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Canada's rank in OECD studies 20100610

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Canada's rank in OECD studies 20100610

  1. 1. 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
  2. 2. Outline The Problem Policy Analysis Economic Analysis Implementation Factor Analysis Conclusion
  3. 3. Canada Lags in E-health Use E-health Tool Use in 7 OECD Countries 0 10 20 30 40 50 60 70 80 90 100 AUS CAN GER NET NZ UK US Country %ofPhysicians 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.
  4. 4. 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.pdf Accessed Jun 11, 2010
  5. 5. Why? Not for lack of trying Lots of Programs and $$$ EMR implementation is complex
  6. 6. Natural History of EMR N=112 100% Implemented EMR in 1999-2000 40% Inefficient Users 25% Efficient Users 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
  7. 7. 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 Electronic Medical Records in Ontario. http://www.infoclin.ca/assets/intel%20emr%20white%20paper.pdf Accessed Jun 11, 2010.
  8. 8. Macro Policy Framework Recognize the societal value of EMRs? Involve professional civil society? Create an enabling e-environment? (security, standards, interoperability)
  9. 9. Macro Policy Framework Encourage markets for new services? Leverage network effects? Engage patients and patient advocacy groups?
  10. 10. Economic Drivers Framework by Wang, Bates, Middleton Economic drivers of EMR uptake Adapted for Canadian Context Examines ROI for all players Wang 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.
  11. 11. 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
  12. 12. Governance Pre-Implementation Implementation Post Implementation Project Leadership Involve Stakeholders Technology Usability Factors Work-flow Redesign Training Implementation Assistance Privacy & Confidentiality Support Technology Process People Feedback and Dialogue Choose Software Sell Benefits & Address Barriers Data Pre-Load and Integration Early Planning Incentives User Groups Business Continuity
  13. 13. Methodology Compare EMR programs in Ontario, BC, Alberta and New York City Key Informant Interviews Review of Documentation Scores are un-weighted No = 0 Partial = 0.5 Yes = 1
  14. 14. Canada’s First Primary Care Informatics Consulting Firm Policy Framework Analysis Economic Analysis Implementation Factor Analysis
  15. 15. EMR Policy Framework Element NY Ontario Albert a 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 0.5 Provide 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 0 Provide Key ICT Infrastructure (secure e-mail) 1 0 0.5 0.5 Set and Implement Interoperability Standards 1 0.5 0.5 0 Engage Patients and Patient Advocacy Groups 0.5 0 0 0 Rigorous Monitoring & Evaluation 1 0 0 0 Score 10.5 5.0 4.0 4.5   Maximum Score = 11 No = 0 Yes = 1 Part = 0.5
  16. 16. Canada’s First Primary Care Informatics Consulting Firm Policy Framework Analysis Economic Analysis Implementation Factor Analysis
  17. 17. 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
  18. 18. US Canada  Benefits (Savings) COST $46,400 $78,000 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 $58,896 $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     $95,646     $95,646 Net (Benefit-Cost)     $108,142     $23,406 MD Net Benefit/Loss     $12,496     - $72,240
  19. 19. Net Loss to Physicians Who Implement EMR in Canada: $72, 240 Over 5 Years
  20. 20. Still think physicians are ‘resistant to change’?
  21. 21. Canada’s First Primary Care Informatics Consulting Firm Policy Framework Analysis Economic Analysis Implementation Factor Analysis
  22. 22. No. Success Factor NY Ontario Albert a 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
  23. 23. Canadian Provinces Do Poorly on Economic and Policy Drivers of EMR Uptake
  24. 24. 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)
  25. 25. 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
  26. 26. 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

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