What brought EHRs to every corner of the Norwegian healthcare system

Transcript

1. what brought EHR’s to every corner of the Norwegian healthcare system Arild Faxvaag, MD, PhD Visiting scientist at DGIM, BWH Visiting professor at Harvard medical school
2. nothing to disclose no competing interests
3. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
4. non-systematic review methods: surveys, document analysis, interviews qualitative analysis funding of primary studies: NTNU, Norwegian Research Council, Central Norway Regional Health Authority, Helsebygg, Directorate of health, Sør- Trøndelag University College acknowledgements: Hallvard Lærum, Jan-Tore Lium, Tom Christensen, Eivind Vedvik, Berit Brattheim, Anders Grimsmo, Eric Monteiro, researchers in the Nordic e-Health research network.
5. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
8. • five million citizens • not a EU member • major industries: marine, maritime and (at least for now) fossil energy • 400 municipalities • strong egalitarian traditions
9. • hospitals owned by the government • no co-pay for in- patient services • employees paid per hour • primary care physicians: • most self-employed • gatekeeper function • public funding + co- pay • other municipal healthcare services (nursing homes, mother/child health centers)
10. • second most expensive healthcare system in the world • principle of egalitarianism • people live along the coast • geography an issue in health operations design and optimization • many acute care teams with relatively few patients
11. • second most expensive healthcare system in the world • principle of egalitarianism • people live along the coast • geography an issue in health operations design and optimization • many acute care teams with relatively few patients
12. Hospitals GPs Nursing homes Community health centers prevalence of EHRs • GPs: purchaser = user; optimal business case; • 3-5 vendors — heavy competition
13. Hospitals GPs Nursing homes Community health centers • reaching 90 % saturation took (takes) 15 years • planning horizon in strategy documents typically five years
14. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
15. Strategy Stakeholders Goals Mechanisms pre-1990 1996: “More health for every Bit” 2005: ...and it`s going to get better! 2005: National eHealth strategy 2007 and 2010: Te@mwork 2013: One citizen — one health record
16. Strategy Stakeholders Goals Mechanisms pre-1990 R&D, Ministry of finance 1996: “More health for every Bit” Ministry of health Hospitals The Norwegian Data Protection Authority 2005: ...and it`s going to get better! Care quality and Patient safety (MInistry of health) 2005: National eHealth strategy Ministry of health The Data Protection Authority 2007 and 2010: Te@mwork Ministry of health The Data Protection Authority 2013: One citizen — one health record Ministry of health and social affairs Public health The patient
17. Strategy Stakeholders Goals Mechanisms pre-1990 R&D, Ministry of finance Secondary use of HC data e-health business development 1996: “More health for every Bit” Ministry of health Hospitals The Norwegian Data Protection Authority Innovation Health business re- engineering and improvement 2005: ...and it`s going to get better! Care quality and Patient safety (MInistry of health) Health business re- engineering and improvement Information security 2005: National eHealth strategy Ministry of health The Data Protection Authority Information security Networking health professionals Standardization 2007 and 2010: Te@mwork Ministry of health The Data Protection Authority health business improvement Networking health professionals Free flow of information 2013: One citizen — one health record Ministry of health and social affairs Public health The patient One record per citizen Process- and decision- support. Second. use of HC data Patient access
18. Strategy Stakeholders Goals Mechanisms pre-1990 R&D, Ministry of finance Secondary use of HC data e-health business development R&D funding 1996: “More health for every Bit” Ministry of health Hospitals The Norwegian Data Protection Authority Innovation Health business re- engineering and improvement government funding of the development of a national EHR- system for hospitals 2005: ...and it`s going to get better! Care quality and Patient safety (MInistry of health) Health business re- engineering and improvement Information security incentives for e-communication. regulatory framework 2005: National eHealth strategy Ministry of health The Data Protection Authority Information security Networking health professionals Standardization incentives for e-communication. regulatory framework 2007 and 2010: Te@mwork Ministry of health The Data Protection Authority health business improvement Networking health professionals Free flow of information Regulatory framework Incentives for e-communication. National health data network e-health services with national scope 2013: One citizen — one health record Ministry of health and social affairs Public health The patient One record per citizen Process- and decision- support. Second. use of HC data Patient access Regulatory framework merging of services building e-health services with a national scope. Large e-health directorate
19. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
20. • When innovations you have bought are out- innovated • When trying to comply with privacy regulatory requirements and ending up with 17.000 health information systems • When trying to use health-it to change a system • When trying to build policy directly into code and systems • When building something that ends up as a critical infrastructure
21. Health policy making e-Health policy making Health ICT Commissioning Health ICT Engine- ering Implementation and organizational development Health information systems operation management Healthcare management Health operations management Macro level Meso level Micro level Healthcare practice supported by, and represented with use of a Health ICT Healthcare practice delivered through a Health ICT Technological infrastructure Health information infrastructure Health ICT Assess- ment Knowledge representation and configuration
22. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
23. hospitals • who are the users • how do they rate the systems • which clinical tasks are supported? • which features are actually used? • national survey in 2001.
24. Laerum H, Ellingsen G, Faxvaag A. Doctors’ use of electronic medical records systems in hospitals: cross sectional survey. BMJ (Clinical research ed). 2001 Dec;323(7325):1344–8.
25. Laerum H, Ellingsen G, Faxvaag A. Doctors’ use of electronic medical records systems in hospitals: cross sectional survey. BMJ (Clinical research ed). 2001 Dec;323(7325):1344–8.
26. going paperless (2003-4)
28. Lium J-T, Laerum H, Schulz T, Faxvaag A. From the front line, report from a near paperless hospital: mixed reception among health care professionals. Journal of the American Medical Informatics Association : JAMIA. 13(6):668–75.
29. • 1. Lium J-T, Tjora A, Faxvaag A. No paper, but the same routines: a qualitative exploration of experiences in two Norwegian hospitals deprived of the paper based medical record. BMC Med Inform Decis Mak. 2008;8:2. • Lium J-T, Laerum H, Schulz T, Faxvaag A. From the front line, report from a near paperless hospital: mixed reception among health care professionals. Journal of the American Medical Informatics Association : JAMIA. 13(6):668–75. Lium J-T, Tjora A, Faxvaag A. No paper, but the same routines: a qualitative exploration of experiences in two Norwegian hospitals deprived of the paper based medical record. BMC Med Inform Decis Mak. 2008;8:2.
30. primary care Christensen T, Faxvaag A, Lærum H, Grimsmo A. Norwegians GPs’ use of electronic patient record systems. Int J Med Inform. 2009 Dec;78(12):808–14.
31. • functional but boring • not tailored to a particular user • must be worn for work
32. • «epidemiology» of EHR implementations • policies affecting EHRs • effects and side effects of e-health policy • features of EHRs • effects on care delivery system
33. Modified from: Lau, Francis, Medinfo 2010
34. • most EHR-implementations bring about change on the system level • profound, shallow, reactive, intended, unintended, surprising, dangerous • trying to change is risky, what we learn from it must be shared • an implementation project that does not aim at achieving profound, positive effects on the system level is simply not worth it. • clinicians are the performers — health-it is about enhancing human performance • few clinicians fully understand their role in a care delivery system and how only a e-health structure can bring about the necessary accountability and operative safety we all see is is needed
35. thank you! afaxvaag@partners.org arild.faxvaag@ntnu.no