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

OutlineThe Problem

Policy Analysis

Economic Analysis

Implementation Factor Analysis

Conclusion

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

% o

f Phy

sici

ans

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.

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.pdfAccessed Jun 11, 2010

Why?

Not for lack of tryingLots of Programs and $$$

EMR implementation is complex

Natural History of EMR

N=112

100%Implemented

EMR in 1999-2000

40%Inefficient

Users

25%EfficientUsers

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

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 ElectronicMedical Records in Ontario. http://www.infoclin.ca/assets/intel%20emr%20white%20paper.pdf Accessed Jun 11, 2010.

Macro Policy Framework

Recognize the societal value of EMRs?

Involve professional civil society?

Create an enabling e-environment? (security, standards, interoperability)

Macro Policy Framework

Encourage markets for new services?

Leverage network effects?

Engage patients and patient advocacy groups?

Economic Drivers

Framework by Wang, Bates, Middleton

Economic drivers of EMR uptake

Adapted for Canadian Context

Examines ROI for all playersWang 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.

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

GovernancePre-Implementation Implementation Post Implementation

Project LeadershipInvolve Stakeholders

Technology Usability Factors

Work-flow Redesign

TrainingImplementation Assistance

Privacy & Confidentiality

Support

Technology

ProcessPeople

Feedback and Dialogue

Choose SoftwareSell Benefits & Address Barriers

Data Pre-Load and Integration

Early Planning

IncentivesUser Groups

Business Continuity

MethodologyCompare EMR programs in Ontario,

BC, Alberta and New York City

Key Informant InterviewsReview of Documentation

Scores are un-weighted No = 0 Partial = 0.5 Yes = 1

Canada’s First Primary Care Informatics Consulting Firm

Policy Framework Analysis

Economic Analysis

Implementation Factor Analysis

EMR Policy Framework Element NY

Ontario

Alberta 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 0.5Provide 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 0Provide Key ICT Infrastructure (secure e-

mail) 1 0 0.5 0.5Set and Implement Interoperability

Standards 1 0.5 0.5 0Engage Patients and Patient Advocacy

Groups 0.5 0 0 0

Rigorous Monitoring & Evaluation 1 0 0 0

Score10.5 5.0 4.0 4.5

 Maximum Score = 11

No = 0 Yes = 1 Part = 0.5

Canada’s First Primary Care Informatics Consulting Firm

Policy Framework Analysis

Economic Analysis

Implementation Factor Analysis

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

US Canada

 Benefits (Savings)

COST$46,40

0$78,00

0

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$58,89

6 $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    $95,64

6    $95,64

6

Net (Benefit-Cost)    

$108,142     $23,406

MD Net Benefit/Loss    

$12,496    

-$72,24

0

Net Loss to Physicians Who Implement EMR in Canada:

$72, 240

Over 5 Years

Still think physicians are

‘resistant to change’?

Canada’s First Primary Care Informatics Consulting Firm

Policy Framework Analysis

Economic Analysis

Implementation Factor Analysis

No. Success Factor NY Ontario

Alberta

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

TOTAL SCORE (Max=12)

11 4.5 6 9.5

Canadian Provinces Do Poorly on Economic and Policy Drivers of EMR Uptake

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)

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

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