Hospital-community electronic medical record

Transcription

1 Hospital-community electronic medical record Country: Israel Partner Institute: The Myers-JDC-Brookdale Institute, Jerusalem Survey no: (6)2005 Author(s): Nirel Nurit, Rosen Bruce, Gross Revital Myers-JDC-Brookdale Sherf Michael, Blondheim Orna Clalit Health Services Health Policy Issues: New Technology, System Organisation/ Integration, Quality Improvement, Others Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change Featured in half-yearly report: Health Policy Developments Issue 6 1. Abstract This innovation relates to a new information technology that integrates medical records and medical information from various care settings in the community and in hospitals. If regularly used by medical staff it is expected to assist in improving continuity and quality of care, avoiding dangerous medical mistakes, and reducing costs related to duplications. 2. Purpose of health policy or idea Purpose: To improve health care information technology in order to improve continuity and quality of patient care, avoid dangerous medical mistakes and reduce costs. Characteristics: As medical treatment becomes more technically sophisticated, there is a growing need for transfer of information between care sites. However, only low rates of patients present a referral letter or discharge letter that includes relevant information. Therefore, Clalit identified the need for an integrated medical record system to facilitate access of physicians at different sites to the relevant medical information needed for providing high quality care. The integrated electronic medical record is designed to collect medical data in an automatic, on-line manner from seemingly incompatible data sources, which are decentralized. The data is brought together as information that is reliable and available for all care providers, at each site of care. The solution, developed and implemented by db motion, was based on the requirement to collect data from the existing systems without having to replace them, change their function or change the way they are utilized. In addition, the solution utilizes existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet. The solution developed by db motion consists of an information highway between the data creators and consumers in the organization that enables an information consumer to request and receive specific patient information automatically and quickly, without the need to install any program at the end user's station (by using a standard Internet browser), and without making any changes in the existing work processes or in the organization's structure. The solution provides available, up-to-date relevant medical information to each site of care while maintaining the highest level of information security, because each physician can only access the information about his patients. In addition, the solution is capable of connecting the user to various databases needed for providing optimal care. The described solution is installed in most of Clalit Health Services' hospitals and in most districts (each district - 1 -

2 controls clinics, labs and institutes), and provides up-to-date information at the point of care. Expected outcomes: An integrated medical record system should help to improve patient care at the community and hospital levels by providing the needed relevant data at all sites of care; reduce the frequency of dangerous medical mistakes (related to contradicting medication, unknown sensitivity etc.); and reduce costs (related to duplications of tests, unnecessary procedures, unnecessarily long hospital stays and medical errors). Approach or instrument: Advanced new information technology. Main objectives To improve health care information technology in order to improve care, avoid dangerous medical mistakes and reduce costs. Type of incentives There are several indirect incentives to use the system: 1. Fear of malpractice liability if information exists and is not used 2. Community clinics in Clalit hold a budget therefore they have an incentive to use the system in order to save costs related to hospital care 3. Hospital remuneration is not based on fee-for-service and therefore they too have an incentive to spend less and rely on tests etc. conducted in the community. 4. The system in itself facilitates coordination of care since it is easy to use and can reduce physicians' workload (less tests and procedures to do in the hospital). Groups affected Clalit health plans' physicians and other medical staff will have accessible background & historical information as well as updated comprehensive information on their patients. This will improve quality of care and reduce costs, Patients will receive better care because relevant medical information will be more accessible and timely., Ministry of Health implementing the system in Clalit may push the MOH and health system in general to develop an integrated national medical record system across all health providers, irrespective of organizational affiliation 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral Innovation: it is very innovative since it links information between hospital and community care and links information from different and not fully compatible computer systems. No such system exists in the Israeli health care system and it is also rare abroad. There is a growing consensus internationally that the widespread institution of health information - 2 -

3 technology, including computerized health records, electronic order entry, and computer-aided decision support, could reduce costs and improve quality of care. In the US, this viewpoint was endorsed and expanded upon by the health subcommittee of the President's Information Technology Advisory Committee (PITAC), which has laid out a framework for a 21st Century health care information infrastructure. Controversy: no controversy, all key actors acknowledge the advantages. The system does not require changes in current software in each site and therefore does not affect the daily work in these sites. System impact: changes the communication between hospital and community facilites and is likely to highly affect continuity and coordination of care (if used regularly). Visibility: the public is not yet aware of this innovation. No media exposure. Transferability: In many other health care systems, as in the Israeli situation, information flow between hospitals and community-based care providers is problematic. Similarly, the need to link together information from many systems is not at all unique to Israel. The system itself may also be transferable with some modifications. 4. Political and economic background This policy is aimed at attaining Clalit Health Plan's strategic goals of improvement in quality of care and service, and reducing costs. These goals are part of the annual working plans and the integrated electronic medical record system contributes to achieving them. The new information technology system is also in line with the national policy recommended by the Ministry of Heatlh (MOH) to enhance a nationwide integrated hospital-community information system. This policy envisions online communication between all medical facilities in Israel. To date the MOH has established a committee to develop a strategic implementation program for this policy. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea There is a growing consensus that the widespread institution of health information technology, including computerized medical records, electronic order entry, and computer-aided decision support, could reduce costs and improve quality of care. Clalit Health Services has for many years developed electronic medical records in their community clinics, laboratories, diagnostic clinics and hospitals since However, until recently, these electronic records were not compatible and information could not flow from one site to the other. Clalit came to the conclusion that an integrated medical record would help it improve patient care and reduce costs by facilitating access of physicians at different sites to the relevant medical information needed for providing high quality care. However, it faced the problem of collecting medical data in an automatic, on-line manner from seemingly incompatible data sources. The data needed to be collected from the decentralized sources within the organization and brought together as information that is reliable and available for all care providers. At the same time, due to severe financial and competitive pressures, Clalit faced severe limitations regarding the amount of money it could invest in the effort

4 The solution developed and implemented by dbmotion, (an Israeli commerical high-tech company), was based on the requirement to collect data from the existing systems without having to replace them, change their function or the way they are utilized. In addition, the solution utilizes existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet. The driving forces: The former director general of Clalit health services initiated development of the new technology given the low rates of patients who present a referral letter or discharge letter that includes relevant information. The motivation was to improve the quality of care by providing physicians at each site with easy access to all relevant medical information for treating the patient. As medical treatment becomes more technologically sophisticated, physicians cannot rely on patients reports regarding previous treatment tests or medications, which may not be accurate. Therefore the director general identified the need to develop integrated electronical record systems to facilitate transfer of information that would improve the continuity and quality of care. Initiators of idea/main actors Providers Payers Patients, Consumers Private Sector or Industry Others Approach of idea The approach of the idea is described as: new: Stakeholder positions Clalit health services - they have initiated this innovation and believe that it will improve both the quality and continuity of care and save costs (related to excess duplication and medical errors resulting from deficient information on patient care). Implementation is dependent on their decisions and financing and therefore they have a strong influence on the process. db- Motion commercial IT company - they have a commercial interest in marketing their technology and thus support it. They influence the implementation process (quality of communication, timeliness etc.) Clalit Hospital management - they support the project because they see the potential for improving access to medical information needed for patient care. The hospital does not pay for the technology. Their influence on the ability to implement the program is high. Physicians in hospitals and community - Clalit has not conducted structured training or marketing of this program and therefore many physicians are not aware of the potential of this system, and therefore do not use it regularly. Some physicians who know about it do not use it (are not comfortable with IT technology, do not have time etc.). However, other do use it and find it very helpful. Clalit physicians' trade union - they oppose the new technology because of the additional work it imposes on physicians (entering and updating data). Their influence is not high - physicians who learn about the system and see it's advantages can use it in spite of their opposition. Patients - They may be concerned about medical confidentiality regarding their medical records. On the other hand this innovation will improve the quality of their care and will reduce duplications in tests etc. It will also lower the probability of medical errors in drug prescriptions and procedures since all parties will have all the relevant information even in emergency situations when the patient cannot provide necessary information on medical history etc. They do - 4 -

5 not have any influence and may not yet be aware of the new technology. Actors and positions Description of actors and their positions Providers Clalit hospital managers very supportive strongly opposed Physicians in hospitals and very supportive strongly opposed community Payers Clalit health plan management very supportive strongly opposed Patients, Consumers Patients very supportive strongly opposed Private Sector or Industry db-motion (commercial IT company) very supportive strongly opposed Others Clalit physicians' trade union very supportive strongly opposed Influences in policy making and legislation No new legislation needed. The Patient's rights law enables creating this integrated medical records system. Legislative outcome Actors and influence Description of actors and their influence Providers Clalit hospital managers very strong none Physicians in hospitals and very strong none community Payers Clalit health plan management very strong none Patients, Consumers Patients very strong none Private Sector or Industry db-motion (commercial IT company) very strong none Others Clalit physicians' trade union very strong none Positions and Influences at a glance Adoption and implementation Despite the fact that Clalit operates a network of acute care hospitals, the various hospitals in its network do not all employ the same computer systems. Thus, on the technical side, Clalit had to overcome the challenge of connecting disparate hospital information systems. The solution is based on an innovative software that links information between hospital and community care sites and from different and not fully compatible computer systems

6 The described software solution is installed in most of Clalit Health Services' hospitals and in most districts (each district controls clinics, labs and institutes), and seeks to provide up-to-date information at the point of care. To date, the technology is also installed in a few government and voluntary sector hospitals as well as in Clalit-owned facilities. This enables transfer of comprehensive information on Clalit patients. According to the system's developers, it has thousands of users and has required minimal investment in training and implementation. According to dbmotion, "The solution has contributed to the efficiency of processes and to the improvement in quality and availability of medical information, all this at minimum maintenance. The system has reduced the general concern regarding medical negligence due to the lack of available information. In addition, the system saves major costs by preventing "double-testing" which were previously done due to lack of cross site up-to-date information. The adoption of the system has been extremely easy and consequently the number of users grew from a few dozen to thousands in a matter of three weeks." Recently two big MOH hospitals have linked to the system enabling online connections with Clalit facilities and transfer of information on Clalit patients. These hospitals saw the advantages and therefore voluntarily bought the system and implemented it. The main problem in the implementation of this technology is updating the information. Lab test results are entered automatically but other data need to be entered and updated manually. Physicians in the community and in hospitals need to regularly enter diagnoses, medications etc, which takes time and effort. Therefore, the quality of the data depends on the cooperation of physcians. To date, Clalit has not yet initiated a structured effort for assimilating this technology and therefore the quality of the data is not yet optimal. Furthermore, the physicans' trade union demands special remuneration for the added work involved in updating the system. Another problem is the ADSL infrastructure that is needed for operating the advanced version of the software, which is user-friendly and provides easy access to data. Only lately has this infrastructure been installed in community settings

7 Monitoring and evaluation No formal evaluation has been conducted yet. 6. Expected outcome The policy is likely to improve patient care at the community and hospital level and reduce dangerous medical mistakes that are related to insufficient information on patients. However this is dependent on regular use of the system by phsycians, nurses and other providers. The effect on costs is undefinitive. Cost savings related to duplications are likely to be achieved. However their extent is unknown and savings related to other aspects of care are not clear. Unexpected or undesirable effects: The installation of the new system may raise expectations amongst physicians for easy access to all types of information, and this may not be a realistic expectation. The current hardware may not be advanced enough in every site, and not all the providers are yet connected to the system. On the otherhand, physicians may not use it when treating patients (lack of time, computer phobia, and a feeling that it is not user friendly enough). Thus, the advantage may not be realized. The quality of the data in some areas may not be high enough, since it depends on manual entry (e.g. diagnoses). Therefore, the system may be misleading and should be used with care. Over time, patient advocacy organizations may raise objections relating to confidentiality of information, in particular information on psychosocial issues such as psychiatry conditions, domestic violence etc. Easy access to comprehensive information on patient care may be used against Clalit in negligence lawsuits. Finally, the existence of data may encourage malpractice lawsuits, in case of medical errors that could have been prevented by use of this system. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Quality - The system will probably improve patient care at the community and hospital level by increasing continuity of care and reducing medical mistakes that are related to insufficient information on patients. However this is dependent on regular use of the system by physicians, nurses and other providers, as well as on the quality of the data entered. Equity - is expected to improve if information is not dependent on the patient, thus relevant information can be retrieved even when communication with the patient is difficult because of age, language and cultural barriers. Using the system is expected to especially improve their care and therefore increase equity. Cost efficiency - The effect on costs is unclear. Cost savings related to duplications are likely to be achieved. However their extent is unknown and savings related to other aspects of care are not clear. 7. References Sources of Information Personal communication with program officers - 7 -

8 Blondheim Orna. RHIO - from Vision to Reality, to be presented at the Healthcare Information and Management Systems Society, February 2006, San Diego CA. Author/s and/or contributors to this survey Nirel Nurit, Rosen Bruce, Gross Revital Myers-JDC-Brookdale Sherf Michael, Blondheim Orna Clalit Health Services Suggested citation for this online article Nirel Nurit, Rosen Bruce, Gross Revital Myers-JDC-Brookdale Sherf Michael, Blondheim Orna Clalit Health Services. "Hospital-community electronic medical record". Health Policy Monitor, October Available at -