lessons learned (and being learned) in the implementation of ehr in british columbia

Lessons learned (and being learned) in the implementation of EHR in British Columbia

Overview

• Government run single-payer health insurance scheme has provided BC with advantages in the development of health data repositories – data been leveraged for policy and process development and

research/quality improvement • Efforts underway across the province to integrate electronic health

systems into the healthcare setting – have highlighted advantages in having an already establish publicly funded

system– also face similar hurdles that exist independent of single-payer system

• Purpose today is to provide a very high-level overview of the single personal health number and data landscape and impact on EHR implementation

Privacy• Legislation• Interpretation of

law• Gov. enablers/

restrictions

Process• Access Model• Permissions• Decision support

Technology• Design • Function• Data capture

Data Access Integration Pillars

Healthcare Policy Framework

Federal Governance• Canada Health Act – establishes criteria and conditions that

provincial health law must meet to receive federal transfer payments

Provincial Governance• Medicare Protection Act and Regulations – publicly managed

and fiscally sustainable health care system for BC in which access to necessary medical care is based on need and not individual’s ability to pay

• Pharmaceutical Services Act – government authority to set pricing

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Federal Legislation• Canadian Charter of Rights and Freedoms • Privacy Act • Personal Information Protection and Electronic Documents Act (PIPEDA)

Provincial Legislation• Freedom of Information and Protection of Privacy Act (FIPPA)• Personal Information Protection Act (PIPA)• E-Health (Personal Health Information Access and Protection of Privacy) Act

Public • Provincial government institutions • Health Authorities, Hospitals, Community Healthcare, etc.

Private• Private sector organizations• Private doctor’s office

Privacy Legislation – collection, use, and disclosure

• FIPPA s. 26 states that a public body can collect information directly from an individual if it relates directly to a program or activity of the public body

• FIPPA s. 32 states that a public body may use personal information in its custody or under its control if consistent with the purpose collected or if consent is obtained– Disclose within Canada – Reasonable and direct connection – Necessary for performing statutory duties or for operating

a program or activity of the public body

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Privacy Legislation – disclosure for secondary use

• FIPPA s. 35 a public body may disclose personal information in its custody for research purpose if– The research cannot be reasonably accomplished unless the information

provided is identifiable – The information will not be used to contact a person to participate in

research– Any data linking is not harmful to the individuals and is in the public interest – The head of the public body has approved

• security and confidentiality• Removal and destruction of identifiers at earliest time reasonable• Prohibition on subsequent use without express authorization from public

body– Person receiving data has signed an agreement to comply with approval

conditions and this act7

Privacy Legislation – Lessons Learned

• We rely on one piece of legislation , however it has been interpreted in a multitude of ways, slowing or preventing the sharing of data – Different requirements by each health authority to meet

FIPPA standards– Data linkage between public bodies has been stalled by

determination over who owns the data and who should promise what before it is disclosed

• This has impacted research and quality improvement• Need clarity in requirements

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Privacy Legislation – Lessons Learned

• It has been expressed to government that there is a need for healthcare specific legislation, as has been the case with– Public health related information which has been facilitated by

the mandate under legislation to report;– The BC Cancer Registry disclosure of data because it was created

with a mandate to facilitate research;– The disclosure of lab data under eHealth Act

• Other provinces have already moved to this with varying levels of additional benefit over BC’s current framework

• Advocate the need to reinterpret “purpose” to include research, QI, and population and public health

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restrictions




Healthcare IT

• Shift in BC to electronic health records is ongoing – private physician offices have excelled at this whereas health authorities are slowly coming onboard

• Focus has been on integrating systems across the province

• Purpose is to provide real-time data and increase patient safety

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The BC Context

The BC Context

• Medical Services Plan (MSP) is BC’s provincial health insurance plan

• Mandatory for everyone in the province for 6 months or longer

• Covers physician and hospital services• Prescriptions are covered by PharmaCare or private

insurer

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One Personal Health Number

• MSP links to one personal identifier – Personal Health Number (PHN) (CareCard)

• In 2013, shift to BC Services Card = CareCard + Drivers License

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Enterprise Master Patient Index (EMPI)

• Initiative supported by the BC Ministry of Health (MoH)• Database used to maintain consistent, accurate, and current

demographics • Leverages PHN to clean up duplicative records and ensures updates

to patient information is up-to-date• Solves the problem where multiple systems across the organization

become inconsistent with patient’s most current data – one system is updated and that information is not reflected in other systems

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Enterprise Master Patient Index (EMPI) - Advantages

• Client safety• Fewer duplicate and overlay records• Save money on repeated lab or medical imaging tests• Staff can query, retrieve, and update EMPI in real time• Validate MSP eligibility to ensure proper reimbursement • Changes to client identity information in EMPI from

anywhere in BC will automatically be updated in electronic record

• PHN for new patients (babies, non-residents) automatically generated

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What does this mean for patient care?

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Complete patient file

Lab results from

LifeLabs

Specialist in

Vancouver

ER visit in Dawson

Creek BC

Clinical & System Transformation

• 3 Health Organizations will be implementing EHR – Selected Cerner platform

• In alignment with MoH strategic priority requiring all health authorities to rationalize and standardize their clinical information systems to Cerner or MediTech

• Over 42,000 staff, providers, students, and non-employees will be impacted and require education

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Why are we doing this? Evidence-based clinical practices and order sets as standard

Powerful new shared clinical information system

Computerized provider order entry

Closed loop medication management

Electronic clinical documentation

Clinical decision support

CST spans across several

areas of the continuum of

care including:

acute care inpatient and

outpatient units,

ambulatory care and

residential care across

VCH, PHSA and PHC.

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The diagram below represents the phased rollout of the new clinical practices and clinical information systems across VCH, PHSA and PHC.

Phase 3: Implementation 2015 – 2018

1. View radiology images and reports from all Provincial Health Authorities

2. View lab results from BOTH private and Health Authority labs

Province Wide Data

• BC Renal Agency – PROMIS– Patient Records and Outcome Management Information System

• BC Cancer Registry– Information on all cancers diagnosed for BC residents

• BC Centre for Disease Control – Panorama– Public health information

• Perinatal Services BC - BCPDR– BC Perinatal Data Registry database containing clinical information on all births

collected from obstetrical facilities• Cardiac Services BC – HEARTis

– Provincial cardiac information system with clinical and demographic info on every cardiac procedure within BC’s system of cardiac care

• Provincial Laboratory Information System (PLIS)– Provide lab tests online for healthcare and reduce lab duplication

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Public Health Surveillance - BCCDC

• BCCDC supports surveillance, detection, treatment, prevention, and consultation

• Panorama provides up-to-date information – Immunization– Family health– Communicable disease case management– Outbreaks– Notifications– Work management– Vaccine inventory

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Panorama

Fraser Health

Authority

Interior Health

Authority

Vancouver Island Health

Authority

Northern Health

Authority

Vancouver Coastal Health

Authority

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Healthcare IT Hurdles

• Data quality – questions that we are struggling with – What data will be captured? – What data will be masked?– Will data be structured or unstructured?– Who should decide above – provider, staff, decision support,

etc? • This is more than a technical decision, it often has resulted in

a shift in how we view healthcare– Technical decision will impact patient care but also impact

decision support possibilities

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Healthcare IT Hurdles

• Education plays a significant role in data accuracy • Continuation and integration of legacy systems is a struggle,

particularly when we are facing hundreds of systems integrating into one new platform

• Over 500 policies are required to support the change across the 3 health organizations to support the change in the clinic– In addition to EHR platform, device choice impacts clinical workflow – Same language required for one EHR platform – acronyms, ICD, etc.

• Have yet to address how data will be queried, aggregated, or de-identified

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Healthcare IT– Lessons Learned

• Often technology per se is not a limiting factor assuming there is a substantial budget

• What has been a struggle has been determining how the data will be captured and how legacy systems will be dealt with

• Involving decision support, researchers, and clinical informatics in the development of the build of the system is something we have done to ensure that the needs of researchers and QI are represented and then able to be leveraged for a data warehouse

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restrictions




Processes

• Introduction of EHR has impacted multiple processes, often without consideration ahead of time– Access model– Provisioning of access– Education and training– Clinic workflow

• Impact on secondary use of data often an afterthought – S.35 FIPPA requirements in relation to EHR – Transition from paper to electronic systems for both clinical

studies and retrospective review

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Data Access for Secondary Use

• Rich data source available because of provincial mandates, PHN, and shift to electronic records

• Access is regulated by provincial privacy legislation• Interpretation of access under FIPPA has varied both in

substance and in process– Inconsistent interpretation of clinical trials patient care or

research– Results in untimely access and increased risk of inappropriate

access– Clarity around roles of data stewards and access processes is

needed

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Population Data BC

• Individual data sets on health, education, early childhood development, workplace, and environment

• Individual-level information that is linked using PHN and de-identified for policy-making, qualitative improvement, and research

• Health data available– MSP– PharmaCare– Discharge Abstract Database– Home and Community Care– Mental Health– BC Cancer Agency– PharmaNet

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Process – Lessons Learned

• Often forgotten by parties in the transition to EHR, however, necessary for the success of these platforms

• Requires new groups to collaborate– IT– Informatics– Research – Privacy – Health records– Clinical staff– Clinical educators

• Must keep in mind the end user and patient care when developing these processes

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restrictions




Summary Lessons Learned

• Privacy, process, and technology must work together, not in parallel

• Having the technological capacity does not necessarily result in a successful integration, privacy and process are required to support it

• The privacy requirements must be clearly understood and part of the technological build

• Process should not be left to IT or to Privacy only, they must work together and with the end user to develop processes; when this is not done this results in unnecessary complications and increased privacy risk

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• One simple example of how these 3 must work together has recently arisen with the eHealthViewer– Technology has provided provincial data sharing enabled by the

PHN and EMPI– Processes around a centralized data source, like eHealthViewer,

need to be clear, precise, and consider the multiple end users; we have found that the application of the access model has varied

– Privacy legislation can greatly complicate and restrict use of this platform, with uncertainty around whether clinical studies should be seen as patient care

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• The pillars often operate separate of one another in the build and design phase, but once the integration of the pieces is done, we have found that they do not always align

• This has been complicated even further when trying to integrate a EHR system across separate health authorities – multiple privacy interpretations, multiple processes, and varying technology to become one system

• While undergoing these struggles we are learning to collaborate and remember better patient care when in the thick of it.

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restrictions




Questions

lessons learned (and being learned) in the implementation of ehr in british columbia

Documents

public body fippa

public body person

provincial health law

single personal health

privacy legislation

privacy legislation

electronic health systems

data landscape