Implementing Electronic Health Records

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Created in 2001, Canada Health Infoway (Infoway) is the federal agency charged with assisting the provinces to implement electronic health records (EHR). In 2003, Infoway established an objective of providing 50% of Canadians with EHRs by 2010. It is now clear that the goal will not be reached. Infoway and the provinces have encountered a variety of issues which have impeded progress.

Recent developments

Since its creation in 2001, Canada Health Infoway has been allocated $2.1 billion dollars from the federal government for fullfilling its mandate to accelerate the development and adoption of modern systems of health information in Canada. As well, Infoway's mandate  included defining and promoting standards governing electronic health infostructure to ensure interoperability. The mandate has been translated into a goal of covering 50% of Canadians with EHRs by 2010. 

The goals of the pan-Canadian approach to  implementing EHRs for Canadians are:

* Ensure the ERH elements are built with consistent standards, thereby enabling future interoperability within and across jurisdictions and simplifying the movement of knowledge and people across jurisdictions;

* Serve as a catalyst for new infostructure developments and ensure common platform quality across all jurisdictions;

* Where possible, encourage cooperation, thereby eliminating redundancy and duplicative efforts in systems design, vendor negotiations, etc.;

*Reduce long-term costs and implementation time by leveraging scale and cross-jurisdictional knowledge (Canada Health Infoway 2007).

Canada has taken a "hub and spoke approach" of collecting and storing information and making it available to eligible users.   A hub and spoke approach means that records are kept in a central repository and are available to all eligible users. The UK, Norway and  the U.S. Veterans Administration have also adopted this approach.  It has the advantage of enabling on-demand accessing of information by practioners.  But it can encounter greater resistance from providers because they do not maintain their own data systems.

But perhaps the most unique aspect of the pan-Canadian model is the strategic investor role of Canada Health Infoway. Federal investment in provinicial health IT development is tied to achievement of specific implementation steps. Funding allocations are based on the potential for success and conformity with agreed to standards. Moreover, Infoway uses a shared funding and governance model  with the governing board composed of stakeholder members, including deputy ministers of health from across the country. This model is appropriate in a confederation like Canada  requiring pan-Canadian cooperation to implement large scale projects  with shared federal, provincial and territorial features. According to a recent review of the Canadian model, it has a number of important advantages:

• it allows pan-Canadian priority setting in a "depolitized" environment,
• creates a sense of urgency and competition for funds which can spur provincial and local investments,
• focuses on delivering value for money,
• facilitates jurisdictional participation andhelps to ensure that local jurisdictional priorities are aligned with national ones,
• helps to facilitate coordination around procurement, ensuring that funding decisions are based on a rigorous assessment of proposals, and
• sets clear jurisdictional accountability for deliverables (Canada Health Infoway 2007). 

Recently, Infoway has acknowledged that the goal of covering 50% of the population with EHRs will not be reached.    In spite of widespread support among providers and the public for EHRs a series of new developments have impeded progress.  From the begining, it was clear that the federal government would have to make incentive funds available to the provinces to encourage implementation of EHRs. The federal government embraced that role but has made new funding available on a relatively slow basis.  In the summer 2009, the federal government indicated that it was delaying until the 2010/2011 fiscal year, an allocation of $500m which had been promised for this fiscal year (Health Edition 2009). .  To date Health Infoway has been awarded $1.9b; the estimated full cost of Canada-wide implementation is $10-12 billion. 

Second, implementation scandals in several large provinces (Ontario and BC) came to light in the summer 2009 (see below Implementation). 

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
current    previous

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers

• Patients, Consumers

• Private Sector or Industry

• Media

Stakeholder positions

Stakeholders ranging from the federal, provincial and territorial governments, political parties and provider groups such as the Canadian Healthcare Association, and the Canadian Medical Society, and the College of Family Physicians of Canada have been supportive of implementing EHRs.  EHRs are viewed are as improving quality of care and accountablity.  For example, the Canadian College of Family Physicians views EHRs as "essential to patient care within the primary care system" (College of Family Physicians of Canada, 2007).   At the annual meeting of the Canadian Medical Association in 2009, delegates  passed resolutions in support of EHRs and called on the federal government to release the promised $500m for Infowaty this year (French, 2009).  Back in 2001,The Canadian Association of Emergency Room Physicians recommended that electronic records be implemented in all emergency rooms (Canadian Association of Emergency Room Physicians, nd).

Having said this, it has been harder to reach out to physicians than to large health delivery organizations such as hospitals.  Physican groups have expressed concerns that they be reimbursed for hardware, software and training.  Ensuring patient privacy is also an issue but primary care physicians are also concerned that laws safeguarding privacy apply to provider as well as patient data (College of Family Physicians of Canada, 2007).  

Patient groups and the public have not raised concerns about privacy in any substantial way.  Canada has strong patient privacy legislation and perhaps having that legislation already in place is reassuring to most of the public.

Actors and positions

Government
federal, provincial and territorial	very supportive		strongly opposed
Providers
Canadian Medical Association	very supportive		strongly opposed
Canadian Healthcare Association	very supportive		strongly opposed
Patients, Consumers
patients and consumers	very supportive		strongly opposed
Private Sector or Industry
EHR hardware and software providers	very supportive		strongly opposed
Media
national newspaper	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

NA

Legislative outcome

n/a

Actors and influence

Government
federal, provincial and territorial	very strong		none
Providers
Canadian Medical Association	very strong		none
Canadian Healthcare Association	very strong		none
Patients, Consumers
patients and consumers	very strong		none
Private Sector or Industry
EHR hardware and software providers	very strong		none
Media
national newspaper	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

Implementation has been a shared responsibility of Infoway and the provinces and territorities.

Having developed a model, Infoway has approved almost all of the $1.6 billion that had been allocated by the federal government by the end of 2008. Another $500 million was committed by the federal government in  the 2009 budget,  but now has been delayed until the beginning of the 2010/11 fiscal year The estimated total cost of implementing a complete interoperable health information system is expected to range from $10-12 billion.  No information is available on total provincial contributions to date, but Ontario alone has spent at least $1billion.

Progress has been made: pan-Canadian standards  have been in areas such as interoperable health records, clinical information, SNOMED (a clinical terminology that facilitates the interoperability of electronic health records), laboratory messaging, and nomenclature have been made available for solutions. Infoway has developed a Standards Collaborative which aims to encourage wider adoption of standards. As well, privacy issues are being addressed in a privacy forum which acts as locus of exchange about privacy issues and resolutions across the country. In 2009, Infoway launched a new certification service which ensures that  consumer solutions provide adequate privacy and security provisions and are interoperable with existing components of the EHR infostructure  (Canada Health Infoway, 2009). 

With regard to two main goals which were expected to be achieved by 2010, partial progress has been achieved. The most widely publicized goal was that 50% of Canadians would have electronic health records by 2010. The Infoway annual report for 2008/09 indicated that the core components of an EHR will be in place for only 17% of Canadians by 2010. A second goal for 2010 was that Canadians in every province and territory will benefit from new health information systems. Infoway expects that this goal will be achieved because in every jurisdiction at least one element of HIT infostructure will be in place (Canada Health Infoway, 2009). 

Infoway acknowledges that a number of issues have affected progress to date.  They include: costs constraints, different starting points and varying priorities among jurisdictions, the limitations of natural project sequencing, human resource constraints, and the time required to implement change management strategies. 

There are many examples of specific projects that have been implemented in jurisdictions. Some of them can be found on the Infoway website.

Jurisdictional progress has been uneven. In 2007, Infoway projected that by 2010, only 3 (Alberta, Prince Edward Island and the Northwest Territories) of the 13 jurisdictions will have full interoperable EHR infostructure in place. British Columbia and Quebec were well underway toward achieving the goal of enabling providers to retrieve a unique patient record within their regions. Ontario, Newfoundland, Manitoba and Saskatchewan are further behind and require more funding. New Brunswick, Nova Scotia, the Yukon and Nunavit require more time and more funding. In every province there has been slow progress in improving physician use of EHRs (Canada Health Infoway,2007).

The story of provincial implementation has been particularly interesting in Ontario.  Ontario is one of the most influential (largest population, usually the wealthiest) provinces but has not been a leader in implementing EHRs. The province began by creating an independent agency, Smart Systems for Health, which was to create the groundwork for implementing new digitized systems.  Although Smart Systems for health was successful in accomplishing that goal, it was perceived by the public and the government as not accomplishing enough. The government then created a new organization, eHealth Ontario, in 2008, to lead Ontario's development of EHRs. In 2009 the Office of the Auditor General published a widely leaked special report on Ontario's experience to ward the goal of providing EHRs for all Ontarians (Office of the Auditor General, 2009).

Amid widespread publicity, the report described delays by the Ministry of Health and Long-Term Care in making information available, procurement scandals in the form of large contracts being awarded in violation of government procurement policies and procedures, and alledged favoritism toward certain providers with senior staff with personal and political connections with the government.  The auditor leveled the harsh criticism at staff of the Ministry of Health and Long-Term Care who did not follow government procurement policies in contracting with as many as 300 consultants and did not provide adequate oversight of the outcomes of EHealth's activities (Howlett 2009c).

The publicity led to firing of the eHealth CEO, and the resignation of a number of Board members, including the Chair (Howlett, 2009b; Picard 2009) and culminated with the resignation of the Minister of Health and Long-Term Care (Howlett 2009b). The Auditor's report, publicized by the media in front page stories and on the evening news, was very critical of the amount of money spent to date in Ontario (over $1 billion) with relatively little progress to show for it (Picard, 2009; the Canadian Press 2009; Ferguson, Talaga and Benzie 2009). For example, over $800m was spent on one network that is used at 1% capacity (Radwanski, 2009). 

British Columbia also encountered implementation problems.  In October 2009, the provincial Auditor General indicated that a report on B.C.'s implementation of EHRs was underway.  Meanwhile the Royal Canadian Mounted Police (RCMP) was conducting a fraud investigation concerning the province's former top ehealth bureaucrat and other officials.   Charges have not been laid but the some of those being investigated were placed on mandatory leave.  Software companies have also raised questions about the openness and transparency of the ehealth bid processes.  One company formally complained to the Minister of Health (Meissner 2009).

All provinces are expected to submit auditor's reports to the federal government by next spring. It could be that other provinces have experienced similar problems as Ontario and B.C.(The Globe and Mail, 2009). 

In the early fall, 2009 it was also announced that the federal auditor general was conducting a review of Health Infoway.  That report is not yet completed.

 

Monitoring and evaluation

The Health Council of Canada has been charged with  monitoring progress towards implementing EHRs in Canada. In 2008, the Council stated "Change is underway but too slowly" ( Health Council of Canada, 2008). As of March 2008, the Council  reported that 7% of Canadians have an electronic health record, 64% of all diagnostic images taken in hospitals and clinics are digital, 30% of published lab tests are available to providers electronically, and 24% of Canadians benefit from drug information systems that provide their physicians and pharmacists with a personal medical profile (Health Council of Canada, 2008). While recognizing these achievements the Council has been critical of the slow pace of progress.

Expected outcome

Eventually Canadians will have EHRs; there is strong public and jurisdictional support for new technology in health care. Jurisdictional governments are convinced that investments in EHRs will improve safety and quality as well as save money in the long run. However there are clear barriers to faster progress:  funding has been limited; progress has been spotty in reaching out to Canada's physicians (94% of physican records were paper based in 2007); and there is a limited supply of experienced health information technology managers in the country.

There has been speculation in Ontario that over-reliance on the expertise of technology consulting firms, combined with pressure to produce results, led to the overspending and lack of results in the Ontario (Globe and Mail, 2009). It now seems clear that in Ontario and BC there was a lack of oversight. 

To increase the pace of progress, the CEO of Infoway indicated that achieving the benefits of EHRs requires time and money (Alverez, 2009). There is no doubt that greater public awareness and support could result in increased pressure on governments to make the money available. But as the example in Ontario shows, poorly managed projects  result in negative publicity, wasted resources and further delays. 

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

References

Sources of Information

• Alverez, R . (2007). If Canadians want to realize the benefits of electronic health records, it is up to the public to demand them.  The Globe and Mail.  Special Information Supplement.
• Canadian Association of Emergency Room Physicians. (nd). Informatics and the Elelectronic Health Record.  Available at www. caep.ca
• College of Family Physicians of Canada ( 2007). Electronic Records. Retrieved from www.toolkit.cfpc.ca
• Canada Health Infoway (2009).  Building  a Healthy Legacy Together.  Annual Report 2008/2009. www.infoway-inforoute.ca
• Canada Health Infoway.(2007) 2015:  Advancing Canada's next generation of healthcare.  www.infoway-inforoute.ca
• Globe and Mail. (2009). The menance of 'scoop creep'. Editorial.  October 8, 2009.
• Ferguson, R., T.  Talaga and R.Benzie (2009). EHealth operation bled $1B.  The Toronto Star. Wednesday September 30.
• French, J. (2009) Doig urges physicians to move toward electronic health records. The Star Phoenix. August 20. www.thestarphoenix.com/health
• Health Council of Canada (2008). Rekindling reform: health renewal in Canada, 2003-2008.  www.healthcouncilcanada.ca
• Health Edition (2009). Federal money for Canada Health Infoway delayed. Vol 13, No 39. www.healthedition.com
• Howlett, Karen. (2009a). eHealth Ontario's board loses two top directors: resignations precede auditor's report.  The Globe and Mail.  Thursday, September 24.
• Howlett, Karen (2009b). McGuinty forced to shuffle cabinet after health Minister resigns.  Front Page. The Globe and Mail October 7.
• Howlett, Karen. (2009c). Ranks of high-priced consultants swelled at eHealth, report finds.  The Globe and Mail.  Monday October 5.
• Meissner, D. (2009). B.C. A.G. conducts e-health review amid scandal allegations. The Canadian Press. October 18. www.news1130.com
• Office of the Auditor General. (2009). Ontario's Electronic Health Records Initative. Special report. October. Queen's Printer. Toronto.  
• Picard, Andre. (2009)  The real eHealth Ontario isn't over Choc Bites.  The Globe and Mail. August 11.
• Radwanski, Adam. (2009). After eHealth, McGuinty's fear of scandal threatens to paralyze him. The Globe and Mail. October 8. Front page. 

Reform formerly reported in

Canada Health Infoway Process Stages: Evaluation

Author/s and/or contributors to this survey

Margaret MacAdam, Ph.D. Senior Fellow for Health

Suggested citation for this online article

MacAdam, Margaret. "Implementing Electronic Health Records". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/ca/b14/4