Canada's rank in OECD studies 20100610
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Canada’s First Primary Care Informatics Consulting Firm
Canada’s Rank in OECD Studies
A Failure of EMR Policy in Canada
Karim Keshavjee, MD, MBA, CPHIMS
E-health Conference, Vancouver Canada
June 1, 2010
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OutlineThe Problem
Policy Analysis
Economic Analysis
Implementation Factor Analysis
Conclusion
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Canada Lags in E-health Use
E-health Tool Use in 7 OECD Countries
0
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AUS CAN GER NET NZ UK US
Country
% o
f Phy
sici
ans
Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: primary care doctors' office systems,experiences, and views in seven countries. Health Aff (Millwood) 2006; 25(6): 555-571.
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Percentage of Physicians Who Use an EMR in their Practice in Canada
9.8%
2007 National Physician Survey
http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/ENG/National/pdf/Q39/Q39_NON_CORE.only.pdfAccessed Jun 11, 2010
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Why?
Not for lack of tryingLots of Programs and $$$
EMR implementation is complex
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Natural History of EMR
N=112
100%Implemented
EMR in 1999-2000
40%Inefficient
Users
25%EfficientUsers
35%Back to Paper
Adapted from: Keshavjee K, Burgess K, Pairaudeau N, Kyba R. 7 Years after EMR Implementation: A Tale of Woe and Hope. Poster presented at E-health 2007 conference. http://www.infoclin.ca/assets/7yearsafteremrimplementation_poster_final.pdf Accessed Jun 11, 2010
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Macro EMR Policy
Framework Developed in 2007
For Intel of Canada
Do Governments and Implementers Acknowledge
the Following Issues?
Keshavjee K. EMR Implementation in Ontario. A Position Paper to increase the deployment of ElectronicMedical Records in Ontario. http://www.infoclin.ca/assets/intel%20emr%20white%20paper.pdf Accessed Jun 11, 2010.
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Macro Policy Framework
Recognize the societal value of EMRs?
Involve professional civil society?
Create an enabling e-environment? (security, standards, interoperability)
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Macro Policy Framework
Encourage markets for new services?
Leverage network effects?
Engage patients and patient advocacy groups?
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Economic Drivers
Framework by Wang, Bates, Middleton
Economic drivers of EMR uptake
Adapted for Canadian Context
Examines ROI for all playersWang SJ, Middleton B, Prosser LA, Bardon CG, et al A cost-benefit analysis of electronic medical records in primary care. Am J Med. 2003 Apr 1;114(5):397-403.
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Implementation Programs
A best practices EMR implementation framework
17 Factors Required for EMR success
12 Factors are Statistically Significant(and Materially Significant)
Keshavjee K, Bosomworth J, Copen J, Lai J, Kucukyazici B, Lilani R, Holbrook A M. Best Practices in EMR Implementation:A Systematic Review. Proc. of 11th ISHIMR Conference, 2006. http://www.infoclin.ca/assets/emr%20poster%2011-08-06.pdf Accessed Jun 11, 2010
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GovernancePre-Implementation Implementation Post Implementation
Project LeadershipInvolve Stakeholders
Technology Usability Factors
Work-flow Redesign
TrainingImplementation Assistance
Privacy & Confidentiality
Support
Technology
ProcessPeople
Feedback and Dialogue
Choose SoftwareSell Benefits & Address Barriers
Data Pre-Load and Integration
Early Planning
IncentivesUser Groups
Business Continuity
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MethodologyCompare EMR programs in Ontario,
BC, Alberta and New York City
Key Informant InterviewsReview of Documentation
Scores are un-weighted No = 0 Partial = 0.5 Yes = 1
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Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis
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EMR Policy Framework Element NY
Ontario
Alberta BC
Funding all physicians (specialists and GPs) 1 1 0.5 1
Provide long-term, sustainable funding 1 1 1 0.5
Provide Practice Management Services 1 0.5 0 0.5Provide Information Management
Services 1 0 0 0.5
Provide CDPM Incentives 1 1 0.5 1
Self-Help and Peer Sharing 1 1 0 0.5
Engage Key Medical Players 1 0 1 0Provide Key ICT Infrastructure (secure e-
mail) 1 0 0.5 0.5Set and Implement Interoperability
Standards 1 0.5 0.5 0Engage Patients and Patient Advocacy
Groups 0.5 0 0 0
Rigorous Monitoring & Evaluation 1 0 0 0
Score10.5 5.0 4.0 4.5
Maximum Score = 11
No = 0 Yes = 1 Part = 0.5
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Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis
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US Canada
Costs
Initial Cost Annual
Over 5 years Cost Annual
Over 5 years
Hardware[1] $6,600 (q 3 yrs) $13,200 $10,000 (q 3 yrs) $20,000
Implementation[2] $3,400 $3,400 $5,000 $5,000
Software[3] $1600 $1600 $9600 $4,000 $4,000
Support[4] $1500 $1500 $9000 $2,400 $12,000
Scanning[5] - - $12,000 $60,000
Productivity Loss[6] $11,200 $11,200 $5,000 $5,000
Gov’t Subsidy - - -$28,000 -$28,000
TOTAL Cost/MD $46,400 $78,000
Economic Analysis
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US Canada
Benefits (Savings)
COST$46,40
0$78,00
0
MD Benefits
Chart Pulls[7] $5 600 $15,000 $4,800 24% $5,760
Transcription[8] $9,600 28% $13,440 0 0 $0
Charge Capture[9] $383,100 2% $15,324 $188,000 0% $0
Billing Errors $9,700 78% $15,132 $9,400 $0 $0
Total MD Benefit$58,89
6 $5,760
Health System Benefits
Drug Reactions[10] $6,500 34% $8,840 $6,500 34% $8,840
Drug Utilization $109,000 15% $65,400 $109,000 15% $65,400
Lab Utilization $27,600 8.80% $4,858 $27,600 8.80% $4,858
Radiol. Utilization $59,100 14% $16,548 $59,100 14% $16,548
System Benefit $95,64
6 $95,64
6
Net (Benefit-Cost)
$108,142 $23,406
MD Net Benefit/Loss
$12,496
-$72,24
0
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Net Loss to Physicians Who Implement EMR in Canada:
$72, 240
Over 5 Years
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Still think physicians are
‘resistant to change’?
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Canada’s First Primary Care Informatics Consulting Firm
Policy Framework Analysis
Economic Analysis
Implementation Factor Analysis
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No. Success Factor NY Ontario
Alberta
BC
1 Governance 1 0 0 1
2 Project Leadership 1 0 0 1
4 Choose Software 0 1 0.5 1
5 Sell Benefits/Address Barriers 1 0 0.5 0.5
6 Pre-load/Integration 1 0 1 0.5
7 Tech Usability 1 0 0.5 0.5
8 Early Planning 1 1 0.5 0.5
9 Workflow Redesign 1 0 0.5 0.5
10 Implementation Assistance 1 1 1 1
11 Training 1 1 1 1
13 Feedback & Dialogue 1 0 0.5 1
16 Information Incentives 1 0.5 0 1
TOTAL SCORE (Max=12)
11 4.5 6 9.5
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Canadian Provinces Do Poorly on Economic and Policy Drivers of EMR Uptake
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So What?Do poor policies lead to poor uptake of
EMRs?
Global: Yes, Canada lags the World
Local: We don’t know
Alberta, BC and Ontario Won’t Publish Their Evaluations
(New York City Does)
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So What?
Physicians hear from their colleagues and decide to ‘wait and
see’
Industry notices ‘resistance to change’
We have invested tens of millions in EMR with very little to show for it
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Summary
Canadian Policies Not Conducive to EMR uptake
Economic Drivers Need Improvement
EMR Services Do Not Meet Global Best Practices
EMR Policies Need to be Updated
Focus on the Frameworks