Health Information Technology: Innovation to improve health care quality, access and availability
Submitted by Canada Health Infoway 2010–07–13 15:53:19 EDT
Theme(s): Innovation Using Digital Technologies
Canada Health Infoway (Infoway) is the country's driving force in accelerating the implementation of electronic health records (EHR) for Canadians from coast to coast to coast. The Federal Government has provided Infoway with $2.1 billion to develop — in partnership with the provinces and territories — the health information and communications technology (ICT) needed to transform Canada's health system.
The total cost of this effort is estimated at between $10 and 12 billion. The associated savings and efficiencies are estimated to exceed $6 billion annually, once all components are implemented. Canada's investments in health ICT also offer the prospect of lowering system cost at a time when investment prudence and an interest in stemming escalating health care costs — now more than $181 billion annually — are crucial.
Looking at the broader economic impact; based on Infoway's total capitalization of $1.2 billion in 2007, the Conference Board of Canada estimated EHR activity would create approximately 37,000 jobs by 2010; every dollar invested by Infoway and our partners would generate $1.34 in overall GDP; and these investments would generate an estimated $1 billion in corporate pre–tax profits.
Infoway's response to the Industry Canada consultation paper on a digital economy strategy for Canada centres on the health care sector's adoption and use of ICT. Variances in levels of ICT adoption and use across the sector are examined as are differences in the pattern of ICT adoption across health care organizations based on their type and size. We also look at the use of performance indicators such as Infoway's comprehensive benefits evaluation framework to track the impact of ICT and digital technology on health care.
We consider the challenges to health care adoption of ICT, particularly the connectivity or interoperability of solutions, essential both to the pan–Canadian approach to an EHR network and to optimizing the full potential value of ICT in the health sector. We look at tactics needed to meet those challenges including ensuring health care providers in rural and remote communities have access to high speed/broadband networks and providing incentives for ICT adoption.
We consider the need for Canada to look at health sector organizations that are lead users of ICT, and learn how to use the keys to their success to unlock the potential for greater adoption and use of ICT across the sector. We detail Infoway's strategy to build on our investments in change–management initiatives, knowledge exchange and peer–leader networks. And we examine how governments can encourage ICT adoption and use in health care through such approaches as business transformation in primary care and investment in the country's human capital.
Infoway's response to the consultation paper also addresses a number of questions specific to increasing innovation, promoting ICT adoption in Canada's public and private sectors, the barriers to implementing a digital strategy in the health sector, requirements for next generation networks, the status and potential of Canadian research and development, and the growth of Canada's ICT industry and skills development.
Canada Health Infoway (Infoway) is a not–for–profit corporation created by the country's First Ministers to foster and accelerate the implementation of electronic health records (EHR) from coast to coast to coast. Since its inception in 2001, Infoway has collaborated with every province and territory to support a range of electronic health record projects to improve patient safety and enhance the availability and quality of patient care. Almost 300 projects are currently underway, or completed, across Canada.
Since 2001 the Federal Government has provided Infoway with a total of $2.1 billion to develop electronic health records for Canadians. While the cost associated with this effort is estimated at between $10 and $12 billion, the associated savings and efficiencies are estimated to exceed $6 billion annually once all components have been fully implemented. Furthermore, investments in health IT infrastructure offer the prospect of lowering system costs at a time when prudence investment and interest in stemming escalating health care costs, now more than $181 billion annually, is needed.
In 2007, the Conference Board of Canada assessed the economic impact of Canada's EHR investments. Based on Infoway's total capitalization of $1.2 billion in 2007, the Board estimated EHR activity would create an estimated 37,000 jobs by 2010; every dollar invested in Infoway and its jurisdictional partners would generate $1.34 in overall GDP; and these investments would generate an estimated $1 billion in corporate pre–tax profits.
Infoway appreciates this opportunity to comment on the goals of a Canadian digital economy strategy, the steps needed to reach those goals and how we can best collaborate to create a strategy for future success.
The first section of our comments focuses on the health care sector's adoption and use of information and communication technology (ICT). The second section of our comments contains our responses to a number of specific discussion questions posed in the Consultation Paper. Our comments are sectorial based from the perspective of our mandate, experience and plans concerning the development and adoption of health information technology systems.
Section one: Adoption and use of ICT in the health care sector
In any discussion of health care sector adoption and use of ICT we need to forestall a tendency towards broad characterization of "low" levels of ICT adoption and use across the entire sector. Health care services are delivered across a broad continuum; in some areas use of ICT is quite extensive, in others ICT use is at a nascent stage. We also need to consider whether the term "low" is used in absolute or relative terms. For example, is ICT adoption in health care low relative to other industries or other countries, or is it just low in absolute terms? And if we are looking at absolute terms, it really depends on which area of the health care sector is being considered.
With these caveats in mind it is fair to say that across the health care sector there is a low level of ICT use for general practitioners and specialists in community practice settings as well as in some areas of public health, mental health and long–term care. But even in stating this it must be recognized there is variability at play — some specific facilities in these sub–sectors are heavy users of ICT.
Conversely, there are other elements of the health system that have significant levels of ICT adoption. Looking at hospitals, laboratories, digital imaging, pharmacies and home care for example, we see a high level of ICT use; as high as 100 per cent in some regions when it comes to hospitals, laboratories, and pharmacies.
Health care is delivered by many practitioners through different organizational/legal entities and almost always at a distance from one another. Thus interoperability between the various points of care and those systems is critical. This is another area where the use of interoperable ICT is still deficient.
Differences in the pattern of adoption amongst various types and sizes of organizations in the health care sector
In clinical practices at the community level, the adoption of electronic medical records (EMR) is higher when there are more than six health care professionals working in a practice together. However EMR adoption rates are lower in practices with between two and five practitioners, and even lower among solo practitioners. Essentially, adoption patterns are more relevant by type and size of practice. And, generally speaking, larger organizations such as Toronto's University Health Network or Montreal's McGill University Health Centre have more sophisticated ICT usage than smaller organizations.
The use of performance indicators to track the impact of ICT and digital technologies on health care
Infoway developed a business case for each of its investment strategies from the onset. Many other countries have also done this before investing in health–sector technology. However, Infoway has gone a step further than most, developing and applying a comprehensive benefits evaluation (BE) framework to its investment strategies. Indeed, tracking and reporting benefits based on access, quality and productivity has been a core area of attention for Infoway. As such, it represents a unique approach compared to many other nations investing in EHRs. However, in the case of ICT investments made outside of Infoway strategies (e.g. at the facility or micro level), the degree to which individual institutions have applied performance indicators and/or metrics to their ICT investments is not clearly defined.
To apply our benefits evaluation framework, an ample degree of implementation must be in place. That was apparent in our first BE study, which was conducted on digital imaging/picture archiving and communication systems last year with positive results. More than three–quarters of Canada's diagnostic imaging is now digitalized, providing greater availability of diagnostic services as health care practitioners in urban centres can review images of patients in rural or remote areas. As a result, lag time for diagnosis and the need for patient travel are greatly reduced. And once digital diagnostic imaging is fully implemented throughout Canada, the technology is anticipated to generate as much as $1 billion a year in health system efficiencies. Furthermore we will see productivity increases equivalent to having as many as 500 additional specialists.
Later this year Infoway will release a BE study on the drug information systems we have invested in across Canada. The results show significant benefit impact especially in the reduction of adverse drug events. Understanding the impact of health information technology investments will be further enhanced with the potential for secondary use of data from EMRs and EHRs for performance indicators on a number of fronts.
We believe the establishment of targets and performance indicators play an important role in both establishing and improving Canada's digital advantage.
The key challenges or barriers to ICT adoption in the health care sector
The first challenge concerns the connectivity or interoperability of solutions, which is a core part of the value proposition for a pan–Canadian approach to electronic health records. Until this is adequately addressed, Canada will not be fully optimizing the total potential value of ICT within the health sector. Interoperability standards are a national asset and funding for development, maintenance and support needs to be provided. Infoway has played a limited role because our standards mandate to date has been limited to EHR standards, not the broader standards needed for health ICT. Many other standards are required for the efficient and effective deployment of healthcare ICT systems. Thus, ongoing and predictable funding needs to be ensured to establish the needed health ICT standards and keep them relevant. Furthermore, some countries have mandated use and conformance through legislation and regulation and this should be considered in Canada.
The second challenge concerns value for money for solo practitioners, especially physicians, and how they are currently required to practice due to the reimbursement model (ie: fee–for–service for a five to seven minute visit). The commercial business case is not fully evident and documented and is an area in which Canada could devote more research attention. In many cases adequate financial incentives are lacking for small practices to adopt ICT, or else they do not feel their up–front capital investment in ICT will yield the appropriate return.
Conditions that best provide incentives for adoption of ICT by health care providers
The first condition that would act as an incentive for ICT adoption is a business–driven approach that improves clinical value to clinicians where the use of ICT is a desired support tool. This requires a broad–based business transformation. Looking at laboratories or pharmacies for example, implementing ICT has resulted in greater throughput and a higher transaction rate, which can generate a return on investment that justifies the initial outlay of time and money.
Globally, the drivers employed by different countries have varied significantly. No single solution has proven successful in every jurisdiction. What is employed depends on the norms and situation of a particular country, as well as what is already in place and how hospitals, laboratories and physicians work and practice.
What we need to ensure health care organizations and providers in rural and remote communities are not left behind in terms of access to advanced (high speed/broadband) networks
Infoway has made a concerted effort to invest in telehealth to ensure these groups are not left behind. To date, we have allocated some $110 million for telehealth projects. Our investment strategy contributes to increased utilization and expansion of telehealth services throughout Canada, with an emphasis on areas of need such as Aboriginal, official language minority, northern and remote communities. However, broadband availability to some communities has been a challenge to the implementation of some of our investment programs, most specifically in Nunavut.
To address this challenge, Infoway has made special accommodations such as providing 100 per cent of funding for projects in the north using shared services in the south, or targeting First Nations applications in the north, as well as connections between BC and Yukon, and between Northwest Territories and Alberta. However, Canada needs to invest in the network to ensure these technologies can work seamlessly over long distances to remote communities. And that applies not just in the health sector, but in other applications such as education. In short, the availability of high speed/broadband networks to centres of care is crucial.
Organizations in the health care sector that are the lead users of ICT and the key to their success
Canada's health sector has many individual examples of leadership in using ICT. These include the Group Health Centre in Sault Ste. Marie, the University Health Network in Toronto, Trillium Health in Mississauga, MUHC in Montreal, and Alberta's health system, including the growing use of synoptic reporting in that province.
Key to the success of these organizations in adopting and using ICT has been the development and achievement of a vision and a strategy, followed by sustained commitment to fulfill the vision. Each of the above–noted examples has been characterized by strong leadership from the onset, supported by the appropriate financial commitments to completion.
Strategies for increasing health care sector adoption and use of ICT
Effective strategies in place include Infoway's gated–funding approach, which pays 50 per cent of project investment funds for demonstrating achievement of adoption targets. Also, Infoway supports pan–Canadian and regional efforts through the promotion of solution adoption and benefits realization, using an integrated approach to change management, knowledge transfer, clinician adoption and benefits evaluation.
To accelerate health sector adoption and use of ICT, Infoway will be building on its investments in funding change–management initiatives, knowledge exchange and peer–leader networks. As part of Infoway's new funding strategies, we will invest up to $40 million in a set of initiatives to support jurisdictions and clinicians in adopting and using electronic medical records as well as to demonstrate clinical innovation. These investments are earmarked to encourage innovation in clinical practice and information technology; producing and reporting tangible results and benefits of the solutions; and supporting broad clinician engagement and uptake.
More specifically we will be exploring:
- A physician office workflow best–practices study to integrate the EMR into multiple physician work flow patterns;
- Continued investment in our peer–to–peer leadership networks program by leveraging and augmenting the existing networks to support key stakeholders and influence EMR environments;
- Investments in projects that can demonstrate clinical innovation and the value of using ICT that can be replicated across Canada;
- A physician–office start–up program to support knowledge exchange to jurisdictions with no physician EMR program in place; and
- A focused benefits evaluation program for EMRs to assess and define the benefits derived from their use, with deliberate focus on improvements in quality of care.
The role of governments in encouraging adoption and use of ICT and digital technologies in the health care sector
Governments can encourage ICT and digital technology adoption and use in health care through:
- Consistent national approaches to business transformation in primary care and chronic disease management;
- A comprehensive national agenda for driving the implementation and adoption of health ICT;
- The provision of incentives and the creation of an environment for the successful implementation, adoption and use of health ICT;
- Ensuring the availability of secure private next–generation broadband networks for health care;
- The various standards necessary for ICT are fostered, developed, supported and maintained. As stated earlier consideration should be given to requiring their use.
- Restating national policy on health ICT and optimizing on investments to date;
- Investing in Canada's human capital to ensure talent capacity to respond to domestic opportunities and compete internationally in the ICT world.
Section two: The health care sector and beyond
Infoway comments regarding specific questions in the Consultation Paper
Q: Should Canada focus on increasing innovation in some key sectors or focus on providing the foundation for innovation across the economy?
Canada should consider a sectorial approach focused on those sectors where the return on investment would be greatest for employment creation and the provision of innovation products to both domestic and international markets. Canada should focus on increasing innovation in both dimensions in a selective way. From the foundational perspective, the government needs to continue and expand the environment for innovation through policies and stimulus investments. Key sectors that are strategic should get particular focus.
Q: Which conditions best incent and promote adoption of ICT by Canadian businesses and public sectors?>
Adoption of ICT should be based on a business case in both private business and in the public sector. Where investment stimulation is needed to "get the ball rolling" then government might consider creating short–term incentives. And if we need to create that impetus then government needs to be a stakeholder to create the appropriate environment. There has to be a real marketplace for the resulting ICT innovations. As well as creating the environment for marketing and selling, government should think about creating investment vehicles to stimulate the creation and adoption of ICT.
Q: What would a successful digital strategy look like for your firm or sector? What are the barriers to implementation?
Canada's ICT initiatives in the health sector need to focus on managing change, promoting fundamental business transformations and creating value, both social and economic. We see the need for four key elements to be in place to help ensure the success of such a strategy:
- Leadership that defines policy options and a commitment to get things done, with a clear vision for specific goals supported by appropriate funding and governance;
- An approach that engages stakeholders and reflects their priorities and plans in managing change and creating both commercial and social value;
- Implementation that uses and optimizes the best human resources available, and quality project management to ensure product design, delivery and deployment of ICT solutions;
- Targets defined for use, solution quality, user adoption and outcomes are required and necessary. The resulting benefits need to be broadly communicated.
Q: What speeds and other service characteristics are needed by users (e.g., consumers, businesses, public sector bodies and communities) and how should Canada set goals for next generation networks?
Speed and service characteristics need goals. Canada should undertake a current bench mark exercise against OECD/G20 nations and establish targets based on the benchmarks for next generation networks and find a reward mechanism to meet a set of targets established against the benchmark.
Industry Canada should consider commissioning a study to evaluate future communications needs. For instance, the number and size of digital diagnostic images and digital pathology images is increasing rapidly, and usually sent over a wire line. As well, the use and capabilities of smart phones and devices like iPads in health care is increasing. Consequently, we need to better understand future network requirements.
With regard to consumers, it is important to stress that one of the foundational elements of Infoway's vision for health infrostructure in Canada includes empowering patients to manage their own care by creating portals featuring self–care tools and basic personal health information. In an effort to ensure patients can become more active partners in their own care, Infoway has committed to invest in a limited number of consumer health solutions using a portion of the federal funding allocated in Budget 2010.
Regulatory legislative frameworks should optimize the use of tax credits (e.g. capital cost allowance) for ICT investment for the public, private and not–for–profit sectors.
Rural and remote areas do not represent a major "commercial" market opportunity and thus should be treated as a special–needs focus with subsidization or incentive investment to help offset the small commercial market.
Q: What steps should be taken to ensure there is sufficient radio spectrum available to support advanced infrastructure development?
With regard to radio spectrum infostructure, Canada should ensure there is adequate spectrum for the delivery of social programs such as education and health, deployed and delivered by the private sector at a cost that is reasonable. As well, Canada should commission the study of future band–width requirements in health and then analyze that information against the capabilities of available spectrum.
Q: Do our current investments in R&D effectively lead to innovation, and the creation of new businesses, products and services? Would changes to existing programs better expand our innovation capacity?
There is an opportunity to stimulate more domestic innovation. But more importantly we need to stimulate the procurement, deployment and use of innovations. Speaking of the publicly delivered health sector, it is difficult for innovative companies to sell and deploy their wares in a highly regulated and costly procurement environment. Canada needs to work with the provincial, territorial and municipal governments to drive location–specific tax restructuring and specific incentives to expand existing sites and promote the necessary investment climate to expand to new locations.
Q: What is needed to innovate and grow the size of the ICT industry including the number of large ICT firms headquartered in Canada?
There needs to be a marketplace for these innovations. The culture of public and private sector entities needs to become more open to risk and innovation, in addition to changes to the procurement policies mentioned above. A tax write–off should be considered for those that do not pay off.
Q: What do you see as the most critical challenges in skills development for a digital economy?
We need more college and university programs to retrain ICT professional from other industries as health care ICT professionals. Government incentives to offset the development of these programs should be considered. These are quality jobs that require innovative thinkers and a high degree of training that we want to source domestically.
Q: What is the best way to address these challenges?
University programs can best address these challenges. However, universities should also provide clinical training for non–clinicians because ICT professionals need that knowledge to be effective. We should also develop special programs in conjunction with universities, offering curriculum and financial rewards for ICT excellence. As well, we should promote special scholarships, bursaries and endowments for both students and institutions. And we should expand research grant programs to drive excellence in ICT education and support transformation advances in ICT technology.
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