Running head: WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 1

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1 Running head: WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 1 What can Canada learn from New Zealand, Denmark and the United Kingdom about Electronic Health Record (EHR) adoption? Increasing adoption, health system benefits, and the transformation of patient care. 25 February 2012 Kevin Grant, B.Sc., M.A. kevin@smartairmedia.com Profile: Phone: Summary: Career and Education Summary

2 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 2 Table of Contents Table of Contents... 2 Introduction: Canada s Current EHR Landscape... 3 An Introduction to the pan-canadian EHR... 3 International EHR Examples... 5 United Kingdom EHR... 5 New Zealand EHR... 5 Denmark EHR... 6 An Overview of EHR Adoption Success Factors... 6 Socio-Technological... 7 Setting Realistic Expectations... 7 Building Stakeholder Consensus... 8 Implementation Should Be An Iterative Process... 8 Sensitivity to Regional Needs Keeps Things On Track... 9 Allow Teams To Adjust... 9 Standardization... 9 Flexible and Standards-Based Widely Available Network Standardization of Terminology Interoperability EHRs Are Powerful Only If Information Can Be Freely Exchanged Make EHR Available in All Health Care Settings Single Consumer Health Identifier Take Full Advantage of Electronic Messaging in the EMR Remove Technology Barriers Introducing Computer Technology Early and Keep the Technology Cost Effective Remove Hardware and Connection Barriers Monitored and Highly Compliant System Certification of Vendor Systems Incentives Provide Financial Incentives Mandating Doctors to Use EHR With Education Privacy Security and Privacy Protection that is Policed and Audited Pubic Access to EHR Conclusion Canada s Success Factor Report Card References Appendix A- Factors Involved in Successful EHR Implementations... 32

3 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 3 Introduction: Canada s Current EHR Landscape Health information technology (HIT) and more specific Electronic Health Record (EHR) technology have become burdened with the expectations that these tools can improve the quality, safety, and efficiency of health care. The benefits of EHR systems include real-time decision support for health care providers through the delivery of immediate, accurate, and detailed clinical information. Frequently EHR are viewed as providing financial benefits (Ashish et al., 2008; Alvarez, 2004; Brown et al., 2008). Canada has formed an organization called Infoway whose mandate is to foster the development of the pan-canadian Electronic Health Record [system] [and] is mandated to promote leading practices and raise awareness about patient safety. (Brown et al. 2008, p. 116). Infoway has consistently reported that there is a lot of work to be done to maximize the patient safety benefits and to create an EHR system that interoperates effectively across Canada (Alvarez, 2004; Ashish et al., 2008). Infoway s pan-canadian EHR is fundamentally about improving the flow of information between different care settings by giving primary care professionals and patients the right information at the right time in the right place (Brown, 2008). This paper identifies the success factors that drive EHR adoption. The lessons learned from Denmark, the United Kingdom, and New Zealand will be drawn upon as well as research studies published in health care and health informatics peer-reviewed journal literature. An Introduction to the pan-canadian EHR Canada recently launched a public marketing and communications campaign for Infoway, the organization behind Canada s pan-canadian EHR. The media campaign in 2012

4 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 4 includes television advertising, media communication, and Internet resources (e.g. The four marketing messages for the campaign are: Improve the quality of care patients receive in Canada. Provide health care providers with access to the most accurate and complete information possible when treating a patient. Maintain a sustainable health care system for years to come. Governments are working together toward a commitment to connecting each point of care in your community, and eventually across the country through the development of EHRs. So no matter where you are in Canada, you will receive a better quality of care. The following are the benefits of the pan-canadian EHR are communicated by Infoway: Improved treatment in an emergency o Having instant access to a patient's health information will reduce the chance of misdiagnosis and possible unforeseen complications in an emergency situation. Better management for chronic conditions o For Canadians living with chronic illnesses, EHRs can make monitoring day-to-day risk factors much easier for patients and physicians. Shortened wait times o Adopting EHRs will help patients take advantage of cancelled appointments and create shorter wait times. Reduced duplicate tests o With an EHR system in place, redundancy in medical testing will be reduced. Better diagnosis & treatment o EHRs can help Canadians receive better diagnoses because they will paint a more comprehensive picture of a patient's health history. Increased access for remote areas o Having EHRs in place will help improve and make advanced health care even more accessible to people who live in remote areas. Canada has just begun implementing a pan-canadian EHR and has an opportunity to apply the leanings from other successful International EHR implementations. In true Canadian style, a measured and cautious approach has been taken to evaluate other EHR systems with high success factors. The goal has been to bring uniquely Canadian insights to the problem of solving the EHR implementation in Canada (Maloney, 2008; Brown et al., 2008).

5 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 5 International EHR Examples There are many International examples of countries that have made significant progress creating the infrastructure that forms the backbone of a successful EHR. Europe has many working examples and has a track record of success and leadership. This paper will examine Denmark and the United Kingdom (UK) as two European examples. New Zealand is the poster child of a sophisticated, elegant, fully interoperable, and widely available EHR. United Kingdom EHR The UK government s National Programme for Information Technology, NHS Connecting for Health (NHS CFH) is deploying a range of IT initiatives including the NHS (National Health Service) CRS the UK s EHR. The NHS CRS works at arms-length to the UK Department of Health and have been plagued with contractual problems, cost overruns, delays, negative publicity, and critical views from health care professionals in the UK (Cresswell, 2009). The UK can be viewed as a less than perfect implementation of an EHR. From the UK s mistakes come a variety of important learnings that Canada seems to be learneding from. On the positive side, the UK has a very high level of adoption amongst physicians that is unrivalled internationally. The factors involved in this adoption rate are a long history of computerization and financial incentives from the National Health Service that encouraged health care providers to use EHR systems for decision support (Ashisha et al., 2008). New Zealand EHR More than 80% of New Zealand s physicians use EMR systems for their clinical records and New Zealand has the highest level of EMR functionality when recently surveyed (Protti et al., 2008).

6 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 6 New Zealand s government played an important role in the high adoption rates of their EHR. In New Zealand, doctors were required by law to submit claims and capture other data electronically. This mandated approach succeeded because the New Zealand government also invested in education to reinforce the advantages and safety improvements their EHR would bring to their health care system (Ashisha et al., 2008). Denmark EHR Denmark s physicians almost universally use EHR to capture their clinical notes and their health care system is one of the most paper-light countries in the world (Protti et al., 2008). Their national EHR network is used by over three-quarters of the New Zealand health care community and spans over five thousand organizations. An Overview of EHR Adoption Success Factors Appendix A summarizes the lessons learned from Denmark, New Zealand, the U.K., and other nations. Each of the lessons learned will be discussed in more detail and the findings are related to how Canada can apply these lessons to improve the adoption of their evolving EHR. The following categories of lessons learned were abstracted from the literature: Socio-Technological o Setting Realistic Expectations o Building Stakeholder Consensus o Implementation Should Be An Iterative Process o Sensitivity to Regional Needs Keeps Things On Track o Allow Teams to Adjust Standardization o Flexible and Standards-Based Widely Available Network o Standardization of Terminology Interoperability o EHRs Are Powerful Only If Information Can Be Freely Exchanged o Make EHR Available in All Health Care Settings o Single Consumer Health Identifier o Take Full Advantage of Electronic Messaging in the EMR Remove Technology Barriers

7 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 7 o Introducing Computer Technology Early and Keep the Technology Cost Effective o Remove Hardware and Connection Barriers o Monitored and Highly Compliant System o Certification of Vendor Systems Incentives o Provide Financial Incentives o Mandating Doctors to Use EHR With Education Privacy o Security and Privacy Protection that is Policed and Audited Pubic Access to EHR Socio-Technological Socio-technological factors are the impacts of technology on people and organizations and their subsequent reaction to technological change. Canada has already learned from International examples of EHR systems with respect to socio-technological issues: Canada has a strong regional awareness and has not attempted to implement a topdown one EHR for the entire country (this failed in the UK). Canada s Infoway defined a clear scope for the project and spent considerable time reaching consensus on the objectives, goals, mandates, and policies for the pan-canadian EHR. Infoway used an iterative approach to developing the plan and recently began actively promote the vision to the public to ensure success. Canadian health care teams are being given time to adjust to new systems through pilot implementations, and a phased approach to EHR rollout. Addressing socio-technological factors is extremely important for the successful adoption on an EHR. The UK is an example of how socio-technological factors were ignored at the cost of EHR success. Denmark and New Zealand highlight examples of EHRs that successfully navigated the tricky socio-technological factors. Setting Realistic Expectations The UK has been plagued with contractual problems, cost overruns, delays, negative publicity, and negative views from health care processionals. Expectations were set very high and the complexity, scale, and aggressiveness of the EHR project in the UK. The project was

8 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 8 plagued with multiple socio-technological problems resulting from unrealistic expectations of what the EHR can and should accomplish. Many commentators such as Cresswell and colleagues (2009) have argued that if the expectations were lowered considerably, in the medium-term, there would be more honesty and transparency surrounding project issues. Open dialogue and honesty provides teams with information that can help them solve and overcome problems more efficiently. Building Stakeholder Consensus Cultural change has the greatest chance of success when users can be meaningfully engaged in the design, development, and considerations. Resistance to change has been observed as a threat to the success of the British EHR. Stakeholder consensus disconnects have been blamed for this problem (Cresswell & Sheikh, 2009; Hudson, 2006). Research has shown that top-down implementations can contribute to increased user resistance and are more risky. Small, locally implemented projects that work from the bottom-up often result in more user acceptance and smoother launches (Cresswell & Sheikh, 2009). Change that is incremental, gradual, and negotiated is more effective because it is easier for the end users to accept. If a system is imposed, then end users often develop workarounds to avoid using the system, or only use the parts of the system that are useful to them (Hudson, 2006). Implementation Should Be An Iterative Process The UK has suffered through a very linear approach to implementation that has not actively involved stakeholders in an iterative way. The British have learned that planning and implementation should be iterative. Implementation remains flexible if stakeholders are engaged

9 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 9 frequently. This allows the EHR to be more adaptable to change and more responsive to improvements (Cresswell & Sheikh, 2009; Hudson, 2006; Schade et al., 2006). Sensitivity to Regional Needs Keeps Things On Track The UK s EHR has experienced mission creep that has distracted policy-makers from a focus on the project goals. Many have argued that the overall plan for a national EHR has been derailed because the project overlooked the needs of individual regions. The initial plan was to link together regional systems and this was later changed to a national system that was not sensitive or responsive to local needs (Hudson, 2006). Overlooking local needs resulted in a lack of public and professional belief in the EHR project (Cresswell & Sheikh, 2009). EHRs are used by people and without the support of the end users EHR systems can quickly become laborious, difficult to maintain, and poorly functioning systems. Allow Teams To Adjust The UK EHR was implemented from the top-down and is commonly perceived as being imposed by government. The UK subsequently adapted the approach through soft launches in certain health care department. This allowed teams to adjust to the new technology and workflow (Cresswell & Sheikh, 2009). Health care professionals and organizations were given more time to adapt to the new technology. End user perception improved because they were consulted and felt listened to. Standardization Canada s Infoway has a bold commitment to EHR interoperability across disparate health information systems. Canada has policies that ensure information can be shared and synchronized while maintaining the integrity and security of the information exchanged. The

10 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 10 pan-canadian Standards Collaborative establishes standards that build the foundations for interoperability and best of breed EHR solutions (Infoway, 2011). Canada adapted International standards and did not set strict limits on these standards, offering the broadest standards support of any nation. Examples of the supported standards in the pan-canadian EHR include: IHTSDO (SNOMED CT) HL7 International (HL7) Regenstrief Institute (LOINC) NEMA/MITA (DICOM) Integrating the Healthcare Enterprise (IHE Profiles) ISO (ISO/TC215 Health informatics) All successful global EHR projects standardized from the beginning and made their network extremely flexible so systems of all kinds could easily talk to one another. Flexible and Standards-Based Widely Available Network All New Zealand s primary care providers, midwives, all hospitals, all radiology providers, and pathology laboratories, and most specialists use Health Level Seven (HL7) messaging standards to communicate over a virtual private network (VPN). New Zealand has become a world authority on HL7 EMR interoperability. Their full commitment to one standard that is applied consistently and widely has lead to a highly interoperable and efficient. Denmark focused on very high levels of connectivity with simple system setup to reduced barriers to adoption. Denmark chose EDIFACT for their communication standard in the 1990s and then in 2001 converted to XML standards, which are true global open standards. They rejected HL7 standards because there were few systems in Denmark that could communicate in HL7 standards at that time (Protti et al., 2008).

11 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 11 Standardization of Terminology New Zealand is a charter member of the International Health Terminology Standards Development Organization and has purchased and developed the SNOMED coding terminology. Through standardized terminology and coding standards, information in the EHR can be input so that it is readable and can be freely exchanged between EHR systems. Denmark uses the International Classification of Primary Care standardized terminology to record and code each patient encounter. This is an older system and it makes it harder for the Danes to compare their data to other countries who use newer classification standards. The new coding systems such as ICD-10 are much more structured and detailed with more modern classification schemes that are more EHR-friendly. The Danes are transitioning to the SNOMED coding terminology and have a plan in place to make the transition (Protti et al., 2008). New Zealand was using the International Classification of Disease (ICD) coding system and is in the middle of transitioning to the SNOMED CT classification system brining them on par with other countries (Protti et al., 2008). Interoperability Futurescan is an annual guide to healthcare trends and is written by an expert panel of well-known healthcare leaders and supported by data from survey responses from more than 1,600 healthcare leaders. The experts agreed that the power of EHR rests in their ability to integrate the "record" of a patient's health experience with the clinicians and institutions that provide care. The power of EHR systems resides in the ability of these tools to interactively support and streamline the care delivery process (SHSMD, 2007). One of the main ways that EHR systems become powerful is through interoperability. Interoperability results in freely available access to information across systems. Canada s EHR

12 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 12 (Infoway) C.E.O., Richard Alvarez (2004) agrees that interoperability through national EHR standards is essential for Canada. The ability of systems and health care practitioners to be able to talk to each other from many points of care in a coherent way, then we have consistent data and technology standards. [Canada s EHR s] role is to champion the development and implementation of those standards. (Alvarez, 2004, p.56). Canada s Infoway has already made great strides in standards-based interoperability and has applied many of the interoperability lessons learned from other nations. Infoway continues to invest in standards-based EHR solutions (Infoway, 2011). The standards continue to evolve and the following EHR standards are currently under development in Canada: Client Registry Standards Provider Registry Standards Laboratory Standards Diagnostic Imaging Standards Drug Standards Interoperable EHR Standards Public Health Surveillance Standards National e-claims Standards Transport Level Interoperability Standards Security Standards EHRs Are Powerful Only If Information Can Be Freely Exchanged Interoperability is of great concern to health care experts globally for very solid reasons. New Zealand is an example of a country that has true data interoperability. GPs can automatically download pathology and imaging reports from a variety of public and private diagnostic providers (Ashish et al., 2008). In addition, New Zealand offers an electronic immunization registry that is integrated with their EHR (Burke et al., 2010). Interoperability is also about ubiquitous availability of the EHR in all health care settings. If a setting does not have and EHR it cannot interoperate with other settings that have EHR

13 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 13 systems. This is common problem when EHR systems are being rolled-out across a country and can pose a real deterrent to adoption. Careful planning is required to rollout EHR systems quickly with interconnectivity as a priority. Without ubiquitous interoperability, EHR adoption becomes siloed. Make EHR Available in All Health Care Settings Global research has show that it is common for inpatient care to often have no access to EHR information because EHRs are not widely used in hospital settings (Ashish et. al., 2008). Hospitals adopt EHR systems more slowly. Ashish and colleagues (2008) found almost no highquality reliable data on EHR use in acute care settings and they confirmed a lack of systematic information about EHR use in this critical sector of health care across 7 nations (US, UK, New Zealand, Australia, Netherlands, Germany, Canada). In Canada, poor underlying levels of EHR use in primary care and hospital settings has hindered widespread EHR interoperability in Canada. Alberta and Newfoundland are in the process of implementing province-wide programs to allow data sharing across hospitals, clinical laboratories, and physician s offices (Manoney, 2008; Gudbranson, 2006; Infoway, 3007). Hospital and health system leadership in Canada will be needed to make this a reality Single Consumer Health Identifier New Zealand has a distinct advantage with a strict adherence to standards linked to a single consumer health identifier. This ensures data can always be exchanged between all EHR systems across the country (Ashish et al., 2008). In database terms, the identifier acts as the primary key so patient EHR data can be safely and reliably exchanged in such a way that the systems know they have exactly the right information for the correct individual.

14 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 14 Canada s provincial health care systems should standardize on a single way of identifying a person across regional EHR system. New Zealand introduced a universal health identifier from the beginning and this has greatly simplified EHR interoperability. Take Full Advantage of Electronic Messaging in the EMR The Danish have taken full advantage of electronic message transfers for lab results, lab requests, discharge summaries, referrals, and all other forms of electronic documents. Denmark s network enables health care professionals to securely retrieve messages at any time. New Zealand and Denmark both use secure virtual private networks (VPNs) for connectivity (Burke et al., 2010). VPNs have the advantage of being private, easy to setup, and easy to use with a broad range of hardware and software. New Zealand s electronic EHR messages are automatically filed and organized into the electronic health record for the relevant patients. Auditing, privacy, and accountability are built into the EHR with all messages being subject to acknowledgement prior to the transfer data. New Zealand s general practitioners typical exchange clinical messages with between 50 to 60 organizations (Protti et al., 2008). Remove Technology Barriers Canada does not have a clear direction on how to remove technology barriers to adoption at this time. It is not clear whether Infoway has a strategy to address this issue (Canadian Home Care Association, 2008). There is little evidence in the literature of activity to address this issue in Canada. Removing technology barriers is a key contributor to EHR success. Introducing Computer Technology Early and Keep the Technology Cost Effective The UK s EHR was introduced early and has a long history of computerization. The UK kept hardware costs low by ensuring that hardware requirements were always reasonable and

15 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 15 cost-effective. The cost of computer technology in hospitals and general practitioner settings has been found to be a significant barrier to adoption. If costs are kept reasonable, then adoption will be significantly higher (Ashish et al., 2008; Schade et al., 2006). Remove Hardware and Connection Barriers Physicians in the UK use a broad range hardware that connects to a common EHR platform. This helped to keep hardware costs low and removed the technology barrier to adoption. New hardware did not always have to be purchased and existing network connections could often be used (Huston, 2006; Schade et al., 2006). Monitored and Highly Compliant System Denmark has a highly controlled compliance-based process for installing and monitoring systems and networks. Systems are regularly monitored for compliance through a centralized system (coordinated by a company called MedCom). Patterned system solutions are tested, standardized, and implemented in a controlled way to ensure reliability, interoperability, security, and lower cost of maintenance (Protti et al., 2008). New Zealand took a similar approach to Denmark and created the New Zealand Health Information Standards Organization (HISO) whose mandate is to define EHR standards. The HISO works with vendors and their customers create standards for specific projects and new EHR services (Shield et al., 2010). Certification of Vendor Systems MedCom certifies all supplier systems in Denmark since Certification is free and the certification process is an opportunity to provide advice, feedback, and education to the end users and organizations implementing the systems. Certification takes one week and the office is visited to run tests and check the communications protocols. Privacy issues can be addressed on

16 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 16 location and systems can be upgraded to newer software that is more secure and safer to use (Protti et al., 2008). In New Zealand an organization called HealthLink has an interoperability-testing laboratory and tests and accredits vendor systems. New Zealand offers broad support for more diverse systems than is typical globally and HealthLink continually tests new systems and accrediting (Protti et al., 2008). Incentives Canada has not invested in incentive programs or offered pay-for-performance incentives that have worked well in the U.K. and in some U.S. markets (Ashish, 2008). International research has show that EHR systems often fail to be adopted in hospitals because they are expensive and disruptive in hospital settings. Without clear incentives, hospitals often see little choice but to continue without EHR systems. Canada could leverage the momentum of incenting hospitals to adopt EHR technology because hospitals reach out into the community and hospitals have a snowball effect on EHR rollout (Jha et al., 2005). When hospital outpatient facilities begin using EHR there has typically been a growth in EHR adoption from physicians, labs, health care suppliers, and other hospitals. Provide Financial Incentives The UK s National Health Service approached the incentive issue from a financial angle by directly offering financial incentives to encourage health care providers to use EHR systems for decision support (Ashish et al., 2008). This approach was very successful in the UK.

17 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 17 Mandating Doctors to Use EHR With Education New Zealand required health care professionals to use their EHR system and backed-up these mandates with end user education that helped physicians and health care workers understand the advantages of moving the entire country onto the EHR. Canada s EHR (Infoway) C.E.O., Richard Alvarez (2004), has gone on the public record stating that physician involvement is a key to the ability of Canada to fulfill it s EHR mandate. Alvarez statements are diplomatic and cautious and there is no talk of mandating physicians to use the EHR. There is little attention given to education of health care professionals about the advantages and strengths of a pan-canadian EHR. Canada needs clearer direction and policy around the issue of incentives. Privacy Canada began early with their investigation of privacy and security issues and an Electronic Health Record Infostructure (EHRi) architecture was defined in 2005 (Infoway, 2005) in combination with Infoway s Privacy Mandate. Canada Health Infoway s privacy mandate is to incorporate the protection of personal health information in its activities in accordance with applicable Canadian laws and privacy principles (Infoway, 2012). The privacy strategy and legislation is evolving in Canada and the provinces and territories are responsible for health care delivery, privacy legislation and electronic health records (EHR) solutions within their own geographical areas. Each of these elements is currently at a different point in the development and implementation process. Legislation, policy, and security technology are all in flux as this process is undertaken. Best practices learned across the country are being consolidated through The Privacy Forum established in The Forum includes representatives from each federal, provincial,

18 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 18 territorial Ministry of Health and privacy oversight body. The Forum s objective is to share and leverage their collective knowledge and experience on privacy matters in the development of interoperable EHR. Canada has not always looked for International advice and insights regarding privacy issues. Canadians often consider their privacy policies to be strict and in many ways better than other International examples. This could be seen as a weakness of the Canadian approach to privacy. Denmark and New Zealand offer many innovative ideas about privacy that Canada could learn from. Security and Privacy Protection that is Policed and Audited The Danish Act on Processing of Personal Data implements the European Union Directive 95/46/EC that addresses the protection of individuals with respect to processing personal data and how freely that data can be moved from system to system. Audits and investigations are possible when required and the Danish Data Protection Agency conducts these investigations in an effort to protect people s privacy. Danish law forbids the interconnection of IT systems across sectors (e.g. taxation and health) (Protti et al., 2008). New Zealand s privacy code (since 1993) is widely understood and consistently enforced. Widespread awareness of the privacy laws has kept privacy concerns in people s minds. Their privacy code limits the reuse of personally identifiable information and there are mandated approvals required to obtain and share personally identifiable health information. New Zealand s clear and well-defined health care privacy code has made it straightforward to develop and support EHR systems. This is one of the most important reasons why New Zealand has been able to innovate and excel in their EHR implementation when compared to other countries (Protti et al., 2008).

19 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 19 Pubic Access to EHR Canada has no plans to offer a public portal for individuals to manage their health care information. The Canadian model is too new for this type of evolution. Public access to health care information is tricky and evolves as an EHR matures. Public access is a costly service to offer, has many privacy issues, and is disruptive to the health care profession within the country. Public access to health care information changes the way health care is viewed by the end user and health care professionals. A shift in paradigm within the country is required to evolve in this direction. Denmark and Israel both have public portals that allow end users to manage their health care online. Denmark has created a national health portal in 2005 to provide information about the Danish National Health Service to its citizens and patients. The portal has evolved into a centralized hub of electronic communication between patients and the health service. Over 800,000 Danes have applied for access to the national health portal. Citizens can also view the history of who has viewed their EHR (Protti et al., 2008). New Zealand has planned to offer centralized regional portals, however, they are exploring a GP as steward model where patients can view their medical records and consult with their GPs from their home computers using and web-based tools (Protti et al., 2008). Public involvement, public transparency, and public access are important for the longterm support of the EHR. Public health care portals empower end users with information that helps them understand the importance of the EHR. When end users understand and appreciate the value of the EHR then the level of acceptance and integration increases.

20 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 20 Conclusion The paper will be concluded by offering a letter grade for each of the factors implicated in the successful adoption on an EHR. The end result is a grade that represents how successful Canada is likely to be in building a widely accepted and widely adopted EHR based on the literature review. See the table below for the grades assigned to Canada by the authors. The final report grade assigned to Canada is a B+. Canada is definitely on the right path to achieving a successful pan-canadian EHR. It is recommended that Canada invest more time and energy to reduce the barriers to technology and offer incentives for EHR adoption.

21 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 21 Canada s Success Factor Report Card Type of Success Factor Success Factor Grade Based on Literature Review Socio-Technological Setting Realistic Expectations A Building Stakeholder Consensus B+ Implementation Should Be An Iterative Process A+ Sensitivity to Regional Needs Keeps Things On Track A+ Allow Teams to Adjust B+ Socio-Technology Grade Standardization Flexible and Standards-Based Widely Available Network A Standardization of Terminology Standardization Grade B+ Interoperability EHRs Are Powerful Only If Information Can Be Freely Exchanged A Remove Technology Barriers Make EHR Available in All Health Care Settings Single Consumer Health Identifier B+ Take Full Advantage of Electronic Messaging in the EMR B+ Interoperability Grade B+ Introducing Computer Technology Early and Keep the Technology Cost Effective Remove Hardware and Connection Barriers Monitored and Highly Compliant System Certification of Vendor Systems Barrier to Technology Grade Incentives Provide Financial Incentives D Mandating Doctors to Use EHR With Education A B C D D D D D C Incentive Grade C- Privacy Security and Privacy Protection that is Policed and Audited A+ Privacy Grade A+ Pubic Access to EHR (Too early to evaluate) Not Applicable Final Grade B+

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25 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 25 Notes]. Retrieved from Healthcare Information and Management Systems Society (HIMSS) website: Selecting%20a%20Partner%20for%20Your%20HIT%20Project.pdf Healthcare Information and Management Systems Society (HIMSS). (October 22, 2010). Meaningful Use Vendor Rating Scale for Eligible Professionals Stage One [Conference Notes]. Retrieved from Healthcare Information and Management Systems Society (HIMSS) website: Healthcare Information and Management Systems Society (HIMSS). (October 14, 2010). HIMSS EHR Implementation Success Factors for Practices with 1-5 Physicians [Conference Notes]. Retrieved from Healthcare Information and Management Systems Society (HIMSS) website: Healthcare Information and Management Systems Society (HIMSS). (October 13, 2010). HIMSS EHR Implementation Success Factors for Practices with 6-10 Physicians [Conference Notes]. Retrieved from Healthcare Information and Management Systems Society (HIMSS) website: Healthcare Information and Management Systems Society (HIMSS). (January 2012). Getting Started with an EHR [Online Fact Sheet]. Retrieved from Healthcare Information and Management Systems Society (HIMSS) website:

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32 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 32 Appendix A- Factors Involved in Successful EHR Implementations Lesson Learned EHRs Are Powerful Only If Information Can Be Freely Exchanged True Interoperability of All Data Survey of 1,600 global healthcare leaders New Zealand Details Futurescan is an annual guide to healthcare trends and is a report written by an expert panel of well-known healthcare leaders and supported by data from survey responses from more than 1,600 healthcare leaders. Experts agree that the power of EHR rests in their ability to integrate the "record" of a patient's health experience with the clinicians and institutions that provide care to make it an interactive tool to support and streamline the care delivery process. Hospital and health system leadership will be needed to make this a reality (SHSMD, 2007). New Zealand is an example of a country that has true data interoperability. This allows GPs with EHRs to automatically download pathology reports and imaging reports from a variety of public and private diagnostic providers. (Ashish et al., 2008) New Zealand also offers electronic immunization record integration with their immunization registry that is integrated with their EHR. (Ashish et al., 2008) Make EHR Available in All Health Care Settings Lack of Interoperability Because of a Lack of EHR in Some Health Care Settings U.S. U.K. New Zealand Australia Netherlands Germany Canada Single Consumer Health Identifier New Zealand Introducing Computer Technology Early Keep the Technology Cost Effective U.K. Provide Financial Incentives U.K. Without ubiquitous interoperability EHR adoption can be siloed and this typically involves inpatient care that does not access EHR information because EHRs are not widely used in the hospital settings (Ashish et. al., 2008). Achieve a high level of ambulatory EHR adoption but lagged with respect to inpatient EHR. (Ashish et. al., 2008). Ashish and colleagues (2008) found almost no high-quality reliable data on EHR use in acute care settings and they confirmed a lack of systematic information about EHR use in this critical sector of health care across 7 nations. New Zealand has a distinct advantage with a strict adherence to standards linked to a single consumer health identifier. This ensures data can always be exchanged between all EHR elements across the country. (Ashish et al., 2008) The U.K. has long history of computerization and kept the prices of hardware and networking low to encourage adoption and reduce barriers to adoption. (Ashish et al., 2008) Offering financial incentives from the National Health Service to encourage health care providers to use EHR systems for decision support. (Ashish et al., 2008)

33 WHAT CAN CANADA LEARN ABOUT HEALTH RECORD ADOPTION? 33 Mandating Doctors to Use EHR With Education New Zealand Do Not Place Excessive Limits On Systems That Can Connect U.K. Flexible and Standards-Based Widely Available Network Denmark New Zealand New Zealand s government played an important role in the high adoption rates of their EHR. In New Zealand doctors were required by law to submit claims and capture other data electronically. This mandated approach succeeded because the New Zealand government also invested in education to reinforce the advantages and safety improvements their EHR would bring to their health care system. (Ashisha et al., 2008). The UK has allowed physicians to connect with a broad range of diverse system to a common EHR platform. This helped kept hardware costs down and removed the technology barrier to adoption. New hardware did not always have to be purchased and existing network connections could be used. (Ashisha, 2008) They started early and made their network extremely flexible so systems of all kinds could easily talk to one another. Denmark focused on very high levels of connectivity with simple and easy system setup so there were reduced barriers to adoption. (Protti et al., 2008) All New Zealand s primary care providers, midwives, all hospitals, all radiology providers, and pathology laboratories, and most specialists use Health Level Seven (HL7) messaging standards to communicate over a virtual private network (VPN). New Zealand has become a world authority on HL7 EMR interoperability. Their full commitment to one standard that is applied consistently and widely has lead to a highly interoperable and efficient (Protti et al., 2008) Denmark chose EDIFACT for their communication standard in the 1990s and then in 2001 converted to XML standards, which are true global open standards. They rejected HL7 standards because in Denmark there were few systems that could communicate in HL7 standards at that time. (Protti et al., 2008) Take Full Advantage of Electronic Messaging in the EMR Denmark New Zealand The Danish have taken full advantage of electronic message transfers for lab results, lab requests, discharge summaries, referrals, and all other forms of electronic documents. Denmark s secure network lets physicians retrieve their secure messages at any time and all messages are automatically filed and organized into the electronic health record for the relevant patients. All message transactions are acknowledged and audited for full accountability. (Protti et al., 2008) New Zealand s general practitioners typical exchange clinical messages with between 50 to 60 organizations. New Zealand also has a secure VPN that is very similar to Denmark s technology and implementation. (Protti et al., 2008)