Thursday, January 31, 2008

Canadian Healthcare EHR

I participated on a panel at a conference in Canada last week that was thoroughly enjoyable on several levels, including skiing. :-) The conference was an international gathering, focusing on Canada's plans to deploy a national EHR and maximize the secondary use of clinical data for quality improvement and research. I found myself daydreaming, “If I had responsibility for leading the adoption of EHRs and secondary use healthcare data in Canada, what would I do? How would I approach the challenge?” Of course, I don’t pretend to understand the intricate details and issues in Canada which would impact an actual strategy-- but sometimes, naivety in situations such as this, is not a vice. The eyes of the innocent see fewer barriers, prejudices, and biases, I suppose.

These are the thoughts I summarized and shared with our Canadian colleagues:

Leverage the Early Adopters: There are usually three camps of physicians and their willingness to adopt an EHR-- (1) Those that pull technology into their practices and welcome EHRs into the care of their patients; (2) Those who are ambivalent; and (3) Those that strongly resist. I think none of us question whether EHRs will be used ubiquitously, but only question when that will occur in time. If the culture of Canada is not willing to be more pushy about the issue, then simply leverage the physicians in the first camp. Pull them closely into the CIHI/Infoway mission and team. Offer them hard and soft financial subsidies for early adoption of EHRs. Trumpet their adoption and hold them up nationally as role models. Eventually, the ambivalent and resistant camps will either be marginalized and/or acquiesce.

Educate the Patients: Inform and market the value of EHRs to patients by sharing anecdotes of EHR success with them in other healthcare systems, such as Intermountain, Sentara, Northwestern, e.g. Grab their attention first with metrics—e.g., number of avoidable patient deaths and safety events (this was the tipping point issue in America, initiated by the Institute of Medicine Study); cost of their healthcare now vs. later and how that tax money can be better spent on things such as health prevention, primary and secondary education, and the environment. In a recent poll in the US, 87% of patients said that they would be more likely to choose a physician who used an EHR in their practice than one who did not.

Data Tariffs and Financial Incentives: This is harder to execute in Canada, but money talks in healthcare. In the US, the Federal government is rewarding physicians under a “Pay for Performance” (P4P) program in which physicians submit de-identified clinical data in a standardized format to a national data warehouse. This data includes indicators which suggest that best practices in chronic disease management are being followed by the physicians. Technically, an EHR is not required to submit the data. It can be hand-abstracted and manually entered in the Federal database, but realistically, it’s not possible without an EHR. In return for submitting this data, the Federal government provides higher reimbursement rates for treating patients with chronic diseases. This P4P model is not economically extensible—i.e., if suddenly every physician in the US participated, healthcare costs would actually go up due to the higher reimbursements. However, at this stage, it is having an impact, if nothing else, as a portending gesture of the future. There are similar models being adopted and piloted under private payers, too. In the UK presentations, I noticed that they use a tariff-based system, which is a more extensible long term economic model and does not drive up costs. If physicians do not submit their data in a complete and timely fashion, they are taxed at a higher rate.

Physicians, Airline Pilots, and Generational Issues: At one time, airline pilots ruled the airline industry. Flight schedules were actually scheduled around the conveniences and preferences of the pilots. They commanded huge salaries and pensions. It was the most sought-after profession in the US. In 1978, airlines were "deregulated" by the US government, essentially removing the barriers to competition and free market efficiencies. Competition ensued and suddenly the pilots weren’t the tail wagging the dog of the airlines anymore. A few years earlier, anticipating the impending deregulation, Lamar Muse started Southwest Airlines and completely changed the nature of the business. Southwest hired pilots under a completely new set of expectations. The passenger’s value and convenience were the most important priority, not the pilots’. The rest is history. Pilots in Southwest Airlines now participate in any activity, including baggage handling and trash pick-up, which make Southwest more attractive and efficient to the paying passengers. With this new generation of Southwest pilots and airlines, the expectations across the entire industry have changed, though the pain of change is still not over in the older cultures such as American Airlines and Delta. I see the same inevitable events in the case of healthcare. Our medical students and residents have a completely different set of values on issues such as patient involvement in their care plan and patient conveniences, and in particular, the role of an EHR in modern healthcare. I oversimplify here for the sake of dramatic effect, but the younger physicians ask of me, “Where is my EHR?” The older physicians demand, “Don’t bother me with your EHR” (of course there are numerous exceptions to this stereotype, so don't be offended). The younger physicians disdain healthcare settings which are not computerized. They would no rather admit to paper medical records than admit to their friends with iPods that they still listen to 8-track tapes—not cool. Culturally, paper-based records are not an acceptable option anymore to this generation. I think, unless Canada is willing to push the issue harder, you may face a timeline of EHR adoption that requires a generational turnover before rapid progress can be achieved. The cultural and political pressure on US healthcare to become more computerized is much higher than in Canada, I sense, and our adoption rate is ramping up.

The Tao of Buy-In: Sometimes, I would rather be a philosopher than a CIO in healthcare, but reality being what it is, I have to blend the two together in order to eat. When I sense resistance against a fundamentally sound project or idea, rather than increasing my efforts at buy-in, I reduce them. I assume a low-profile, and slowly chip away at the project quietly, while acquiring key buy-in when it comes easy-- but I take the project off the radar screen. Often times I have found that the suspicious side of human nature becomes even more suspicious when attempts to achieve buy-in become more intense. It’s the same phenomenon in romantic relationships, right? Sometimes, the harder you chase and court a mate, the more suspicious that mate becomes that you are desperate for love, and must therefore suffer from some sort of hidden character flaws or dreadful disease which make you generally unattractive to others. As a Taoist philosopher would say: In order to achieve maximum buy-in, be less convincing. Try less to achieve and simply do.

Canada’s Unique Opportunity: Canada is in a truly unique opportunity to achieve in clinical data collection, management, and analysis—more and better than any other country in the world. You are standing at the brink of opportunity in which you can apply all the right and wrong lessons from other countries to achieve incredibly more effective solutions. You have the culture and the economy to do it right.

Engage the Employer Groups: Ultimately, as I mentioned in my presentation, the employer pays for either good or bad healthcare in the form of a productive—or unproductive—workforce. Employers know this, too, but struggle for a place to gain a foothold of influence, I suspect. Reach out to them from CIHI and Infoway. Look for opportunities to work directly with employers to flex their economic muscle and engage physician adoption of EHRs and secondary use of healthcare data. I need to learn more, but it sounds as if you have a model of this in Group Health?

Leverage and Publicize Early Victories: There are clearly pockets of success in Canada. I heard numerous stories. These stories need to be collected and publicized—treat them like a commercial marketing plan or a political campaign strategy.

Make this a National Issue: I agree that a national EHR will not likely reelect a Prime Minister on its own merits, but it can play a major role. In the US, the voting population is disillusioned with the high cost and the poor quality and safety of healthcare. The populace is also, now, reasonably well-informed about the poor state of computerization in healthcare and how EHRs and secondary use of data can help reduce costs while improving quality. Numerous news articles in print and TV have helped enormously with this education. As a result, computerization of healthcare in the US is now a nationally recognized issue and a major part of every political campaign strategy. The topic of EHRs in healthcare even made it into President Bush’s State of the Union speech last night. With the right sense of Federal charisma, leadership, and education of the populace, Canada can make this a national issue and push the adoption of EHRs along faster. Access to care will, in fact, improve over time with the expanded utilization of EHRs in Canada. As the population’s health is better managed, patients will place fewer demands on the bottleneck areas of providing care.

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