The Dangerous decade:

Challenges for builders of national health

information systems

Enrico Coiera

e.coiera@unsw.edu.au

Setting the scene - a dangerous decade

• Over the next 10 years we will build and deploy more ICT

in the health system than ever before in history.

• These systems will be larger, more complex, and see a

shift from local/regional to national/supranational scale.

• The costs and benefits of such systems have major

implications for national GDP and accounts.

• The demands for health system modernization are so

compelling that we have no choice but implement nation-

scale health IT (NHIT).

• Yet we are at the same place in industry maturity as

aviation in the 1950s.

• The risks of failed or delayed implementation, cost over-

runs, and safety risks are still too real.

The two core problems we are trying to

solve

1. Sustainability

2. Safety and Quality

The Sustainabilty Funnel: when demand

for resources and supply diverge

Australian Population Growth and Aging

Budget Papers 2002/03: Intergenerational Report

85+

65-84

•In 2007, 13.4% +65,

and 2047, >25%

[87% increase]

•Very old (+85) rises

from 1.7% to 5.6 %

[329%]

Projected Australian Commonwealth

Health Spending

Budget Papers 2002/03: Intergenerational Report

•In 2007, 3.8% GDP

•In 2047 7.3%

[92% increase]

Ageing -> 25%

growth, rest is new

technology and drugs

A shortage of health workers today

Source: Dean, D; AHA Conference 2001

Dependents as % working age populationIn 2007 5 people of working age support every person aged >65.

By 2047, will only be 2.4 people.

Budget Papers 2002/03: Intergenerational Report

Child

Aged

Combined

Average Annual Income Tax Paid, by Age Group

WORKERS

Safety and quality

• 10% of admissions to acute care hospitals are

associated with an adverse event (ACSQHC 2001).

• About 2% of separations associated with serious

adverse events causing major disability (1.7%) or

death (0.3%) (Runciman et al. 2000).

• 1 million general practice encounters each year in

Australia involve an adverse event (AIHW 2008)

• Adults receive recommended care just over half the

time (55%) and children just under half the time

(46%) (McGlynn et al., 2003)

Adherence to quality indicators according to condition

(McGlynn et al. 2003)

In 2020 the health system will have to

• … treat proportionately more people

• … with proportionately more illness

• … to a higher standard of safety and quality

• … in a more evidence-based way

• ... with relatively fewer tax dollars

• … and proportionately fewer workers

MAKING THIS HAPPEN IS THE PROBLEM WE NEED TO SOLVE

How will we do this?

• In 2020, each clinician cares for more patients than today, more effectively, because:– Some burden of care shifts to the consumer (new

tools, new skills, new norms)

– Some burden of care shifts to new clinical roles

– Some burden of care shifts to smart machines

– Our services and systems are safer and more effective because they are purpose „designed‟, not inherited and patched up

– Many of the innovations are unimagined today (remember Gaudi!)

E-health can help improve system sustainabilty

and patient safety

• Gartner (2009) report provides many examples where E-health:

– Improves patient safety (eg reduce prescription, medication errors, avoid ADEs)

– Improve clinical efficiency (eg reduce duplicate tests, or admissions via home monitoring)

– Help clinicians care for more patients (e.g. EMR, CPOE reduce length of stay)

– Helps burden of care shift to the consumer (e.g. electronic messaging reduces GP visits by 10%)

Strategy: How do we make it happen?

Case study 1: English NHS NPfIT

• World‟s largest civil IT project, £13 billion over 10 years to improve services and quality of patient care

• NHS is a nation-scale, single-payer health system

• Adopted a top-down strategy for system architecture, standards compliance, and procurement

• Many notable wins but also plenty of setbacks, clinical unrest, delays, cost overruns, paring back of promised functionality. Hospitals a problem.

• Demands from political quarters to shut it down : “Conservatives pledged to cancel the programme …Liberal Democrats described it as "a disaster … from the start.” BMJ 28 Jan 2009

Problems with top-down strategies

• One size doesn‟t fit all.

• No easy migration plan. Non compliant systems shut down and replaced even better fit local needs.

• Imposed redesign is expensive, wasteful, generates disaffection. Staff retraining/workflow adjustment can introducing errors.

• Long delay until ROI means „stuck‟ with ageing systems and technology despite significant changes,i.e. more brittle to change.

• To meet emerging needs service providers will build work-arounds, adding “unwanted” local variation tosingular national design.

Case study 2: US HIEs

• Pre American Recovery and Reinvestment Act (ARRA), US

embarked on a bottom-up strategy to NHIS development.

• Service providers form coalitions to interconnect existing

systems into regional health information exchanges (HIEs).

• Preserves existing systems. New technologies, system designs

can be adopted locally where is need and capacity

• Standards not mandated but adopted on a business needs

basis. Little central intervention.

• Does not create a single central record, but allows remote view

of local records, perhaps abstracted or aggregated regionally.

• Expectation that Regional HIEs eventually aggregate into a

nation-scale system.

Variable HIE success

• Indiana HIE - www.ihie.org

– Based on Regenstrief Institute EHR

– Connects 39 hospitals, 10,000 physicians and

> 6 million patients

– 85 primary care providers, 20 locations

– securely aggregates and delivers lab > 5

million results, reports, medication histories,

and treatment histories regardless of system

or location

• Other successes e.g. Massachusetts (maehc.org),

Spokane (inhs.org).

• Less e.g Santa Barbara County: combination of

technical, leadership, and funding (Miller,2007;

Brailer, 2007), NE Pennsylvania (Robinson, 2007),

Oregon (Conn, 2007).

Problems with bottom-up strategies

• Cannot predict how expensive or feasible it is for a local system to interface with an HIE.

• Cannot predict how much information is available to other providers.

• Incompatible data models may make reconciling information across different systems arbitrarily complex.

• Unlikely to be aligned with national policy goals.

• The price for preservation of local systems is a weaker national system, which may have data holes, and data quality problems.

• Business model unclear

Middle-out: A third way

• Need to acknowledge government, providers have different starting points, goals and resources.

• All come together to agree on common NHIT functions, standards, strategy.

• Providers then bring existing systems up to national standards e.g. customized interfaces or make new purchases standard compliant.

• End product has rich capability for information sharing, resilient over time, preserves what works.

• Allows government to pursue policy goals.

J Am Med Inform Assoc. 2009;16:271-273.

Middle-out: Government‟s role

• Define policy framework to converge public and

private, local and central systems into a functionally

national system.

• Fund public sector to join the NHIS.

• Incentives for private sector where the business case

is weak but national interest is strong.

• Develop public goods e.g. standards, broadband,

health informatics workforce, evaluation of progress.

• Legislation to protect privacy and interests of citizens.

• Avoid as far as possible what it is not good at, like

designing, buying or running IT.

The Dangerous Decade

Strategic Risks (1)

• HIT safety:

– Emerging data about risks associated with rushed

implementation, poor training, software performance.

– We are yet to experience our first HIT ‘air crash’

– Safety is a systems issue and software is just one

component of the socio-technical system

– Standards needed not just for technology (e.g. HL7) , but at

services level (system functions), implementation quality

(certification of process quality) and for the hands of users

(certification of competence)

– Routine monitoring of IT related safety incidents should be

mandatory as should rapid response to incidents

Strategic Risks (2)

• Expectations: “Past performance (in one setting)

does not predict future performance (in another):

– HIT Centers of excellence often used as benchmarks for

outcomes, but often have home-grown solutions, developed

incrementally over decades, with large resource including

academic informaticians and IT staff (e.g. >200 at Partners)

– Industry solutions are usually implemented entirely

differently, from generic packages, with little local expertise

available, and ongoing monitoring and modification.

– Need to base expectations upon robust outcomes at the

bottom, not the top!

Strategic risks (3)

• Solving the wrong problem:

– An "EHR first" strategy will miss easy wins to demonstrate success, keep political momentum, preserve end-user buy-in, build public confidence.

– What is ROI for a fully shareable national record vs regional systems, viewable nationally?

– Easy wins? Web-based knowledge services, decision support (e-psychiatry), electronic prescribing, home monitoring, online bookings,discharge summaries, personal health records.

Summary

• We are in the exciting, but not risk free, decade of heath IT

• The two core problems we are trying to solve are health system sustainability, and safety and quality

• Top down and bottom up strategies for building national health information systems have had mixed success

• There is a third way, middle out, bringing together jurisdictions, consumers, health service providers and clinicians, to agree on „meaningful use‟ and eachcontributes what they are most expert at.

Thank you

e.coiera@unsw.edu.au