Balancing Supply and Demand of an Electronic Health Record in the Netherlands; Not too open systems for not too open users.

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1 Balancing Supply and Demand of an Electronic Health Record in the Netherlands; Not too open systems for not too open users. Ton AM Spil Christiaan P Katsma University of Twente The Netherlands Abstract About twenty suppliers of Electronic Health Records (EHR) battle for the favor of about hundred hospitals in the Netherlands. The Minister of Health has been promising for over a decade that every citizen in the Netherlands will have an EHR. Until now this promise has not been met. One of the main requirements for this national EHR is an agreed definition of an open EHR by both vendors and users. This paper first studies the demand side using the results of thirty eight interviews with end users asking them their core processes and their expected value of an EHR. Next we have a look at the supply side with an overview of the Dutch market and a focus on open EHR s as possible overall solution. This solution is further elaborated by using the experience with Enterprise Application Integration (EAI) in industry. The contribution of this paper is twofold. First from a combined analysis of our data our main conclusion is the supply of EHR in the Netherlands is not open yet. Only suppliers with a small market share really offer external process integration. Only if the main suppliers are stimulated (by the government) to open up, a national EHR can arise. Secondly from a detailed analysis the following results stand out: A majority of the end users (demand side) do not get support in their relevant working processes. Communication is badly supported and direct patient contact (what they think most important in their work) is even endangered by new systems. Availability, a benefit where all stakeholders agree upon, does not seem to be enough to open the market and create a good diffusion of EHR in the Netherlands. Much more focus should be laid on quality of care and communication with patients and colleagues. 1. Introduction The nearly twenty year old promise of Electronic Healthcare Records solving all major problems in healthcare[1] is renewed by the promise of open EHR to integrate all existing EHR s [2]. The last promise itself seems to be emerging now but has been around for a decade already [3]. Creating an EHR is definitely an evolutionary process [4] which means that professionals that do not use an EHR yet will not easily adopt an advanced open EHR. Adoption of new innovations is highly dependent on the relative advantage that end users perceive in the new product [5]. Delone and Mclean [6] would call this the net benefits of the EHR and Venkatesh et al [7] would call this performance expectancy. In qualitative studies Schuring and Spil use the relevance concept which in their definition is the net value of performance expectancy and effort expectancy [8]. They all agree that the expected value of the system to the end user plays an important role in the adoption and diffusion process. Earl and Sampler [9] conclude that a distinguishing characteristic of IT is that two sides need to be adjusted: both demand and supply. In section 2 this paper starts out with a background on Electronic Health Records. We continue towards open EHR by comparing the developments of Enterprise Application Integration in industry. In section 3 we empirically study the demand side by interviewing thirty eight end users. Its counterpart the supply side is compared in section four by an investigation of twenty suppliers of EHR s. Finally in section 5 and 6 the findings and the analysis are discussed including an exploration of the road toward open EHR /07 $ IEEE 1

2 2. The Electronic Health Record 2.1 EHR background Since 1991 the impact of literature on Electronic Health Record has increased each year[10]. The electronic health record (EHR) is a central component of an integrated health information environment. It is conceived as a distinct service, having its own models and dynamics. There are many names and acronyms for computer-based systems in healthcare, such as Electronic Medical Record, Patient Care Information System, Electronic Care Record, Electronic Health Record, Computer-based Patient Record and Electronic Patient Record. This difference in nomenclature often reflects the different points of view of the authors or refers to different levels in functionality of the system[11]. The most commonly used definition of an EHR is the one from the medical record institute: a computer stored collection of health information about a patient linked by a person identifier [12] Although the term Patient Care Information System best expresses its function, i.e. supporting patient care, the term Electronic Health Record (EHR) will be used in this paper, because it is the most complete term. The definition of an Electronic Health Record that is used in this research is based on the definition of a computer-based patient record of the Institute of Medicine [13]: An Electronic Health Record (EHR) is a patient record that resides in a computer system specifically designed to support care providers by providing accessibility to complete and accurate patient data, medical alerts, reminders, clinical decision support systems, links to medical knowledge and other aids. This means that an EHR is not just an automated version of the paper record in which patient data are stored, but that an EHR is an active system supporting health care professionals in the care process [11] Many solutions have been proposed how to built an EHR[14, 15]. An active component in an EHR will be central to its success[16]. Staroselsky (et al) show that the new breed of Electronic health records have the potential to improve this active component as they can provide decision-support, which has been demonstrated to improve provision of preventive services [17]. EHR implementations often fail because the implied views of medical work do not fit with the real nature of that work [18]. This paper therefore studies the working process of the end users and studies how the suppliers support this and tries to uncover the real nature of medical work by introducing relevance of EHR. 2.2 Open EHR There is need for the reduction of efforts for exchanging electronic patient records or parts of electronic patient records between partners. For this, we could employ open EHR methodology.[19] Although definitions of the EHR vary, open EHR has adopted the following concept of the EHR [2]: An electronic longitudinal collection of personal health information usually based on the individual, entered or accepted by health care providers, which can be distributed over a number of sites or aggregated at a particular source. The information is organized primarily to support continuing, efficient, and quality health care. The record is under the control of the consumer and is stored and transmitted securely. The Ocean group, an open EHR research group in Australia shows five aspects of an open EHR: 1. Patient centered 2. Clinical data 3. Generalist level 4. Sink & Source 5. Accumulator of information It is Patient-centred and most of the time allows patients to access their information on the internet. An open EHR shows Clinical data of three categories [20]):- retrospective - what has occurred; - evaluative - opinions and decisions about what should occur, care plans; - prospective - prescribed actions which should occur. The open EHR will be on a Generalist level, either on local, regional or (inter)national level. It is both a Sink & source, meaning that you can access information but also enter information with the same system. Finally it is an Accumulator of information so it will use many sources and will actively push and pull information. This definition of the open EHR resembles the integration perspective on industrial and commercial 2

3 business information systems. According to Beretta [21] this integration perspective can be divided in two main aspects: First the ability for seamless information integration[22, 23] and secondly the process support along the different nodes in the healthcare chain[24]. This latter aspect is very significant since an open EHR not only is about the transfer of the correct patient information between the different actors in the healthcare chain (the what). It is also about the way in which this information is transferred between these different actors in the chain (the how). It does not come down to the sole unambiguous definition of data, but also what kind of eventual operations across the care process enroll. This business logic is developed to a rather mature level in for example supply chain -and production information systems (e.g automotive and consumer electronics industry) [25]. The development towards an open EHR conceptually then is not new when we take the perspective of business information systems in the last decade. We can learn a lot of the corroborative knowledge that is collected about the rise of such systems and their implementations. In a limited historical overview one can describe three developments in business information systems that are relevant for our research ambition: 1. The transfer from functional towards integrated information systems, realized by the development from Material Requirement Planning (MRP I and II, via Enterprise Resources Planning (ERP) towards Enterprise Systems. Or the adoption of Enterprise Application Integration (EAI) as a system independent alternative to achieve integration. 2. The subsequent transfer from these integrated information systems towards information systems or standards that support entire supply chains or processes over the formal borders of organizations. Examples are Supply Chain Management systems (SCM) [25] or Extended Enterprise Applications (EEA) [26],[27]. 3. The recent development of platform -and technology independent services like web services or Service Oriented Architectures (SOA) for a further support of so called loosely coupled systems in process chains or even business networks [27]. Outside the healthcare domain new developments have increased information integration and process functionality along entire supply chains or business networks. It are especially the developments in 2 and 3 that combine information integration and process support (middle column in Figure 1; based on [25-28]). The right column shows some examples of the application of these concepts to the healthcare specific domain. Based on standards (e.g. HL7), messaging (e.g. CorbaMed) and EAI (only vendor specific) Grimson et all [29] showed some of these concepts in 2000 were operational in the healthcare domain. Nevertheless the integration levels A and B were either supported individually or when integrated only vendor specific [29]. To successfully introduce an open EHR in the healthcare domain both integration levels A and B (figure 1) should be supported simultaneously across entire healthcare chains. In our exploration of the recent Dutch supplier and demand situation we use figure 1 and investigate both the information and process perspective of the offered applications. Analogous with [30] our research ambition is to investigate the specific progress since 2000 in the healthcare domain. Integration level A Information integration across the entire (healthcare) chain B Support for the Process logic across the entire (healthcare) chain Current existing solutions outside the healthcare domain based on [25-28] Business Bus (RosettaNet, CFPR) Business port (Tibco, SAP BC), SCM, EAI, EEA Web Services and SOA s (WSDL, J2EE) Examples in the healthcare domain in 2000 based on Grimson [29] HL7, CorbaMed, HISA Vendor specific solutions in one system (SAP, Peoplesoft, Cerner) Not available Figure 1 open EHR unraveled in two perspectives 3. Expected value of EHR; the demand side In the IT-diffusion literature, relevance was originally defined by Saracevic [31] as a measure of the effectiveness of a contact between a source and a 3

4 destination in a communication process. This is a somewhat abstract wording of what we would call the degree to which the user expects that the IT-system will solve his problems or help to realize his actually relevant goals. We use the word expects since we want to make more explicit that relevance is a factor that is important in the course of the adoption process, not only in evaluation. Many researchers of diffusion have sought to explain differences in diffusion patterns. Venkatesh et al [7] propose a synthesized model of user acceptance, which they call the UTAUT (Unified Theory of Acceptance and Use of Technology). In this model, they propose four constructs that play a significant role as determinants of user acceptance and usage behavior. Of these four, the performance expectancy construct is the strongest predictor of use intention. Chismar and Wiley [32] confirm this in the healthcare industry. Performance expectancy is a concept that evolved over time. It resembles Rogers [5] Relative Advantage, Davis [33] perceived usefulness, Thompsons [34] Job-fit, usefulness and outcome expectations[35]. Schuring & Spil [36] used to call the factor relevance, which is in fact the net value [37] of performance expectancy and effort expectancy. Their USE IT model [8] and specifically the relevance part of it is used to analyze the expected value of EHR for thirty eight end users. The main focus in these interviews was on the Expected Value which is defined as the degree to which IT-use helps to solve the here-and-now problem of the user in his working process [8]. Even if an innovation is valuable for the organization or for the society it might never come to actual use of the innovation, simply because the right moment is never there. Expected Value is a key factor in explaining IT-use[8] in their case studies. The following questions can be used to study this; the complete interview scheme is given in [34]: -Whatishighonyourownagenda? - What have you experienced as most important when treating your last three patients? - Which aspects of your working process you would consider problematic? - By which processes in particular? - What change proposals would get your real support? - How important are these changes in the healthcare chain? - Which aspects of your work you would not want to miss? 4. Expected solutions; the supply side The Supply side of EHR started about twenty years ago from the existing Hospital Information Systems suppliers. Because these systems were administrative, the EHR remained administrative and only financial modules were used by the professionals. About ten years ago the first publications were printed about integrating existing healthcare information systems for medical purposes. The NUCLEUS EAI solutions show that the research problems at that time are still valid in practice these days. Identification and standardization were the most important issues at that time[3]. In practice we find small new suppliers that find a niche market for healthcare integration. Around the millennium definitions and prototypes were created by the OCEAN group in Australia. In six years time they created interoperability within the EHR[2]. A downloadable version is now on their website [2] and the system is well studied [38]. In the meantime a research group in the Netherlands created a CORBA based open EHR for stroke patients (CVA)[39]. The first experiences in PropeR in practice are still limited. Systems Integration had become a research subject in the healthcare environment[29]. The expected value of the supply is difficult to measure. Openness at least is one of the measures that we applied. The use of standards seems to determinate whether the system is open or not. In the EAI this would mean information integration. Process support and human computer interaction are the two important values from an end user perspective. Many more values can be shown but this paper focuses on the EAI perspective. 5. Real value of EHR 5.1 Method demand side Thirty eight (possible) end users of EHR s were interviewed about their process and the expected value of an EHR in their own situation. The USE IT interview model was used that is documented by Spil and Schuring [8]. The interviews took place in eleven different hospitals (10% of the total in the Netherlands, see appendix) and tool more than one hour each. The professionals were deliberately taken from thirteen different disciplines (see appendix) because homogeneous groups of the end users were 4

5 very difficult to construct. Not only medical specialists were interviewed but also other end users like documented in the appendix. There was a big difference between the results for the physicians and the other users which will be reported in another paper. In this paper we focus on the main end users, the physicians. 5.2 Results demand side In a former study [40] we could see five factors which the end-users find relevant for an EHR: 1. Availability 2. Less administrative work (letters, search activities and redundancy) 3. Analyses (information for research and information for management) 4. Uniformity of working processes 5. Reliability In this study we can elaborate on this because we have a much broader range of empirical data. On one hand we support the results above by showing some quotes from the new interviews. On the other hand we add five new factors that were all given by the main end users, the physicians. Availability is mentioned in most interviews from the other users (see appendix A) as an important value of an EHR. Especially in hospitals with more locations the availability was an important issue. Sometimes availability at home was stated. A couple of physicians said: we can better prepare for consults. The availability during clinical visits was still a problem. Some suggested mobile solutions for that. Many said: access anywhere anytime. Only six out of twenty two physicians thought this to be relevant to their working process. Some physicians actually decreased their secretary staff and many thought it might be possible later to do so. During consult some more time was spend but in the processing of the data merely administrative time was gained. One physician actually said we got a happier administration now after implementing an EHR. Only three more doctors mention this to be a value of the EHR. The rest of the value comes from the other users. An EHR makes it possible to analyze data on a higher level and a uniform working method. With analyses is meant that it is possible to create management information and information for research. This gives the professional information for his or her medical research but what is more important it can deliver research data for medical research on (inter) national level. Then again one of the doctors was very negative about uniformity and expressed himself as follows: writing in an EHR is like writing your own verdict. Another doctor agreed with him. She said: every patient is different. Reliability can sometimes be seen as the opposite of availability. The latter one seems to be more important to the end users. Moreover for the physicians because none of the twenty two doctors mention reliability as relevant for the upcoming EHR. Maybe they assume that it just is reliable. In some interviews we specifically asked what they favored and in both interviews the doctors were in favor of availability. If we only look from the physician s point of view we have to add five more factors above the factors mentioned in this section and in the earlier study: 1. Direct contact with the patient 2. Quality of care 3. Collaboration with colleagues 4. Time 5. Just being a good doctor The contact with the patient was mentioned as most important in the working process and often also as something the physician could not do without. One of the doctors explicitly showed his concern about the computer getting in between. We expected quality of care as a main factor in our previous study but since we focused on several stakeholders of EHR this factor did not show. In this study seven of the twenty two doctors specifically start out the relevance part of the interview with stating that good care or the quality of care is most relevant to their working process. One even said that although it will cost production, the quality of care will make the introduction of EHR all right. Communication with colleagues inside and outside the healthcare institute was found to be important by seven of the twenty two physicians. One physician recalls an extreme situation when he gets a patient referred with a cutted wrist without some forewarning. Another physician says: we hardly have time to communicate. 5

6 That brings us to the next factor time which is mentioned in many disguises but most of the time as we just do not have time. Some think that paper offers a quicker working process. Although an EHR is supposed to shorten consulting time, which it is not confirmed to do in this study, one of the physicians makes a plea for longer consulting time. This would be in line with the importance of direct contact with the patient. Finally six physicians spontaneously state that they: just want to be a good doctor. The organization does not always help them according to the sighs during the interviews about the bureaucracy Method Supply side Eight of the twelve suppliers (see table 1) were studied by the authors in three ways. 2Cure, a EHR supplier is not in the table because it merged with Chipsoft. Curamé and Cegeka were left out because they had less than 3% of the market share. First all documentation was studied. Then demos were given and finally a discussion between one of the authors and the supplier was held. Because more than 12% of the market developed a system itself, one indoor application was studied (Intrazis) and the documentation of CSC, DBmotion and I MED ONE was studied. Finally more in general the research activities in the open EHR arena were studied and for each supplier the open readiness was explored Results supply side The Dutch healthcare market is small (about hundred hospitals) and the number of suppliers of EHR s is large (about twenty suppliers). But nearly sixty percent of the market is in the hands of two suppliers, Isoft, market leader, especially in Academic Hospitals and Chipsoft, quickly becoming market leader in the General Hospitals. The other 40% of the market is divided by at least 18 suppliers. At two conferences of the Dutch Association of Medical Administration document challenges were held, first in general and the second conference specifically for a given case. All suppliers claim to have an open system but this is not the case if we consider the definition given in section 2. Most of the systems are best used together with a hospital information system from the same supplier. From that group closed systems, Chipsoft had a good score in the documentation challenge. From the more open systems, NORMA was chosen as a good option. Only DBMotion can be considered as an open system but little is known yet about this supplier in the Netherlands. In section 6 we will explore the last category. Supplier Package Information Isoft Mirador 1 Chipsoft Various SAP McKesson MI Consultancy CS-patient & carecenter e.g. Intrazis, Zouga IS-H*MED X/Care module HER Norma 2000 integration towards other systems Dedicated interface. Needs customization Dedicated interface. Needs customization (based on Hl7v3) In general dedicated interface Connectivity module (customization necessary for external systems other than SAP) Partly possible (raw data transfer, no standards), but mainly focused on own Horizon EHR standard Dedicated interface Proces logic support towards other systems share 2003 [38] share 2006 Market Market Indicatio Na 2 37% <37% Dedicated interfaceprotocols, need customization n 18% >21% Probably Na 12% >12% Connectivity module (customization necessary for external systems other than SAP) Passport and horizon but not visible in techniques. 5% 5% 3% 3% Na 3% >3% Table 1 condensed results of the analysis the five largest Dutch EHR Suppliers and one indoor application [41]. The only supplier giving decision support as process support was Curamé. Chipsoft had a good fit with the patient logistics and MI consultancy offered much freedom in design. In general the process support is 1 Interview is based on Mirador Isoft recently introduced Lorenzo as new healthcare information Mgt system 2 Na: Not availlable 6

7 rather disappointing. The system is much more a descriptive system rather than a prescriptive system. Finally, the human computer interaction was valued by studying the input and the output of the EHR s. Most of the suppliers concentrated on the letter as main output. This seems to be a bit limited scope but the case kind of forced them that way. The input gave many possibilities but all of them rather timeconsuming. The user interface resembled a spreadsheet in most of the EHR packages. Other EHR suppliers are: Curamé, Cegeka, CSC, ITB, IBM, VCD, Medlook, Coparec, Mozas, LifeLine, ESP, Midline, Philips and Siemens. In the appendix a list of hospitals with own development is given. In several regions in the Netherlands (Leiden, Utrecht and Twente) initiatives are taken to start working on a regional EHR. Per definition this cannot be a closed system. 6. Analysis In this section we take the two distinctions that we used so far together to analyze the open readiness of both EHR demand and EHR supply. Table 2 summarizes the main results and we analyze them from one to four. Information Integration Demand 1. Communication Availability Time Supply 2. Current state Table 2 Analysis model Process Integration 3. Quality of care Patient contact Being a good doctor 4. Not available Spil (et al) [40] showed that availability was the most relevant factor in hospitals that already implemented an EHR. Many Dutch professionals in healthcare do not use any form of electronic health record. The net benefits of existing EHR s do not seem enough to convince the end user to adopt the innovation. Next to that the business value of EHR is not proven yet. Administrative time can be won but consultation time cannot be won. One way or the other, Time will play an important role in the diffusion of the EHR. The results of this study show that the EHR can save time and effort because it results in less administrative work. It can be realized because there is less searching for data, data does not have to be entered several times and letters can be generated easier. The first reason occurs because the access of the data is better. There has to be made difference between who can save time and effort. A secretary or medical doctor s receptionist can save more time and effort with an EHR than a medical specialist can. The first period after the implementation, so called shakedown phase the medical specialists have to insert all the data, this takes time. There is also more time necessary during a consultation. The specialists say that they can return to the old consultation length after half a year till a year. And after the shakedown phase the medical specialist say they save time and effort. But there were no measurements on the necessary time during consultation. In an article from Mitchell and Sullivan [42], they conclude that in five from the six cases the consultation length was increased by seconds. Finally communication with colleagues is found very important by the professionals but most of this communication takes place by phone, fax and paper letters. The latter ones were presented as main output of the EHR at the recent Dutch conference showing the bad current situation. Research on open EHR evolved for about one decade but the externalization of knowledge does not yet take place. There is a big gap between research and practice. In the Netherlands two research groups have studied open EHR but until now that did not go beyond a pilot in practice. The Ocean group has a first version on the internet but this will not directly be applicable in the Netherlands. All suppliers in the Netherlands show a willingness to create or have created the information integration already. In most of the cases it works if the EHR supplier is also the HIS supplier. Only a big quality of care push can convince the end user. Some of the interviewees even state that quality of care may cost production and therefore money. Motivation by paying proper input of data might also help diffusion of EHR but intrinsic motivation by supporting the patient contact and the quality of the working process (just being a good doctor) would be much better. Open EHR might be able to create just that because third parties might be interested to pay for research information that the doctors will have to deliver. This will close the 7

8 business cycle. On the other hand can open EHR also improve communication and off course quality of care. Also information to the patient will be easier to give. None of the market leaders seems able to open up to create a regional or national EHR. This means that relative new players in the market would have to take care of the integration of existing and non-existing patient records. Although backed up by large international organizations the risk of such an enterprise seems high. Another possibility would be web-based systems that arise from groups of patients (like CVA and Diabetes) or suppliers like Medlook where the patient can create his or her own medical record on the internet. This last group of systems is out of the scope of this study. Two other developments might influence the diffusion of EHR in the Netherlands. One development is a big project from the government to build an architecture for EHR in the Netherlands (AORTA). The identification and standardization problems are handled in this project. Another project is the medication information project. Healthcare insurance companies already have the information available about all medicines delivered to the patients. Making the medication data available to all physicians might pave the way for the EHR. Both projects are again beyond the scope of this study but could not go unmentioned. It is astonishing to see that the medical sector that is substantially under pressure apparently does not obtain what it deserves. In 2000 Grimson et all [29] showed the main deficiencies of open EHR already. At that time they showed the possibilities of BPR and EAI and expected a substantial improvement of web technology. Our review shows that suppliers fail to deliver the necessary solutions that can support healthcare professionals individually as well as institutions. The argument of new technology does not count anymore with plenty practical examples of comparable solutions available in business information systems outside the healthcare domain. At a time in which web services and SOA are ready to enter the arena, the healthcare specific suppliers still struggle with integration aspects. 7. Conclusions The availability of information is the expected value of an EHR that is agreed upon by all end users. The question is whether this is enough to start such big changes in healthcare. We conclude therefore that from the physician point of view the electronic patient record is not very relevant. From administrative point of view it is very relevant if we consider time and effort. We therefore think the physician should be rewarded more for using the EHR. At this moment EHR suppliers fail to show the value of an EHR. Many professionals state that the welfare of the patient, communication with colleagues and the quality of care are the most important aspect of their working process. An EHR could make a big improvement on these aspects but at the moment only reaches availability and administrative values. A more open regional and national approach toward EHR might make a breakthrough in the early majority of users that is badly needed. The supply of EHR in the Netherlands is not open yet. It is not following research like Proper and Ocean and is not following the developments of EAI in industry. Only suppliers with a small market share really offer external process integration. Only if the main suppliers are stimulated (by government and by customers) to open up, a national EHR can arise. The end users (demand side) do not get support in their relevant working processes. Much more focus should be laid on quality of care and communication with patients and colleagues. 10. References 1. Ellingson, G. and E. Monteiro, Big is beautiful: Electronic Patient Records in Large Norwegian Hospitals. Methods of Information in Medicine, (4): p Beale, T., et al. Open EHR [cited 2005; Available from: 3. Kilsdonk, A.C.M., B. Frandji, and A. van der Werff, The NUCLEUS integrated electronic patient Dossier breakthrough and concepts of an open solution. International Journal of Bio-Medical Computing, (1-2): p DeWar, C., Bring the EHR to life. Nursing Management, 2006(January): p Rogers, E.M., Diffusions of innovations. 1995, New York: The Free Press. 6. DeLone, W.H. and E.R. McLean, The DeLone and McLean Model of Information 8

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