The success of large scale EHR implementation: A matter of

Transcription

1 The success of large scale EHR implementation: A matter of governance L. Esterle, Inserm, A. Kouroubali, Forth, M. Bruun-Rasmussen, Mediq, L. Ciglenicki, ProRec Slovenia, J. Devlies, Ramit, G. Hurl, ProRec Ireland and G. de Moor, Eurorec 1

2 Initial statements Implementation of EHR at a national (or regional) level: a radical innovation for health care Technical challenges (interoperability, privacy, safety, etc.) But also political, social and organizational issues often overlooked => these issues could compromise the implementation process. 2

3 EHR-Implement approach 1. Deep analysis of national initiatives at various stages of EHR-implementation on a large scale on the political, organizational and social issues ; 2. Comparison of the initiatives, identification of the main issues; 3. Elaboration of the main recommendations for policy and decision makers. 3

4 The case studies A mix of several criteria, including contextual ones: Various population size Various national health systems (centralized or not) Different stages in the EHR national strategy =>Six national case studies in Belgium, Denmark, England, France, Ireland, Slovenia. None of them has completed the initiative implementation at the end of

5 Relationships with EHR Building blocks for EHR Federation of multiple EHR systems Common standards for EHR EHR Initiative (country) ezis (Slovenia) ipms (Ireland) Locator services (Belgium) National ehealth strategy (Denmark) Electronic patient record (England) Electronic patient record (DMP) Objectives and target Model of safe data exchanges PAS for public hospitals Regions and groups of hospitals Hospitals and primary care Starting year Various times 1995 At the end of 2008 Feasibility studies Still running 50% of hospitals Still running Some implementation not fully in use, Still running 50% of hospital beds and 100% in primary care All patients 2003 Still running All patients over 16 Stopped and 2004 revived in a new form 5

6 Elements of the governance The initial strategy The role of actors The implementation process

7 1. Initial vision Observation: Various but close objectives for the NHS: Continuity of care, better communication between parties, patient benefits, etc. For the majority of countries: ehealth and/or EHR= major tool for the reform or improvement of the NHS Improve the performance of the NHS : quality and productivity ( England) Improve the coordination and continuity of care (France) More transparent and accountable public health sector (Denmark) On the opposite, more pragmatic way in Slovenia, Belgium, and Ireland : Equip the country with the infrastructures necessary for ehealth 7

8 1. Initial vision Recommendations Large-scale implementation of EHR systems needs to correspond to a clearly defined vision integrated in the strategy for the health sector. However, EHR implementation ti should not be used as the main and/or only instrument for healthcare reform. It could be only an enabler of reform. 8

9 2. The role of the actors: The national authorities Observation: Inthe majority of cases, full political i l support, but sometimes too much political pressures Examples: In centralized countries (England, France): Very strong pressures => unrealistic expectations, lack of autonomy in the management of the project, lack of the stakeholder participation; In Denmark: Less centralized and more consensual decision process (strategic group); In Slovenia: Driving role of the national health insurance. 9

10 2. The role of the actors: Management of the project Observation: The creation of an adequate structure to manage the initiative is highly desirable, but not so obvious Examples: Slovenia: National Center for Health Informatics to be created in 2008, but location still under discussion i at the end of France: creation of the GIP-DMP, but lack of autonomy (government pressures) Denmark: After failure of initiative, new national organisation: Connecting Digital Health, 10

11 2. The role of the actors : Participation of the stakeholders Observation: The participation i i of the stakeholders differs from one country to another with some consequences Examples: In Denmark, refusal of the basic structure of an EHR established by the National Board of Health; In France, no prior consultation ti of the users, which h gave rise to many reserves and controversies; Greater participation p of the stakeholders when implementation at the local level in Belgium and Ireland; Real progress in England when hospitals and companies work as one team. 11

12 2. Role of the actors Recommendations Governance should be established to define and to respect clear roles for the different actors at each stage of the process; Stakeholder engagement is vital throughout the EHR selection, decision and implementation process. Stakeholder involvement ensures system ownership and motivation towards supporting and using the EHR. 12

13 3. Implementation process Implementation plan and evaluation Funding principles i 13

14 3.Implementation process: Realistic implementation plan and evaluation Observation: Wide gap between the initial i i forecasts and the realization generally due to an unrealistic and rigid schedule Examples: In Denmark, definition of the EHR standards initially envisaged in the strategic plan of 1995, but not effective at the end of 2005; In England, in 2002 the national EHR was planned for Now for 2015 or later; In France, initiation of the DMP in 2005 to be implemented in 2007 for the entire population. No implementation at the end of Observation: Lack of systematic and regular evaluation Examples: In France, Denmark, etc : no systematic evaluation; In England: Independent audits allowing identification of the problems. 14

15 3.Implementation process: Funding Observation: insufficient funding for the initiative, underestimation of the costs for implementation and maintenance of the infrastructure. Examples: In Belgium: Delayed and fragmentary public funding In France: Underestimation of the cost to develop the DMP In England: Underestimation of the human resources for implementation and maintenance in the hospitals. 15

16 3. Implementation process Recommendations Projects should be realistically estimated in terms of complexity, resources and timescale. A flexible schedule and process should be adopted. Use of strategic tools and continuous evaluation of an EHR implementation initiative allows for feedback that leads to changes and adaptation to accommodate emergent needs. Funding should be provided and assured, and responsibilities for sustainability clearly defined. 16

17 Key factors of success for implementing EHR on a large scale Support of the policy makers and authorities, but without their pressure; Clear definition of the role and intervention of the various actors, including the stakeholders; Adoption of an adaptative long term process; Regular and systematic evaluation; Sufficient funding for development, implementation and maintenance. 17

18 Thank you for your attention All national reports and other documents available on the website: p 18