Canadian Experience with Health Information Technology

1
Canadian Experience with Health Information
Technology

• Richard Alvarez
• President CEO
• Canada Health Infoway/Inforoute Santé du Canada
• May 14, 2004

2
Todays Presentation

• State of healthcare delivery in Canada
• Current state of Electronic Health Information
  Systems deployment in Canada
• Canada Health Infoway a catalyst for deploying
  Electronic Health Information Systems
• Strategy for a Pan-Canadian Interoperable
  Electronic Health Systems
• Progress to date
• Lessons learned
• Areas of global support and collaboration

3
Canada is a very large country, but with a
relatively small population

• Geography
• 10 provinces, 3 territories
• 2003 Population 31,629,700
• Ontario 12.2 M
• Quebec 7.5 M
• BC 4.1 M
• Alberta 3.2 M
• Manitoba 1.2 M
• Sask. 1.0 M
• NB .7 M
• Nova Scotia .9 M
• NFLD/LBR .5 M
• PEI .1 M
• Yukon, .1 M
• NWT, NVT
• Government
• Federal, Provincial, Territorial
• Two official languages English and French

YT 0.03 M
NT 0.04 M
NU 0.03 M
NL 0.5 M
BC 4.1 M
MB 1.2 M
AB 3.2 M
PE 0.1 M
SK 1.0 M
ON 12.2 M
QC 7.5 M
NS 0.9 M
NB 0.7 M
4
Public accountability for healthcare in Canada is
a shared federal and provincial responsibility

• Healthcare is constitutionally a
  provincial/territorial jurisdiction
• The provinces/territories
• Plan, finance, manage, evaluate health services
• Provide public coverage for defined services
  (e.g. medical services, prescription drugs,
  dental care) for defined groups (seniors,
  children, welfare recipients)
• The federal government
• Sets and administers national principles or
  standards for the healthcare system, e.g. the
  Canada Health Act
• Five principles Public administration,
  Universality, Portability, Comprehensiveness,
  Accessibility
• Assists in financing of provincial healthcare
  services through fiscal transfers
• Fulfills defined health functions
• Direct health service delivery to Veterans,
  native Canadians living on reserves, Military
  personnel, inmates of federal penitentiaries, and
  the Royal Canadian Mounted Police
• Health protection, disease prevention, health
  promotion services

5
Canadas healthcare system is predominately
publicly financed and privately delivered

• A predominantly publicly financed and privately
  delivered healthcare system
• An interlocking set of ten provincial and three
  territorial health insurance plans
• Provides access to universal, comprehensive
  coverage for medically necessary hospital,
  inpatient and outpatient physician services
• Components include
• Independent not-for-profit health authorities and
  hospitals (some provinces)
• Independent private fee-for-service physicians
  reimbursed via provincial health insurance plans
  (some salary or capitation arrangements)
• For-profit entities provide long term care, home
  care, alternative/complementary care, and
  services which are not medically necessary
• Private supplementary insurance exists for non
  medically necessary services such as vision and
  dental care as well as prescriptions
• Funding of healthcare
• Healthcare is financed primarily through F/P/T
  and corporate taxation
• Funds are transferred from the federal government
  to provinces by direct block transfer based on
  funding formulas

6
Since 1997 Canadian healthcare expenditures have
been increasing - 121b in 2003 10 GDP
10.0GDP
10.0GDP
8.9GDP
121b
78b
70b
Source Canadian Institute for Health Information
7
In 2003 Canada spent 60 of its healthcare budget
on hospitals, drugs and physicians
Total Canada Healthcare Budget 121 billion
Capital 5.6 billion
Public Health 7.9 billion
4.6
Other Health 10.2 billion
6.5
Hospitals 36.4 billion
8.4
30
Other Institutions 9.6 billion
9.6
11.9
16.1
12.9
Other Professionals 11.9 billion
Drugs 16.1 billion
Physicians 12.9 billion
Source Canadian Institute for Health Information
8
The Canadian Health System is a mix of public
70 and private 30 sources of funding
Other Professionals Eg. Chiropractors,
Dentists Midwives, etc. t
Source Canadian Institute for Health Information
Source Canadian Institute for Health Information
9
Healthcare Professionals
Source Canadian Institute for Health Information
10
National Health Measures
Source Canadian Institute for Health information
11
Healthcare is typically over 30 of a provinces
total expenditure

• Health Expenditures
• 2003 Provincial Expenditures 78 billion
• Ontario 29.8 b
• Quebec 17.1 b
• BC 11.3 b
• Alberta 8.4 b
• Manitoba 3.3 b
• Sask. 2.5 b
• NB 1.8 b
• Nova Scotia 2.2 b
• NFLD/LBR 1.4 b
• PEI 0.3 b
• Yukon, 0.5 b
• NWT, NVT
• Health as a of the Provincial and Territorial
  Government budgets
• Ranges from low of 15 in Nunavut to high of
  43.2 in Ontario
• Average across Canada is 38.1

YT 15.4
NT 22.1
NU 15
NL 37.7
BC 39.9
MB 42.2
AB 39.0
PE 35.0
SK 38.5
ON 43.2
QC 31.1
NS 40.1
NB 35.0
Source Canadian Institute for Health Information
12
Canada like many other countries is trying to
reform its healthcare system

• Canada, like most other industrialized countries,
  has struggled to contain escalating healthcare
  costs and improve quality and outcomes
• At the same time, there has been a shift from a
  focus on hospitals/providers to a focus on
  population health, home care and integrated
  healthcare delivery systems
• As part of these efforts, nine of ten
  provincesall but Ontariohave adopted
  regionalized structures
• Each regional body (Regional Health
  Authority/RHA) oversees a varying degree of the
  full continuum of care
• Regional bodies are making significant efforts to
  standardize their technology platforms and
  integrate patient and administrative data
• Increasingly, there is recognition of the need
  for new methods to healthcare delivery that are
  enabled by information technology
• A number of recent government studies and reports
  have been completed to direct the healthcare
  reform process ex. National Forum on Health the
  Kirby Commission, and the Romanow Report

13
Canada Healthcare Market Trends and Issues

Changing Human Resources
Integrating Delivery Systems
Increased Account-ability
Changing Health Issues
Shifting Governance

• Aging baby boomers
• Burden of chronic disease
• Redefinition of health
• Redefinition of medically necessary

Consolidation of control at regional
level Changing role of Federal
Government Increased role of payers in practice
management
Policy demand for evidence of outcomes Consumer
demand for information High expectations of
knowledge revolution
Aging population of providers Gender shift among
physicians Mal-distribution of health human
resources
Shift to home and community care Primary care
reform Challenges of equal access Integrating
information systems
Public expenditures are expected to significantly
increase as an aging Canadian public wants both
equal access and high quality health care. There
is a continual public debate about the need for
increased private financing and operation of the
healthcare system.
14
Canada also views information technology as a key
enabler of healthcare reform

• Since the mid 1990s some provinces initiated
  their own integrated delivery network
  initiatives. The most notable examples include
• Alberta wellnet http//www.albertawellnet.org/
• Saskatchewan Health Information Network
  http//www.shin.sk.ca/
• Ontarios Smart Systems for Health Agency
  http//www.ssha.on.ca/
• From 1998-2001 Canada completed a number of
  national studies on health information
  technology ex. Canada Health Infoway report,
  Pan-Canadian Health Infostructure Tactical Plan.
  http//www.hc-sc.gc.ca/ohih-bsi/chics/index_e.html
  
• In 2001 Canada Health Infoway was formed (a
  not-for-profit agency) and was provided with 1.2
  billion to implement electronic health record,
  telehealth and disease surveillance solutions
  across Canada. http//www.canadahealthinfoway.ca/
• Infoways investments to date has focused on
  infrastructure, enterprise registries, and domain
  repositories for laboratory, drug and DI data.
• To gain synergy and leverage national investments
  two interprovincial collaboratives have been
  formed one in the west/north and the other in
  Atlantic Canada
• Western Health Information Collaborative
  http//www.whic.ca/
• Health Infostructure Atlantic http//www.gov.ns.ca
  /health/hia/default.htm

15
Canada Health Infoway, Inc is a major part of
enabling and accelerating healthcare reform

• With 1.2 Billion and the provincial / territorial
  related funding of 600-800 Million, there is 2
  Billion in new money to be spent on 7 strategic
  areas
• Electronic Health Record systems (regional and
  inter-regional)
• Registries (Provider, Client and Location)
• Drug Pharmacy Information Networks
• Diagnostic Imaging and RIS systems (regional /
  provincial based)
• Laboratory information systems
• Telehealth
• Health (infectious disease) Surveillance
• Infrastructure (middleware focused)
• Funding will be flowed to provincial and
  territorial level jurisdictions and their EHR
  programs, with flow through to regions and
  hospitals that have aligned EHR plans.
• Replicability is key to regional / hospital use
  along with consistent health business priorities
  at all levels national, jurisdictional and
  regional / hospital.

Infoway has become the focal point in Canadas
push to exploit Information Technology in the
Delivery of Healthcare
16
Regional Health Authorities and Hospitals in
Canada

Selfcare

• Health Organizations
• Number of Health Authorities
• Typically 6-20 Regional Health Authorities in
  each province
• Ontario is not regionalized
• Number of Hospital Facilities 927
• Ontario 253
• Quebec 211
• BC 115
• Alberta 102
• Manitoba 77
• Sask. 65
• Nova Scotia 35
• NB 28
• NFLD/LBR 26
• PEI 7
• Yukon, 8
• NWT, NVT

YT 2
NT 7
NU 1
NL 13
BC 6
MB 11
AB 9
PE 5
SK 12
ON n/a
QC 18
NS 9
NB 8
Source Canadian Institute for Health Information
17
Ontarios Healthcare Organization is not
Regionalized while not the same, it is more
like a US state

Selfcare

• 38 of Canadas population
• Over 23,000 physicians
• 253 Hospitals governed by 154 Hospital
  Corporations
• 560 Long Term Care facilities with 67,400 beds
• 42 Community Care Access Centres (Home Care)
• 37 Local Public Health Boards and 55 community
  health centres
• 204 hospital labs 96 community labs200 million
  tests annually
• 2700 community pharmacies
• There are regional programs and networks, but no
  regional health authorities
• Funding, programs, policy set from the
  provincial government (different than US)

NU 1
MB 11
ON n/a
QC 18
Source Canadian Institute for Health Information
18
Patient Flow in Canada there are 8 venues of
care
Selfcare
Public Health Clinic
Provider Office
AmbulatoryCare Clinic
Mental Health Clinic
Long Term Care Facility
Hospital
Home Care
19
Electronic health records, electronic medical
records and personal health records?

Selfcare
Public Health Clinic
Provider Office
PHR
EMR
AmbulatoryCare Clinic
Mental Health Clinic
Long Term Care Facility
Hospital
Home Care
20
How IT has attempted to meet the challenge -
four waves of healthcare IT

• Infrastructure
• Integration brokers ? ? ? ? ?
• EMPIs ? ?
• Data repositories ?
• Financial and administrative
• Financial EDI claims processing ? ? ? ? ?
• Practice management ? ? ?
• Venue specific clinical applications
• Hospital departmental systems ? ? ? ? ?
• CPR/CPOE ?
• Physician office and ambulatory clinic EMR ?
• Home care ? ? ? ?
• Long term care ?
• Public health clinics ? ? ?
• Mental health clinics ? ?
• Multi-venue clinical integration
• Longitudinal electronic health record ?

?- indication of solution penetration In
Canadian market
21
Current State of HIT Adoption Connectivity

• Canada under-invests in health IT, like most
  countries
• 1.4 of total healthcare expenditures spent on IT
• Prescribing Drugs on-line
• Primary Care Physicians 8 , Specialists 11
• Wired In

Currently no mechanism exists to consistently
measure HIT or EHR use and results in Canada
Source 2003 Health Care in Canada, Canadian
Institute for Health information
22
Canada Health Infoways Mandate

• Our 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 with
  tangible benefits to Canadians.
• To build on existing initiatives and pursue
  collaborative relationships in pursuit of its
  mission
• Our Goal
• Infoways six-year plan is to have the basic
  elements of interoperable EHRs in place across 50
  percent of Canada by 2010
• What we do Core Business
• We invest with public sector partners to develop,
  replicate and re-use compatible electronic health
  systems faster, better, and more cost-effectively
  than any of our partners can do alone. As a
  strategic investor, Infoway provides the means
  for members to reduce costs and share the risks
  associated with new technology development and
  implementation

23
Infoways Strategy
Mandate Develop the key elements of
interoperable EHR solutions six year timeframe

• The Strategy
• Focus on seven targeted Investment Programs
• Leverage investments reuse, replicate, align,
  deploy
• Collaborative planning with health ministries and
  other partners
• Form strategic alliances with private sector
• Focus on end-users to gain acceptance
• Public sector sponsors with investment in
  projects

• Infoways Investing Philosophy
• Accelerating the development of EHRS involves
  breaking new ground
• Reduce costs and overall risk accelerate
  implementation
• Adjust strategy to reflect learning and experience

24
Eight Investment Areas Reflect a National
HealthCare Information Systems Strategy

• Infostructure includes the architecture and
  standards to support an interoperable EHR

• Disease Surveillance Systems will support the
  management and control of infectious diseases eg
  SARS.

• Electronic Health Record Systems, including EMPI,
  repository, systems integration and clinical
  presentation layer to view the health record
  Generation 2 and/or do orders and some clinical
  decision support Generation 3.

• Registries are required to uniquely identify
  healthcare providers, clients and locations of
  care

• Drug Information Systems enable physicians to
  view a patient's complete drug profile online,
  order a prescription electronically and receive
  notification of drug interactions automatically.

An Electronic Health Record (EHR) Systems - a
secure lifetime record of an individuals key
health information.

• Diagnostic Imaging Systems enable authorized
  health care providers to view online a patient's
  test images, such as MRI, and reports, regardless
  of where the test was conducted and from any
  location .

• Laboratory Information Systems enable secure
  online viewing of patients' lab test results by
  authorized providers, regardless of where tests
  were completed

Drug Information Systems
Laboratory Information Systems
Disease Surveillance Systems
Telehealth
Registries client, provider, location

• Telehealth is the use of communications and
  information technology to deliver health care
  services over large and small distances,
  including remote and rural areas.

Infostructure architecture standards
25
A Blueprint to Tie it Together
Conceptual EHRS Blueprint
Disease Surveillance
Telehealth Laboratory
Information Systems Diagnostic Imaging
Systems Drug Information Systems
Registries Infostructure
100
100 -150
Generation 2 Generation 3 Electronic Health
Record solutions in 50 of Canada
150 -200
220 -280
Infoway 1.0 - 1.2 B
Jurisdictions and additional investment 0.6 -
0.8 B
185 -240
80 -110
190 -260
T20
T1
T5
Implementing EHR Building Blocks Infostructure,
Registries, Drug, Diagnostic Imaging, Laboratory,
Telehealth, Health Surveillance
Pan-Canadian interoperable EHR
Pan-Canadian Interoperable Electronic Health
Record

• EHR is the unifying force that securely brings
  together all the patients disparate information
  for the health care professional
• EHR is the visible, tangible result that extends
  and integrates our investments in clinical
  information systems (i.e. DI, Registries, DIS,
  etc.) and infostructure (e.g. EHRS Blueprint) for
  interoperability across the continuum of care

21
26
Evolution of the Electronic Health Record

• Order entry and results reporting for laboratory
  tests, medications and images.
• Alert notification (eg. duplicate tests, drug
  interaction)
• Provisioning of CPGs

Generation 4
The Mentor

• Patient demographics
• Provider demographics
• Location demographics

Generation 3
The Helper
Generation 2
Functionality and Value Chain Optimization

• Laboratory test results
• Dispensed medications
• Diagnostic image results

The Documenter
Generation 1
The Foundation
Enablers
End of 5 Year Plan
22
27
Infoways Role with its Partners is as a
Strategic Investor
Infoways role as an investor focuses on initial
investment in a solution its deployment. Our
unique role is in providing strategic leadership.
Intervener
Developer
Strategic Investor
Funder

• Set standards and requirements for robust,
  interoperable products and outcomes
• Provide leadership in researching and setting
  strategic direction for EHR and development to
  speed implementation
• Establish success criteria
• Flow or withhold funds based on status and
  quality of products

28
Investment Formula
Allocation Principles

• Predictability
• Facilitate compressed negotiations
• Higher investment for new solution development
  less for mature solutions or existing
  technologies

• Favour shared services approach
• Acknowledge added costs of early adopters
• Defined by program
• determined by capital, technology and
  implementation risks

Formulas by Program of Infoway investment
PROGRAMS
REPLICATIONSITE 1
REPLICATIONSITE 2-N
FIRST TO DESIGN, BUILD, IMPLEMENT
Drug Information Systems
60
50
80
50
50
50
Diagnostic Imaging Systems
100
100
100
Infoway-specific for interoperability and reuse
requirements
Infoway has formulated a tiered investment
formula to encourage and reward innovation and
early adoption
29
Tangible Results 2003-2004 Highlights
Lead Projects Launched
Jurisdictional Collaboration

• Top 3 EHR priorities of each provincial
  territorial govt identified (Nov 2003)
• Reuse discussion of Drug Information Systems,
  Diagnostic Imaging and Registry Application (Jan
  2004)
• Framework for Evaluating Benefits

• Shared Diagnostic Imaging System - Fraser
  Thames Valley (Dec 2003)
• Registry Applications (BC,SK,AB,MB,NL)
• Drug Information System Alberta (Oct 2003
  launch)
• NeCST developed and recognized internationally
  (Feb 2004).
• Blueprint creates framework and standards (July
  2003)

Detailed Jurisdictional Deployment and Readiness
Planning


Results Today Accelerated Re-use and Adoption
across Canada in 2004-2005
30
Some Impacts

• Shared Diagnostic Imaging Systems
• Provide small hospitals with access to digital
  imaging at lower cost than equipping themselves.
• Previously skeptical radiologists are praising
  system for helping manage workloads. Estimates of
  20 improvement in Radiologist productivity
• Emergency Room physicians find it easier and
  quicker to coordinate tests and results
• Cost avoidance estimated at 370 million
  annually, Canada-wide, by eliminating duplicate
  procedures and film
• Drug Information Systems
• Project underway to develop national messaging
  standards for dispensed drug and claims
• As much as 30 of elderly persons
  hospitalization results from medication toxicity
• In a recent study, inappropriate prescriptions
  for the elderly fell from 32 to 18 through use
  of a drug information system
• Will allow ER rooms and physicians to review
  patients by type of medication or condition
• Prescription drugs is the fastest growing
  component of health care spending

31
Early Benefits of Collaborative Development

• Some jurisdictions have levered their investment
  by approx. 80 with Infoway investments.
• Every 1 dollar invested by AB in drug
  information system, and NL in client registry
  application, is supported by an additional 0.80
  from CHI.
• Cost avoidance and knowledge transfer across
  jurisdictions through Starter Toolkits.
• Provides prototype legal agreements, governance
  models, RFP templates, requirements
  specifications templates, competitive
  intelligence on solution vendors, etc.
• Reduction in the time required to develop
  solutions.
• Collaborative development approach reduces
  duplication, increases economies of scale,
  leverages experience.

32
Investment Profile

• 53 ongoing and completed projects in 8
  jurisdictions, up from 17 last year
• 125.5 million in approved investments, up from
  10.8 million last year
• Additional 80 million earmarked for specific
  projects but not yet signed

Of Total 1.2b Investment Allocated per Year
2003-4 10
2004-2005 20
2006-2009 40
2005-2006 30
As of March 31, 2004
33
Lessons Learned

• More stakeholder involvement and collaboration
• Focus on end-user training
• Need for buy-in from doctors
• Better project management and accountability
• Critical importance of standards
• Privacy issues critical at every stage
• Benefits must be measured
• Toolkits to capture learnings are key
• EHR enables interoperability

34
Areas of Global Support and Collaboration

• Need Global Standards for Healthcare Records for
• interoperability of disparate systems
• enabling economies of scale
• reducing risk and cost of re-inventing the
  wheel
• supporting backward compatibility with older
  systems
• Need mechanisms for sharing best practices and
  software
• Starter and Implementation Toolkits have been
  key products of the collaborative programs in
  Canada
• Greater international collaboration at all levels
• Need to quantify the benefits
• Engage the Business Schools to accurately
  quantify the costs and the benefits
• Keep marketing the benefits in all forums

35
Areas of Global Support and Collaboration

• Need to reduce the cost of deployment
• Create a global market
• Share pricing arrangements
• International pricing agreements
• reducing risk and cost of re-inventing the
  wheel
• Need to create a buzz with the people on the
  ground
• Keep on the political agenda
• Tie ehealth to all health business investments
• Use a broad collaborative network to communicate
• Keep marketing the benefits in all forums