Table of Contents Executive Summary... 2 1 CPSA Interests and Roles in ehealth... 4 1.1 CPSA Endorsement of ehealth... 4 1.2 CPSA Vision for ehealth... 5 1.3 Dependencies... 5 2 ehealth Policies and Trends... 5 2.1 CPSA Areas of Influence... 5 2.2 Legislation and Regulation... 6 2.3 EMR Adoption and Clinical Use... 6 2.4 Patient Access to Health Information... 7 3 Data Stewardship for Medical Records... 7 3.1 Governance and Oversight... 7 3.2 Physician and CPSA Participation... 8 3.3 Privacy Rights and the Express Wishes of the Patient... 8 4 Information Technology in Support of ehealth in Alberta... 8 4.1 Adoption and Use of EMRs... 8 4.2 Electronic Health Record and Health Information Exchange... 11 5 CPSA Priorities... 12 5.1 Support Professionalism in an ehealth world.... 12 5.2 Promote Physician Engagement in EMR and EHR Adoption... 12 5.3 Develop a Framework for Clinical Value and Appropriate Use... 12 5.4 Balance Information Sharing with Patient Privacy... 13 Page 1
Executive Summary The College (CPSA) supports the appropriate use of information technology by physicians in providing safe and high quality care to their patients. The College demonstrates this commitment through its Medical Informatics Committee (MIC), established to develop expertise and provide input, coordination and advice on ehealth matters. For the purposes of this document, ehealth is defined as the provision of health care services supported by modern electronic information management tools, processes and resources. The College s interest in ehealth reflects its mandate to ensure the quality, safety and continuity of patient care, to establish and maintain ethical and professional standards of care, and to advocate for public policy which contributes to the health of Albertans. The CPSA vision for ehealth is a health care system where: all medical records are fully electronic and secure, with systems able to integrate and exchange health information easily and as appropriate physicians and other health professionals have the training and support to use ehealth tools and processes effectively, efficiently and appropriately. patients continuity of care is optimized by sharing and exchange of information, balanced by respect for their privacy the quality of care is optimized by appropriate access to information, and decision support and practice audit tools there is a comprehensive base of information which supports providers in the delivery of care to their patients, as well as assisting management of the health care system, research and other valid secondary uses of information Achieving this vision will require significant cultural and procedural changes and a long-term perspective. Key dependencies are: the engagement of all physicians effective collaboration by key stakeholders, including the Alberta Medical Association (AMA), Alberta Health, Alberta Health Services (AHS), the Office of the Information and Privacy Commissioner, the Canadian Medical Protective Association, and other health professions representative groups. legal, professional and ethical principles for information exchange that support the doctor-patient relationship public confidence in the confidentiality and security provisions of the ehealth system workflow improvements which have positive impacts on the quality of care, continuity of care, professionalism, time savings and ability to measure effective data stewardship which balances individual circumstances and the operational demands of provider(s) and the health care system a supportive environment which respects and adapts to changing accountabilities, liabilities, costs, benefits, and expectations. Matching of the ehealth development to other social and healthcare delivery trends, such as various shared/collaborative care models. Page 2
The College s ehealth priorities are to: ensure that time-honored principles at professionalism and ethical conduct will be supported in an electronic environment. participate with other stakeholders in developing a strategy to engage physicians and promote EMR adoption and full clinical use continue to support physician and College representation on Alberta EHR design teams and governance committees establish Standards of Practice and Advice for physicians to guide the responsible use of ehealth tools and processes establish criteria for physicians to manage privacy expectations while enabling appropriate sharing of information to the Alberta EHR responsibly exercise its HIA mandate to prescribe the transfer of information from physicians to the Alberta EHR Page 3
1 CPSA Interests and Roles in ehealth For the purposes of this document, ehealth is defined as the provision of health care services supported by modern electronic information management tools, processes and resources. The College s organizational vision is: Albertans are healthier because the College of Physicians & Surgeons of Alberta: Ensures that physicians are competent throughout their careers. Supports physicians in providing compassionate, caring and ethical services to the people of Alberta. Fosters quality health care for all Albertans through innovation, collaboration and cooperation with other key stakeholders. Advocates for public policy that contributes to the health of Albertans. Given the fundamental changes to medical practice brought by information access and information tools and the implicit need for training and support, the College feels it has a role to play in guiding physicians through this transition. Specifically, the College s interests include encouraging the adoption of electronic medical records (EMRs), ensuring the clinical value and appropriate use of EMRs, and enabling the connectivity of tools and information to support patient care and health system management via the Alberta electronic health record (EHR), also known as Netcare. Maintaining the trust and open exchange of information between patients and physicians is fundamental to these interests. This document is intended to articulate the College s vision for ehealth in Alberta and the principles, partnerships and strategies necessary to work towards that vision. 1.1 CPSA Endorsement of ehealth The College supports the appropriate use of information technology by physicians in providing safe and high quality care to their patients. Electronic records have inherent advantages over paper-based records. They offer remote access, concurrent access, enhanced security controls, data backup and recovery, search capability and other base functionality that information technology enables. They also have the potential to improve patient safety and quality of care through: improved accuracy, legibility and clarity of information decision support at the point of care integrated with patient-specific data reminders, alerts and care maps for patients with chronic diseases or defined risks systematic integration of external data sources with internal data analytic capability, (for example to assess quality measurements, track outcomes or comparisons to other evidence, respond to drug recalls or other unique conditions). Electronic tools and processes bring their own unique risks, of course, helping physicians (and system designers and managers) is also part of the ehealth agenda. Page 4
The College demonstrates its commitment to ehealth through its Medical Informatics Committee (MIC), established to develop expertise in this area and provide input, coordination and advice on ehealth matters. 1.2 CPSA Vision for ehealth The CPSA vision for ehealth is a health care system where: all medical records are fully electronic and secure, with systems able to integrate and exchange health information easily and as appropriate physicians and other health professionals have the training and support to use ehealth tools and processes effectively, efficiently and appropriately. patients continuity of care is optimized by sharing and exchange of information, balanced by respect for their privacy the quality of care is optimized by appropriate access to information, and decision support and practice audit tools there is a comprehensive base of information which supports providers in the delivery of care to their patients, as well as assisting management of the health care system, research and other valid secondary uses of information 1.3 Dependencies Achieving the ehealth vision will require significant cultural, technical and procedural changes and a long-term perspective. Key dependencies are: the engagement of all physicians effective collaboration by key stakeholders, including the Alberta Medical Association (AMA), Alberta Health, Alberta Health Services (AHS), the Office of the Information and Privacy Commissioner, the Canadian Medical Protective Association, and other health professions representative groups. legal, professional and ethical principles for information exchange that support the doctor-patient relationship public confidence in the confidentiality and security provisions of the ehealth system workflow improvements which have positive impacts on the quality of care, continuity of care, professionalism, time savings and ability to measure effective data stewardship which balances individual circumstances and the operational demands of provider(s) and the health care system a supportive environment which respects and adapts to changing accountabilities, liabilities, costs, benefits, and expectations. Matching of the ehealth development to other social and healthcare delivery trends, such as various shared/collaborative care models. 2 ehealth Policies and Trends ehealth is an extremely broad initiative that no single organization completely owns or controls. The scope encompasses people and their clinical practices, the policy and processes of information management, and EMR and EHR technologies. 2.1 CPSA Areas of Influence The College can participate in and/or influence the provincial ehealth strategy in the following ways: Page 5
1. Maintain Standards of Practice. The CPSA Standards of Practice define the minimum standards for medical practice in Alberta. The Patient Records (Standard 21) describes requirements for both paper and electronic records. 2. Prescribe the transfer of information to the Alberta EHR. Under section 56.3 (1) of the Health Information Act (HIA), the College has the mandate to direct physicians to make health information accessible to other custodians via the Alberta EHR. How the College exercises that mandate will be a matter of further consultation and deliberation. 3. Advise physicians. The College can advise physicians individually and as a profession on any topic related to medical practice, including ehealth. Unless referenced in legislation, the CPSA Standards of Practice, Code of Conduct or Code of Ethics, this advice is considered guidance. 4. Participate as a stakeholder. The College can appoint CPSA and physician representatives to steering committees, working groups and other structures designed to implement changes to the health system. Through Council or the MIC, it can also publish position statements, policy frameworks and other reference documents that can be used to guide program, project or product requirements in the development phases. 5. Observe and comment. The College can observe and comment on activities and projects without the direct involvement of College staff or representatives, in order to proactively intervene or present a College position. 2.2 Legislation and Regulation The Health Information Act (HIA), in effect since April 2001, provides individuals with the right to request access to health records in the custody or under the control of custodians, while providing custodians with a framework for collecting, using and disclosing health information. The Health Information Amendment Act (Bill 52) introduced new regulatory requirements effective September 1, 2010 which mandated the College to develop: 1) standards of practice respecting the management of information in records and the management of electronic records, (completed July 2011), and 2) written directions for regulated health professionals for making prescribed health information accessible to authorized custodians via the Alberta Electronic Health Record (EHR). Prescribed health information is defined in section 56.1(c) of the HIA as: health information about an individual that is of a class or type prescribed by the regulations that a regulated health professional or an authorized custodian may or must make accessible to authorized custodians via the Alberta EHR." Regarding (2) above, how the College will exercise this mandate has not yet been worked out. See section 3.3(below) for a discussion of one of the principles at issue here. 2.3 EMR Adoption and Clinical Use EMR adoption grew significantly in Alberta with the introduction of the Physician Office System Program (POSP), rising from five per cent of physicians in 1999 to approximately 50-60 per cent of physicians in 2012. To many, this would seem like a huge success, and in many ways it is. However, a number of issues remain: Page 6
EMR uptake by physicians has been stalled at 50-60 per cent for at least the last four years. Many physicians do not take full advantage of EMR system capabilities; some use only the billing and scheduling components. The capacity of EMR systems to import electronic data files from other EMR systems is extremely limited. This hampers patients ability to have their full data file transferred to a physician using a different EMR product, and physicians ability to migrate to different EMR products. 2.4 Patient Access to Health Information The societal trend towards social media and transparent access to information has not extended widely to health information to date, despite of a number of public health portals. The exception is care for certain chronic health conditions, where active communication with the providers is part of the care model. Many EMR products are designed to enable a patient portal which provides access to information and control of some aspects of the patient record, including disclosure. In Alberta, the Personal Health Portal project will deliver this type of functionality and may include data from physician EMRs (via the Shared Health Record project) and integration with Netcare repositories. The objectives are generally to influence patient behaviour, enable patient review of information before and after appointments, enhance communication between the patient and the physician and facilitate information sharing between care givers and family supports. The College supports the concept of greater patient participation in managing their health including convenient and secure access to their own medical information. The challenge will be to assist patients in understanding what that information means in their own clinical context. 3 Data Stewardship for Medical Records Data stewardship refers to the collection, use, disclosure, management and security of health information by a health professional. Within each of these aspects, there are legal, ethical and best practice considerations for how physicians manage the health information in their trust. Maintaining the balance between patient confidentiality and the reasonable use and access to individual patient data for other purposes is critical to maintaining public trust in physicians and the larger health system, and is a major focus for the College in the ehealth domain. 3.1 Governance and Oversight The College s Patient Records standard of practice provides physicians with direction for the management of electronic records under physician control. The Electronic Health Record Data Stewardship Committee (EHRDSC) is a multi-stakeholder, ministerial committee mandated to oversee all data stewardship issues related to the use of the Alberta EHR, including management of the information collected and maintained by that infrastructure. The College strongly supports the multi-stakeholder approach to data stewardship, and has three physician representatives on this committee (appointed in conjunction with the AMA). We also have observer status on the Information Sharing Framework (ISF) Governance Committee, which oversees the operation of a shared-emr system owned and managed by AHS in Edmonton. The College will continue to advocate for effective data stewardship in all ehealth initiatives. Page 7
3.2 Physician and CPSA Participation The health needs of patients are supported not only by the doctor-patient relationship, but also by the team-based and facility-based care delivery models of the health system. There is an accepted responsibility to support the health care system with individual information for health system management, biomedical and clinical research, and other defined uses in the public interest (explicitly defined in the HIA). From the perspective of the College, data stewardship is both a system-wide issue that requires input and consistent policies from all health professions and care delivery organizations, and a local issue for physicians who will benefit from specific advice to assist their ethical and professional decisions. 3.3 Privacy Rights and the Express Wishes of the Patient Physicians have a professional obligation to create, use and maintain a patient s health record in the best interests of the patient. Physicians have also an accepted duty to protect the privacy of their patients and the data collected during the delivery of care; this is one of the fundamental tenets of the doctor-patient relationship. Further, individuals have a fundamental right to privacy and, by extension, the confidentiality of their personal information that is well established in common and statute law. Ensuring that physicians are able to meet their professional and ethical obligations to patients who request that part (or all) of their medical information be kept confidential is essential to maintaining trust and openness in the doctor-patient relationship. In practical terms, this means a physician with an EMR is obligated to: establish and manage access and security protocols for physicians, staff and affiliates with access to the EMR establish charting protocols (and security profiles) for sensitive information in the EMR including a patient s express wishes establish procedures and capabilities to manage exceptional circumstances (i.e., restrict access or disclosure) at the express wishes of a patient or if the physician agrees that it is in the interests of the patient to do so enable systematic disclosures of EMR data to the Alberta EHR or other shared systems manage exceptions to systematic disclosures to the Alberta EHR or other shared systems propagate the express wishes of the patient when EHR data is copied to the EMR support patients who wish to enable/disable masking in Netcare. 4 Information Technology in Support of ehealth in Alberta 4.1 Adoption and Use of EMRs The adoption and use of EMRs is a fundamental dependency and a critical success factor for ehealth. To achieve the ehealth vision, individual physicians as well as the profession collectively must make this transition. The College recognizes the transition to an EMR requires the individual practising physician to transfer paper-based clinical records to the EMR, adapt clinical practices and processes to utilize the opportunities of the EMR including associated decision support tools, and leverage the EMR to function in an environment in which data can flow easily and reliably. Each of these transitions is in itself a complex undertaking. Page 8
The College endorses EMR adoption by physicians, and continues to adapt the Patient Records standard of practice to reflect current practice. Key areas of interest include: transition from paper records to EMR EMR adoption shared control of records integration and interoperability clinical value and appropriate use 4.1.1 Transition from Paper Records Process changes associated with the material transition from paper to electronic medical records require a high level of due diligence. Patient safety and quality of care must be carefully considered throughout the transition period, primarily through maintaining the integrity of the medical record and the clinical processes supported by the medical record. Changes inherent with an EMR must also be managed, such as patient privacy and information security. The College has taken an active position supporting physicians in transition to EMRs by publishing an advice document on the subject. Key elements of this advice include: patient information must be secure confidentiality of patient information must be maintained the integrity of the medical record content must be maintained the integrity of the clinical workflow supported by the medical record must be maintained continuity and quality of care must be maintained through the transition period 4.1.2 EMR Adoption While the College does not have direct accountability for EMR adoption programs, it does actively support these programs. It is of concern to the College that adoption rates have plateaued in recent years in part due to funding instability and other factors. The College will continue to advocate for a comprehensive strategy to facilitate and/or incent physician adoption of EMRs. 4.1.3 Shared Control of Records An emerging model for shared control of medical records is the Information Sharing Framework between AHS and participating physicians (represented by the AMA). This model has physicians practising in AHS-operated ambulatory and outpatient clinics sharing a single patient record with other participating physicians as well as AHS staff. Participating physicians and AHS are each custodians of the patient record. The Information Sharing Framework is enabled by three agreements: an Information Sharing Agreement, an Information Management Agreement and an Information Exchange Protocol. These agreements enable physicians to meet the CPSA standards as well as their duties and obligations as custodians. As the longer term impacts of this model are still under review, further evaluation and consultation may be required regarding the College s role and the standards of practice for shared records. Page 9
4.1.4 Integration and Transfer of Information EMRs have benefits at the practice level. However, to achieve the ehealth vision the data collected in a medical record must be leveraged to enhance the quality and the continuity of care for the patient across the health system and enable secondary uses benefiting the health system. One challenge related to multiple EMR vendors is the need to convert data from one EMR product to another. Whether the conversion is driven internally (e.g., decision to change vendor) or externally (e.g., new vendor qualification process), the transition of records must be managed with the same degree of due diligence as the transition from paper to an EMR. Critical to the exchange and transfer of information are: common charting etiquette and protocols for EMR data standardized collection and coding of discrete EMR data elements, including the creation of supporting identifiers (i.e., prescription number, problem list identifier, etc.) to allow data from disparate sources to be reconciled and consolidated tools and support for system to-system conversions The College will do what it can to facilitate positive change in these areas. The current lack of transferability of data limits the movement of patient information from one EMR product to another, presenting a risk to both physicians and patients. This issue must be addressed, but is beyond the College s mandate. 4.1.5 Clinical Value and Appropriate Use Beyond the inherent operational benefits of EMR use, the broader goals are to enhance the standard of care within medical practice and across the health system. To ensure the technology delivers clinical value, the College is promoting the development of standards or a framework for appropriate use, including how the information in EMRs is collected and exchanged, and/or used to the populate the Alberta EHR. An example is the Meaningful Use framework recently established in the U.S. The Stage 1 objectives of this framework are to: electronically capture health information in a coded format use that information to track key clinical conditions and communicate that information for care coordination purposes implement clinical decision support tools to facilitate disease and medication management report clinical quality measures and public health information Stage 2 expands on criteria for disease management, medication management, support for patient access to personal health information, transitions in care, quality measurement and research, and bi-directional communication with public health agencies. Stage 3 focuses on achieving improvements in quality, safety and efficiency, with emphasis on decision support for national high priority conditions, patient access to self-management tools, access to comprehensive patient data, and improved health outcomes. The College believes that this kind of comprehensive plan, with appropriate incentives and sanctions built around it, is a good approach to system thinking in moving an ehealth agenda forward. Page 10
4.2 Electronic Health Record and Health Information Exchange The College has been an active stakeholder in the development of the Alberta EHR and supporting infrastructure, and continues to support the development of these key elements of ehealth. The Alberta EHR is seen as the preferred means of enabling appropriate access to and sharing of information to support the continuity of care and the quality of care. Key areas of interest include: systematic transfers of information from physician EMRs to the Alberta EHR computerized order entry communication via email or secure messaging support for eprescribing ereferral 4.2.1 Systematic Information Transfers from EMR to Alberta EHR For each project involving systematic disclosure of a physician s information to the Alberta EHR, the College will articulate a formal position of support (or concerns regarding the disclosure or use of information), operationalizing its mandate to prescribe the transfer of health information to the EHR. In the College s view, infrastructure that enables physicians to manage exceptions at the express wishes of their patients will be fundamental to any systematic disclosure from EMRs to the Alberta EHR. 4.2.2 Computerized Order Entry Computerized order entry is a valuable decision support tool incorporated into many EHR projects, particularly useful for the ordering (and subsequent tracking) of prescriptions, diagnostic imaging and laboratory tests. The capability to order diagnostic imaging and lab tests via EMR will provide physicians with a faster and more secure method of conveying these orders, as well as a mechanism to track whether or not the tests are performed. 4.2.3 Physician Communication via Email and Secure Messaging Email is an ubiquitous form of communication, and the College continues to advise physicians to be thoughtful in how they use email for patient communications and for exchanging patient information with third parties. However, public email is an inherently non-secure form of communication that presents risks for both patients and physicians. For ehealth to fulfill its promise, a secure method is needed for transmitting patient information between providers. Password protection is not secure enough; encryption is secure but awkward to set up and maintain; and current secure networks do not extend to all users. 4.2.4 eprescribing The Pharmaceutical Information Network (PIN) was the first operational component of the Alberta EHR. At present, PIN collects dispensing information from virtually all Alberta pharmacies on a batch basis. Authorized users of Netcare can access PIN to view any patient s history of dispensed medications. eprescribing will take this tool several steps farther. Once operational, PIN will allow a physician to prescribe directly from his/her EMR, and the prescription will be posted to PIN. When the Page 11
patient goes to their pharmacy of choice, the pharmacist will be able to access the electronic prescription, pull it down to the pharmacy system, dispense the prescription, then post the dispensing event back to PIN. Not only will the eprescribe system be more secure and less error-prone than the current paperbased system, but the physician will be able to track whether the prescription was filled and if any substitution or amendment was made. 4.2.5 ereferral The process of requesting a consultation by an appropriate specialist is a complicated one, and one that could be significantly facilitated by electronic tools. From locating a specialist with appropriate interests and expertise, providing sufficient and appropriate information to support the reason for the consultation, to facilitating the appointment process, to providing a medium for the consultation report, electronic tools and streamlined processes have much to offer. 5 CPSA Priorities 5.1 Support Professionalism in an ehealth world. The CPSA will ensure that time-honored principles of professionalism and ethical conduct can be supported in an electronic environment. The CPSA will: develop Standards of Practice and Advice for ehealth that reflect the Code of Ethics and professionalism promote professionalism in its participation in Netcare activities 5.2 Promote Physician Engagement in EMR and EHR Adoption The ehealth vision represents a significant evolution in medical records management and information sharing for physicians, patients and the health system as a whole. The transition to electronic information enables the re-design of workflows both within a practice and across the health system, as well as changing expectations for how health information is managed. Many EHR projects directly impact or are entirely dependent on physician participation. The CPSA will: promote and participate in the development of an overall strategy to engage physicians and promote EMR adoption continue to support physician and CPSA representation on EHR design teams and governance committees facilitate and support changes to care delivery models enabled by ehealth functionality 5.3 Develop a Framework for Clinical Value and Appropriate Use The CPSA will: promote and participate in the development of a framework that defines the desired outcomes of EMR deployment in Alberta, and links behaviors and systems to established EMR and EHR programs and objectives Page 12
promote the use of EMRs and EMR-assisted processes to enhance patient safety, quality to care and professionalism. 5.4 Balance Information Sharing with Patient Privacy The ability to apply express patient wishes to shared information is currently very limited (e.g., global person-level masking in Netcare), and there are no guidelines to help physicians or other providers determine when masking (or other special privacy protection) is appropriate. Respecting patient privacy and protecting the open exchange of information between patient and physician while developing the functionality and education to facilitate broader information exchange and interoperability is critical to maintaining the public trust. The CPSA will: provide guidance for physicians to manage patients express wishes regarding privacy, while enabling the appropriate sharing of information to the Alberta EHR continue to monitor data stewardship policies and procedures through its participation in the EHRDSC and ISF Governance Committee. Page 13