Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
2
Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
3
Electronic Records
• EMR – the electronic record in a
physician’s office
• EPR – the electronic record in a hospital
or facility
• EHR – the longitudinal electronic record of
an individual that contains data from
multiple EMRs and EPRs
12-Jul-16
D. Protti - City University London and University of Victoria
4
Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
5
Background to the study
• A Comparison of Information Technology
in General Practice in 10 Countries
• Commissioned by Canada Health Infoway
– Goal: to identify the governmental, collegial,
technological, and other factors contributing to
the success of each country in achieving high
levels (>90%) of GP office automation in the
last ten years.
12-Jul-16
D. Protti - City University London and University of Victoria
6
Data collected in 2005 about
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
•
•
•
•
•
Netherlands
New Zealand
Norway
Scotland
Sweden
D. Protti - City University London and University of Victoria
7
Data was collected from
• Scientific literature
• OECD
• Government, and professional association
reports and web sites
• Personal interviews with GPs, ministerial
and vendor representatives
12-Jul-16
D. Protti - City University London and University of Victoria
8
Health care systems characteristics
• Methods of hands-on delivery of care are
virtually the same in all of the countries
studied
• The way in which the healthcare systems
are financed, administered and managed
vary widely
12-Jul-16
D. Protti - City University London and University of Victoria
9
Health care systems governance
• Regional (Provincial)
– Australia, Denmark, New Zealand, Norway,
Sweden
• National
– England, Scotland
• Insurance - based
– Austria, Germany, Netherlands
12-Jul-16
D. Protti - City University London and University of Victoria
10
Health systems characteristics
• Percentage of GPs who work alone:
– lows of 5% and 10% in Sweden and
New Zealand.
– highs of 80% and 90% in the
Netherlands and Austria.
12-Jul-16
D. Protti - City University London and University of Victoria
11
Health systems characteristics
• Practicing physicians per 1,000 (2003)
– 4.4 in Austria (highest)
– 2.2 in England and Scotland (lowest)
– 2.9 average in OECD countries
– 2.1 in Canada (17th out of 21 countries)
12-Jul-16
D. Protti - City University London and University of Victoria
12
Health systems characteristics
• Physician Reimbursement
– Fee-for-service the most common model
• range from 100% to 40% of income
– exception is Sweden
• >90% of GPs are employed by
Primary Health Centres
12-Jul-16
D. Protti - City University London and University of Victoria
13
Health systems characteristics
• Per capita expenditures (2003 data)
– $US 3807 in Norway (highest)
– $US 1886 in New Zealand (lowest)
– $US 3003 in Canada
12-Jul-16
D. Protti - City University London and University of Victoria
14
Health systems characteristics
• % of GDP (2003 OECD data)
– 11.1% in Germany (highest)
– 7.6% in Austria (lowest)
– 9.9% in Canada
12-Jul-16
D. Protti - City University London and University of Victoria
15
Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
16
% GPs with office computers
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
98%
99%
99%
99%
90%
• Netherlands 97%
• New Zealand 100%
• Norway
100%
• Scotland
95%
• Sweden
97%
D. Protti - City University London and University of Victoria
17
% GPs with “automated”
medication prescriptions
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
98%
90%
99%
95%
90%
• Netherlands 90%
• New Zealand 97%
• Norway
100%
• Scotland
95%
• Sweden
99%
D. Protti - City University London and University of Victoria
19
% GPs recording progress notes
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
64%
25%
90%
90%
24%
• Netherlands 94%
• New Zealand 80%
• Norway
95%
• Scotland
65%
• Sweden
15%
D. Protti - City University London and University of Victoria
20
% who operate “paper-light” offices
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
Some
Few
Most
Some
Few
• Netherlands Few
• New Zealand Few
• Norway
Most
• Scotland
Few
• Sweden
Few
D. Protti - City University London and University of Victoria
21
National health network in use
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
No
No
Yes
Yes
No
• Netherlands No
• New Zealand Yes
• Norway
Yes
• Scotland
Yes
• Sweden
No
All have plans or intentions to have one
12-Jul-16
D. Protti - City University London and University of Victoria
22
% GPs using electronic data exchange
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
86%
25%
99%
97%
10%
• Netherlands 50%
• New Zealand 97%
• Norway
10%
• Scotland
90%
• Sweden
50%
D. Protti - City University London and University of Victoria
23
% GPs receiving laboratory results
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
Many
Many
Most
Many
Few
• Netherlands Many
• New Zealand Most
• Norway
Few
• Scotland
Most
• Sweden
Most
D. Protti - City University London and University of Victoria
24
% receiving discharge summaries
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
Few
Few
Most
Few
Few
• Netherlands Few
• New Zealand
Many
• Norway
• Scotland
• Sweden
Few
D. Protti - City University London and University of Victoria
Many
Few
25
Driving Forces for the
Evolution of Primary Care
Computing
12-Jul-16
D. Protti - City University London and University of Victoria
26
Government funding support
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
Yes
No
No
Yes
No
• Netherlands Yes
• New Zealand No
• Norway
No
• Scotland
Yes
• Sweden
Yes
D. Protti - City University London and University of Victoria
27
Billing mandate
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
No
Yes
No
No
Yes
• Netherlands Yes
• New Zealand Yes
• Norway
No
• Scotland
No
• Sweden
No
D. Protti - City University London and University of Victoria
28
College or Association leadership
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
Yes
No
No
Yes
No
• Netherlands Yes
• New Zealand No
• Norway
No
• Scotland
Yes
• Sweden
No
D. Protti - City University London and University of Victoria
29
Peer Influence
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
No
No
Yes
No
No
• Netherlands Yes
• New Zealand No
• Norway
Yes
• Scotland
No
• Sweden
Yes
D. Protti - City University London and University of Victoria
30
Accreditation of vendor systems
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
No
Yes
Yes
Yes
Yes
• Netherlands Yes
• New Zealand Yes
• Norway
No
• Scotland
Yes
• Sweden
No
In some cases for billing purposes only
12-Jul-16
D. Protti - City University London and University of Victoria
31
Non-financial support received
•
•
•
•
•
Australia
Austria
Denmark
England
Germany
12-Jul-16
No
No
Yes
No
No
• Netherlands No
• New Zealand Yes
• Norway
No
• Scotland
No
• Sweden
Yes
D. Protti - City University London and University of Victoria
32
Benefits of technology to GPs
12-Jul-16
D. Protti - City University London and University of Victoria
33
Benefits of automation in GP practices
• Simplified Repeat Prescription (2.1)
– #1 in Scotland and Sweden
– #2 in all other countries, except Norway
(#3) and NZ (#4)
• Saving time (3.0)
– #1 in Australia, England, Germany,
Netherlands and New Zealand
– #7 in Austria
12-Jul-16
D. Protti - City University London and University of Victoria
34
• Quicker receipt of results (3.2) – range:1-5
• Improved patient management - easier to find
records (3.4) – range:1-5
• Legibility of records and forms - who wrote
what (5.2) – range: 3-7
• More timely communication with other
clinicians (5.5) – range: 1-8
• Availability of clinical data on Internet or
Intranet (6.2) – range: 3-8
• Data for clinical research (7.3) – range: 5-8
12-Jul-16
D. Protti - City University London and University of Victoria
35
Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
36
England
• Clinical computer usage has markedly increased
since the advent of the new 2003 contract
containing the Quality and Outcomes
Framework (QOF).
• As the QOF covers 11 disease areas and
practices are financially rewarded for having
objective evidence of the quality of care they
provide, data entry into GP clinical systems is
taking precedence over handwritten records in
these areas.
12-Jul-16
D. Protti - City University London and University of Victoria
37
Denmark
• Virtually all Danish GPs (and by 2006, all
specialists as well) send and receive clinical
electronic messages.
• Sixty standardized messages (up from 32 in
2002) have been implemented in 100 computer
systems
• Over 90% of the country’s clinical
communications in the primary sector are
exchanged over Denmark’s national network.
12-Jul-16
D. Protti - City University London and University of Victoria
40
Denmark
• In 2005, created a national health portal to
provide information about the Danish National
Health Service to its citizens and patients.
–
–
–
–
–
–
Waiting list information
Quality declarations
Online scheduling of GP appointments
Renewal of prescriptions
Email contact with GPs
Access to online medication profile
12-Jul-16
D. Protti - City University London and University of Victoria
42
• Email contact with GPs - users can consult
their GP using email; similar to telephone
consultation but asynchronous
• Access to online medicine profile - allows
users and health care professionals to
access a detailed profile of medicines
dispensed for each patient
12-Jul-16
D. Protti - City University London and University of Victoria
45
Austria and Germany
• Have introduced national health e-cards (smart
cards)
– Denmark has issued cards to 300,000 so far
• Also issued each physician with their own
healthcare provider e-card which is becoming the
digital signature by which clinicians will have access
to centralized data such as medication profiles.
– Denmark and England are also introducing healthcare
professional e-cards into their systems.
12-Jul-16
D. Protti - City University London and University of Victoria
46
The Austrian e-card
Front = e-card
12-Jul-16
Rear = EHIC
D. Protti - City University London and University of Victoria
47
Outline
•
•
•
•
•
•
Definitions
Background to the study of 10 countries
Study findings
Lessons to be learned
Conclusion
Discussion
12-Jul-16
D. Protti - City University London and University of Victoria
49
There is no one answer or reason
why these 10 countries have a
high degree of utilization of
computer technology by their GPs
There are however similarities
to draw upon
12-Jul-16
D. Protti - City University London and University of Victoria
50
1. Clearly the role of Government health policy
played a part in most of the countries.
– The policies may not have been directly
related to primary care computing (e.g. out of
office hours or physician collectives) but in
many instances, they indirectly stimulated the
introduction of technology.
– Closely related were the financial incentives
and rewards which were provided to GPs if
they automated though this was clearly not
the case in all of the countries.
12-Jul-16
D. Protti - City University London and University of Victoria
51
2. It would appear that a single unifying
organization of some type played a
key role in Denmark and New Zealand
– Interestingly, Denmark’s organization is nonprofit, arms length from government, while
New Zealand’s is a private company.
– The lack of a unifying organization is seen to
be a significant limiting factor in a number of
countries.
12-Jul-16
D. Protti - City University London and University of Victoria
52
3. Other important factors include:
–
–
–
–
12-Jul-16
certification of vendor systems
providing support to GPs
use of communications standards
use of nomenclatures such as the
Read codes in England and Scotland
and ICPC in Norway.
D. Protti - City University London and University of Victoria
53
What seems clear in all ten countries
is the recognition that significant
progress towards an Electronic Health
Record, with all its associated
benefits, is impossible without the full
participation of general practitioners.
12-Jul-16
D. Protti - City University London and University of Victoria
54
As the Australian Minister for Health and
Ageing and Leader of the House of
Representatives said on December 8, 2005
“Doctors are at the heart of the health
system and there can be no integrated
IT-based patient health record while
most doctors' case notes remain on
cardboard cards.”
12-Jul-16
D. Protti - City University London and University of Victoria
55
First attempts at a ranking of
countries
12-Jul-16
D. Protti - City University London and University of Victoria
57
Possible scoring dimensions
1.
EMR functionality (rating & percentage of physicians involved)
–
–
–
–
–
–
2.
Electronic messaging
–
–
–
3.
Medication profiles, laboratory results, imaging reports, etc.
Extent of standards in use
–
5.
6.
7.
8.
Lab results, discharge summaries, medications, consults, etc.
Booking
Breadth of sectors (community, mental health, etc.)
Use of a shared or integrated EHR
–
4.
Medications & allergies, case notes, problem lists, immunizations, etc
Scheduling
Decision support (reminders, alerts, care planning, etc.)
Knowledge tools (Medline, guidelines, etc)
Structured and coded data
Research support
Communications, identifiers & registries, SNOMED, alerts, etc.
EPR functionality (rating & percentage of facilities involved)
Telemedicine/health
PHR, portals and e-mail with patients
Supportive legislation
–
12-Jul-16
Privacy, secondary uses, digital signatures, etc.
D. Protti - City University London and University of Victoria
58
Thank you for your attention
Denis.Protti.1@city.ac.uk
dprotti@uvic.ca
12-Jul-16
D. Protti - City University London and University of Victoria
59
Additional materials
12-Jul-16
D. Protti - City University London and University of Victoria
60
Central servers and central systems
• In a number of countries GPs are choosing
central server solutions to meet their clinical
system requirements.
• More common to provide full functionality across
a wide area network, with all data processed on
a central server.
• System and network administration managed by
someone else – often a government supported
team.
12-Jul-16
D. Protti - City University London and University of Victoria
66