Wednesday, August 22, 2007

Carrots or sticks | Making a case for heightened government involvement in EHR

As confirmed in Frost & Sullivan's 2005 Analysis of the Canadian Healthcare IT Markets, Canada has a national health service which provides hospital care and other medical services to the entire population and is publicly financed. The health service is highly decentralised, with the management and delivery of health services being the responsibility of the provincial and territorial governments, which have jurisdiction over 97% of the nation’s hospitals.

The provinces and territories operate health insurance plans which are obliged to conform to the principles of the Canada Health Act and are collectively known as Medicare. The government responsibilities for healthcare delivery include:

• Setting national standards for health
• Oversee the implementation of the ‘Canada Health Act’
• Provide funding to Provinces
• Promote health protection, disease prevention & health promotion

Provincial/ Territorial
• Managing and delivering health services
• Planning, financing and evaluating the provision of hospital care,
physician and healthcare services

In order to promote healthcare IT, some provinces have set in motion various plans to reform the healthcare IT infrastructure at the primary care level. Ontario’s Primary Care IT Strategy is being implemented to assist primary care physicians with the adoption and implementation of IT in their practices. This involves a dual approach to the procurement of Clinical Management Systems (CMS)—Application Service Provider (ASP) Solutions and Local Solutions.

Over 95% of Canadian Hospitals are Public, Non-profit Entities. The provincial and federal government hospitals account for over 95% of all beds. Private hospitals account for only 4% of all beds, the vast majority of which are in Quebec. Public hospitals operate as not-for-profit organisations with their own governing boards, which have control over day-to-day decisions and allocations of resources. However, boards must stay within annual operating budgets negotiated with their local healthcare commission on an annual basis. All hospitals in Yukon are federally managed.

There has been an increase in Outpatient Care in Acute Hospitals and Hospital Day Surgery Programmes also. Increasingly, fewer patients are hospitalised overnight and those that are admitted to in-patient facilities are generally admitted for shorter periods of time. There is also increasing pressure to reform from an institutional to a community-based model.

The problem is the number of Canadian Hospitals still acting alone (as IT-fifetoms) in their continued procurement of CIS/HIS/IT platforms that are not scalable or standards-based. This is most relevant related to our quest for a national EHR.

To compound issues, significant differences exist across Canadian Provinces on the local, regional and national level in terms of per capita spending on (and inputs to) healthcare systems. However, quality, accessibility, and sustainability of care are also limited because best practices are not freely shared. What results are small, politically charged, competing fifetoms. Action at a national/ federal level would be indispensable, as the lack of accountability ensures higher integration costs. To wit, Canadian Healthcare delivery organizations require much stronger, mandated guidelines on eHealth interoperability. It is difficult and highly inefficient to continue with Hospital Networks (and their numerous stakeholders) working in isolation to improve their healthcare systems---AS eventually all entities will need to be integrated to achieve a national EHR.

The current state of most Clinical Information Systems' (CIS) across Canada, as an example, is draconian in comparison to what is available using today's technologies. Especially from an operational efficiencies standpoint. In fairness, a.>the primary/ acute care HIS/CIS platform across the country is 10-15 years old on average, and b.> Canada Health Infoway's Funding Timeline has replacement funding for primary CIS (tentatively) forthcoming Q3-2009 (and procurement of new systems will likely be delayed until this time, if only to capitalize on this Government compensation.)

Canada Health Infoway, has successfully promoted eHealth standards and guidelines, however, using incentives to progress interjurisdictional cooperation between neighbouring healthcare providers---is akin to herding cats. Simply moderating the procurement process hasn't had the effect it might have.

The difference between the "carrot" (subsidizing standardized IT procurement,)and the "stick" (mandating connectivity standards) would hopefully ensure Vendors either adhered to a standardized level of connectivity, or they would not be allowed to sell in Canada. This act alone could eliminate 50% of the total cost (and at least 40% of the time)to our achieving a national EHR.

The importance of interjurisdictional cooperation in Canadian healthcare cannot be understated in terms of cost to the taxpayer. In order to cut the red tape related to the use of shared health services, it is imperative that an electronic systems standard be established of patient identification. Secondarily, there must be heightened support to introduce mandatory eHealth and telemedicine services (telemedicine, teleconsultation, laboratory services, shared medical imagery (teleradiology),eBilling, ePharmacy, federated eHealth Portals, and sharing of standardized protocols.)

To a growing extent, standardized eHealth contributes to fairer health services across geographical and social boundaries, as well as helping to reduce (or at least limit) the growing costs of the healthcare. Services would not create extra financial burden, as it would depend on voluntary basis of services provider and would present another alternative to the existing system. eHealth by definition requires the sharing of patient identifiable data when and where necessary. When the processing of such personal data relates to a person's health, processing is particularly sensitive and therefore requires special protection. In the eHealth context, the processing of personal data in health systems across multiple jurisdictions varies significantly due to their specifics and the diverse legacy platforms currently in place. It is therefore important to consider whether the Canadian government (Health Canada) should mandate national guidelines (rather than only incentivizing decisions through Canada Health Infoway.) Manadated cooperation between regional and Provincial stakeholders provides, as an example, a framework for greater legal certainty and accoutability of eHealth products and vendors (and services liability within the context of existing product liability legislation. )

Although interoperability is not a goal in itself, since Canadian healthcare delivery organizations (at all levels) are now directing their health policies to subscribe to a new paradigm of common visions, and common values, a definitive focus are now required for eHealth interoperability. In the context of Canada’s (taxpayer-funded) public healthcare system, Canada Health Infoway’s ‘incentivized’ funding methodology has only managed to add a layer of broad standardization, which clearly doesn’t go far enough. The wasteful management and misaligned allocation of funds, while intended to evolve Canada to a national EHR, unfortunately will require strong Federal guidelines and enforcement to protect taxpayer interests. The only thing more blatent than the misappropriation of healthcare dollars in Canada, is the lack of any ROI accountability.

Without a mandated, standardized (versus incentivized) interoperability framework, our Canadian healthcare system is so rife with misappropriation of healthcare funds (by people of relatively high social or economic status) to make money for themselves or to further the aims of their organization---taxpayers will pay twice (2:1) as much to achieve our objectives of a National EHR. If history has proven anything, it’s that without a formal audit process or investigative arm regulating Canadian taxpayer dollars invested in Healthcare---only the illusion of objectivity is provided. Behind the scenes, the spoils are being pilfered so flagrantly it would make Imelda Marcos blush. No Federal watch-dog, no accountability.

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