Active Users

43

netCARE Adoption

-500

500

1500

2500

3500

4500

5500

6500

Apr May Jun Jul Aug Sep Oct Nov

Gap Remaining

Users logged on at least once

44

751

983

343

744

Physicians

Nursing

Allied Professionals

Other

20,301

8,651

2,317

11,488

Physicians

Nursing


Other

Physicians are the most active users of netCARE

Total Number of Users in November – 2,821

Total Number of Patient Files Accessed in November – 42,757

45

Provincial systems are accessible, but uptake is slower

7

15

21

9

Physicians

Nursing


Other

22

46

96

77

Physicians

Nursing


Other

Total Number of PIN Accesses in November – 241

Total Number of PIN Users in November – 52

46

netCARE – Detailed user behaviour profiles

Detailed Utilization (Average per User) in November – All Sites (only shows active users who logged in to netCARE in November)

Users Active in

November 2004

Mins Logged

in

Patient Files

Accessed

EMPI Searches

Lab – Single Result

Lab –Flowsheet

Transcribed Reports

Event History

Physician 341 403 25 19 38 8 20 10

Fellow/Resident/Intern 410 248 28 16 68 11 26 3

Nurse 903 107 8 2 8 2 4 3

LPN 33 163 13 2 11 2 5 4

Therapist (OT, PT, RT) 109 67 5 1 3 0 6 1

Pharmacist 65 96 8 7 9 3 4 2

Dietitian 55 134 11 0 13 6 5 2

Technician (Rad., Lab) 87 39 5 3 7 0 2 0

Unit Clerk 280 215 14 4 7 5 7 4

Health Records 57 268 19 5 6 1 11 12

Other 388 351 16 4 11 3 9 7

Totals (All Users) 2,821 210 15 7 21 5 10 4

47

Capital Health Offers a Combination of Characteristics That Are Ideal for eHealth

• Manages population > 1 million

• Demonstrated success with EHR investments

• Academic (U of A) collaboration on a single clinician

desktop used across the provider community

• Widespread physician support

• Strong, stable executive and clinical leadership

• Track record of successful implementations

• Readiness to substantially expand the EHR initiative

• Strong systems infrastructure for fast implementation of

new initiatives

• Top rated in CIHI and Macleans quality ratings

48

Globe & Mail Oct 18 2004 : Gwyn Morgan

49


“Our health-care system must be measured by both access and quality. It astounds me that the quality standards of our most important

services, i.e. treating illness and saving lives, are below the standards of what the public

expects from private industry.”

50


“When an aircraft accident occurs as a

result of quality-control failure, there is a huge regulatory and public

outcry, and a great effort to get to the root cause.

Yet every week in our country, mistakes are made in our operating rooms, hospital wards

and nursing homes; the cumulative human toll

numbers in the thousands.”

51


“This unacceptable quality record is clearly caused by

placing good people in a dysfunctional

system.”

52


“Canadians want better patient care. To achieve this, we

need to adopt world-class quality

standards and reporting systems for

our health-care system.”

53

Concluding Thoughts

• Reform of the health care system will require large investments in IT

• The health care industry is far behind other industries in information management

• The industry drivers to automate have never been stronger

• It is clear that high quality care is not achievable in the absence of good information systems

• The status of eHealth development across Canada remains unclear

54

Press release in 2010:

eHealth saves lives – Canada leads the way

• When Canada implemented its EHR, it cost $___ million dollars and took ___ years to implement.

• Detailed analysis pre and post implementation by independent academics (published in the peer reviewed journal __________), indicates that we are saving ___ lives per year due to better clinical practice and ___ lives per year due to fewer medical errors. This has a positive financial impact on the system because we are avoiding ___ admissions and ___ patient days per year which would have cost $___ per year.

55

www.courtyard-group.comToronto Edmonton New York

1 annual review of im/it in healthcare the unvarnished version february 21, 2005

Documents