Alan Brookstone, MD

eHealth Consultant

Lead Physician Vancouver Coastal Health Primary Care IT Strategies

The Physician Voice

What is the Physician Voice?

• The External Voice…– Caregiver

– Advocate

– Advisor

– Educator

– Leader

– Peer

• And the Inner Voice…

The Inner Voice

• What’s in it for me?

• I have to be heard

• What this means in terms of my local situation and my patients?

• How do I protect my patient’s right to privacy?

• How do I adopt technology without becoming overwhelmed?

Canada

• Area of Canada - 9,984,670 sq km

• Population (2007) - 33.3 Million

• Area of British Columbia - 944,735 sq km

• Population (2008) - 4.1Million

• Physicians (2006) - 8,635

• Area of Singapore - 692.7 sq km

• Population (2007) - 4.6 Million

• Physicians (2007) – 7,600

Physician Characteristics

• Independent

• Advocate for patient care

• Many run small businesses

• Appreciate the ‘Art’ as well as the ‘Science’

• How do physicians adopt and use technology in their practices?

Where do Physicians fit in the Big Picture of eHealth?

• Activity is currently taking place at multiple levels simultaneously– Internationally– Nationally – Provincially– Regionally

• Primary care Renewal projects, Regional EHR– Locally

• Clinical info systems in local hospitals, DI, labs etc.– Private sector

• How do nations and physicians make good decisions regarding uptake and use of technology including EMRs?

The Environment is Changing

• Healthcare costs are rising at an unsustainable rate

• Patient expectations are changing

• Using EMR/EHR creates new opportunities but also new challenges

• SUCCESS requires a team approach plus a Common Vision– Government, Medical Associations, Funding

Organizations Physicians, other clinical providers

79

23

42

9892 89

28

0

25

50

75

100

AUS CAN GER NETH NZ UK US

Percent

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Primary Care Doctors’ Use of Electronic Patient Medical Records, 2006

Percent reporting routine use of: AUS CAN GER NET NZ UK US

Electronic ordering of tests 65 8 27 5 62 20 22

Electronic prescribing of medication

81 11 59 85 78 55 20

Electronic access to patients’ test results 76 27 34 78 90 84 48

Electronic access to patients’ hospital records

12 15 7 11 44 19 40

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

Commonwealth Fund study - Practice Use of Electronic Technology

Percent reported:

AUS CAN GER NETH NZ UK US

Only Minor Changes Needed

24 26 20 42 26 26 16

Fundamental Changes Needed

55 60 51 49 56 57 48

Rebuild Completely

18 12 27 9 17 15 34

Source: 2007 Commonwealth Fund International Health Policy Survey

Overall Views of the Health Care System in Seven Countries, 2007

Conceptual Cycle of ICT Adoption & Use by Physicians

What is an Electronic Medical Record?

• The EMR is a Provider Centric tool• Generally a physician will use this system with each

and every patient encounter and will record detailed encounter information, some of which is sensitive and not appropriate to share with all other providers.

• This is also the system where patient results, (e.g. laboratory, diagnostic imaging, and other reports ordered by a provider), are delivered to that provider's electronic in-box, (i.e. this information is "pushed " to the provider, negating the need for the provider to go out and seek it).

EMR Myths & Realities

• MYTH: If only we could find the ‘perfect’ Electronic Medical Record (EMR), everything would fall into place (‘killer app mentality’)

• REALITY: EMRs are ‘mission critical’ applications that are required to work 100% of the time every 10 minutes in primary care.

Dr. Karim Keshavjee COMPETE Project - Hamilton Ontario

Goal: Patient Centric Shared Care

SHARED CARE PLAN

The Keys to Success

• Belief in a common vision

• Collaboration

• Innovation

• Common data standards

• Staying the course

• Leading peers by example

This is a Complex Process

• One size does not fit all

• Business and clinical processes need to be facilitated between GPs and between GPs and Specialists e.g. Referrals

• The Triangle of:– People

– Process

– Technology

Max SysMedchart

AB, NS, ON, NT• Nightingale

AB, ON• Jonoke• Practice

Solutions

NS Only

• Dymaxion

ON only

• ABELsoft• AlphaGlobal IT• AssistMed• Asystar• Healthscreen• HTN• McMaster (Oscar)• Omni-Med• P&P Data Systems• PCI• York-Med• xwave

AB Only• Microquest• Optimed• TELIN

• Cerner• CureMD• Deltaware• EPIC• Global

Biometrics• IQMedX• KATSI• Logibec• Logiscels

Info Data• LSS Data

Systems• Max Sys

• Medchart• MedOffIS• Medical

Software Canada

• MediPlus• Medware• Misys• Optimed• Purkinje• RISE• Scripnetics

Provincial Certifications Non-Certified

Vendor Landscape

AB, BC, ON• CLINICARE• Wolf BC Only

• Intrahealth• Osler AB, BC

• EMIS• MedAccess

Source: Branham Group

Amplifying the Physician Voice

• Communication

• Collaboration

Physician Engagement Requires

• A structured mechanism to communicate and facilitate change

• Identification, support and conversion of early adopters into…

• Champions and Agents for ‘Spread’ within local communities

• Involvement of care providers and support staff

To have an Effective Voice

• Need to understand

– Overall goals

– Timelines

– When it is appropriate to be involved

Role of Communication

• During early technology adoption, communication is critical

• Identify local needs– Influenced by political, historical issues and local

programs

– Allow users to stratify themselves appropriately

– Provide dynamic feedback to leadership to ensure programs effectively deployed

VCH Physician Clinical IT Adoption Model

Level 1:Practitioner’s personal use of a computer rarely (if ever) at the point of care. Billingsystem and other software in use in the office, but not directly impacting patient care.Electronic resources not used on a regular basis to look up clinical information.

Level 2:Primary a paper-based practice. Care delivery assisted through use ofelectronic resources, such as online access to clinical practice guidelinesand/or PDA use for looking up medical reference material. Practitionerand office may use email. Internet and other IT tools not used for directmanagement of patient information and patient care.

Level 3:Hybrid Practice: paper and electronic. Practitioner use ITtools to manage focused elements of practice, promotingclinical quality improvement. Practice supported by toolsthat aid in the direct management of patient care. e.g.decision support for practice diabetic population.

Level 4:Practitioner and practice are EMR based forthe vast majority of all patient care. Usetools that support new workflows andchange management to deliver high quality,pro-active practice, that help the practiceachieve higher evidence-based care.

VCH - Physician User Groups (PUGs)

• Geographic, Departmental, Special Interest

• Understanding of specific community needs

• Required facilitation and support

• Allowed communication through– Face to face meetings

– Virtually - Internet and email

– Teach, learn or share

• Led by a respected peer

Physician User Groups

• Provided structure

• Required an e-mail address

• Allowed physicians to be passive observers until the time was right!

• Allowed ‘disconnected’ physicians to reconnect with minimal risk

Function

PUG"Our Needs First"

PUG Network"Global Needs and Education"

PUG"Our Needs First"

VCH

Current - Provincial

• PITO – Physician Information Technology Office

• Approximately 25 Physician User Groups led by respected peers

• Peer-to-Peer network supported by funding from Canada Health Infoway

Collaboration

• Physicians need to get involved

• Help guide solution and system design

The Physician Voice

• Without– Support

– An understanding of context

– Belief in a future vision

• The inner voice dominates, and

• The external voice is ineffective

“Attitude is a little thing that makes a big difference”Sir Winston Churchill

Thank you

Alan Brookstone, MD

alan.brookstone@clearviewgroup.ca