Primary Health Care Initiatives

Presentation to MNIAMonday September 15th 2008Dr. Diamond Kassum – Chief Medical Information Officer, Manitoba eHealth

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TopicsManitoba eHealthiEHR and Active Clinical Projects

Primary Health CarePCISS

PIN

EMR selection and adoption

Infoway initiatives

Access Centres, CAR, Carelinks, BGSC

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Manitoba eHealth – A Provincial Program

Was announced by the Minister of Health on April 11, 2007

Develops information management processes, tools, and technology

A single organization to ensure alignment with provincial and national objectives

Will ensure a long-term province-wide approach

Builds and acquires solutions that meet Manitoba’s health care needs

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Community Care Center

Pharmacy

Laboratory

DiagnosticHospital Emergency

Homecare

Clinic Emergency Services

Specialist Clinic

The Circle of Care

From the EHRS Blueprint © Canada Health Infoway 2003-2005

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Pharmacy

Laboratory

DiagnosticHospital Emergency

Homecare

Community Care Center

Clinic Emergency Services

Specialist Clinic

The Patient Centric & Integrated View of Consolidated Information

From the EHRS Blueprint © Canada Health Infoway 2003-2005

QUALITY SAFETY

ACCESSIBILITY

Clients/PatientsINTEGRATED VIEW

Pharmacy

Laboratory

DiagnosticHospital Emergency

Homecare

Clinic Emergency Services

Specialist Clinic

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An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers. It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies.

Electronic Health Record (EHR)

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An example of an Electronic Healthcare Record

From the EHRS Blueprint © Canada Health Infoway 2003-2005

Phone:204-277-298714 Health RoadManitoba, MBR2T 3E4

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Manitoba eHealth’s TerminologyManitoba’s Electronic Health Record (EHR)A secure and private lifetime record of a patient’s key health history, available to be viewed electronically by authorized health care providers, anywhere, anytime.

Interoperable EHR (iEHR)The project to plan and implement Manitoba’s EHR.

Electronic Medical Records (EMR) – clinic basedA patient medical record in digital format that resides within an integrated system that allows authorized medical staff access to patient information. In this context, within a physician clinic.

Electronic Patient Records (EPR) – hospital basedIs a set of components that comprise the mechanism by which patient records are created, used, stored and retrieved. In this context, within a hospital.

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Manitoba eHealth Strategy to Improve Healthcare Delivery

Point of Service

Systems

Hospital Information System

Clinical Supply ChainEmergency RoomSterile Instruments

Hospital Information System

Clinical Supply ChainEmergency RoomSterile Instruments

Drug System

Drug System

LaboratorySystem

LaboratorySystem

Diagnostic ImagingSystem

Diagnostic ImagingSystem

Tele Health

Tele HealthCommunity

SystemHomecare

Mental Health

Community System

HomecareMental Health

Electronic Medical Records

Electronic Medical Records

Long Term Care

Long Term Care

Public HealthSurveillanceImmunization

Public HealthSurveillanceImmunization

Decision Support

Decision Support

Client RegistryClient Registry

Provider RegistryProvider Registry

Enterprise ArchitectureEnterprise Architecture

Information StandardsInformation Standards

Privacy and SecurityPrivacy and Security

ProvincialFoundation Elements

CRM & Portfolio MgmtCRM & Portfolio Mgmt

OperationsOperations

Service DeskService Desk

Project Methods and Stds

Project Methods and Stds

Health Priorities• Patient access to quality care - shorter wait times • Manage critical human resource shortages - more doctors and nurses• Focus on primary and community healthcare• Closer to home• Sustainability of the health system • Manage health system performance

Health Priorities• Patient access to quality care - shorter wait times • Manage critical human resource shortages - more doctors and nurses• Focus on primary and community healthcare• Closer to home• Sustainability of the health system • Manage health system performance

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POINT OF SERVICE

Hospital, LTC,Community

PhysicianOffice

EMRs

EHR Viewer

Physician/Provider

Physician/Provider

Physician/Provider

Lab System(LIS)

Lab Clinician

RIS/PACS

Radiologist

Pharmacy

Systems

Pharmacist

Public HealthServices

Public Health

Provider

Cancer Care

BusinessRules

EHRIndex

MessageStructures

NormalizationRules

Security MgmtData

Privacy Data Configuration

Longitudinal Record Services

HIALCommunication Bus

Common Services

DataWarehouse

HealthInformation

SharedHealth Record

DiagnosticImaging

LaboratoryDrug

Information

EHR Data & ServicesAncillary Data& Services

OutbreakManagement

PHSReporting

Registries Data& Services

ClientRegistry

ProviderRegistry

Electronic Health Record Architecture

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Current State of iEHR components in Manitoba

PROVINCIAL INFRASTRUCTURE

Registries

POINT OF SERVICE

Hospital, LTC,CCC, EPR

DPIN-HIST

Physician/Provider

Physician/Provider

Lab System(LIS)

Lab Clinician

RadiologyCenter

PACS/RIS

Radiologist

Technologist

DPIN

Pharmacist

ClientRegistry

ProviderRegistry

ADT

Systems

Hospital and

Regional

Cloverleaf

MIMS

(Immunization)

Public

Health

Physician

Office

Manitoba Insured Client

Registry

CDM

Physician/Provider

REGIONALINFOSTRUCTURE

Pharmacy system

Medical Claims (no

view)

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Manitoba’s iEHR Roadmap

Phase 1Planning

June 2007 Dec 2007 Jan 2009

Phase 2.0Procurement

Jan 2010

Phase 2.1Drug/Portal

Phase 2.2Lab

Phase 2.3DI & SHR

Jan 2011 Jan 2012

MB EHRVersion 2SHR Extension

EMR/EPR Integratione-Prescribing

e-ReferralPHS

Data Warehousing

MB EHR Version 1

EMR Approval Process EMR Rollout

MB Electronic Medical Record Adoption

“Clinical Information View”

“Enhanced ClinicalWorkflow”

The EHR Version 1 will be implemented in parallel with the Electronic Medical Records system adoption within primary care.

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Active clinical systems

HSC – SIMS (GE) and EDIS (Eclipsys) SBGH – (ADT), RR, EDIS (Eclipsys AM and SCM) Brandon – (ADT) and RR (Siemens)DSM – LIS (Sysmex etc.) and RIS/PACS (Agfa)CCM (Varian)PHISMIMSDPINCadhamPharmacy – Acute Care (Cerner and GE Centricity)PCH (Momentum MDS)

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In Flight Major Clinical Projects (Provincial)

Client Registry (CR) Uniquely identifies individuals Implemented in 2008

Provider Registry (PRS) Uniquely identifies Health Care professionals In production – to be used in the Electronic Health

Record

Home Care Scheduling Systems Preparing for provincial rollout of home care scheduling

systems

Manitoba Telehealth Implemented in 61 sites in Manitoba Used for visitation, consultation, and education Potential for mobile units Potential for FP office

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In Flight Major Clinical Projects (Provincial)

Radiology Information System / Picture Archiving Communications Systems (RIS/PACS) Implementing provincial system in 50 facilities

Provincial Laboratory Information System (LIS) Implemented in WRHA facilities Infrastructure renewal and software upgrades 2008 Phase 1 provincial rollout started summer 2008

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In Flight Major Clinical Projects (WRHA)

Hospital Information System – (HISP AC) Phase 1 implementation of Electronic Patient Record

(EPR) at SBGH complete (ADT and RR) Phase 2 at SBGH (order entry and clinical

documentation) to be implemented in 2008 and 2009

Hospital Information System – Long Term Care (HISP LTC) Momentum MDS 39 WRHA PCH sites activated

Emergency Department Information Systems (HISP EDIS) Implemented at HSC and SBGH in 2007 Implementation at Seven Oaks, Grace, Victoria and

Concordia Hospitals 2008

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Clinical Practice Expectations with the EHR

Enhanced patient safety and quality of careAccess to key demographics Recent encounters (who and why)Pertinent medical/surgical historyMedication reconciliationChronic disease identification and statusRecent lab and DI info Reduced wait times (consults, integrated scheduling, information exchange)

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Clinical Practice Expectations with the EMR

Enhanced patient safety and quality of careLegible ChartsChronic Disease ManagementQuality IndicatorsAlerts and Reminders Trend Plots (BP, Lab)Access to GuidelinesePrescribingConnectivity

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Result in Measurable Care Outcome Improvement

QualityQuality SafetySafety AccessAccess

•Chronic Disease

Management

•Evidence-based

Care

•Preventive Care

•Medication

Errors

•Diagnosis and

Treatment Errors

•Infection

Prevention

•Blood

Transfusion

Errors

•Scheduling &

Waitlist Mgmt

•Continuity of

Care

•Unnecessary

Duplication

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Physician EMR Adoption in Canada

Skill level with Computers Advanced – 17% Good – 52% Beginner – 23% No use 4%

EMR Penetration in Canada Paper only 58% EMR Exclusive – 10% EMR + paper – 26% 63K licensed physicians –

20% working with EMRs 50K physicians are in

community

Atlantic – 1-25% Quebec – 0-1% Ontario – 10% MB – 12-16% Sask – 10-20% Alberta – 60% BC – 5-17%

Email Usage Clinical Colleges – 63% Patients – 13% Non – clinical – 50% Overall – 87%

Connectivity in Office High Speed – 71% Dialup – 3% No Access – 14%

Tools Access to Medical Info – 55% Billing – 53% Schedules / Appointments – 42% Lab / DI – 30%

‘Insite Conference March 2008’

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Primary Care Information System Strategy (PCISS)

Steering CommitteeReports to DMFPsMike OmichinskiDavid RossChris BurnettScott Kish

Chair CIO Roger Girard

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PIN: Physician Integrated Network

4 PHC ClinicsMorden: Agassiz Medical CentreWinkler: CM Wiebe ClinicWinnipeg: Assiniboine ClinicSteinbach Medical Centre (control)

ObjectivesTo improve access to primary careTo improve Primary Care Providers’

access to, and use of informationTo improve the work life for all primary

care providersTo demonstrate high quality primary

care with a specific focus on Chronic Disease.

PIN

EnablersAdd ancillary staff (nurses, dietitians) Improve clinical reporting practices re

screening and CDMAssess change management

requirements Implement Quality Based Incentive

Funding

PIN

Screening and interventionsPAP smearsFOBTFlu shots

CDMType 2 diabetesHypertensionCCF

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PIN evaluations

Physician - qualitative IncentivesReceptivenessChallenges Impacts

Quantitative (Sept 2007 – March 2008 in 2 clinics)All screening tests increasedFlu shots: 39% to 77%

in one clinic25

PIN issues

EMR vendor complianceData integrityData validityReasons for variationsQBIF

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PIN plan

Steinbach conversion to active site3 year funding to 201165 more physicians (4 – 6 more clinics)ActivitiesData collection and analysis Indicator developmentFunding and remuneration

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PCISS – EMR selection

EMR RFQ - select a set of approved EMRs to be adopted and implemented by physicians ASP and on site version PIN characteristics incorporated Written evaluations completed Demos start this week

BC and AB models used for RFQ Down to 5 in AB (EMIS, EPIC, MedAccess, Practice

Solutions and Wolf)

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EMR adoption support

PCISS Office – Physician Office Support SystemSupports the APLChecks complianceSupports change managementManages vendor contracts

EMR fundingStartup, data collection, benchmarksNot yet approved

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Infoway initiatives

Peer to Peer (P2P)Physicians NursesPharmacists

Demonstration SitesActive EMR required

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Physician Peer to Peer Network

What is the PP2P Network?• A program funded by Canada Health Infoway but operated by

Manitoba eHealth, that provides a Physician Peer Leader as a mentor and advisor who will answer questions regarding EMRs and direct the physician to specialized resources if required.

Why is the program being offered?• Acquiring, implementing an optimizing an EMR into family

practice is complex, and it makes sense to learn from others rather than go it alone. The premise of this program is that physicians will learn best from other physicians.

Who are the Peer Leaders?• The Peer Leaders are practicing Manitoba physicians with years

of experience in implementing and using EMRs in a practice setting.

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EMR Cost calculations

An interactive EMR Worksheet has been developed by Dr. Chris Burnett. It includes cost assumptions for basic and optional technology components that reflect Dr. Burnett’s own experience and the EMR product he uses. The worksheet allows you to input factors that apply to the clinic (e.g. number of workstations required) to estimate a rough cost.

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Demonstration Sites Program

Visit a clinic that has had an EMR in place for years and learn how they work. Or … visit several clinics to compare and contrast solutions.

Demonstration Site

Simulated environmentFaculty of Medicine simulation lab

(Brodie)FP clinic environmentPotential to compare systemsWorkflow analysis possible

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Community HealthWRHA Access Centres

PARISMH in BCNot an EMRUsed for ancillary healthMay be replaced

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Canadian Association of Radiologists (CAR)

DSS (Decision Support System) to help physicians determine which test to orderProvides guidelines and best practice informationPilot in Children’s Hospital 2006-2007FP pilot in Steinbach Family Medical Centre 2008-2009

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CareLink – Patient Access to Quality Care (PAQC)

MHHL initiative, Infoway fundedIntegration of services with PHCHealthLinks involvementPart 1: Supports self-managed care in between office visitsPart 2: Provides access to PHC outside normal clinic hours and connects with FP

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WTTF - BGSC (Bridging Generalist and Specialist Care)

Fed. funded 2 year pilot project involving <150 FPs Develop, implement and test streamlined pathways for referrals to specialistsProvides a catalogue of specialistsIntegrated with a Patient Access Registry Tool (PART)DSS – specialist investigationsWeb based communication pathwaysSelected referrals e.g. colorectal, back pain, mental health, orthopedicsPlanned for activation in March 2009

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Other Resources

Health Canada’s EMR Toolkit [emrtoolkit.ca]• Provides both a structured approach to

acquiring an EMR and a compendium of information and links to other resources.

Canadian EMR [canadianemr.ca]• Site managed by Dr. Alan Brookstone, provides

product comparisons, vendor profiles and personal commentary.

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Quotable quotes

“In all affairs it is a healthy thing to hang a question mark on the things you have long taken for granted.”

Bertrand Russell

“The person who believes it cannot be done should not interrupt the person doing it.”

Ancient Chinese proverb

Questions?

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Your Physician Peer LeadersDr.

DiamondKassum

The Manitoba Lead for the Peer to Peer Network is Dr. Diamond Kassum, Chief Medical Information Officer, Manitoba eHealth

Dr. Johann BlignautFamily Physician,

Winkler

Dr. José FrançoisFamily

Physician,Winnipeg

Dr. Chris BurnettFamily Physician,

Niverville

Dr. Mark DuerksenFamily Physician,

Steinbach

Dr. Johan Du PlooyFamily Physician,

Brandon

Dr. Carol HolmesFamily Physician,

Morden

Dr. Pol MortonFamily Physician,

Baldur

Dr. Mary SeshiaPaediatrician,

Winnipeg

Dr. Felix SikoraFamily Physician,

Winnipeg

Dr. Roy SmithFamily Physician,

Winnipeg