Outline

1. Outline • Definitions • Background to the study of 10 countries • Study findings • Lessons to be learned • Conclusion • Discussion 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 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 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 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. D. Protti - City University London and University of Victoria

6. Australia Austria Denmark England Germany Netherlands New Zealand Norway Scotland Sweden Data collected in 2005 about 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 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 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 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. 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) 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 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 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 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 D. Protti - City University London and University of Victoria

16. Australia 98% Austria 99% Denmark 99% England 99% Germany 90% Netherlands 97% New Zealand 100% Norway 100% Scotland 95% Sweden 97% % GPs with office computers D. Protti - City University London and University of Victoria

17. Australia 98% Austria 90% Denmark 99% England 95% Germany 90% Netherlands 90% New Zealand 97% Norway 100% Scotland 95% Sweden 99% % GPs with “automated” medication prescriptions D. Protti - City University London and University of Victoria

18. Australia 64% Austria 25% Denmark 90% England 90% Germany 24% Netherlands 94% New Zealand 80% Norway 95% Scotland 65% Sweden 15% % GPs recording progress notes D. Protti - City University London and University of Victoria

19. Australia Some Austria Few Denmark Most England Some Germany Few Netherlands Few New Zealand Few Norway Most Scotland Few Sweden Few % who operate “paper-light” offices D. Protti - City University London and University of Victoria

20. Australia No Austria No Denmark Yes England Yes Germany No Netherlands No New Zealand Yes Norway Yes Scotland Yes Sweden No National health network in use All have plans or intentions to have one D. Protti - City University London and University of Victoria

21. Australia 86% Austria 25% Denmark 99% England 97% Germany 10% Netherlands 50% New Zealand 97% Norway 10% Scotland 90% Sweden 50% % GPs using electronic data exchange D. Protti - City University London and University of Victoria

22. Australia Many Austria Many Denmark Most England Many Germany Few Netherlands Many New Zealand Most Norway Few Scotland Most Sweden Most % GPs receiving laboratory results D. Protti - City University London and University of Victoria

23. Australia Few Austria Few Denmark Most England Few Germany Few Netherlands Few New Zealand Many Norway Few Scotland Many Sweden Few % receiving discharge summaries D. Protti - City University London and University of Victoria

24. Driving Forces for the Evolution of Primary Care Computing D. Protti - City University London and University of Victoria

25. Australia Yes Austria No Denmark No England Yes Germany No Netherlands Yes New Zealand No Norway No Scotland Yes Sweden Yes Government funding support D. Protti - City University London and University of Victoria

26. Australia No Austria Yes Denmark No England No Germany Yes Netherlands Yes New Zealand Yes Norway No Scotland No Sweden No Billing mandate D. Protti - City University London and University of Victoria

27. Australia Yes Austria No Denmark No England Yes Germany No Netherlands Yes New Zealand No Norway No Scotland Yes Sweden No College or Association leadership D. Protti - City University London and University of Victoria

28. Australia No Austria No Denmark Yes England No Germany No Netherlands Yes New Zealand No Norway Yes Scotland No Sweden Yes Peer Influence D. Protti - City University London and University of Victoria

29. Australia No Austria Yes Denmark Yes England Yes Germany Yes Netherlands Yes New Zealand Yes Norway No Scotland Yes Sweden No Accreditation of vendor systems In some cases for billing purposes only D. Protti - City University London and University of Victoria

30. Australia No Austria No Denmark Yes England No Germany No Netherlands No New Zealand Yes Norway No Scotland No Sweden Yes Non-financial support received D. Protti - City University London and University of Victoria

31. Benefits of technology to GPs D. Protti - City University London and University of Victoria

32. 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 D. Protti - City University London and University of Victoria

33. 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 D. Protti - City University London and University of Victoria

34. Outline • Definitions • Background to the study of 10 countries • Study findings • Lessons to be learned • Conclusion • Discussion D. Protti - City University London and University of Victoria

35. 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. D. Protti - City University London and University of Victoria

36. 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. D. Protti - City University London and University of Victoria

37. 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 D. Protti - City University London and University of Victoria

38. 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 D. Protti - City University London and University of Victoria

39. 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. D. Protti - City University London and University of Victoria

40. Front = e-card Rear = EHIC The Austrian e-card D. Protti - City University London and University of Victoria

41. Outline • Definitions • Background to the study of 10 countries • Study findings • Lessons to be learned • Conclusion • Discussion D. Protti - City University London and University of Victoria

42. 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 D. Protti - City University London and University of Victoria

43. 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. D. Protti - City University London and University of Victoria

44. 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 non-profit, 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. D. Protti - City University London and University of Victoria

45. Other important factors include: • 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

46. 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. D. Protti - City University London and University of Victoria

47. 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.” D. Protti - City University London and University of Victoria

48. First attempts at a ranking of countries D. Protti - City University London and University of Victoria

49. Possible scoring dimensions • EMR functionality (rating & percentage of physicians involved) • 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 • Electronic messaging • Lab results, discharge summaries, medications, consults, etc. • Booking • Breadth of sectors (community, mental health, etc.) • Use of a shared or integrated EHR • Medication profiles, laboratory results, imaging reports, etc. • Extent of standards in use • Communications, identifiers & registries, SNOMED, alerts, etc. • EPR functionality (rating & percentage of facilities involved) • Telemedicine/health • PHR, portals and e-mail with patients • Supportive legislation • Privacy, secondary uses, digital signatures, etc. D. Protti - City University London and University of Victoria

50. Thank you for your attention Denis.Protti.1@city.ac.uk dprotti@uvic.ca D. Protti - City University London and University of Victoria