A shared electronic record is one of the most complex issues facing the health sector right now, but it’s one that everyone involved feels is very important, a recent straw vote showed. The vote was taken at a Health Informatics (HINZ) seminar held in Auckland this month.
Around 130 health professionals attended the seminar. They ranged from senior staff from the Ministry of Health to general practitioners.
A British study which suggested that shared electronic records had not been realised on a significant scale anywhere in the world was rather put to rest by video-conference presentations from senior IT people involved with two of the biggest health organisations in the US.
Andrew Wiesenthal, associate executive director of the Permante Foundation, part of Kaiser Permante, described how Kaiser now had 14 paperless hospitals and the benefits that had accrued from the change.
Kaiser, a non-profit corporation, is huge. It has 8.7 million members spanning the west and east coasts of the US, and annual revenues of US$37 billion.
Wiesenthal said physicians had to lead such projects; that they couldn’t be entrusted to technophiles. “If you haven’t got that kind of leadership, don’t waste your money; don’t start.”
Leadership and focusing on goals were two of the most important risk areas for large projects, he said.
Another was infrastructure capacity. Despite budgeting US$5 billion over 10 years, Kaiser’s infrastructure was pushed to the limit by the project, particularly when it came to handling large image files.
But the benefits have been huge — and very measurable.
“We’ve been able to retire a lot of legacy systems, saving millions of dollars in annual support costs,” Wiesenthal said.
“We’ve had an 11% decrease in face-to-face visits [with doctors]. There’s been a 7-10% reduction in primary care visits because we are using secure messaging; ancillary utilisation has reduced by being able to notify patients about things like laboratory results. We’ve [also] had a dramatic increase in customer satisfaction statistics; and we’re had much better pharmacological intervention.”
The latter results are impressive. The number of people needing renal treatment for diabetes has been reduced by providing better and more timely information. And the number of coronary deaths has been reduced by 30% for the same reason. That’s not a misprint — 30% is correct.
Wiesenthal said more than five million secure messages had been exchanged between doctors and patients, thus reducing phone traffic. Kaiser had released more than 50 million laboratory results online, more than 20 million of which were reviewed by its members.
Referring to the British view that such projects hadn’t been realised anywhere on any scale, he said bluntly: “That’s baloney. We’ve realised the dream.”
Kaiser had articulated the vision in 2002 and the thinking was that it would finally be achieved it 2015.
The basis of the whole project is the home as a hub, with the patient self-monitoring himself or herself and having patient-based decision support.
“A core team controls ‘exceptions’, which reduces visits to the doctor.
“A care plan is crafted with agreed interventions automated.”
Wiesenthal described electronic patient records as a tool and an enabler to change the way work is done.
“Clinicians must be challenged to alter workflows and reduce variations,” he said.
“It’s only worth doing if you’re clear about your goals and you’re ruthless in achieving them by constructing a business case. The hardest thing is proving value.
“We thought collaboration was one of our biggest challenges, because it’s counter-cultural. Implementation was another, but that’s now a fait accompli.”
Wiesenthal had a very specific message about IT in health. “Do not try to customise what you can get from a vendor. One size fits nearly all. I can’t speak more strongly about that.
“Perfection isn’t reasonable or necessary. You can tweak it around the edges. We aren’t a software house.”
The result of this is that Kaiser has, basically, one IT vendor: Epic Care.
It also has the world’s largest Citrix system.
The $5 billion budget over 10 years includes all software licensing, capital investment in networks, and their maintenance, data warehousing and training, as well as the cost of lost productivity while users are being trained.
Wiesenthal said half of the budget was spent on training and lost productivity.
Plan around the patient
Matt Handley is associate medical director, quality and informatics, at another large US HMO, Group Health Corporation. It has 580,000 patients.
“We were organised around doctors’ offices,” he said. “Now, we’re organised around patients and their communities.
“An automated medical record is the backbone. It allows patients to communicate more actively.”
Group Health has more than 150,000 of its patients online. This represents 48.5% of its adult patients, and 15,000 parents are also accessing their children’s records.
“The patients who benefit most are those who have the greatest difficulty in getting to a doctor,” Handley said.
“We’ve tagged information-sets to different codes and we supply supporting material, to help patients understand and to look after themselves.
“This gives value to internal productivity and it increases doctors’ revenue because simple visits are replaced with more complex ones.”
Handley, who has spent time in New Zealand, said we had a very low level of doctor information exchange and no robust level of data repositories.
“New Zealand doesn’t integrate its primary and secondary care records.
“But the country is big enough to do something powerful and still small enough to do it.”
He described New Zealand’s systems as primitive, depending on costly interfaces.
“Fragmentation is not the solution to privacy concerns,” he said. “A lot of groups hide behind those privacy concerns.”
New Zealand, he said, was small enough to have just one vendor with a single data repository and a few interfaces for ancillary services.
New Zealand has 21 district health boards and a multiplicity of IT vendors providing any number of systems.
“It will always cost a lot of money where there are interfaces,” he said.
“It’s perfectly appropriate for the New Zealand government to pay for one electronic management record for all to use. That would give you a tremendous advantage.”
“There will always be garbage in, garbage out, but you’ll do it a lot better with one common tool rather than a hodge-podge. A common platform provides a great opportunity to share best practice.”
Alan Hesketh, deputy director general of the ministry’s information directorate, asked whether having a single vendor might be a bad idea.
“Compared to what?” Handley responded. “The cost you bear from having multiple vendors is much greater. So long as your one vendor has other markets to help bear its costs [there isn’t a problem].”
He pointed out that there was also a loss of functionality with having various interfaces.
“With a shared system, everyone’s idiosyncratic ways of doing things gets called into question and you get to establish a workflow.”
Computerworld spoke to several health board CIOs about the presentations. They were very much in favour of the ideas put forward, but had two major reservations. One was the impositions imposed by privacy legislation. The other issue was internal. They thought that leadership was very important — “100% needed” — but, as one CIO said: “The biggest problem we would have would be resistance from fragmented special interest groups.”