Integrated Care Records:
An international perspective
Marc Berg
Integrated Care Records: Problems and Solutions
Workshop
December 11-12, 2003 Edinburgh
Overview
 State of the Art: optimism or pessimism?
 Why has the Holy Grail been so difficult to find?
 Some solutions solve many issues, but not the problem…
 How to make the next step?
 Example: Integrated Medication Management
EPRs in Integrated Care
 EPR for GP’s?
 Some progress in UK, Scandinavian countries, the Netherlands,
Australia
 Integrated EPR?
 No; but:
 Much data exchange
 GP – pharmacy
 GP - hospital
 GP – laboratory
 But systems remain very loosely or non-integrated
EPRs in Integrated Care
 The promise: truly redesigning care paths across
institutional borders through ICT
 Stroke care
 Integrated Diabetic Care
 Heartfailure Care
 ….
 In US?
 Not through ICT as much but through institutional mergers
 In HMO’s, integrated primary care is at least a theoretical possibility
EPRs in Integrated Care
 In Europe?
 No, but many local experiments
 Integrated Diabetic Care Record
 Nurse doing retinal imaging, physicians checking at a distance
 ‘Software guided nurse’ for Heart Failure and Cardiovascular
Prevention
 Dermatology clinics (telemedicine supported) etc.
 Etc...
EPRs in Integrated Care
 EPR for GP’s
 Integrated Primary Care EPR
 Integrated Primary Care Redesign using IMIT
 Optimism or Pessimism ...
 ... But progress is slow!
 Many projects fail
 Many projects that initially succeed subsequently come to a
standstill
 ‘Diffusion’ very slow
Medication Management
 State of the art:
(GP, pharmacy, specialist,
hospital pharmacy)
 Paper-based
(often still handwritten)
medication order is
standard
Medication Management
 State of the art:
(GP, pharmacy, specialist, hospital pharmacy)
 No single care professional has routine, integrated
access to complete medication record of patient
Medication Management
 Research in Western countries:
 Between 5 – 15% of medication orders contains
mistakes
 ... 10 – 25% of these result in adverse drug events
IT supported medication management: the dreams
 Electronically available pharmaceutical protocols
 Electronic storage and retrieval of medication information in
(virtual) medication record
 Electronic transmission of medication orders /
Ordercommunication
 Decision support
 Computer-based medication evaluation & review
 Automated medication distribution systems
 Barcode medication administration systems
IT supported medication management: the reality
 Many local initiatives; e.g. local GP –
pharmacy links and data exchange
 Hospital pharmacies often have
electronic medication record,
sometimes available throughout the
hospital, sometimes with
computer-based medication evaluation
& review
IT supported medication management: the reality
 GP’s may prescribe electronically – but patient takes printed medication
order to pharmacy
 Island automation; infrastructure of hospitals, GPs and pharmacies too
often operate independently
 No single care professional has routine, integrated access to complete
medication record of patient
Why this discrepancy between ‘dream’ and ‘reality’?
 Technical limitations?
 No: all dreams are technically feasible
 (all the different aspects have been realized somewhere, sometime)
 Limited standardization?
 No: standardization is not self-evident, but there is enough of a
basis to realize the different dreams
Why this discrepancy between ‘dream’ and ‘reality’?
 In Europe, problems are hardly felt by those professionals that are most
central (GP’s, Specialists):
 Many prescription mistakes are solved ‘later on’ in the medication chain
 By nurses
 By pharmacy assistants
 By GPs (when specialist-generated)
 By patients
 Problems due to ‘breaks’ in the medication chain emerge elsewhere in the
chain
 (contrast US: liability claim-problems result in large investment and
core attention to ‘safety culture’)
Politics of Medication Systems
Pharmacist
GP
Efficiency
Specialist
Hospital
Pharmacist
Safety
Why this discrepancy between ‘dream’ and ‘reality’?
 There were the problems are prioritized…
 … and the possibilities of ICT are seen …
 … one too often aims to build a Porsche to drive the muddy
roads that constitute the health care ‘information highways’
Porsche I:
 Decision Support for physicians during prescription process:
 Is often turned of or ignored
 ‘Government on my desk’
 To give relevant, clear and not too many or repetive advices/reminders is
not an easy task
 In many situations, it is not the end-responsible care giver that enters the
medication!
 Is the ICT infrastructure available???
Porsche II:
 Electronically available pharmaceutical guidelines
 Are very labour-intensive to create, and require much inter-professional
and inter-organizational cooperation
 Yet electronic versions have little added value over paper versions:
 … a common set of pharmaceutical guidelines will only be truly useful as
part and parcel of a common medication management system…
 … and such systems are as yet far from common
Porsche or Pick-up Truck?
 Porsches will hardly be able to function on the muddy roads. Nor will
they solve the core problem of primary care medication management:
No single care professional has routine, integrated access to
complete medication record of patient
 This results in communication errors, confused patients
 This results in errors in prescription, diffusion and administration
 Without such a basis, added functionality cannot give added value
Porsche or Pick-up Truck?
 This results in communication errors, confused patients
 This results in errors in prescription, diffusion and administration
 Without such a basis, added functionality cannot give added value
In such a situation, aiming for a sturdy, simple Pickup Truck to carry basic information back and forth
is a better strategy than attempting to build a
Porsche for an infrastructure that is as yet nonexistent
What’s the strategy?
 Search for the most urgent problem from a quality of care
perspective
 No insight in total medication profile
 Find a problem definition that is shared (as much as
possible) between parties
 Medication management discontinuities (‘breaks’ in the chain)
 Bring political issues out in the open!
 ‘Merely technical’ solutions often contain hidden agenda’s
What’s the strategy?
 Search for the most urgent problem from a quality of care perspective
 Find a problem definition that is shared (as much as possible) between
parties
 Bring political issues out in the open!
 Build upon already started, promising initiatives (motivation,
‘champions’, organizational structures)
 Search for low-tech, robust and cost-effective solutions
 Local IT networks vs National database?
 Make one, result-oriented step at a time, and let the health care field
and the technology evolve together
Example: from Pick-up Truck to Porsche?
1) (Electronic) overview of patient medication at point of care
Simple, proven technology is to be preferred
2) Electronic order communication for GP and Specialist (separately
developed)
Electronic medication order messaging between physician and pharmacy
3) Build in selected protocols in the order communication system
E.g. for patients treated by GP and specialist, diabetes, etc.
4) Active decision support
Optimal integration of decision support functionalities with health care work still
requires much research
Towards multidisciplinary electronic records:
beware of the Porsche fans!
 Final benefits are to be found in measured redesign and
standardization of care delivery processes, made possible by IT.
 Reaping these benefits is not self-evident: truly multi-disciplinary
(medication) records will require a substantial cultural – and
organizational transformation.
 IT can stimulate organizations to get there
 Through the Pick-up Truck, drivers realize the benefits of fast transportation
 Through the common, sturdy design and the lack of specialized functions or
specifications, other parties can join easily.
 .... Yet it can also prevent organizations from doing so
 The Porsche won’t work or will get stuck in the first muddy or dusty through-road