Quality Patient-Centred Care Through Teamwork For comment on 23.4.2009 AOM-P610 Hospital Authority Electronic Health Record Initiatives Purpose The purpose of this paper is to brief members on the role of Hospital Authority (HA) in support of Government s electronic health record (ehr) initiatives and the proposed governance structure of the programme. Background 2. It is the Government s plan to develop a territory-wide, patient-oriented ehr sharing system as an essential infrastructure to support the Healthcare Reform. The plan has been put forward in the HealthCare Reform Consultation Document Your Health, Your Life published in March 2008. 3. In July 2007 the Food and Health Bureau (FHB) established the Steering Committee on ehealth Record Sharing (ehrsc) to take forward the development of a territory-wide information infrastructure to enable sharing of health records of individuals throughout the health care system. HA participates in ehrsc alongside the Department of Health and other healthcare professionals as well as healthcare providers in the private sector. 4. The ehr sharing system is a ground-breaking concept introducing a whole new infrastructure operated by the Government for holding and transferring individual patients personal health data. It enables the entry, transfer and retrieval of such data by different healthcare providers in both the public and private sectors, with procedures for obtaining the necessary consent and authorization by individual patients, and mechanisms for authenticating and controlling access to such data. 5. Recognizing the successful experience and invaluable expertise accumulated within HA in developing its Clinical Management System (CMS), it is considered that the community would benefit from leveraging HA s systems and know-how when developing the ehr sharing on a territory-wide basis. HA is currently in the process of further upgrading the CMS through its Phase III development. 6. In its 4th meeting in December 2008, the ehrsc endorsed the initial ehr Development Plan. Key principles of this plan include:
- 2 - (a) (b) (c) (d) (e) ehr development should be government-led and should leverage on HA s systems and know-how. FHB will set up a dedicated ehr Office to steer and co-ordinate the development of the ehr sharing system, involving all relevant stakeholders in both the public and private sectors as well as the community, with technical support provided by dedicated teams to be set up in HA s IT Services (HAITS) with a view to leveraging on the systems and expertise of HA. Data privacy and system security of the ehr sharing system should be accorded paramount importance and given legal protection. FHB will conduct, in collaboration with the Office of the Privacy Commissioner for Personal Data and the Office of the Government Chief Information Officer amongst others, Privacy Impact Assessment, Privacy Compliance Audit, Security Risk Assessment and Security Audit that will proceed in tandem with the development of the ehr sharing system and when individual components of the infrastructure commence operation. Participation in ehr sharing should be compelling but not compulsory for both patients and healthcare providers. The sharing must be based, first and foremost, on a patient s informed consent to participate in ehr sharing and authorization for individual healthcare providers to access their shared ehr. Healthcare providers may also choose to participate or not to in the ehr sharing system on a voluntary basis. Only predefined scope of health data will be shared by participating healthcare providers via ehr, and such shared data will be accessible via ehr only by other participating healthcare providers directed to and duly authorized by individual patients. Development of ehr sharing system should be based on a building block approach, involving partnership with the private sector. Overseas experience has shown that a big-bang approach to ehr development is fraught with difficulties. The development of ehr in Hong Kong will thus take the building block approach that has proven successful for the CMS, with early involvement of users, pilot projects on a step-by-step approach, modular development of individual components, and gradual extension of scope and functionality. Engagement and participation of the private healthcare and IT sectors would be a key component to ehr development. ehr sharing system should be based on open, pre-defined and common technical standards and operational protocols. The technical standards for information sharing are being built in collaboration with the other stakeholders and will be based on international standards where possible. The sharing of health data should also be based on pre-defined security standards and communication protocols to safeguard the integrity, privacy and security of the data. The Government will share such standards with the private
- 3 - healthcare and IT sectors and facilitate compliance with such standards to ensure inter-operability in ehr development. Major Components 7. Under the ehr development roadmap, the development of the ehr sharing system will be divided into three major ehr components and into two major phases. (a) The ehr sharing infrastructure core component: to design and build the core ehr sharing platform for interconnecting between individual emr/epr systems adopted by individual healthcare providers, and providing functions relating to ehr sharing, including storage and exchange of data between individual systems, and access to and retrieval of ehr data of individual patients in different individual systems which include systems for patient and provider identification as well as consent for access. The system will be based on common standards to be developed by the public and private sectors in collaboration. (b) The CMS adaptation and extension component: to facilitate the adoption and deployment of HA s CMS by private healthcare providers, especially private hospitals/clinics which would like to adopt HA s CMS components for their own use with minimal investment and maintenance. This component will facilitate the deployment of ehr systems by IT vendors in private hospitals, private practitioners and healthcare providers which intend to adopt and use the HA systems. (c) The standardization and interfacing component: to develop technical standards for different healthcare IT systems to interoperate and interconnect through the ehr sharing infrastructure, to advance a validation platform for testing interoperability that could support a future certification scheme for individual emr/epr systems of healthcare or IT service providers, to provide technical support to private healthcare providers which already have their own emr/epr systems and would like to connect to ehr, and to provide the necessary interface to facilitate such interconnection. This component will facilitate the deployment of ehr systems by private hospitals, private practitioners and other healthcare providers which intend to use their own systems while ensuring compatibility with the sharing infrastructure and interoperability with other ehr systems. 8. Under the proposed programme management plan of phase I (from 2009/10 to 2013/14) of the ehr Development, the ehr sharing platform would be ready by 2013-14 for connection with all public and private hospitals, and to have emr/epr and other health information systems available in the market for private doctors, clinics and other healthcare service providers to connect to the ehr sharing platerform. Such systems will include a basic clinical management system that will
- 4 - enable private hospitals to access and use the ehr, and a doctors portal that will allow private sector practitioners to contribute and access e-health records. 9. Under phase II of the programme (from 2014/15 to 2018/19), the ehr will extend the scope and benefits of the programme. This will include increasing the scope and coverage of the ehr sharing system in terms of both further participation of both patients and healthcare providers, as well as continued expansion and enhancement of functionalities of the system. Specific areas of the healthcare system that will be targeted by Phase 2 are patients portal and specific clinical services modules. Patients portal will provide for patient access to the ehr systems for the purposes of accessing, validating and controlling their own health record and managing their ehr consent. The portal is envisaged to be an internet application with secure access and patient identity certification. Specific Clinical Services Modules will be applications used by healthcare professionals and patients in support of specific and focused disease management protocols. These applications would involve expanding the health record to hold relevant information, creating specific applications and user interfaces to promote the use and sharing of the record, and development of algorithms to provide indicators and warnings specifically related to the disease and its management. Progress To Date 10. HA has participated in all the ehrsc meetings and has played a leading role in the Working Groups and Task Forces which contributed to the Development Plan. The HA standards team has been leading the Task Force on ehr Content & Information Standards and the first set of interoperability standards for the ehr is being finalized. 11. The PPI-ePR system has been successfully piloted since 2006. As of March 2009, over 60,000 patients have joined the scheme and over 1,400 private sector users have registered. During 2008, the PPI-ePR was extended to allow limited two-way sharing of data in support of specific clinical programs. In January 2009, the system was enhanced to allow the transfer of radiological images from the private sector to HA. 12. HA has worked with FHB to engage an external 3rd-party consultancy to develop and validate a detailed Project Management Plan. The Programme Management Plan describes how the Hong Kong Government will implement its territory-wide ehr system and provides clarity as to the needs to be met by the ehr programme, the objectives and scope of the programme, the people that will be executing the programme, and their roles and responsibilities. It also includes a communications and engagement strategy with various stakeholders including the private healthcare and IT sectors as well as the general public, and a risk register and risk management strategy.
- 5 - The ehr Engagement 13. Given the importance of participation in ehr development by private healthcare providers, IT service providers and other stakeholders in the community, FHB has solicited the support of HA to conduct an ehr Engagement Initiative (EEI) which will be an open exercise to invite interested private healthcare providers, IT service providers and relevant stakeholders to submit proposals for partnership projects. The purpose of the exercise is to help FHB identify potential partners and partnership projects under different possible partnership models that could further the objective of ehr development, including facilitating the development of sharingcapable and interoperable emr/epr systems in the private sector, and their interfacing and interconnection with the ehr sharing infrastructure in future. 14. FHB will also be promoting the concept of ehr sharing among the general public including patients and healthcare providers, through both pilot projects involving ehr sharing and other patient-centred healthcare programmes using ehr as a vehicle. 15. In 2008, HA engaged IBM for a Consultancy service to assess market s interest in partnering with HA to leverage HA s IT assets (including developing CMS III). An interim Report was accepted by ITGC but issuing the proposed Market Sounding Document was put on hold in May 2008 after HA reported a number of Personal Data Loss Incidents that took priority to action. Also, the Government, as a priority, progressed the planning for the ehr initiative resulting in the scope of HA s potential involvement to support this initiative now more clearly defined. 16. The CMS III Project Steering Committee and the Government are now requesting HA to consider re-activating the IBM Consultancy, to revise the scope to cover the ehr work that HA will be required to perform, and to leverage this process to engage the Private ICT Sector as part of the EEI for potential ehealth partnership projects, focusing on the Local HK Market. This consultancy will also recommend appropriate Governance Mechanisms for Public-Private Partnerships. Governance regarding ehr Development 17. As described in the ehr Development Plan above, HAITS is being requested by FHB to lead multiple streams of work to support the development of the ehr sharing system. Since there will be significant synergy between CMS III development and ehr development, and because ehr activities are being separately funded as part of an overall ehr Programme, it is vital to clearly define the lines of responsibility and accountability, financial accounting, and planning and monitoring mechanisms. 18. It is proposed that HAITS will set up an ehr Programme Management Office (ehr PMO) to oversee all ehr related matters and projects. Through the ehr PMO, HAITS would report to FHB, specifically the ehr Programme Steering Committee (ehr PSC) and the ehr Office under FHB, on matters relating to the ehr programme and HAITS support for such. (Table 1)
- 6 - Table 1. ehr Governance 19. A separate budget and account will be maintained on ehr related projects by HA. The funding of HAITS support for ehr development will be allocated via the existing mechanism between HA and FHB, and will continue to be subject to rules and processes for day-to-day management and administration. HAITS will submit through ehr PSC to ehr Office before each financial year, the workplan, the budget, programme deliverables and manpower plan for agreement to facilitate the ehr Office to arrange and approve funding. HAITS will report periodically to the ehr PSC on programme implementation progress, expenditure situation and other relevant issues. 20. It is anticipated that components of CMS III will be used in the ehr, and that use for the ehr may require enhancement or modification. On the other hand, it is also anticipated that technology developed for the ehr may be useful for CMS III. ehr PMO will keep the IT Governing Committee (ITGC) informed of what components are being used and any other impact which ehr development will have upon CMS III. Establishing an HA Subsidiary to Contract with Private Sector 21. The Government has invited HA to consider establishing an HA Subsidiary Company to facilitate HA contracting with the Private Sector Healthcare Providers for the delivery of the ehr solution and related services. The proposed HA
- 7 - Subsidiary s Board, apart from HA s representatives, will also include members from FHB or specifically the ehr Office of the Government. 22. This approach will provide direct oversight of HA s support to FHB in the engagement of and contracting with private sector healthcare providers regarding ehr development, including specific partnership projects, and provide a simplified and structured mechanism for the Government to be involved in delivering and operating the ehr projects involving the private sector healthcare providers, insulating HA to some degree from potential issues arising from such. 23. In the future, with the agreement of the HA Board and the HA Subsidiary s Board, the role and scope of this HA Subsidiary could be expanded if necessary to meet changes in the approach and/or the market. Staffing Implications 24. A large increase in IT/Health Informatics manpower will be required to meet the demands of ehr development, current estimates are 200 head count at the peak, and the ehr budget includes accommodation costs for these staff. HA will be actively seeking opportunities to outsource portions of the ehr development to reduce the dependence on HA staff. 25. The HA employs many specialists in health informatics and health IT development. Some existing staff will be co-opted into positions in the ehr development and new skilled staff will be sought. Legal Implications 26. FHB will work with the HA s Legal Services Department on establishing the HA Subsidiary Company to facilitate HA contracting with the Private Sector Healthcare Providers for the delivery of the ehr solution and related services. Publicity 27. As development of ehr will leverage on the successful experience and goodwill accumulated within HA in developing its CMS, it is likely that ehr and its related publicity would put the CMS development under public scrutiny. In anticipation of this, HAITS will work with the HA Corporate Communications team on a positive publicity campaign regarding the CMS. Advice Sought 28. Members are invited to note and comment on the proposed action plans to initiate and support the ehr.
Hospital Authority AOM\Paper\P610 23 April 2009-8 -