28-aug-15denis protti - university of victoria 1 local clinician involvement in clinical information...

Apr 19, 2023 Denis Protti - University of Victoria1

Local Clinician Involvement in Clinical Information

Systems:

Necessity or Luxury – A Review of International

Experiences

ASSIST (Harrogate, Preston)

October 1 & 2, 2003


Questions to be discussed

• Is it important to solicit meaningful physician input early and often and act upon it?

• Does finding meaningful ways to engage physicians require creating an organizational climate and culture that respects the heart of medicine? – Is this the key to maintaining

physician loyalty and involvement?


• Some management teams believe that ideas should be well fleshed out and ready for implementation before discussing them with physicians. – When that occurs, do physicians

feel their input is actually sought?

– And if they recommend changes at that point, will it be difficult for management to retreat and follow another course of action?


• How can one best square the need for centralised/standardised policy with getting local support and use?

• Does the opinion of national clinical bodies matter?


Outline

• The Danish Experience

• The New Zealand Experience

• An American Experience

• The British Experience

• NPfIT – Clinicians Involved?


The challenge of being an afternoon speaker


Outline







EPR in Danish Hospitals

• 11/14 counties have an IT strategy for the health care sector.

• As of 2001, there were a total of 52 EPR projects in the country.

• The projects were in different phases and were controlled on different levels

• Between 5% and 10% of all beds in Danish hospitals are covered by an EPR system.


What’s most interesting about Denmark is

MedCom


Pre-MedCom

• Late ’80s– A GP who also worked P/T in

hospital biochemistry lab – Chief pathologist at the

hospital– Head of IT in the county– Proposed a project for Funen

County IT strategy •Electronically transmitting lab

results


MedCom Today

• Over 90% of 2000 GP clinics/practices are computerized

– 86% use their computers to send and receive clinical EDI messages

• 10% of non-users

– Those who will retire in next 3 years

– Those just starting without the capital (1-2 year delay)


MedCom Facts

• Used by ¾ of the healthcare sector– >2,500 different organisations

• All hospitals, all pharmacies, all laboratories and ~1,800 general practices take part

• ~Two million messages a month are exchanged (over 60% of the total communication in the primary sector)


MedCom Facts (cont’d)



• MedCom’s standardised messages implemented in 50 IT systems, including:– 16 doctor systems– 12 laboratory systems– 9 hospital systems– 4 pharmacy systems



• Physicians pay for their own systems

• Upcoming agreement with County Association and the PLO will mandate electronic communication

• Specialists use of computers range from 40-90% depending on the county with their use of EDI clinical messages ranging from 15-70%


MedCom funders

• 1/3 from Ministry of Health• 1/3 from County Association• 1/3 from Other Sources

– Ministry of Social Services (recently)

– Danish Doctors Association (early on only)

– Dan NET– Danish Pharmacy Association


Seven Driving Forces

1. Communication benefits of MedCom

• Improves dialog with hospitals• use to wait 5 days for results of

tests (now almost as soon as it comes off the equipment)

• Automatically notified when patient registered in an Emergency department

• Discharge summaries now arrive within 1-3 days (use to be 4+ weeks) – standard set by Counties


Driving Forces (cont’d)

2. Out of Office Hours (OOH) system mandated

• Started 1997• GP available from 1600 - 0800

hours (could be up to 3 GPs present)

• ~30 across the country – some based at hospitals

• Negotiated by PLO and County Association

• GPs doctors had to learn how to use a computer if they wanted to be paid


Driving Factors (cont’d)

3. Peer influence – collegial pressure– GPs go to see each others computers

4. PLO wrote conversion software to facilitate the transfer of patient data from one GP to another

5. Access to the Internet (2-3 times/day)– e.g. waiting times for x-rays for all

clinics in Funen County – can see what procedures are done at

each clinic– can decide with patient where they

should go



6. County Support– Provides GP with a diskette of all their

patients when first starting (been doing since 1992)

– Training done by data consultant – visit practice regularly

– Help desk– Practioner coordinator for each

specialty (psychiatry, general surgery, etc.)• Works 2 hours/month• Coordinates wishes of GPs to

hospitals and vice-versa• IT agenda moved forward through

them



7. Standards set by MedCom– Contract signed with Counties

and PLO obliging everyone to use them

– Clinicians and vendors involved!– MedCom tests and certifies

vendor systems– Steering committee of paying

agencies meets every 3 months to review compliance data


The Danish GPs are so

automated that


Outline







GP Uptake of I.T. in New Zealand

0

20

40

60

80

100

1994 1997 2000 2003

Year

Perc

enta

ge o

f GPs GP Computer

Use

EDI NetworkSubscriptions

Clinical Useof Internet


New Zealand Facts

• Over 95% of GP offices are using one of nine Practice Management Systems – 75% use their systems to electronically

send and receive clinical messages such as laboratory results, radiology results, discharge letters, referrals, delivery of age-sex registers to their IPA/PHO, etc.

• ~ 50% of GPs now use the Internet on a regular basis from their offices - including communicating with their patients.


New Zealand Facts (cont’d)

• Specialists use of computers range from 30-90% depending on their region. The private specialist use of a full EMR is limited to 15-20%.

• Like the Danes, GPs increasingly favor referring patients to specialists who are able to send information back to them electronically.

29Denis Protti - University of VictoriaApr 19, 2023

AGPAL ACCREDITED

2,200 New Zealand sites

1,200 Australian sites

1-800 support across Australasia


New Zealand Facts (cont’d)

• Used by 75% of all healthcare sector organizations in New Zealand. – All hospitals, radiology clinics,

private laboratories – ~1,800 general practices. – > 600 specialists, physiotherapists,

other allied health workers

• Over 3 million messages a month are exchanged,

• 95% of the communication in the primary health care sector.


Driving Forces in New Zealand

• Unlike the Danish success story, HealthLink received no government funding to initiate the service and its growth and success is based entirely on the market model of “supply and demand”.



• The development of IPA’s (Independent Practitioner Associations) encouraged the uptake of information technology in primary care in New Zealand. – IPAs paid the costs for their member

GPs to access the HealthLink network as part of their membership services.

• HealthLink facilitated change by offering an “electronic claiming only” service for claims submission free of charge for the first 6 months.



• The past decade has also seen the emergence of the new position of “Practice Manager” within a physician general practice.

• The Practice Manager has become a pivotal person to assist with the installation, management and training for any physician office system.

• The Practice Manager responsibilities include financial management, IT and the human resource function in larger practices.


HealthLink increasingly used to assist with chronic disease

management


• As a result of these applications of information technology in primary care:– Child immunization rates went from

75% to 95%. – Control of diabetes improved – for

patients with HbA1c higher than 9 pre-enrolment was 34% and this was reduced to 7% post-enrolment

– There was an 80% reduction in wait time for statins for diabetes patients.

– There was a reduction in acute admissions - this was running at 9% per annum. By 2002, the growth rate was reduced to near 0%.


New Zealand’s critical success factors

• A national health identifier NHI• Early adoption of HL7• Development and acceptance of the

1993 Privacy Act and the 1994 Health Information Privacy Code along with “practical” implementation of these

• Mandatory electronic claiming for GMS (government subsidies for GP care)

• Collaboration with private and public organizations

• Multi-vendor co-operation and understanding of the business opportunities


NZ critical success factors (cont’d)

• Healthlink’s strategy has always been to work very closely with primary care physicians – to stay close to them and to

support them.

• HealthLink is intricately and comprehensively tied to the GPs – “like the parmesan in the spaghetti

is how one observer described it”.


An interesting aside

• At one stage the New Zealand Government spent several millions of dollars on an alternative product “The Health Intranet of New Zealand”.

• This failed at the point where they tried to connect the Intranet to General Practice computer systems. – The GPs were very unhappy to let

government representative agents touch their computers – making the Health Intranet impossible to implement on the ground.

– The government agents had no understanding of how General Practice works



• HealthLink employs nurses to act in liaison roles with General Practice, and so provide direct contact with the GPs.

• HealthLink provides a help desk that has become the GP’s first point of contact when requesting help with their EMRs - like the Danes.

• HealthLink has also stayed very close to the GP system providers – again like the Danes.



• HealthLink spend a lot of effort on demonstrator and beta testing sites.

• They also work closely with the physician EMR vendors to debate projects thoroughly at all stages – before during and after implementation.

• Many of the HealthLink initiatives were a result of demand of the primary care physicians– e.g. discharge summary from hospitals,

radiology test results (DI), orders (still in progress), delivery of claiming data – i.e. responding to market needs


The Kiwi docs are getting ready for


Outline







But first

Selected observations from the American

literature


• “Much research has been done in an attempt to identify the key factors that predict EPR/EHR implementation success. Over 150 factors have been identified, but only two, top management support and user involvement are consistently associated with successful implementations.”

Sittig DThe Importance of Leadership in the Clinical

Information System Implementation Process November 2001

http://www/informatics-review.com/thoughts/leadership


• “Experience suggests several factors that may increase acceptance and use of clinical information systems by physicians. First, broad physician involvement in the selection and implementation of the system from the outset is essential. Systems with no real sponsorship from the medical staff are likely to fail.”

Anderson J Increasing the Acceptance of Clinical Information

Systems MD Computing; Jan-Feb; 16(1): 62-5; 1999


• “Clinician ‘buy-in’ will require that their involvement is substantial and real. The project team must have strong clinician representation from the outset and throughout the project, including the planning, implementation, and post-implementation phases. Clinicians need to believe that the decisions they make matter.”

Krall M Achieving Clinician Use and Acceptance of the Electronic Medical

Record 1998http://www.kaiserpermanente.org/medicine/permjournal/winter98pj/

emr.html


• “The need for physician involvement with clinical information systems has been advocated since the first installations in the 1960’s. Even though the initial systems were rather rudimentary, the systems that were backed by strong physician leadership have been able to evolve and develop into sophisticated tools as information technology has become integrated into all facets of clinical care.”

Schneider M et alPhysician Involvement in Clinical Systems—A Cost-Effective

Investment

HIMSS Proceedings, Session 125 2000


• Whether or not the CPR project leader is a physician, heavy involvement of physicians is common to all awardees, as members of both the CPR project staff and governing committees. Physicians with direct roles in the CPR efforts typically continue to devote at least some of their time to clinical practice, which appears to be important to retaining credibility with the medical staff.

Metzger JB et al Lessons Learned from the Davies Program

2000 http://www.cpri-host.org/davies/nuggets.html


One Particularly Relevant American Experience

• Kaiser Permanente (KP) is a not-for-profit group model HMO (Health Maintenance Organization) with headquarters in Oakland, California.

• The organization is divided into regional service areas spanning the United States from Hawaii to the East Coast.

• It has used a centralized organizational model for their business and information technology operations since 1997.

• Kaiser has eight million members and 80,000 care-givers across all regions (2/3 in California).


• The Kaiser Permanente Colorado Region’s CIS implementation began with 2 medical office pilot sites (80 physicians and 80,000 members) in 1997 and was successfully completed (500 additional physicians and 250,000 additional members) between March and October, 1998.

• The region has achieved full CIS usage and has eliminated use of its paper records for all but archival purposes.


Kaiser’s research findings

• 80 percent of the success of system implementations the size and complexity of KP-CIS is attributable to managing human factors.

• Commitment from, and involvement of clinicians in the implementation of a project is of utmost importance. – Involvement is best achieved by

soliciting active participation from both providers and staff from project initiation through project closure and beyond.

• .


The KP approach

• When Kaiser Permanente undertakes any project, the project leaders develop a series of Guiding Principles that provide direction during the entire project to the project team and to the larger KP community.

• Once defined and accepted by executive management, these guiding principles are communicated throughout Kaiser Permanente.


The Kaiser CIS guiding principles

1. The leadership and sponsors must be visible, available, and supportive throughout the project.

2. The rationale for implementing KP-CIS must be understood across the Program.

3. Implementation activities must focus on realistic timeframes that address system usability at the point of care. CIS must be based on acceptable clinical content.

4. Providers and staff must believe that CIS enhances their ability to achieve superior clinical outcomes and improve provider/patient relationships.

5. Providers and staff must be continuously involved in CIS planning, implementation, and maintenance.

6. Regions must take the lead in implementing CIS


Kaiser guiding principles (cont’d)

7. Providers and staff must acquire the skills to effectively use CIS. Skills acquisition must accommodate individual learning styles.

8. Practicing providers and staff members must be engaged as members of the project team to ensure credibility with the staff, compatibility with the local culture and work flow, and clinical utility.

9. Honest, timely, regular, and pertinent communication to the user community is essential to adoption.

10.Providers and staff must be prepared to adapt to the changes that CIS will bring.

11.The appropriate technical and clinical support structures must be in place to ensure adoption and continued use of CIS.


Lessons to be learned from Kaiser

• Unwavering executive support during the CIS implementation was a major factor in its adoption by the user community. – Implementing a CPR produces

extraordinary change in nearly every facet of operations. Success would be unlikely without executive commitment to support of these changes.


Kaiser lessons (cont’d)

• Identify and appoint physician-advocates throughout the organization. – Clinical workflow change is more

successful when physician advocates communicate the rewards and benefits to the user community.

• It is necessary to develop formal communications for physicians who are to use this new CPR to assist them in understanding how the system will impact their work.


Kaiser lessons (cont’d)

• Plan for recurrent objection themes from clinicians. – A common provider objection is the

perception that they must perform clerical tasks that take time away from patients.

• Clinician order entry may seem to be more labor intensive for some primary care users than for specialists. – For example, internists may have more

complex patients than pediatricians.


In closing from Kaiser

• Commitment from, and involvement of, end users (particularly the clinicians) in the implementation of a project was also of utmost importance. Involvement is best achieved by soliciting active participation from both providers and staff from project initiation through project closure and beyond

Wolfe J Implementing a CPR to Serve Kaiser Permanente’s Eight Million

Members HIMSS Proceedings, session 85

2000


Everything in life is relative


Outline







• Crucially, all of the ERDIP projects have involved clinicians and had clinicians on the local project teams. "We would not have achieved all we have without the level of clinician involvement we've had."

Philip Crouch ERDIP programme manager

http://www.nhsia.nhs.uk/text/pages/inform/informish6/informp5.asp2003

http://www.nhsia.nhs.uk/text/pages/inform/informish6/informp5.asp


• “The Walsall ERDIP project was managed by a small team with the support of the NSF groups. This close involvement of clinicians was important and any national programme office will require people with operational experience. It is also necessary to avoid turning larger programmes into a project management industry.”

Walsall Core National Evaluation report5/11/2002


Key messages for ICRS, derived from the South Staffordshire

experience

• The EHR is still in its early stages of evolution so that continued learning from formative and summative evaluation, co-ordinated across different communities and different suppliers, will be important. – Questions of who will be responsible for this

and how it is linked to system supplier performance will need to be answered.

South Staffordshire Electronic RecordDevelopment and Implementation Project:

Final Evaluation ReportJuly 2003


• Dr John Pilling stresses not only the careful preparation necessary for such a scheme, but also the absolute need for clinician involvement throughout and constant liaison, through a committed project team, between all those involved. These are lessons that are of equal validity not just for this PACS project, but for every IT project in the healthcare field.

http://www.bjhc.co.uk/issues/v19-7/v19-7editorial.html


• It is not the choice of device but involvement of clinicians that counts.

• I could go on, but there is no, one solution that will fit all clinical scenarios. It is imperative that clinicians are involved in all these discussions and that we do not decide what types of mobile devices will work for them.

Sue Wilson Head of IM&T (acute services)

Sherwood Forest Hospitals NHS Trusthttp://www.e-health-media.com/news/item.cfm?ID=496

Aug 18, 2003

http://www.e-health-media.com/news/item.cfm?ID=496


Fear not, we are making progress


Outline







NPfIT’s official position

• Patient, clinician and supplier engagement is critical to the ultimate success of our solution. We:– are meeting regularly with SHA chief executives

and four lead CEOs– are integrating the work of the 28 CIOs with NPfIT– have a consensus from the Medical Royal Colleges

on a core patient summary or data spine– have consulted with over 240 clinicians and NHS

IT professionals in producing the initial OBS– have now got a core group of clinical

representatives working in the Design Authority• We recognise that two way communication and

involvement is vital.


• Professor Martin Severs from the University of Portsmouth has joined the National Programme as Director of Clinical Assurance – he will take the lead on developing and ensuring clinician involvement in the National Programme.

• Professor Severs told the conference that in his first three weeks in post he had already reviewed levels of clinician involvement: – “I found there extensive levels of

involvement of clinicians at all levels of the programme.” He admitted that this finding had “quite surprised” him.

E-Health InsiderNational Programme 'Mobilises' for Delivery

27 Mar 2003


• “The National Programme stresses that clinicians and other NHS staff have been consulted on specifications and requirements from the outset. Most of the input into the OBS for ICRS has come from clinicians working full time in the NHS, stated Mr. Granger.”

• “Professor Peter Hutton, head of clinical engagement with the national programme, added: In two to three weeks there will be an announcement on a route in for almost everyone in the NHS to be involved. From that point on we will be taking a lot more note of individual user requirements.”

Granger Confirms Centre to Allocate LSP ContractsE-Health InsiderAugust 14, 2003


But … there are other views

• A particular concern is limited engagement with clinicians so far. – “Lack of clinician involvement has

been a consistent theme in past failures.”

– “There is a culture here that means you just can’t force solutions on clinicians, they have to be cajoled and persuaded.”

E-Health InsiderApril 2003


• “Despite some early discussions, many general practitioners and consultants have not heard of the integrated care record service or the information spine.

Nick BoothSharing patient information electronically throughout

the NHS BMJ, 327:114-115, 19 July 2003


• “News of the National Audit Office’s involvement in reviewing the national programme was first reported in Computer Weekly this week, in a report which stated that the NAO would examine arrangements for managing high-level risks on the NPfIT and arrangements for gaining the local commitment of clinicians.”

E-Health InsiderAugust 22, 2003


• Over many years, NHS informatics developments have suffered from being under-utilised by their potential users…. The position of informatics should be stressed to empower decision makers to take steps to harness its capability, notably through ensuring that clinical involvement in informatics is enhanced and integral to day to day working, without which few health informatics systems will perform up to their promise.”

BCS Health Informatics Committee & ASSISTMore Radical Steps (2003) Initiatives

August 2003


Questions to be discussed

• Is it important to solicit meaningful physician input early and often and act upon it?

• Does finding meaningful ways to engage physicians require creating an organizational climate and culture that respects the heart of medicine? – Is this the key to maintaining

physician loyalty and involvement?


• Some management teams believe that ideas should be well fleshed out and ready for implementation before discussing them with physicians. – When that occurs, do physicians

feel their input is actually sought?

– And if they recommend changes at that point, will it be difficult for management to retreat and follow another course of action?


• How can one best square the need for centralised/standardised policy with getting local support and use?

• Does the opinion of national clinical bodies matter?


Let the discussions begin


ICRS roll out

• Phase 1 by end 2004




ICRS phase 1 - 2004

• Booking of outpatient appointments online

• NHS email and access to online knowledge

• Electronic laboratory and radiology results

• Some clinical communications e.g. GP referral letters

Providing simple functionality and making best use of existing systems


ICRS phase 2 - 2006

• Access to a more detailed patient record including: >specialist results>GP prescribing record>hospital discharge summaries

• Digital imaging• Computerised referrals and requests

Migrating on to active and interactive functionality


ICRS phase 3 - 2008

• Working towards full integration of health and social services including:>decision support software>screening>community wide prescribing>computer support for care planning

• Supporting advanced features e.g. telemedicine

Continuing development and enhancements


Key milestones • Summer 2003

– Final Output Based Specification to be completed for ICRS– Short-list of LSP applicants to be finalised

• October 2003– Initial contracts to be awarded for two LSPs (London and

North East England)– Contract to be awarded for e-booking service provider

• November 2003– Early implementation work commences

• December 2003 – Further three contracts to be awarded for remaining LSPs

• April 2004– National roll out of Phase 1 of ICRS begins in earnest

28-aug-15denis protti - university of victoria 1 local clinician involvement in clinical information...

Documents

denis protti university

medcom slide

primary sector slide

danish experience

medcom facts contd slide

year delay slide

american experience

danish hospitals