Barriers

Barriers and Solutions to Implementation of Electronic Health Records (EHR) : Barriers and Solutions to Implementation of Electronic Health Records (EHR) Presented By: Carol Gregoryk Maricon Sanelli Jodi Walker


Outline : Outline Introduction Learning Objectives Key Definitions Canada Health Infoway Mission, Goal, Vision Electronic Health Record (EHR) Barriers and Solutions to Implementing EHR National Provincial (Saskatchewan, Manitoba, Ontario) For Fun Conclusion Discussion Questions References


Introduction : Introduction


Slide4 : “Most clinicians are passionate about the quality of care they deliver and are interested in continuously improving it” p. 2 Canada Health Infoway Corporate Business Plan 2007-08 “Health care does not look good on paper…paper puts patient safety at risk” p. 3 Canada Health Infoway Corporate Business Plan 2007-08 “Canadians…want to play a greater role in health care. (…) This will require access to their health data. (…) (Health Canada, 2001)


Why a need for information management? : Why a need for information management? Growing consumerism Aging population Greater pressure on resources Shifting care settings (Maloney, 2007)


Slide6 : Interoperability Challenges - Managing health information and delivering quality care is a huge challenge in a system that includes multiple points of care. (Maloney, 2007) 700 hospitals 40,000 general practitioners 315,000 nurses 29,000 specialists 26,000 pharmacists 1,600 long-term care facilities


Learning Objectives : Learning Objectives


Participant Accomplishments : Participant Accomplishments You will upon viewing the presentation, utilizing the reading materials or links provided, and participating in the discussions: Become familiar with the barriers in implementing EHR at the national and provincial levels; Become aware of the proposed solutions to the barriers; Discern the applicability of the solutions to your own EHR scenarios.


Key Definitions : Key Definitions


Slide10 : Interoperability - Ability of two or more systems or components (computers, networks, operating systems) to exchange information and to use the information that has been exchanged. (Applied Clinical Trials, 2007) Barrier – Any condition that makes it difficult to make progress or to achieve an objective; "intolerance is a barrier to understanding" (WordNet, n.d.)


Canada Health Infoway : Canada Health Infoway


Canada Health Infoway : Canada Health Infoway Creation of Infoway Began in 2001 Need to involve IT in renewing the health care system Need to integrate many disparate health IT systems across Canada (40,000) Members: Deputy Health Ministers from the federal, provincial and territorial governments $1.6 billion Cdn in federal funding to date Independent, not-for-profit corporation (Maloney, 2007)


Canada Health Infoway (cont’d) : Canada Health Infoway (cont’d) Mission “To foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis” (Alvarez, 2002)


2010 Goal : 2010 Goal “…..by 2010, the electronic health record will be available in eight provinces and territories representing 50% of Canadians by population” p. 9 Canada Health Infoway: Corporate Business Plan 2007-08


Vision 2015 : Vision 2015 “Electronic health record provides individuals in Canada with a secure and private lifetime record of their key health history and care within the health care system.” p.4 Canada Health Infoway Corporate Business Plan 2007-08 Finish what has been started Electronic medical record implementation in physician offices and physician entry in hospitals.


Where are we now?Canada Health Infoway Private Sector- Business Update : Where are we now? Canada Health Infoway Private Sector- Business Update


Infoway’s Future EHR : Infoway’s Future EHR “ …..the record is available electronically to authorized health providers and the individual anywhere, anytime in support of high quality care.” p. 6 Canada Health Infoway: Clinician eHealth Support Network


Photo Source: Maloney 2007 : Photo Source: Maloney 2007


Understanding EHR : Understanding EHR ¨Lifetime record of an individual’s health.” Integration of: • Electronic Medical Record (EMR) – Care Provider’s. Electronic Patient Record (EPR) – Hospital’s. Personal Health Record (PHR) – Individual’s. Includes: Birth Records. Childhood Records: immunizations, school, dentistry, optometry,… Adult Records: fitness, sickness, risk factors,… End of Life Records: …Terminal Care, Death. (Covvey, 2006)


EHR: The Promise : EHR: The Promise Access Reduced wait times Improved access to care in remote and rural communities Increased patient participation in care Quality Improved participation of diagnostic and laboratory results Fewer adverse drug events Productivity Increased access to integrated patient information Better prescribing practices Reduction in duplicate or unnecessary diagnostic tests (Health Canada, xx)


National Barriers to Implementing EHR : National Barriers to Implementing EHR


Slide22 : “Infoway’s funding and mandate have limitations. More needs to be done to provide health care infostructure across all points of care.” p. 10 Canada Health Infoway 2007. Corporate Business Plan 2007-08


National Barriers : National Barriers Unprepared workforce Lack of IT resources Physician office automation Clinician adoption (e.g. lack of proven case studies to provide illustration of impact) Lack of interoperable standards Privacy Jurisdictional capacity Further capitalization (inconsistent commitments by federal and some provincial governments to fund completion) (Maloney, 2007; xx)


Solutions to National Barriers : Solutions to National Barriers Clinician education & training in order to understand, accept, and adopt EHR Acceptance of charting electronically IT resources Establish EHR standards for common understanding Health human resources Government stability funding EHR projects Universities educating health care students on EHR Compatible privacy policy (i.e. harmonization) amongst provinces and territories Structured change management approaches


Lessons Learned : Lessons Learned “…it is important to build on lessons learned form other organizations.” (Health Canada, 2001)


Input Into Future Activities : Input Into Future Activities NHS in the United Kingdom offers the following strategic approach to mitigate EHR national barriers: “For the strategy to be delivered effectively at the national level, we need highly motivated, well led, fully coordinated partnership arrangements in relation to four key processes: Stakeholder input Policy development National program management Performance management” (Health Canada, 2001)


Provincial Barriers to Implementing EHR : Provincial Barriers to Implementing EHR Saskatchewan Manitoba Ontario


Saskatchewan Go Riders! : Saskatchewan Go Riders!


History of eHealth Government of SK 2007 : History of eHealth Government of SK 2007 Early Nineties: Recognition of need for information technology. Saskatchewan Association of Health Organizations (SAHO) start extensive information technology planning process concluding an electronic provincial health network and patient information was required.


History of eHealth : History of eHealth 1997 formation of Saskatchewan Health Information Network (SHIN) saw the beginning of the data collection and links to CIHI, Canada Health Infoway and Health Canada 2003 SHIN integrated under SK Health and was renamed Health Information Solutions Centre (HISC) HISC manages the development of provincial information technology and management planning.


Current eHealth Initiatives Government of SK 2007, Current Health Initiatives : Current eHealth Initiatives Government of SK 2007, Current Health Initiatives 2001 saw HISC working with regional Health authorities towards common, shared health care information systems using Integrated Clinical Systems (ICS). Clinical viewer Pharmacy CPI/Registration Lab Transcription Home Care


The Blueprint : The Blueprint A standard joke now in Saskatchewan, the following diagram is familiar to many in information technology and is commonly thrown on the overhead at all working groups and conferences. HISC 2006 The overall plan links all electronic health solutions to a common electronic record with reporting systems. The challenge is the link.


Electronic Health Record Goal : Electronic Health Record Goal “Faster, Safer, Better, Secure: - getting the right information, to the right individual, at the right time, in the right place!” Government of Saskatchewan 2007: Electronic Health Record


Example Project : Example Project Healthy Living in Healthy Communities Home Care Standardization and Electronic Health Record http://www.goprocura.com/cms/?News_%26amp%3B_Events:Case_Studies to download the case study “Saskatchewan Home Care- A provincially standardized solution” Gregoryk 2006


Provincial Project Steps : Provincial Project Steps Pre-implementation Mapping business processes Request for proposals Vendor Selection System Build Table build for definitions and reporting requirements Testing Deployment Provincially hosted product at HISC


Barriers and Challenges : Barriers and Challenges Rural geography Many locations not owned by health authority Massive miles traveled with multiple rural bases Lack of infrastructure and resources for IT Local IT up to network challenge in urban center, not multiple rural sites Lack of funding and resources Freeze on funding initiatives dependent on provincial government. Lack of human resources in most professions. Lack of telecommunication lines Lack of community network lines used to secure privacy. Reluctant user buy-in


Solutions : Solutions Meet rural challenges through use of wireless internets and development of VPN tunnels for data security Increase centralized funding from HISC and province for targeted initiatives. Coordinate local training with opportunity to practice away from work and buddy system to ensure inter-user reliability once implemented. Change process considerations for impact on end-user.


Solutions : Solutions “…a comprehensive care system that supports the distributed care team..(and)..allow them to share key observations linked to results of diagnostic tests, data entered by the patient/client themselves, and sophisticated decision support tools” J. Smith 2003


Manitoba Go Bombers! : Manitoba Go Bombers!


EHR Brief history : EHR Brief history Many of the hospitals in the province had their own computer system and technical support. Recognizing building disparate systems on different platforms was counter productive, Manitoba formed e-Health in June 2006 to provide support and solutions that will lead to a province wide EHR within three to five years (Canadian Medical Association, 2007).


Goal of e-Health : Goal of e-Health The province approved $150 Million to implement an EPR over the next three to five years. The goal is to have every patient’s current medical information including test results and prescriptions immediately accessible online to authorized caregivers in hospitals and clinics in the province, 24/7 ( Canadian Medical Association, 2007).


e-Health projects Completed and about to be Introduced : e-Health projects Completed and about to be Introduced Hospital Information System (HISP) Lab Information System (LIS) Provincial Client Registry Primary Data Centre Provincial Radiology Information/ Picture Archiving and Communications (RIS/ PACS) Utilization Management System (UM System) Emergency Department Information System (EDIS) www.manitoba-ehealth.ca/ehr.html for more info


Example Project : Example Project The Primary Data Center (PDC) provides a centralized location where all regional applications and programs can securely reside for the Manitoba eHealth Provincial Program (formerly e-Health Services, a division of the WRHA). The PDC is capable of functioning 24 hours a day, seven days a week, eliminating data outages due to unfavorable weather, physical violations, construction mishaps and equipment failure (WRHA, 2006).


Example Project (cont’d) : Example Project (cont’d) The PDC is one of the most secure data centres in the country. The facility is only second in the country, in terms of security, to the facility used by the Canadian Security Intelligence Service (CSIS) in Ottawa. The facility created for the e-Health Provincial Program has met all the requirements to call itself a Tier III Data Center. This includes at least 20 major mechanical, electrical, fire protection, security and other systems requirements. By December 2007 the PDC will be classified as a Tier IV data center, the highest rating available. (WRHA, 2006)


Barriers : Barriers Current computer systems do not have the capacity to support the network required for an additional 8,000 RN’s, LPN’S, RPN’s, as well as, an additional 200 allied health professionals. (WRHA, 2007) As many as 4,000 health care professionals within the WRHA do not have access to e-mail.


Barriers : Barriers Understanding and addressing the culture shift in how nurse’s communicate. “Historical model of paper documentation” (Kirkley & Stein, 2004). Worker resistance: The older the generation, the more resistance there is. (Kirkley & Stein, 2004). The average age of the nurse practicing in Manitoba is 54 (CRNM, 2004).


Barriers : Barriers Funding- for hiring IT personnel, building networks, developing education packages and scheduling education sessions to help prepare the workforce for computerization


Implementation Challenges : Implementation Challenges Lab Pharmacy Diagnostic Imaging


Implementation Challenges : Implementation Challenges Interfacing new technology with existing systems- some existing systems are too old, others have no system in place at all, e.g., Pharmacy, Lab, Diagnostic Imaging (DI). Equipment and location-how will nursing and allied health use EHR ? A variety of devices should be available, some people will want to sit, others will prefer a laptop, others will prefer a notebook. (Kirkley & Stein, 2004) Staff preparation and training


Implementation Challenges : Implementation Challenges Physician engagement A review by the Canadian Medical Association (CMA), revealed there is limited physician involvement in advancing the e-health agenda, there is no articulation of the physician role in the EPR’s creation. Some provinces have established a structured approach to working with physicians and instituted IT programs to support the automation of physicians’ offices, Manitoba has not. ( CMA, 2007).


Implementation Challenges : Implementation Challenges Physician office automation The focus of e-health has been building large applications for drug information, laboratories, diagnostic imaging and telehealth. Currently, there is not a province wide initiative to automate physicians’ offices. Connectivity to these offices are crucial to ensure all points of care are captured. (CMA, 2007)


Solutions : Solutions Hospitals throughout the province that have not joined the Regional Health Authorities need to commit soon to avoid delays in e-health and provincial projects Budgets increased to allow for training of staff and leasing of computer equipment Form committees at each site comprised of various disciplines to discuss projects and help devise implementation strategies Promote EHR to staff as a positive change that will improve patient care


Ontario Go Leafs! : Ontario Go Leafs!


Ontario’s e-Health Approach : Ontario’s e-Health Approach The strategic approach is designed to accelerate e-Health implementation and to use information technology more effectively within the health sector. The key components of Ontario’s approach to e-Health implementation are: building province-wide technology infrastructure developing health care tools and applications allowing health information to be shared more easily. (Ontario, 2007)


Current e-Health Initiatives : Current e-Health Initiatives Continuing Care Initiatives Health Care Provider Access to Prescription Drug Claims History Ontario Laboratories Information System (OLIS) Pediatric Electronic Health Record (eCHN) Public Health e-Health Strategy SSHA ONETM Network, ONE ID, ONE Mail and ONE Pages Telemedicine Physician IT Program Health Care Records Diagnostic Imaging/Picture Archiving and Communication System Enterprise Master Person Index (EMPI) For more details, go to: http://www.health.gov.on.ca/ehealth/initiatives/initiatives_mn.html


EHR in Ontario : EHR in Ontario Ontario's Smart Systems for Health Agency (SSHA) is the organization that is implementing e-Health initiatives in Ontario “Provides the secure Information Technology products and services to connect authorized health professionals so they can securely share patient information. Using that information, health professionals become more effective - making more informed decisions about our care.” (Ontario e-Health Program Website, 2005)


Slide58 : (University of Waterloo, 2006)


EHR’s (SSHA) Vision & Mission : EHR’s (SSHA) Vision & Mission Vision: SSHA’s world-leading e-Health services will help transform health care delivery in Ontario by enabling the secure electronic exchange of health information among providers and patients. Mission SSHA works with the health care sector to enable providers and patients to: Electronically share health information quickly and securely, and Make better care decisions (SSHA, 2007)


Example Project : Example Project Ontario Laboratories Information System (OLIS) A single information system allowing all laboratory test information to be electronically exchanged amongst authorized practitioners and lab service providers in Ontario. A source of system and program management information for the ongoing enhancement of lab services A key component of Ontario’s electronic health record strategy To find out more about OLIS, go to http://infranet.uwaterloo.ca/inftalks/2005-2006/2006-03-22/default.pdf (University of Waterloo, 2006)


EHR in Ontario : EHR in Ontario We’ve come a long way… but there is more to do. (University of Waterloo, 2006) Ontario has the LEAST progress in EHR! (Maloney, 2007)


Barriers & Challenges : Barriers & Challenges


EHR Barriers & Challenges : EHR Barriers & Challenges Human-based challenges are the majority of the barriers Lack of deeply understanding health system/e-health challenges faced Lack of a definition of the EHR (or lack of will to define EHR), while building high expectations Lack, or at least failure to articulate, a strategic basis for much of e-health and the EHR (University of Waterloo, 2006)


EHR Barriers & Challenges (cont’d) : EHR Barriers & Challenges (cont’d) Failure to build adequate e-health HR capacity Excessive dependence on consultants Lack of competency certification standard, process Few accessible/affordable education and training programs Little funding for staff education Cost and time required are grossly underestimated Lack of MoHLTC champions for some projects and “strategies” Lack of attention to e-health readiness of EHR feeder systems (e.g. Incomplete suites of systems; incomplete data within system) (University of Waterloo, 2006)


Solutions : Solutions Create a trusted panel focused on understanding the big picture and the health/e-health/EHR challenges faced Conceptualize and articulate a strategic, business-driven framework for e-health and the EHR Invest in the development of e-health HR capacity through universities and colleges (University of Waterloo, 2006)


Solutions (cont’d) : Solutions (cont’d) Re-engineer Ministry of Long Term Care (MoHLTC) processes; introducing flexibility, opportunities for innovation, adaptability Move all project development into SSHA while resourcing it properly. (University of Waterloo, 2006)


Solutions (cont’d) : Solutions (cont’d) In 2007/08, the Ontario government is providing an additional $64 million to promote its comprehensive e-Health strategy – including moving toward a secure EHR, and expanding systems that provide drug and laboratory information as well as diagnostic imaging. (Ontario, 2007)


For Fun! : For Fun!


Conclusions : Conclusions


Solutions(Dickinson, 2006) : Solutions (Dickinson, 2006)


Emerging Themes : Emerging Themes A review of the barriers and solutions at national and provincial levels points to a number of “themes”.


Emerging Themes : Emerging Themes Barriers or Challenges: Rural geography Lack of infrastructure Lack of resources- cost, time, people Human aspects: Understanding Paper mentality Aging workforce Physician reluctance


Emerging Themes : Emerging Themes Solutions for Positive Outcomes Provincial Adequate: Education and change management Resources, both IT and caregivers Security of files Continuity of patient care Infrastructure, networks and compatibility Support from IT and Administration at the patient’s bedside. Public Education


Emerging Themes : Emerging Themes Solutions for Positive Outcomes National Infoway Corporate Business Plan 2007-08 Participate in healthcare renewal Collaborate with partners Target investments Support solution deployment Promote solution adoption and benefits realization e.g. change management, regional end-user support networks.


2015 Canada Health Infoway EHR 2015 : 2015 Canada Health Infoway EHR 2015 Full implementation of EHR requires: Accelerated health infostructure dialogue Consistent standards for infostructure, interoperability, and movement of knowledge and people Consistent platform quality across jurisdictions Cooperation, eliminating redundancy and duplication Reduction of long term costs and implementation time.


Key to Success Smith (2003) : Key to Success Smith (2003) Health care providers must drive implementation of EHR Focus on the patient Provide value Create a positive change experience Build a foundation to grow on.


Overcoming EHR hurdles is a national and provincial future reality… : Overcoming EHR hurdles is a national and provincial future reality… Photo Source: Maloney 2007


Thank you! : Thank you!


Discussion Questions : Discussion Questions


What do you think? : What do you think? Given the challenges of implementing an EHR, do you feel your province has the proper supports and plan in place to make an EHR a reality by 2010 ? Why or why not? Who will you tell?


Tell Us : Tell Us Which EHR barrier(s) is most troubling from your perspective? Why?


You and IT? : You and IT? IT training has been identified as a solution to the barriers for EHRs. What do you need for IT training and do you feel your employer will provide this when the time comes? Should it be paid by your employer or is it professional development?


References : References Alvarez, R. C. (2002). The promise of e-Health – a Canadian perspective. Internet Health Journal of Research, Application, Communication & Ethics. Retrieved on October 14, 2007, from http://www.virtualmed.netfirms.com/internethealth/ehi200214.html Applied Clinical Trials. (2007). CDISC Clinical Research Glossary, Version 5.0. Retrieved November 4, 2007 from Applied Clinical Trails Web Site: http://www.actmagazine.com/appliedclinicaltrials/article/articleDetail.jsp?id=392455&pageID=6 Canada Health Infoway (2007). Electronic health records: Transforming health care, improving lives: Corporate business plan 2007-08. Canada Health Infoway, 2007. Canada Health Infoway (2006). Business Update. Canada Health Infoway. Retrieved on Oct 13 2007 from http://www.infoway-inforoute.ca/en/pdf/Private Sector-business Update v5.pdf Canada Health Infoway (2007). Standards Collaborative Update: Infoway road show. Retrieved October 13, 2007 from http://www.infoway-inforoute.ca/en/pdf/7_2007-08 _PS_Standards%20Collaborative.pdf


References (cont’d) : References (cont’d) Canada Health Infoway (2007). Clinician eHealth Support Network: the ehr and emrs: Distinctions, overlaps and inter-relationships. Canada Health Infoway, 2007. Canada Health Infoway (2007). Vision 2015: Advancing Canada’s next generation of health care. Canada Health Infoway, 2007. Canadian Institute for Health Information (2007). Home Care Reporting System: Data elements. Canadian Institute for Health Information. Retrieved on October 28, 2007 from http://secure.cihi.ca/cihiweb/dispPage.jsp Canadian Medical Association (2007). Information Technology and Health Care in Canada: 2007 status report. Canadian Medical Association, Toronto, ON. Retrieved on October 28, 2007 from http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/HIT/2007_status_report/IT-handbook-e.pdf Covvey, H. D. (2006). Waterloo Smarter Health Seminar Series: In Pursuit of the EHR Holy Grail. Retrieved October 14, 2007, from http://infranet.uwaterloo.ca/inftalks/2005-2006/2006-02-22/default.pdf


References (Cont’d) : References (Cont’d) Dickinson, H. (2006). The Future of KT: Trends and Issues. Department of Sociology, University of SK, 2006. Dillon, T., W., Blankenship, R., Crews, T. (2005). Nursing attitudes and images of electronic patient record systems. CIN: Computers, Informatics, Nursing, 23(3), 139-145 Government of Manitoba (n.d.) Manitoba e-Health. Electronic Health Record. Government of Manitoba retrieved on October 28, 2007 from http://www.manitoba-ehealth.ca/ehr.html Government of Manitoba (n.d.). Hospital Information System Project. Government of Manitoba retrieved on October 28, 2007 from http://hisp.sbgh.mb.ca/ Government of Saskatchewan (2007). Current Health Initiatives: Integrated clinical system. Government of Saskatchewan 2007 retrieved on October 28, 2007 from http://www.health.gove.sk.ca/current-ehealth-initiatives Government of Saskatchewan (2007). Health Information Solutions Centre: Electronic Health Record Blueprint. Government of Saskatchewan 2007 retrieved on October 28, 2007 from http://www.health.gov.sk.ca/ehr-strategy


References (cont’d) : References (cont’d) Government of Saskatchewan (2007). History of Health Information Network. Government of Saskatchewan . Retrieved on Oct 28, 2007 from http://www.heatlh.gov.sk.ca Gregoryk, C. (2006). Case Study: Implementing a province-wide solution for Saskatchewan home care, challenges and methodology. Procura, Victoria BC. Health Canada (2001). Towards Electronic Health Records. Office of Health and Information Highway, Health Canada retrieved on October 28, 2007 from http://www.hc-sc.gc.ca/hcs-sss/alt_formats/iacb-dgiac/pdf/pubs/2001-towards-vers-ehr-dse/2001-towards-vers-ehr-dse_e.pdf Kirkley, D.M., Stein, M. (2004). Nurses and clinical technology: Source of resistance and strategies for acceptance. Nursing Economics, 22(4), 216-223. Maloney, S. (2007). Canada Health Infoway: Latest Development in Electronic Health Records. PowerPoint presentation presented at the Executive Edge Conference on November 1, 2007, Toronto, Ontario Canada


References (cont’d) : References (cont’d) Moody, L.E., Slocumb, E., Berg, B., Jackson, D. (2004). Electronic health records documentation in nursing. Nurses’ perceptions, attitudes, and references. CIN: Computers, Informatics, Nursing, 22(6), 337-344. Neville, D., Keough, M. , Barron, M., MacDonald, D., Gates, K., Tucker, S., Cotton, S., Farrel, G., Hoekman, T., Bornstein, S., O’Reilly, S. (2004) Towards an Evaluation Framework for Electronic Health Records: An inventory of electronic health record initiatives across Canada. Health Canada Office of Health and Information Highway retrieved on October 28, 2007 from http://www.nlchi.nf.ca/pdf/Initiatives_mar04.pdf Ontario e-Health Program. (2007). Retrieved October 14, 2007 from Ontario Web Site: http://www.health.gov.on.ca/ehealth/initiatives/initiatives_mn.html


References (cont’d) : References (cont’d) Ontario Smart Systems for Health Agency (SSHA). (2007). Mission, Vision & Values. Retrieve October 14,2007 from SSHA Web Site: http://www.ssha.on.ca/about/mission.asp Smith, J. (2003). This Way: EHR Success, Canadian Healthcare Manager. Toronto, June 2003 10(2). University of Waterloo. (2006). The Ontario Laboratory Information Systems (OLIS): A Strategic Change Initiative for e-Health Ontario. Waterloo Smarter Health Seminar Series. Retrieved October 14, 2007, from http://infranet.uwaterloo.ca/inftalks/2005-2006/2006-03-22/default.pdf Winnipeg Regional Health Authority: e-Health update. Retrieved 18 October 2007. www.manitoba-ehealth.ca/ehr.html WordNet. (n.d.). WordNet: A lexical database for the English language. Retrieved November 4, 2007, from http://wordnet.princeton.edu/perl/webwn?s=barrier