Update on the Integrated Hospital-Community EMR

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1 Update on the Integrated Hospital-Community EMR Country: Israel Partner Institute: The Myers-JDC-Brookdale Institute, Jerusalem Survey no: (12) 2008 Author(s): Nirel, Nurit and Revital Gross Health Policy Issues: New Technology Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract An extensive evaluation of the integrated hospital-community MR (OFEK) is being conducted. Preliminary findings indicate an increase in utilization of OFEK during the years The evaluation will assess subsequent effects on quality of care and costs. A new user interface for OFEK was developed also, putting all the different software that the physician uses on one platform. This enables rapid access to OFEK directly from the EMR, and is expected to increase utilization of OFEK. 2. Recent developments The program is being extensively evaluated by the Brookdale institute since 2006 in cooperation with researchers from the research division of Clalit health services. Another development is that recently the integrated hospitalcommunity electronic medical record (OFEK) has gained increasing prominence in the Clalit Health Care Services sick fund. A new phase of the program is the "new user interface" technology which is now being developed and will be implemented in the system within 6 months. This new technology consists of putting all the different software that the physician uses (e.g. patient medical record; OFEK; administrative data) on one platform. The main advantage is that this will enable rapid access to OFEK, which is expected to facilitate much more use of this system. 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 - 1 -

2 Innovation - OFEK is a very innovative system since it links information between hospital and community care and links information from different and not fully compatible computer systems. The "new user interface" which is now developed is also innovative in connecting the patient file to the other components of the system. No such system exists in the Israeli health care system and it is also rare abroad. Controversy - At this stage the system is consensual Systemic impact - This technology changes the communication between hospital and community facilities and is likely to highly affect continuity and coordination of care (if used regularly). Public visibility - visibility is high among professionals and policy makers but it has not been exposed to the general public Transferability - In many other healthcare 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. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Initiators of idea/main actors Providers Patients, Consumers Private Sector or Industry Others Stakeholder positions Central management Clalit health services: The management supports OFEK as well as the expansion of the program and introducing the "new user interface". They believe that due to the improved technology the use of OFEK will increase and generate more efficient and effective integrated hospital-community care. This in turn will lead to improved quality of care and efficiency. We are not aware of changes in the positions of other actors. Actors and positions Description of actors and their positions Providers Central management Clalit health very supportive strongly opposed services Clalit hospital managers very supportive strongly opposed - 2 -

3 Physicians in hospitals and very supportive strongly opposed community 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 legislation is required Legislative outcome Actors and influence Description of actors and their influence Providers Central management Clalit health very strong none services Clalit hospital managers very strong none Physicians in hospitals and very strong none community 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 Introduction of the new improved technology ("new user interface" ) was initiated by the central management of Clalit as part of the trend which can be seen in all the sick funds today, to develop e-health technologies in health care. These include among others: web sites for getting clinical results and facilitating administrative procedures; web sites through which the sick funds can disseminate information for self care and rights, and monitor self care of chronic patients. E-health is thus used for providing care as well as for better communication with patients. The OFEK system is perceived as using e-health internet technology to achieve integrated care and therefore it is encouraged within the sick fund, and additional funds are allocated to continuously upgrade the system. Even though there were no structured programs for assimilating the integrated hospital-community electronic medical record (given the objections of the community physician union as reported in a report"hospital-community electronic medical record". HPM October 2005), over time the use of the system has slowly permeated into the daily work of many community physicians, as they realized the advantages of an integrated information system

4 Monitoring and evaluation The evaluation of OFEK is conducted at the Myers-JDC- Brookdale Institute in cooperation with researchers from Clalit Health services. The evaluation monitors the utilization of the system by hospital and community medical staff and focuses on the influence of using the integrated hospital-community EMR (OFEK) on quality of care and costs of care in the hospital as well as in the community setting. Data on utilization of the system indicates that utilization had increased by 600% between , using the number of entries into the system as the main measure of utilization. The other objectives of the evaluation are: 1. to assess the effect of introducing e-health technology (OFEK) on quality of care and costs; 2. to assess the effect of utilization of OFEK on quality of care and costs The evaluation design: The evaluation has two separate parts, one focusing on the hospital setting and the other on the community setting. The design for evaluation of objective 1 in the community setting: Before and after measurements in a group of intervention and control clinics. The design for evaluation of objective 2 in the community setting: Multivariate analysis with the dependent value defined as quality measures and cost measures and the main independent variable is the extent of utilization of the system controlling for other intervening variables. The design for evaluation of objective 1 in the hospital setting: Before-after design in departments of internal - 4 -

5 medicine, general surgery and emergency rooms in six Clalit- owned hospitals in three time periods. The control group in this case are hospitalized patients that are not members of Clalit health services and therefore did not benefit from integration of care that the OFEK system enables. There is an emphasis on measures that are expected to be directly affected by improved communication between hospital and community services. A preliminary data analysis informed the selection of measures. The measures were taken from screens that were entered most frequently. Similarly, the specific lab and imaging measures chosen were those most frequently used by physicians. The measures can be classified into several types: Measures for community settings: 1. Clinical measures related to physician care e.g. - changes in number of lab tests, imaging ordered by the clinic, prescriptions, referrals to outpatient clinics, number of hospitalization days. 2. Measures related to nurse work procedures: e.g. number of enters to the OFEK screens related to planned discharge. Measures for hospital settings: 1. Changes in number of "unnecessary" hospitalizations (e.g. one day hospitalization, re emergency hospitalization within one week) 2. Changes in number of specific lab tests and imaging ordered during the hospitalization For each measure, the evaluation includes assessment of the saving in costs related to the change in the measures. For example, if the number of lab tests ordered by the hospital will decrease as physicians enter OFEK and retrieve results of tests conducted in the community, the evaluation will assess the savings in cost related to this. 5. Expected outcome The OFEK system was implemented in order to achieve improved quality of care and reduced costs. The objective of the evaluation is to examine whether these goals were achieved. At this time we do not yet have results and cannot provide a definitive answer. To date, there are initial findings from the evaluation, demonstrating an increase in utilization of OFEK during the years The further development of the OFEK technology and implementation of the "new user interface" which is ly taking place is expected to lead to more extensive use of the system, because the system will be even more accessible to the physician. Due to the new technology, when the physician or nurse opens the EMR immediately there will be a connection to the OFEK system (from the EMR) facilitating the use of data from both hospital and community files. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Quality - As ly reported, the system will probably improve patient care at the community and hospital levels by increasing continuity and coordination of care. It may also reduce medical mistakes that are related to insufficient information on patients. The new technology will contribute to improving quality as it facilitates regular utilization

6 Equity - This technology is expected to improve if information flow and is not dependent on the patient to pass the information from hospital to community and vice versa. 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. 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. 6. References Sources of Information Nirel Nurit (PI) Research proposal funded by the National Institute for Health Policy and Health Services Research. The virtual patient file (the "OFEK" system) : An Evaluation of an Integrated Hospital-Community computerized System. Submitted 2006, approved for funding Reform formerly reported in Hospital-community electronic medical record Author/s and/or contributors to this survey Nirel, Nurit and Revital Gross Suggested citation for this online article Nirel, Nurit and Revital Gross. "Update on the Integrated Hospital-Community EMR". Health Policy Monitor, November Available at -

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