The success of large scale EHR implementation: A matter of

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The success of large scale EHR

g

implementation: A matter of

governance

L Esterle Inserm A Kouroubali Forth M

L. Esterle, Inserm, A. Kouroubali, Forth, M.

Bruun-Rasmussen, Mediq, L. Ciglenicki,

ProRec Slovenia, J. Devlies, Ramit, G. Hurl,

ProRec Ireland and G. de Moor, Eurorec

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Initial statements

• Implementation of EHR at a national (or

regional) level: a radical innovation for health

care

• Technical challenges (interoperability, privacy,

g

(

y

safety, etc.)

• But also political, social and organizational

But also political, social and organizational

issues often overlooked

• => these issues could compromise the

implementation process.

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EHR Implement approach

EHR-Implement approach

1. Deep analysis of national initiatives at various stages of

EHR-implementation on a large scale on the political ,

organizational and social issues ;

2. Comparison of the initiatives, identification of the main

iissues;

3. Elaboration of the main recommendations for policy and

decision makers

decision makers.

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The case studies

• A mix of several criteria, including contextual ones:

– Various population size

– Various national health systems (centralized or not)

• Different stages in the EHR national strategy

• =>Six national case studies in Belgium, Denmark,

England, France, Ireland, Slovenia. None of them has

completed the initiative implementation at the end of

2008.

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Relationships

with EHR (country) Initiative Objectives and target Starting year At the end of 2008

Feasibility

Building blocks for

EHR

eZIS (Slovenia) _{data exchanges}Model of safe 2008 Feasibility studies Still running

iPMS (Ireland) PAS for public _hospitals_hospitals 2004 hospitals 50% of Still running Federation of multiple EHR systems Locator services (Belgium) Regions and groups of

hospitals Various times

Some implementation not fully in use,

Still running Still running Common standards for EHR National eHealth strategy (Denmark) Hospitals and primary care 1995 50% of hospital beds and 100% in primary care EHR Electronic patient record

(England) All patients 2003 Still running

Electronic

patient record All patients ₁₆ 2004 Stopped and revived in a

patient record

(DMP) over 16 2004 revived in a new form

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Elements of the governance

• The initial strategy

• The role of actors

The role of actors

• The implementation process

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1. Initial vision

• Observation: Various but close objectives for the NHS:

Continuity of care better communication between parties patient Continuity of care, better communication between parties, patient benefits, etc.

• For the majority of countries: eHealth and/or EHR= major tool

f th f i t f th NHS

for the reform or improvement of the NHS

• Improve the performance of the NHS : quality and productivity ( England)

p y ( g )

• Improve the coordination and continuity of care (France) • More transparent and accountable public health sector

(D k)

(Denmark)

• On the opposite, more pragmatic way in Slovenia, Belgium, and Ireland : Equip the country with the infrastructures y

necessary for eHealth

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1. Initial vision

Recommendations

• Large-scale implementation of EHR systems needs to

correspond to a clearly defined vision integrated in the strategy p y g gy for the health sector.

H EHR i l t ti h ld t b d th i

• However, EHR implementation should not be used as the main and/or only instrument for healthcare reform. It could be only an enabler of reform.

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2. The role of the actors:

The national authorities

Ob i I h j i f f ll li i l b

• Observation: In the majority of cases, full political support, but sometimes too much political pressures

• ExamplesExamples

:

– In centralized countries (England, France): Very strong pressures => unrealistic expectations, lack of autonomy in the

f f

management of the project, lack of the stakeholder participation; – In Denmark: Less centralized and more consensual decision

process (strategic group);

p ( g g p);

– In Slovenia: Driving role of the national health insurance.

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2. The role of the actors:

Management of the project

Ob i Th i f d

• Observation: The creation of an adequate structure to manage the initiative is highly desirable, but not so obvious

• Examples:

– Slovenia: National Center for Health Informatics to be created in 2008 b t l ti till d di i t th d f 2008

2008, but location still under discussion at the end of 2008. – France: creation of the GIP-DMP, but lack of autonomy

(government pressures)

(g p )

– Denmark: After failure of 2003-2007 initiative, new national organisation: Connecting Digital Health,

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2. The role of the actors :

Participation of the stakeholders

Ob i Th i i i f h k h ld diff f

• Observation: The participation of the stakeholders differs from one country to another with some consequences

• Examples: p

– In Denmark, refusal of the basic structure of an EHR established by the National Board of Health;

I F i lt ti f th hi h i t

– In France, no prior consultation of the users, which gave rise to many reserves and controversies;

– Greater participation of the stakeholders when implementation at p p p the local level in Belgium and Ireland;

– Real progress in England when hospitals and companies work as one team

as one team.

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2. Role of the actors

Recommendations

• Governance should be established to define and to respectGovernance should be established to define and to respect clear roles for the different actors at each stage of the process;

• Stakeholder engagement is vital throughout the EHR selection, decision and implementation process. Stakeholder involvement ensures system ownership and motivation towards supporting y p pp g and using the EHR.

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3 Implementation process

3. Implementation process

• Implementation plan and evaluation

F

di

i

i l

• Funding principles

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3.Implementation process:

Realistic implementation plan and

evaluation

Ob i Wid b h i i i l f d h

• Observation: Wide gap between the initial forecasts and the realization generally due to an unrealistic and rigid schedule

• Examples: p

– In Denmark, definition of the EHR standards initially envisaged in the strategic plan of 1995, but not effective at the end of 2005;

In England in 2002 the national EHR was planned for 2005 Now for – In England, in 2002 the national EHR was planned for 2005. Now for

2015 or later;

– In France, initiation of the DMP in 2005 to be implemented in 2007 for the entire population No implementation at the end of 2008

the entire population. No implementation at the end of 2008.

• Observation: Lack of systematic and regular evaluation

• Examples:p

– In France, Denmark, etc…: no systematic evaluation;

– In England: Independent audits allowing identification of the problems.

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3.Implementation process:

p

Funding

• Observation: insufficient funding for the initiative,

underestimation of the costs for implementation and

maintenance of the infrastructure

maintenance of the infrastructure.

• Examples:

– In Belgium: Delayed and fragmentary public funding

– In France: Underestimation of the cost to develop the DMPIn France: Underestimation of the cost to develop the DMP – In England: Underestimation of the human resources for

implementation and maintenance in the hospitals.

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3. Implementation process

Recommendations

• Projects should be realistically estimated in terms of complexity, j y p y resources and timescale. A flexible schedule and process should be adopted.

• Use of strategic tools and continuous evaluation of an EHR

implementation initiative allows for feedback that leads to changes and adaptation to accommodate emergent needs. p g

• Funding should be provided and assured, and responsibilities for sustainability clearly defined

sustainability clearly defined.

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Key factors of success

for implementing EHR on a large scale

• Support of the policy makers and authorities, but without their pressure;

• Clear definition of the role and intervention of the various actors, including the stakeholders;

• Adoption of an adaptative long term process; • Adoption of an adaptative long term process; • Regular and systematic evaluation;

• Sufficient funding for development, implementation and g p , p maintenance.