Wednesday, July 23, 2008

Taking e-Health to the next level

Chief executive officers, chief information officers and other senior managers from healthcare provider organizations across Canada, along with representatives of sponsoring supplier firms, shared a diverse set of views and some fascinating insights into healthcare IT implementation challenges at the eighth eHealth Summit, held June 11-13 in Mont Tremblant, Que. The conference is organized annually by Canadian Healthcare Manager

An overview of the current status of eHealth in Canada was provided by Shelagh Maloney, executive director, external liaison, for Canada Health Infoway. Roughly one in three youth and adults in Canada — nine million people — are living with one or more medical conditions, Maloney said. Central to addressing the critical challenge of managing chronic diseases is to get these patients involved in their care.

“If you’re like a growing number of Canadians,” she noted, “you want to take an active role in managing your healthcare.” Maloney cautioned that there’s no quick fix to this problem — a point that was repeated by other speakers at the summit. She referred to the progress that’s being made toward implementation of electronic health records (EHR’s), but also eluded to an area that became a minor theme throughout the conference: health consumerism.

“The health consumerism trend is creating an environment where providers and patients alike want the right information, at the right time, to make the right decisions,” Maloney said, adding that consumer eHealth solutions, many of which deliver a broad range of information to patients, are gaining support.

CANADA’S progress in eHealth was put into a global perspective by Susan Hyatt, president and CEO of the corporate strategy firm HyattDIO Inc., and a former vice-president at Canada Health Infoway. A “global business platform” for the delivery of healthcare is being enabled by eHealth, she said, in which English is the pervasive language, brands are going global and eHealth infrastructures are prevalent, even in poorer countries.

“We’re seeing the emergence of a global healthcare bazaar,” Hyatt said. “And when things go global, everyone is affected.” To stress the point, she showed a map of the world in which such unlikely candidates as India, South Africa and China were identified as having “strong EHR, eHealth activity.”

Common to all national initiatives are a clear and well-articulated vision, a common architecture, and transparent governance and accountability frameworks. In Canada, however, there are some additional factors at work. “The privacy commissioners in Canada are engaged in early dialogue,” said Hyatt. “As well, Canada has portfolio management with targeted investment programs, and a well-defined co-investment strategy to manage risk.” However, there’s one significant area where Canada, along with the United States, lags: the adoption of electronic medical records (EHR/EMR’s) by primary-care physicians. This problem is well-known, yet Hyatt acknowledged that solving it remains something of a conundrum.

IN THE SUMMIT’S keynote presentation, Kevin Leonard returned to the question of technology and the role of the patient in managing chronic diseases more effectively. Leonard is associate professor in the Department of Health Policy, Management and Evaluation at the University of Toronto, and research scientist at the University Health Network’s Centre for Global eHealth Innovation.

The economic logic for patient involvement is compelling, Leonard said: “Out of a total healthcare spend of $146 billion in Canada; about $90 billion is for chronic diseases. And it’s estimated that of this, $50 billion is spent on providing information such as test results, care advice and repeat prescriptions.”

Just as customers having access to their personal financial information has reduced the banking industry’s costs, great savings will also be gained in the healthcare system, as more patients bypass the “hands-on” personal method and obtain personal health information for themselves. Consequently, a tremendous amount of strain will be removed from the healthcare system. Consumers from all types of industries are playing larger roles in both purchasing and developing products and services. The growth of social networking websites such as YouTube and Facebook are prime examples. In healthcare, however, such grass-roots contributions have been slower to come to the fore, although recent initiatives like Google Health, Microsoft Health Vault and Patients are emerging as alternatives to the status quo.

Healthcare has been slow off the mark in this area, Leonard suggested, because the system uses language and jargon that’s not accessible to the average consumer, and because patients may not yet appreciate the benefits to be gained from better access to their information. As well, there are no “information access” points to facilitate communication between patients and the healthcare system.

Ultimately, patients lack the encouragement, the education and the means to gain the information they need. To get patients more involved in an effective way, Leonard argued that more research is needed to determine how to do it properly. This research might help answer several questions, for example:
• How should patient access to EHR’s be supported?
• Who should control access?
• Does this lead to improved patient outcomes?
• How does increased record ownership address privacy issues?

He proposed that for these and other questions to be answered effectively, patients need representation by a formal organization. “This organization must represent both the ill (chronic and otherwise) and recognized, and invited to the table with other organized stakeholders.”

ONE OF THE KEY challenges in eHealth implementation is that of leadership, an issue that was addressed at the summit by John Hylton, president and CEO of John Hylton & Associates, and Canadian Healthcare Manager’s regular leadership columnist. Hylton presented some startling statistics: 90% of healthcare organizations run without a plan, and of the 10% that do have a plan, 90% fail to execute their strategies successfully. As well, 95% of a typical workforce doesn’t understand its organization’s strategy, and 60% of organizations don’t link strategy to budgeting. To the extent that eHealth and technology fit into an organization’s strategy, this lack of foresight can lead to some big problems.

“It needs to be recognized that different stakeholders want different things from health reform and from health technology,” said Hylton. “Unless we can agree on what we’re hoping to achieve, the wheel-spinning will continue.”

It’s also important to realize that technology is not a panacea. “Many expect way too much too soon from technology, while others harbor disappointment and even resentment about failed technology projects,” he said. “The truth is somewhere in between.” Hylton warned that if we consider all of healthcare’s many technology needs together — not only eHealth and information and communication technologies — then its apparent our current ability to assess, deploy and pay for innovation is inadequate.

“It’s also helpful to remember that there are many healthcare issues that preoccupy funders, administrators and trustees,” he said. “Technology is just one. Constant change and shifting priorities have created a planning environment that frustrates intelligent planning and decision-making, and there’s no doubt this impacts technology planning and decisions as well.

“As the OHA, for example, recently observed, ‘the current funding environment does not effectively support the adoption, collaboration and integration necessary to enable the realization of eHealth’s true value.’” Hylton said improvements in the use of technology will only come about when healthcare leaders, particularly system leaders, start to be much more intentional about the path they want to follow. Moreover, in every healthcare system, some individual or team has to “own” this priority. Budgets and personnel must be aligned to ensure success, and incentives need to be put in place that are directly tied to achieving measurable improvements in the uptake and effective use of technology.

“Strategy-focused organizations work through competing challenges and interests to identify the key strategic priorities that are most important for achieving improved performance,” he said. “The bottom line is that we need more strategy-focused organizations in healthcare. You might say all this is Management 101, but the fact of the matter is that our health system needs more Management 101.”

THE LEGAL risks involved in the implementation of EHR’s were the subject of a presentation by Richard Corley, partner with Blake, Cassels & Graydon LLP, who described his perspective as that of a “deal lawyer specializing in complex IT and outsourcing transactions in the healthcare field.”

The development of eHealth in Canada has seen a rapid increase in complex IT health system deals, Corley said, and recently the deal structures have tended towards more integrated multi-vendor environments, smaller and shorter deals, more onshore/offshore combinations, and a greater emphasis on better governance. There are expanding legal requirements around privacy, security, record disposal, medical device regulation and liabilities for claims. The laws and regulations that apply most directly to healthcare providers are the requirements under federal and provincial privacy laws in Canada, including the Personal Information Protection and Electronic Documents Act (PIPEDA) and the more directive requirements under the Health Insurance Portability and Accountability Act (HIPPA) in the United States, whose security rules apply to the storage, maintenance or transmission of electronic protected health information by health plans, healthcare clearinghouses and healthcare providers.

There are numerous requirements for security in EHRs, Corley noted, including subcontractors’ breaches and the losses and thefts of storage devices. Another concern, which has made the news on too many occasions in Canada, is the improper destruction of paper-based records and EHR’s. He also discussed the risks posed by projects that integrate and implement new eHealth information systems with existing systems and/or outsource the provision of such services to a third-party service provider. Integration and outsourcing projects are notoriously difficult to implement effectively and many have proven unsatisfactory, he said.

Best practices for IT integration include: clarifying objectives and gaining executive support for the project; clearly documenting requirements, scope and costs; securing expert help and internal support; good governance before, during and after implementation; allowing enough time for due diligence; avoiding unnecessary complexity; maintaining required flexibility; planning transition and repatriation; ensuring that required expertise is maintained; and having a contract to address contingencies.

WHERE WILL eHealth be by 2015?
Offering answers to that question at the eHealth Summit was an expert panel that took out its crystal ball and peered into the future. The panelists were David Cowperthwaite, project manager for Panorama; George Eisler, CEO of the BC Academic Health Council; Michael Lauber, chair of Ontario’s Smart Systems for Health Agency; and Judy Middleton, CIO of the William Osler Health Centre.

The panel was by no means filled with wide-eyed optimism, but it did express confidence that by 2015 EHR’s would be in place for the majority of Canada’s population. However, there was consensus, albeit from varied viewpoints, that achieving that end will produce further resourcing and funding challenges: once the eHealth infrastructure is built out, how will it be maintained?

“There’s a big difference between implementation and adoption, and usage for benefits,” said Cowperthwaite. “I worry that a lot of people will still not be getting good care in 2015, and there will remain an enormous gap with First Nations.”

Lauber was more optimistic that technology could be delivered to rural areas, and that enhanced broadband delivery will ensure the viability of initiatives such as telehealth. Eisler, however, worried that Canada won’t have enough people trained in technology to maintain the system.

From a hospital perspective, Middleton echoed this concern, because advanced facilities will require both predictable funding and access to highly qualified personnel.

The ninth annual eHealth Summit will be held June 10-12, 2009, in Montebello,

The eHealth Summit Series is an annual forum (organized by Canadian Healthcare Manager Magazine for Canadian healthcare executives to exchange ideas, find out about innovations, share common challenges and discuss the strides that have been made in eHealth implementation across the healthcare continuum. The spirit of the conference is purely educational and 'think-tank' oriented.

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