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PHYSICIAN EHEALTH TECHNOLOGY
AUGUST 2010
ExEcutivE Summary
acknowlEdgEmEntS
thE 2010 landScapE
2010 to 2015 mobilizing patiEnt information
2015 to 2020 optimizing patiEnt information
Enabling programS
SEquEncing and dEpEndEnciES
riSk ovErviEw
roadmap Summary onE pagE viEw
notES, bibliography and rEfErEncES
04 08 11
15 20 24
27 29
30 32
table of
contents
executive summary the aging population, increasing complexities of care, and growing consumer trends for health care service place high demands on community-based physician practices. Since these providers service 80 percent of patient encounters in ontario, it would considerably change health care delivery in this province if this group were moved to more e-enabled health information workflows. patients, providers, and the health care system all stand to benefit.
In the current community-based IT landscape, many Electronic Medical Record (EMR) installs are only partial implementations—hybrid paper/electronic offices and “EMR islands” in which the value of the technology is not fully realized for patients, providers, and the health care system. While funding for new EMR installs is now available, the risks of implementation failure remain high.
The Physician Task Force was commissioned to develop a Physician Technology Roadmap to help define a path towards meeting the information needs of community-based providers.
The Task Force’s mandate was to develop a Roadmap that clearly laid out a five- to 10-year plan for technology deployment to significantly help community-based physicians and their multi-disciplinary care teams improve their delivery of care.
The Task Force has returned to deliver one loud and clear message from all members: our work must yield immediate clinical practice benefits within the next three to five years, and set the foundation for the subsequent five years.
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We want to readily and easily realize the potential of real-time data powered by technology, knowing that it empowers the provider and patient alike to achieve the best possible care and outcomes. In this report you will find that the recommendations do not focus on devices, but rather on data.
The value proposition of the Roadmap is to create data-rich environments that leverage technology and data, and thus:
enable the provider as an informed �
resource;
enable the patient as an informed �
and engaged participant; and
enable informed decision-making. �
our work must yield practical results within the next three to five years and set the foundation for the following five.
The current funding of the EMR and the known risks of its adoption demand the rapid deployment of risk mitigation strategies, which is made possible by using emerging data deliverables, such as laboratory information, hospital reports, and medication management information. The immediate goal is to mobilize and electronically deliver select sought-after data to community-based practice EMR installs, with the intent of driving successful, thorough EMR installs and entrenching practices in e-enabled workflows. This short-term result will position us to realize an entirely improved health care system in the future. Once the foundation has been laid, providers and patients will seek improvements and innovation. The Roadmap anticipates this need and outlines a pathway for optimizing data in the future. Implicit in the Task Force recommendations is that community- based providers must have practices in which EMRs are well-deployed. Clearly stated, EMRs are the preferred conduit for all functionality and workflows associated with excellent e-enabled medical care and its associated records. As some of the Task Force members are practitioners, we recognize that many of our colleagues are not so much technology averse as they are wary of negotiating a multitude of legislative, business practice, and technological hurdles.
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Mobilize the data now. We recommend that all community-based physicians already using EMRs should be able to receive comprehensive laboratory and hospital reports for tests and consultations that they have ordered or that they have been copied on. Laboratory data must be discrete and meet all EMR specification functionality. Hospital reports should be integrated into the EMR as searchable text with all the EMR functionality available. Furthermore, roster data needs to electronically reconcile directly with their patients’ EMRs and clinical management system. New EMR installs would also benefit from data mobilization as it would reduce the risk inherent with implementation, as well as drive greater utilization and active use of the EMR. To this end, we recommend that new EMR installs be pre-populated with current provider pertinent laboratory, hospital, and roster information and pre-configured to receive data on an ongoing basis to better enable delivery of care. In recommending the above, the Roadmap offers the opportunity to realize a return on past and current technology investments.
Once data is mobilized for the community providers, patients can be engaged using timely and efficient means. Enabling patients to access their data electronically through a Personal Health Record (PHR) containing information that is in context can expand the
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potential for provider-patient co-management and complement the traditional office encounter. Engaging and enabling patients in their health management is recognized in the Roadmap as a key consumer ehealth demand and a health system necessity.
Community-based practices deserve robust, innovative, user-responsive ehealth tools. While mobilizing key data now is paramount to success, optimizing data becomes a focus in the last five years of the Roadmap. This core component of the Roadmap focuses on the adoption and exploitation of standards by all systems, technologies, and users thereof such that we can ultimately realize a truly integrated experience for the community-based provider. This work begins now with the definition and evolution of standards, followed by deployment and implementation. Once defined, standards designed to simplify and facilitate the exchange of information will allow and encourage innovation. To these ends, you will find Task Force recommendations on data standards. The challenge will lie in instituting rules for the right reasons while preventing the negative consequences of rigid data and workflows that are inconsistent with the time-sensitive nature of community-based medical care. It will remain in the best interest of the patient, the providers, and the
what kinds of solutions are we proposing?
mobilize data now; optimize data later.
health system to ensure that the medical record lives to tell the story of patient care. The rich narrative, which is at the heart of great medical care, cannot be sacrificed in the quest for standards.
Community-based physicians have been waiting a long time to be included in the electronic flow of data and to realize the value of technology investments. It doesn’t have to be pretty and it doesn’t have to be perfect. Our strongest recommendation is to accelerate select key data deliverables now, and then work on improving them. Getting it pretty and perfect is a luxury that we can ill afford.
dr. StEphEn mclarEn BSc, MD, CCFP, FCFP
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glenn alexander CIO & eHealth Lead Champlain Local Health Integration Network
dr. Joseph cafazzo Lead, Centre for Global eHealth Innovation University Health Network
Emmanuel casalino Senior Director, Physician eHealth Program eHealth Ontario
maureen charlebois Chief Nursing Executive & Group Director, Clinical Adoption Canada Health Infoway
dr. david daien Family Physician Summerville Family Health Team
dr. david dixon Family Physician Byron Village Medical Centre Adjunct Professor, Department of Family Medicine, University of Western Ontario
lucy fronzi Senior Manager Group Health Centre
Eric gombrich CEO, EMIS Information Technology Association of Canada (ITAC) Health
cheryl kennedy Physician Practice Manager Haliburton Highlands Family Health Team
dr. marcus law Family Physician South East Toronto Family Health Team
wing-Si luk Vice President, Product Management & Strategic Relationships, OntarioMD
dr. Stephen mclaren Chair Markham Family Health Team Markham Family Physicians
dr. John reeves Advisor McCann Health
dr. peter rossos Chief Medical Information Officer, Centre for Global eHealth Innovation University Health Network
christine Sham Senior Program Consultant, eHealth Liaison Ontario Ministry of Health and Long Term Care
dr. John Stewart Family Physician Medical Associates of Port Perry
frank vassallo Vice President, Practice IT Adoption and Operations OntarioMD
mEmbErS of thE taSk forcE
acknowledgementsthe physician technology roadmap represents the work and active contributions of all task force members and advisors. we thank them and their organizations for their commitment of time, knowledge, and expertise. their four months of work culminated in ontario’s first physician technology roadmap, which directly addresses the needs of community-based providers, who for some time now have been asking for ways to transform their practices with the aid of technology and information solutions.
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derek birtch Nurse Practitioner, Clinical Informatics Specialist, My CARE source – Patient Portal, NephroCare Grand River Hospital
dr. bill crounse Senior Director, Worldwide Health Microsoft
dr. david daien Family Physician Summerville Family Health Team
fraser Edward Manager, Market Development - Healthcare Research in Motion
dr. bill fera Vice President, Medical Technologies; Medical Director, Interoperability University of Pittsburgh Medical Centre
dr. kevin J. leonard Associate Professor, Department of Health Policy, Management and Evaluation (HPME) University of Toronto Founder, Patient Destiny
dr. danny z. Sands Senior Medical Informatics Director Cisco
mike Spoljar Nurse Practitioner McMaster Family Health Team
adviSorS to thE taSk forcE
dr. bill crounse Senior Director, Worldwide Health Microsoft
dr. bill fera Vice President, Medical Technologies; Medical Director, Interoperability University of Pittsburgh Medical Centre
fraser Edward Manager Market Development - Healthcare
dr. danny Sands Senior Medical Informatics Director Cisco
linda weaver Vice President, Product Management TELUS Health Solutions
prESEntErS to thE taSk forcEacknowledgements
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Physician practices must evolve continuously and respond to health care system, patient, and consumer pressures. Currently, they generally do not have comprehensive tools to help manage these pressures. The Roadmap lays out the tools and technologies necessary to help the physicians respond to these pressures. the recommendations of the task force were guided by the following strategic themes:
enable the provider as an informed resource; �
enable the patient to also be an informed and �
engaged participant; and
enable informed decision-making in the �
clinical process.
These strategic themes were unifying concepts that allowed the Task Force to identify concrete elements of the Roadmap, ensuring that they reinforced and supported the Roadmap’s objectives.
the 2010 landscape this physician technology roadmap is primarily focused on community-based practices, including primary care physicians, specialists, and their multi-disciplinary teams. we recognize that the scope embraces solo, duo, and larger practices. while the main audience for this report is community-based physicians, the task force acknowledges that there are other practitioners involved in the provision of care who will take interest in this roadmap. as such, the roadmap uses the term physicians to only describe community-based physicians, strictly applying the term to that group. where the impact of this roadmap may affect other groups, the term provider is used.
The Task Force was convened to craft the Roadmap for the next 10 years (2010 to 2020), not to debate the merits of technology-enabled provider offices, as these benefits are already well understood by the members of the Task Force. The Roadmap addresses the technology that needs to be delivered and how this technology will be used in physician practices. In Ontario, there are 23,000 physicians, of which 16,000 are community-based physicians.1 These 16,000 physicians provide 80 percent of the care delivered to Ontarians.2 Of these, 11,000 are primary care physicians and 5,000 are specialists.3 About one third of Family Physicians have a specific focus in their practice,4 leaving 32 percent of Ontario’s physician manpower embracing comprehensive family medicine. In terms of numbers, new family medicine graduates trail specialists, with just 32.5 percent of new physicians choosing family practice as their first choice for residency in 2009.5 The technology imperative is to assist physicians in improving the delivery of care.
Ontario’s diverse and ever changing demographics contribute to the enormous care pressures that community-based practices and the entire health system face. The challenges are many: an aging population6(with increasing complex care issues), higher consumer demand for improved delivery of care, and a projected increase in health care spending. Spending is expected to consume 55 percent of the provincial budget by 20187, which means that Ontario’s health system is on an unsustainable path.
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It is worthy to note that the Task Force’s strategic themes align with the four principles of family practice as defined by The College of Family Physicians of Canada:
1. The family physician (FP) is a skilled clinician.
2. The patient-physician relationship is central to the FP role.
3. The FP is a resource to a defined practice population.
4. Family Medicine is community based. the task force also made the following recurring observations:
Electronically enabling providers is an absolute �
requirement for ehealth to have clinical impact;
Practice transformations absolutely must �
support/enhance practice workflows;
Patient data must be mobilized and made �
available to physicians in real time, powered by technology;
EMRs are the preferred single point-of- �
service tool and conduit for evidence-based content that can be used by providers to obtain functionality and workflows associated with excellent e-enabled medical care and its associated records;
All relevant information from external sources �
(e.g., drugs, laboratory results) must be integrated and / or accessible through the EMR;
Enhanced information availability and improved �
practice efficiency will promote widespread adoption of the EMR and other technologies such as the PHR, kiosks, and home monitoring devices, and will result in improvement of patient safety and quality of care;
The patient-physician relationship is essential �
and must be preserved or enhanced through the use of technology; and
Patients must continue their increasing �
involvement in managing their overall care.
The Task Force discussed key issues from the �
provider and patient perspectives.
Through research, discussions, and working group sessions, the following observations emerged to describe the 2010 technology context for physicians. These observations focus on the most immediate information needs of physicians to manage care delivery in their practices.
Numerous national experiences have cited �
electronic laboratory data and radiology reports as a key determinant of expedient adoption of electronic medical records. Only 25 percent of family physicians in the province had an electronic interface to external laboratories, according to the 2007 National Physician Survey.8
Currently, 40 percent of Ontario’s family �
physicians use EMRs.9 Only 10 percent are chartless and thus defined as “deep” EMR installs.10 A 2008 study done by KPMG showed that 75 percent of physicians with EMRs were generating all of their patient prescriptions using their EMR.11 However, currently there is virtually no e-prescribing in place, and drug interaction decision support is limited to each EMR install. Further, 47 percent reported receiving 90 percent or more of new laboratory results electronically, while 40 percent use their EMR regularly for preventative care, and 40 percent have complete cumulative patient profile information for all their patients.12
Today, although some access has been �
granted through portals to hospital reports and laboratory information, uptake and active usage remain low.13
Information flows and interfaces from hospital �
data sources to local physicians’ EMRs exist but are the exception not the rule.
Workflow support and efficiency is a key EMR �
adoption concern for physicians. According to a 2008 survey of EMR adoption, the following factors may encourage EMR adoption among Ontario’s physicians: enabling electronic exchange of information with external systems, improving ongoing support, improving transition and ongoing change management support, broadening adoption throughout the physician community, and continuing to enhance EMR functionality.14
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patients value their direct interaction with their physician and are ready to be engaged in a direct and pragmatic manner.
The Task Force members brought to the discussion their understanding of the patient experience. From the patient’s perspective, the themes brought forward indicated that patients wish to be more informed and engaged in the health care process; they also value direct interaction with their physicians and are ready to be engaged in a direct and pragmatic manner.
here are some other themes that emerged:
Patients want to receive their diagnostic test �
results as soon as they are available. Today’s patients are more informed and sophisticated, and they want access to their results and information to help understand their meaning. Forty-seven percent of patients cite access to results as important in reinforcing the patient-provider relationship.15
Patients are experiencing overload with �
medical information from media sources and are looking to their provider to help them make sense of the information. Twenty-three percent of patients use media-based medical information, 12 percent of whom have trouble understanding its relevance and connection to their own personal health care.16
Interdisciplinary primary care practices are �
increasingly available to patients. Patients need more help understanding these new care models, their benefits and limitations, the meaning of enrolment, and the scope of provider practices.
Almost all patients, when requesting �
information from their chart, receive it in a paper-based format. There has been a noted increase in the demand for electronic communication between patients and their providers. Patients now want electronic access to their own medical information and to their chosen clinics and providers.
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RICH SET OF IMMEDIATE BUSINESS PRIORITIES
STRENGTHEN eHEALTH TECHNOLOGY LANDSCAPE
EHR
ONTARIO
EMR
PHR
EM
R
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the task force strongly believes that while visions are critically important, they must be underpinned by an equally rich set of immediate business priorities. these priorities, we believe, will significantly help providers improve delivery of care. from 2010 to 2015 the goal of the roadmap is to secure a solid foundation. post 2015, the technology priorities for provider offices builds upon the successes and foundation of the first five years, so that data flows throughout the health system in a patient-centric way.
The practical and methodical definition of standards for data will be the focus, as they will provide a concrete direction for the optimized communication and flow of data over the longer term. This approach is intended to strengthen the ehealth technology landscape. It also fosters creative development of products and interfaces that meet the community’s needs.
The immediate priorities on the Roadmap focus on enhancing the value of existing and established ehealth programs and investments. It envisages that by 2015 the following priorities become reality:
Emr adoption One hundred percent of community-based physicians are using EMRs and the EMR is the standard for community-based care. End user functionality, workflow, and the speed and efficiency of solutions are valued.
laboratory information Providers have comprehensive and timely laboratory results for their patients in their EMR, regardless of the provincial location where the testing was done.
hoSpital rEportS Important health information about a patient’s care administered within an institution and/or a community setting is automatically and immediately sent electronically to the providers’ EMRs.
2010 to 2015
mobilizingpatient information
ebuSinESS Patient roster management is entirely automated and manual updates are a thing of the past. Provider offices and the Ministry of Health and Long-Term Care effectively co-manage rosters. Patients know their enrolment status.
conSumEr ehEalth The patient-physician relationship is enhanced by technology and by enabling individual Ontarians to easily access the health information needed to co-manage their care. The PHR is available and populated with meaningful health data and information from providers and patients.
mEdication managEmEnt Providers have a comprehensive and accurate view of the medications prescribed and dispensed to their patients. ePrescribing is a reality across the province and patients can review their own drug history.
ecommunicationS Providers are communicating and collaborating electronically with their peers and their patients. Information, knowledge, and referrals flow to support enhanced patient care and care experiences.
These priorities continue to reinforce themes of key importance to support providers with e-enabled patient care. The categories align to clinical and care priorities that have been communicated by other members of the health care community in Ontario.
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By 2015, providers actively and effectively use EMRs. They realize the benefits that improved workflow and information management can have on patient care and outcomes. These benefits are a result of an electronic, data-rich environment with one point of entry.
The relative timescale and recommended technology deployment timeline is presented on pages 30 and 31. It provides a graphical representation of the Task Force’s recommended Roadmap across the two time horizons (the five-year period ending in 2015, followed by the five years ending in 2020).
ElEctronic mEdical rEcord adoption The EMR is not a specific milestone in the Roadmap: it is a critical, patient- and provider-centric prerequisite to many of the components within the Roadmap. EMR technologies are the primary provider tools for capturing, aggregating, and integrating patient clinical data, although this data may originate from numerous sources within or outside of the physician’s control.
Considering that 80 percent of patient care is provided by community-based providers, it is absolutely critical that the vast majority of providers become complete users of EMRs. In 2009, a second round of EMR adoption funding was made available to all community-based physicians. In 2010, 40 percent of Ontario’s physicians use an EMR. By 2012, adoption of EMRs is expected to increase to 65 percent, and then to 100 percent by the end of 2015. The Task Force believes that the data mobility specified in the Roadmap heightens the value proposition of the EMR and serves to increase the depth of installs and its utilization in practice.
The underlying driving force behind technology adoption is the achievement of electronic connectivity for community-based providers with the broader health care system, taking their practices in directions that cannot be envisaged without the use of technologies – to manage the health of their patient populations, and provide effective preventative care.
laboratory information The Task Force’s desire is to have standardized laboratory data flow to providers in as close to real time as possible through their EMRs. As of 2010, the Ontario Laboratories Information System (OLIS) has nearly 500 million laboratory results from foundational partners, which include three community laboratories and four
participating hospitals. The immediate priority is to make laboratory information available from community and hospital laboratories, followed by public health laboratories. The Task Force proposed that the 2010 OLIS-EMR integration pilot be expanded to make OLIS available to all requesting providers by 2011. From 2010 to 2015 the focus would be on data source completeness and data flow.
OLIS offers another value proposition to providers with new EMR installs: by pre-loading these installs with a wealth of patient data, providers and their patients will see an immediate benefit. By 2015, the Task Force recommends that OLIS, or another mechanism barring timely completion, be the sole source for 100 percent of all Ontario laboratory data. Further, that data should flow electronically to the EMRs of all providers (who have ordered or been copied to) as discrete, usable data.
hoSpital rEportS Receiving timely information is the lifeblood of all providers. The Task Force strongly recommends that hospital reports flow automatically to all EMR-enabled providers. It is envisaged that by 2011 all providers will be receiving hospital reports about their patients (diagnostic reports, cardio-respiratory reports, operative and consultation notes, clinic reports, etc.) directly into their EMR. Recent Ontario examples have clearly demonstrated the powerful benefits to providers and patients. eHealth Ontario must invest in the rapid expansion of this capability, thus making this important service available across the province as quickly as possible.
ebuSinESS With a growing number of providers in new enrolment models and the number of rostered patients increasing, eBusiness capabilities are more critical than ever before. Providers require patient administration capabilities such as automated rostering tools, billing consolidation, and patient enrolment. They must also effectively manage their practices and help their patients understand the services available to them. An important priority in 2011 is the rollout of eBusiness capabilities to meet the needs outlined above and reduce the use of manual and paper-based processes. Newly installed EMRs should be preloaded with six months of available data, along with the most up-to- date roster information for the provider.
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conSumEr ehEalth The PHR is important for e-enabled care. With chronic conditions, especially diabetes, more pervasive throughout our population, it is imperative that technology assist providers and consumer patients in collaboratively managing disease and providing preventative care. By 2011, the Task Force recommends that lessons learned from provincial, national, and global PHR initiatives be gathered and a provincial strategy be developed. The Task Force envisages that by 2013 a PHR will be in use provincially for a select targeted group of patients who can benefit from enhanced self-care, a population such as those with diabetes. By 2015, the roll-out of the PHR for all consumers in Ontario is well underway – for self-management of health and wellness.
mEdication managEmEnt By 2015, Ontario providers need to have access to a number of new medication management capabilities. The Task Force heard from providers participating in ePrescribing pilots. They said the pilots clearly demonstrated that value is quickly achieved through ePrescribing. Getting medication management information into the hands of providers yields immediate patient safety results through consistent drug information being shared between prescribers and pharmacists.“Going back to the old approach” is not an option. The Task Force recommends the delivery of a new standards-based ePrescribing solution within all certified EMR products by 2015. The ePrescribing solution will be part of a new provincial Medication Management system. When successfully implemented, providers across Ontario will be able to have a complete and usable view of a patient’s drug profile, regardless of who ordered the prescription and where it was filled.
ecommunicationS To harness the value of mobilized data, eCommunications capabilities are a requirement for all providers. As a first step, the Task Force strongly encourages regulatory / advocacy bodies to inform providers about the existing and available methods for electronic communications with patients and to develop a unified message for the providers.
With peers promoting the possibilities presently available, the barriers and impediments that surround eCommunications are removed. This simple message could jumpstart the process of electronic communication between providers and patients. The tools should include robust electronic communications between and amongst providers, other care professionals, specialists, system planners, as well as patients. Greater definition needs to include eCommunications capabilities such as electronic consultations and electronic referrals between and amongst providers and patients. Telemedicine, accessed through the EMR, will provide a more comprehensive communications capability to community-based providers.17 These tools strengthen the value achieved in building data-rich EMRs and consumer ehealth applications.
data and mESSaging StandardS To reiterate, the short-term action plan recommended by the Physician Task Force is:
Make electronic laboratory data �
available now;
Make hospital reports available �
electronically; and
Continue to codify electronic patient data �
elements, where practical and efficient, to heighten interoperability and end-user efficiencies.
While achieving the ideal state is the goal for all interconnected health systems, it cannot and must not delay the ability to mobilize patient data, which is the focus of the first five years of the roadmap. The Physician Task Force recommends that where a national standard currently exists and can be easily adopted—with sufficient practical reasons—it must be mandated that provincially-funded systems do so in Ontario. However, even in the absence of a standard, patient data is exchanged, recognizing that additional data “massaging” will be required. There are many examples where providers and patients have benefited from mobilized data – this must be allowed to continue across Ontario.
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if the first five years of the physician technology roadmap are about mobilizing data, then the ensuing five are to build on that foundation. by 2015, pan-canadian data and messaging standards are identified and definitions completed by 2017. by 2020, additional value is achieved by optimizing the full potential of the standardized data. new opportunities and innovations will emerge from 2015 to 2020 as a result of the foundations established.
2015 to 2020
optimizing patient information
The Task Force believes that sharing data helps produce the highest standards of patient care and patient safety. Inherent in that belief is that patients are active partners in managing and promoting their overall health. The provider, therefore, must function in an information-rich environment that maintains the rich narrative of medical care, and supports them in engaging with their peers and their patients in new and effective means to deliver the highest quality of care. The health system benefits because of the better use of system resources, along with informed and engaged patients and enhanced population health.
By 2020, the Physician Technology Roadmap envisages the following capabilities within providers’ offices:
ElEctronic mEdical rEcord adoption By 2020, the EMR is the ubiquitous, standards-based tool in clinical practice. It is actively used to manage and exchange patient information. It allows providers and their multi-disciplinary teams to proactively monitor and care for their patients regardless of where that care was received. The EMR has been integrated with key provincial and local systems so that paper/fax exchange of patient information has been completely replaced with the movement of data between systems electronically. The EMR development is now expected to support mobilization of information through a national set of enforced data and messaging standards. These standards promote alignment within the vendor community such that they develop a suite
of products and services with ubiquitous data portability and interoperability. The availability, portability, and provisioning of the data has been addressed, providing a more useful EMR for both providers and their multi-disciplinary care teams. Finally, the technology for natural language processing and semantic interoperability has been perfected, supporting the sharing among providers of the rich narrative that is the foundation of high-quality, patient-centric care. Practice analysis, care gap identification, population health management, and prevention are readily performed. The required end-to-end support is skilled and thorough in assisting provider offices to successfully entrench EMRs.
laboratory information Building on the progress of the Physician Technology Roadmap to 2015, results and reports from all public and community laboratory sources in the province are readily delivered electronically to providers based on standardized nomenclature. OLIS is now the conduit for all testing completed in Ontario. Providers are able to electronically order laboratory tests and receive results directly from their EMRs, enabling them to follow the laboratory test life cycle from ordering to collection, processing, and result delivery. Laboratory data is standardized and normalized for universal availability and mobility of the information.
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hoSpital and community-carE rEportS In 2020, patient data sharing is bi-directional. All providers are actively sending and receiving a full suite of electronic data about their patients. The data is categorized for purpose of use, supports the full lifecycle of clinical care, and addresses information required for diagnostic purposes as well as clinical reporting. Data is received by providers from hospitals and community care providers, and it is sent by providers to hospitals and community-care providers (such as a pre-admission / pre-operative profile). The data also extends to preventative care information from provincial repositories, and discharge and follow-up summaries from hospitals.
conSumEr ehEalth Ontarians are actively engaged in the management of their care and are beneficiaries of mobilized data from provincial and practice-based systems. They have access to a PHR that helps them and their providers to co-manage care. Consumer ehealth offerings enable new and innovative means for patients to collaborate with their providers and with condition-specific social networks. In-person appointments are complemented by new communication channels and the use of mobile devices. Care consultations happen closer to where patients live, work, and play.
The PHR builds on the successes of the comprehensive EMR and a rich data set from across the health care system. It allows for the co-management of health conditions, especially chronic conditions. It also allows providers to give patients access to data in the EMR and the provincial repositories, information that is meaningful, contextualized, and useful to them. The provider is able to update a PHR through the EMR, or through provincial repositories directly where necessary.
The PHR serves to remind, recall, and engage patients in their preferred communication choice. It serves broadly as a system resource and educational tool, providing contextualized data that is supported and well understood. It is primarily a patient engagement tool that focuses on prevention, health promotion, and optimal care. Consumer ehealth provides system education, enrolment status, and care team member availability, as well as scheduling, recall, and reminder capabilities. This allows patients to access trusted, reviewed, and recognized information about health conditions – specifically theirs.
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the health system benefits because of the better use of system resources, along with informed and engaged patients and enhanced population health.
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mEdication managEmEnt Medication management is electronic – on-line interactions have replaced paper for Ontario providers, patients, and pharmacists. Specifically, the provider supplies all patients and their pharmacists with electronic prescriptions. Building on the successes of the first five years of the Roadmap, a province-wide patient drug record is now available to all providers. The Medication Management content is available to providers and integrated into the EMR. A prescription history, regardless of prescribing providers and source, is electronically accessible. The provincial Medication Management system provides a complete list of medications for a patient. It also has more effective narcotics access and control, and drug allergy capabilities. Providers supply patients with “fill anywhere” prescriptions. “All Drugs / All People” has been achieved. Medication Management is seamlessly integrated and is an integral component of the provincial technology landscape. It supports the various front-line care provisioning systems.
ecommunicationS By 2020, providers are interacting, consulting, collaborating, and providing care for patients both in-person and through multiple electronic channels. These tools and technologies are available to all providers in the province. They are adequately supported through commodity services that are ubiquitous and easy, and may be provided by private or public sector organizations. Care models are enabled and supported by the necessary changes in the legal, regulatory, incentive, and practice models available to providers in the province.
Providers are supplying electronic patient referrals to other providers for other forms of care within the system. They never lose sight of their patients’ state or the outcome of the patients’ care as progress is updated and available to the provider in their workflow. More importantly, this information is available to the patient. They receive their diagnostic results, confirm follow- up activities, schedule appointments, communicate with their providers, and access trusted sources of information.
Telemedicine continues to be a standard physician tool integrated with the EMR.
chronic diSEaSE managEmEnt The nature of data-rich environments with data management tools allows for the flexibility of focusing on any combination of diseases or health conditions, thereby offering increased benefits for patients, providers, and the overall health system.
The Chronic Disease Management platform provides universal identification and care of Ontarians with chronic conditions. It also provides a core subset of the PHR. This platform allows patients and providers to collaborate and co-manage these chronic conditions according to the established and evolving care guidelines in the province. Chronic Disease Management tools are dynamic and leveraged to optimize health by closing care gaps, preventing chronic disease, and optimizing outcomes for those living with a chronic disease.
data and mESSaging StandardS The Physician Task Force recognizes the important role that data and messaging standards play in promoting ideal system-to-system interoperability.
The step-wise journey envisioned by the Task Force is to move the available data into the EMR now and start the process of embedding meaning into data with standards where the risks of context loss is negligible and acceptance of the standard is high. The journey would continue into the second five years of the Roadmap with the optimization of the data through standards as national congruence and agreement occurs and as technology advances to ensure acceptance by providers (i.e., ease of use, accuracy of the record, retaining the narrative, etc.). The timeline recommended by the Task Force targets national agreements in the 2015-2017 period, allowing vendors the opportunity to innovate and create advanced products.
By 2020, Ontario is aligned with national standards. The last five years of the Roadmap ensure that provincially-funded systems adhere to data and messaging standards. Not only will this simplify and facilitate the exchange of information, but it will encourage innovation. Now vendors and users understand how information throughout the health system can be used toward the meaningful use of data, with reduced focus on one-off interfaces and mapping of data fields.
2015-2020 realizes structured, codified data that preserves the rich narrative that exists in medical care, and which can be shared easily to produce a dynamic view of a patient’s overall health. The tools for data reporting, queries, clinical care gap identification, and practice program evaluation will build clinical value from data in the EMR. The focus is on the enhanced ability for end-users / interdisciplinary care teams to use data to improve practice and, where desirable, participate in data sharing, as supported by national data and messaging standards and the existence of data sharing agreements.
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enabling programs the roadmap developed by the physician task force has focused concretely on the programs that will need to be delivered in the two time horizons outlined to move the task force’s strategic themes forward. the task force has identified four critical programs that would be necessary for the roadmap components to be delivered successfully. these enabling programs are not unique to any particular capability, but would be common and required for many, if not all, of the programs on the roadmap to be successfully implemented. they would be necessary for the removal of obstacles that could hinder or impede the progress and achievement of the roadmap.
the enabling programs that were selected by the task force include:
nEtwork connEctivity The success of ehealth is dependent on the ability of people and systems being able to communicate and exchange information regardless of geography. Providers must be able to easily and readily connect to a reliable network with defined parameters, and clearly stated expectations and anticipated costs. This is not negotiable. In instances where network communications are not available or are cost prohibitive, eHealth Ontario should intervene until such time that a private, third-party alternative is made available. Due to the increasing reliance on the part of providers to access and exchange patient data with remote systems, there must be redundancies or back-up plans in place to address network outages. Patient care cannot be jeopardized by such events. The Task Force recommends that reliable and secure network connections be available to providers. eHealth Ontario can help ensure that connectivity issues and costs are not a barrier to provider participation in ehealth.
data StandardS and mobility A common theme of data flow and mobility emerged in the Task Force discussions. The 2010-2015 Roadmap will result in mobilizing data that already exists electronically by using relevant current standards. In the longer term, a set of comprehensive, consistent, nationally-adopted standards are necessary to support ubiquitous data flow among providers and with patients. The development and adoption of a national set of data and messaging standards is one of the key enabling programs in this Roadmap. Where readily available and possible, the use and evolution of existing standards is encouraged. Over the next 10 years, a concerted effort on standards deployment, implementation, and compliance is necessary to support the longer-term vision of the Roadmap, aligning Ontario with the evolving national standards being led by Canada Health Infoway.
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financial compEnSation and incEntivE alignmEnt Primary care practice models are changing in Ontario, with a particular increase in patient enrolment models. With the advent and proposed usage of many new tools for managing care, as prescribed in the Roadmap, the financial and incentive models available to providers in Ontario must keep pace with these changes. New and enhanced financial and incentive models need to be developed to support provider usage of these new capabilities. A focused effort on ensuring financial compensation and incentive alignment is necessary to garner provider support for the Roadmap.
lEgal, rEgulatory, and liability prErEquiSitES New and unintended use of technology has often had to contend with existing legal, regulatory, and potential liability constraints. The Task Force recommends an aggressive Roadmap, recognizing that to be achievable and sustainable, the existing legal, regulatory, and liability frameworks need to be enhanced. The necessary changes or clarifications must take place for providers to adopt and use these capabilities in their practices. To support the necessary changes in the legal, regulatory, and liability frameworks, the frequent and timely communication of changes must occur with provider communities. Without changes to the existing frameworks, achievement of the Roadmap will be challenged. Predictably, progress will stagnate and providers will not risk their practices and patient safety on new capabilities. Recognizing and addressing the constraints at the onset could offset that impact.
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sequencing and dependencies
Within the Roadmap, the sequencing was developed largely within each capability area. A focused effort on creating timely deliverables early in the Roadmap timeline is designed to establish momentum, mitigate implementation risk, demonstrate early progress, and highlight lessons learned for latter releases. This was typically followed by recommendations for data mobility or the flow of data to providers’ offices and/or integration with providers’ workflows. It also ensured more robust capabilities in standalone provincial applications and providers’ EMRs. It was important to the Task Force that the end-state vision of any individual capability was not compromised, but that early, demonstrable delivery of value to providers was part of the Roadmap in the first two years.
throughout the development of the roadmap, the task force was careful in ensuring that the capabilities recommended were sequenced appropriately to meet the needs of providers and their associated care teams, while not dissuading any momentum currently being developed. it did not want to present a sequence that was highly complicated or interdependent since this type of approach would impede the success of the roadmap.
Throughout the deliberations on the Roadmap, the Task Force was careful to minimize the development of any unnecessary or complicating dependencies. A certain number of dependencies will naturally emerge throughout the delivery of the Roadmap. The Task Force recommends that the parties involved strive to minimize these dependencies and err towards maintaining the Roadmap’s inherent timeline. That being considered, the Task Force recognizes that key critical communications and connectivity components will emerge, along with certain legal and regulatory dependencies. The Task Force recommends that these be identified by the delivering parties early on so that they do not become impediments to the delivery of the Roadmap.
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risk overview as the task force closed their deliberations on the content of the roadmap, a risk review of the various elements was completed against ontario’s health care landscape. this was to ensure that the task force reflected on the most critical risks involved in achieving the roadmap over the two time horizons, and recommended some course of risk management to ensure achievement of the roadmap. critical risks were identified by the task force, and then subsequently categorized based on the likelihood of occurrence and severity of impact. the most critical of these risks in terms of likelihood of occurrence and severity of impact are summarized below:
lEgal, rEgulatory, and liability riSkS This area poses one of the most prominent risks to the Roadmap’s timeline and purpose. Data sharing and governance must be addressed and resolved. The Task Force recommends that the delivering parties engage with their respective legal and regulatory bodies very early on to mitigate the impact of proposed changes. Community providers need clear and simple language that reassures them and encourages them to adopt technology.
managEmEnt of changE The Task Force has recommended an ambitious Roadmap in terms of schedule and capability. The implication of the Roadmap is that providers’ practices will experience a large degree of change over the two time horizons. The successful management of this change to reduce the impact on the provider’s practice is a key risk that must be mitigated. These changes must be made easy for the provider practice. Support for implementation and the ongoing optimization of system use are key implementation enablers. The Task Force recommends that each delivering program consider their change plans in unison with the other programs that are delivering within a particular time period to minimize disruption to provider practices.
providEr capacity The Task Force highlighted the provider capacity to absorb and adopt many of the Roadmap’s capabilities as another key risk factor. The Task Force recommends that the delivering programs consider mechanisms that allow providers to augment their own capacity and that of their practices. For these ehealth capabilities to live up to their promise, they must enhance providers’ capacity, not reduce it, even in the initial stages.
inStability of funding and incEntivE alignmEnt Instability of funding programs that support the capabilities detailed on the Roadmap will have an adverse impact on achieving the plans contemplated in the Roadmap timelines. Additionally, incentives and payment models need to be reviewed to ensure that they are aligned to, and enhance the delivery of, the various programs on the Roadmap. Disruptions in these sources of funding risk continued progress on the Roadmap. Misaligned incentives and funding models risk adoption and usage of these programs by the provider community. The Task Force recommends that delivering programs consider their funding and incentive models carefully to ensure that Roadmap elements are optimally supported and that they are achievable.
implEmEntation momEntum Failure to ensure that momentum—especially early momentum on the Roadmap—is achieved and maintained poses a significant risk. The Task Force recommends that particular focus goes into ensuring that early, demonstrable results emerge in line with the Roadmap. This catalyst is necessary to maintain the momentum for full delivery of the Roadmap, since missing early elements of the Roadmap will have a cascading and collateral impact. The ambitious nature of the Roadmap implies that timely delivery is a critical success factor. These are the right things to do and the timing is right—deliver value to providers by making existing electronic data mobile and available through EMRs.
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StandardScommunicatE known StandardS and compliancE rEquirEmEntS
communicatE datES and procESS for futurE StandardS SchEdulE and compliancE ExpEctationS
availablE data StandardS influEncE EmrS whErE practical and fEaSiblE
eBusiness
Consumer eHealtH
Medication
ManageMent
eCommuniCations
data mobilizEd
communicate existing provider - patient electronic communication guidelines from regulatory colleges. Educate and initiate email communication with patients
limited production rollout of procured eprescribing solution of a provincial drug information System
lessons learned gathered from provincial and international phr pilots and implementations
new installs of Emr preloaded with 6 months of data and up-to-date rosters. comprehensive patient administration tools available thorugh the Emr (e.g., eroster)
ecommunication is enabled among providers for ereferrals and econsultations
access to telemedicine from the Emr
connect eprescribing and Emr solutions
phr for chronic disease management (e.g., diabetes) is available for all in ontario
phr targeted at a select identifiable population, (e.g. diabetes) is available to patients
real-time claims management from physician offices
patients with phr able to view their enrollment status
patient rosters reconciled electronically
emr adoption
programs that promote and communicate value of Emr adoption. physician it support options as informed by provincial experiences and lessons learned
achieve >65% by 2012 adoption of Emr in community-based primary care physiciam offices
laboratory information
oliS available to all requesting physicians
100% of ontario laboratory information available to all requesting physicians
hospital reports
hospital reports available to community-based providers in usable and consumable formats
all Emr-enabled physicians receive electronic hospital reports on all their patients
community physician technology roadmap
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
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data and communication StandardS for EmrS arE dEfinEd
data and communication StandardS for EmrS publiShEd, tEStEd and dEployEd
StandardS arE adoptEd and arE rESulting in innovativE product dEvElopmEnt.
by 2015...community-based providers are practicing in a data-rich environment
by 2020...optimal data & communication assists informed decision-making for both providers and
patients. phr serves to engage and inform patients
data optimizEd
direct patient access to telemedicine online
all drugs, all people: view the horizontal drug profile of all patients in ontario
all providers have access to prescription history regardless of prescribing provider or source
patients able to view their own drug profile online. prescription renewals available online
Start roll-out of phr for all patients
all community-based physicians are successfully using Emr applications
Emr is the ubiquitous, standards-enabled tool that providers use in community-based clinical practice settings for capturing and reviewing information about their patients, providing for care, communications, and consultations.
Electronic laboratory test ordering from community-based physician offices
Standards-based laboratory information
laboratory results viewable through the phr
laboratory information from all sources is standards-based and is integrated / accessible through the Emr in a timely manner.
all patients in ontario have access to a phr.
full econsultation and ereferral capacity for providers in ontario
all physicians receive electronically a full scope of reports and information about their patients categorized for purpose of use and available through the Emr.
all pharmacists receive electronic prescriptions.
physicians interact, converse, and provide care for patients both remotely and electronically. physicians refer electronically, and maintain visibility to care, status, and outcome from their Emr.
community physician technology roadmap
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
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endnotes, bibliography and references
notES
Ontario Medical Association, 2009.
ICES, 2006.
Ontario Medical Association.
National Physician Survey, National Demographics, 2007.
Resident Matching Service (CaRMS). Family Medicine as First Choice, 2002 - 2009.
Statistics Canada, Population Projections Nationally and by Province, 2009.
Ontario Ministry of Finance, Toward Ontario 2025: Assessing Ontario’s Long-Term Outlook, 2010.
National Physician Survey, National Demographics, 2007.
KPMG & Innovative Research Group. CMS Adoption Final Report, October 2008.
National Physician Survey, National Demographics, 2007.
KPMG & Innovative Research Group. CMS Adoption Final Report, October 2008.
KPMG & Innovative Research Group. CMS Adoption Final Report, October 2008.
eHealth Ontario, Internal Information.
KPMG & Innovative Research Group. CMS Adoption Final Report, October 2008.
Patient Centered Care Survey, U.S. 2009.
Patient Centered Care Survey, U.S. 2009.
Ontario Telemedicine Network. eHealth Alignment: eCommunications Implementation Milestones and Adoption Targets, April 2010.
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1
National Institute for Health Innovation (New Zealand). Organizing Health Information in an eHealth Environment. September 2008.
2
Warren, J. Organizing Health Information in an eHealth Environment: Principles & Concepts. National Institute of Health Innovation (NIHI), the University of Auckland, September 30, 2008.
3Intel Digital Health Group. White Paper: The Emergence of Personal Health Systems: Designing Technology for Patients and Clinicians. 2008.
4Conference Board of Canada. Information and Communication Technology – Discussion Paper. May 20, 2008.
5
Ferguson, T. e-Patients. How they can help us heal healthcare. E-Patients Scholars Working Group, 2007.
6UM Research. Power to the People. Social Media Tracker. Wave 4. Universal People Power, July 2009.
7J. Sharp. Web 2.0: Beyond Open Source in Health Care. IT Web Services. Cleveland Clinic.
8
Yacoob, S. Computerized Physician Order Entry: A Disruptive Technology? The Cerner Quarterly. Vol.2, No. 1, 2009.
9
Vision 2020 Workshop on Information and Communication Technologies in Health Care from the Perspective of Physicians. CMA and Office of Health and the Information Highway, Health Canada. May 15, 2000.
10Glover, V. Conversations from the Frontier Centre for Public Policy. Social Policy Renewal. 2007.
11Anita B. The Interactive Personal Health Record. A 2020 Vision for the Canadian Healthcare System. CAPCH.
12
Kaiser Permanente. Kaiser Permanente Project Proves Electronic Health Information and Care Coordination Improve Chronic Disease Management. Press Release. July 9, 2009.
13EHR Blog of Dr. Glenn Laffel. EHR Use and Care Coordination Improves Health Outcomes. Thursday, October 22, 2009.
14
Linder, J.A., et al. Barriers to Electronic Health Record Use During Patient Visits. American Medical Informatics Association Annual Symposia Proceedings, 2006. pp. 499-503.
bibliography
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Linder, J.A., et al. Barriers to Electronic Health Record Use During Patient Visits. American Medical Informatics Association Annual Symposia Proceedings, 2006. pp. 499-503.
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Ludwick, D.A. and Doucette, J. Primary Care Physicians’ Experience with Electronic Medical Records: Barriers to Implementation in a Fee-for-Service Environment. International Journal of Telemedicine and Applications. Volume 2009, Article ID 852254.
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Ludwick, D.A. and Doucette, J. The Implementation of Operational Processes for the Alberta Electronic Health Record: Lessons for Electronic Medical Record Adoption in Primary Care. ElectronicHealthcare. Volume 7, Number 4.
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Protti D. et al. Adoption of Information Technology in Primary Care Physician Offices in Alberta and Denmark, Part 1: Historical, Technical and Cultural Forces. ElectronicHealthcare. Volume 6, Number 1.
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Shoen C. and Osborn R. The Commonwealth Fund. 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries. November 2009.
19Forster, B. Assessing Factors for Successful Widespread Adoption of EMRs. 2009 ITCH Conference.
20
Electronic Health Records 2015: Canada’s next generation of health care at a glance. Canada Health Infoway.
21
Experiences from the forefront of EMR Use: 20 Canadian physician case studies. Canada Health Infoway, 2009.
22
Hodge, T. Electronic Medical Records. Investment Program Strategy. March 18/19, 2009. Canada Health Infoway.
23
Dermer, M. and Fazzalari, A.T. Physician Office System Requirements (POSR). February 21, 2008. Canada Health Infoway.
24Standards Collaborative. Getting the EHR. Fall 2008 Partnership Conference. Canada Health Infoway.
25
Neupert, P. (Microsoft) Investing in Health IT: A Stimulus for a Healthier Canada. Healthcare Quarterly, Vol. 12, Special Issue. 2009.
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rEfErEncES we thank the following individuals for their contributions as references and their generous time in supporting the research and data gathering for this report.
dr. allan brookstone Executive Director CanadianEMR
dr. Ed brown CEO Ontario Telemedicine Network
dr. david butcher Vice-President, Medicine Northern Health Authority, BC
dr. david h. chan Associate Professor, Department of Family Medicine McMaster University
dr. yan chow Director, Information Technology’s Innovation & Advanced Technology Group Kaiser Permanente
dr. kate christensen Medical Director, Internet Services Group Kaiser Permanente
dr. Julie colin Physician Advisor OntarioMD
bernard courtois President and CEO Information Technology Association of Canada (ITAC)
Sandra dalziel Program Manager Patient Destiny
dr. bill fera VP Medical Technologies Medical Director, Interoperability University of Pittsburgh Medical Center
Elaine huessing Executive Director Information Technology Association of Canada (ITAC) Health
Jessica kronstadt Senior Research Analyst, NORC University of Chicago
dr. zun lee Partner, Director eHealth – Healthcare CoE CGI
dr. kevin J. leonard Associate Professor, Department of Health Policy, Management and Evaluation (HPME); Founder, Patient Destiny University of Toronto
dr. danielle martin Member
Health Council of Canada
Jan oldenburg Senior Practice Leader, Internet Services Group Kaiser Permanente
david pattenden Director, Healthcare Microsoft Canada
dr. david price Chair and Associate Professor Department of Family Medicine Faculty of Health Science McMaster University Chief, Department of Family Medicine Hamilton Health Sciences McMaster University
Ed reynolds Chief Technology Officer PEPID Medical Information Services
dr. danny z. Sands Senior Medical Informatics Director Cisco
neil Seeman Director, Innovation Cell University of Toronto
John Sharp Manager, Clinical Research Informatics, Quantitative Health Sciences Cleveland Clinic
rachel Singer Senior Research Analyst, NORC University of Chicago
dr. andrew Szende CEO Electronic Child Health Network (eCHN)
dr. Susan thomas
dr. david wiljer Director, Knowledge Management and Innovation, Radiation Medicine Program Princess Margaret Hospital/University Health Network
dr. andrew watson Vice President, International and Commercial Services Division University of Pittsburgh Medical Centre
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design, layout and illustration: Jasmina Mirkovic creative Supervisor: Daniel Thamotharem Stakeholder Relations and Communications, eHealth Ontario
