Improving Primary Care with Improved Information Management
Healthcare in British Columbia
“Moving data between information holdings is like moving sand between piles. Every time you move some sand you lose a little and pick up some dirt.” – Unknown Information Management Expert, late 1970s
We have a lot of sand piles in primary care. Limited or no interoperability among health information holdings is a big issue for the health system, and a source of frustration for clinicians and patients. Rather than making all of our primary care holdings interoperable, we can create one holding accessible to all authorised clinicians. Let’s not “digitise the goat paths.” A virtual team requires a virtual information system. Improving management of medical information for primary care will improve patient outcomes, reduce administrative burden on primary care healthcare providers, and reduce costs. We can modernise the business model and use existing technology to move from information anarchy to information management.
Decisions can only be as good as the information on which they’re based, and nowhere is this more important than in healthcare. Incomplete, inaccurate, or untimely information can result in incorrect or delayed diagnosis and treatment, which leads to poorer patient outcomes and increased costs. When patients move between types of care (e.g. acute care to primary care), successful hand-off of information is essential to ensure continuity of care and completion of treatment.
Healthcare service delivery in the 21st century is crippled by a business model for information management from the 19th century. Information to support the primary care of patients is fragmented and duplicated in information holdings managed by clinicians. Clinicians maintain stand-alone holdings of patient information to support primary care, an information management model that is essentially unchanged since the early 1800s. Clinicians and patients may store this information in one of many commercial, cloud-based Electronic Medical Records systems (EMRs) or as paper records (Figure 1). There is no data standard for medical information, nor is there a standard EMR.
Exchanging patient information is time-consuming and typically involves the following steps:
Information is exchanged between holdings by downloading data and information from the source clinician’s EMR to an electronic document (e.g. PDF, memo)
The document is then transmitted by email or physical mail to the receiving clinician, who then reviews and uploads the information into their EMR.
In some cases, information is transmitted between clinicians by the patients themselves (“Patient-Net”), if they can.
Clinicians who move between practices (e.g. locums) need to know several EMRs.
We can improve the management of medical information for primary care. The hurdle is the business model for information management, not the technology. One strategy to make best use of enterprise resources is to consolidate and standardise support services in order to free up resources for client-facing services. In our case, we can consolidate responsibility for management of primary care information in a support service that provides one EMR for use by all clinicians. A new government agency would select, procure and administer an existing Commercial-off-the-shelf (COTS) EMR to meet the needs of clinicians. Using COTS software eliminates the cost, delay, and risk of developing an application, and reduces the costs of maintenance, support, and training.
“One Patient, One Record” in a secure, central information repository accessible by authorised individuals with a provincial standard EMR procured and administered by a government agency would provide the following stakeholder benefits:
Physicians
More complete, accurate, and timely information leads to better outcomes for patients and increased job satisfaction for physicians.
Reduced administrative burden, eliminating the need to exchange data among EMRs and reducing time spent downloading, entering, managing, and finding patient information.
Reduced training, increased proficiency, improved efficiency, and easier job movement, such as for locums.
To get a feel for how this would look, check out the scenario “A New Day in Primary Care”
Other Healthcare Providers
Other healthcare providers (e.g. paramedics, pharmacists, physiotherapists, dentists) have role-based access to view patient information and enter notes, which are then accessible to others.
More complete, accurate, and timely information leads to better outcomes for patients and increased job satisfaction for clinicians.
Patients
Patients would be healthier.
Patients authorise access to their medical information, and are not required to transmit information between clinicians.
Medical information is stewarded by a government agency accountable to patients.
Healthcare System
“One Patient, One Record” eliminates the need for physicians and other clinicians to exchange data among data silos and supports chart-based workflow. Time currently spent on system and data administration overhead is redirected to patient care, which lowers healthcare costs and increases population health.
Less duplication of diagnoses, i.e. expensive information is not lost.
Improved continuity of care and completion of treatment lowers overall costs and ensures realisation of benefits from specialised care (e.g. acute care).
Reduced pressure on Hospitals. Better care (Primary, Emergency) in the Community means fewer patients with less serious or advanced conditions presenting in Hospital, and fewer readmissions of those discharged from Hospital.
Less frustration improves recruitment and retention of healthcare providers, especially family physicians.
Lower EMR costs. Bulk provision of a standard EMR lowers the unit cost for software licensing, and reduced duplication of patient information lowers storage costs.
Roadmap
Phased implementation delivers the biggest benefits at the lowest cost as quickly as possible, while respecting the healthcare system’s capacity for change and the need to maintain healthcare services during transformation. Benefits increase with each Phase I - IV.
I. Select a COTS EMR standard for British Columbia for use initially by physicians, and then by other healthcare professionals. A provincial standard COTS EMR would reduce training costs, and a standard (proprietary) data file structure would facilitate data interchange and reduce administrative burden.
II. Establish a provincial Medical Information Management Services (MIMS) agency responsible for procuring the standard EMR on behalf of physicians and providing them with licenses. A supply arrangement would reduce EMR unit cost, and increase leverage with the vendor for improved functionality and support. Funding currently provided to physicians for their EMRs would be redirected to MIMS, and savings from bulk licensing would fund MIMS.
III. Make MIMS responsible for stewarding primary care information and administering access by physicians. MIMS would work with physicians to compile information from other EMRs into the provincial standard EMR, and consolidate duplicate instances of patient information. Primary care physicians would no longer be responsible for data stewardship, and access would be expanded to other physicians, such as those in Acute Care and Urgent Care. Patients would authorise use of their medical information.
IV. Expand role-based access to other healthcare providers (e.g. pharmacists, physiotherapists, dentists) as authorised by the patient. Access to relevant information and team-based care would improve patient outcomes, and lower healthcare costs.
Modern healthcare is delivered by a team with members providing care to patients where and when they need it. A virtual team needs a virtual information system. Updating the business model for primary care information management from the 19th to the 21st century makes much better use of patient-facing resources and improves patient outcomes. About 20% of British Columbians don’t have family physician so if we could improve the efficiency of family physicians by 10%, it would reduce the gap from 20% to 12% (1.1 x 80% = 88%). This change would take government will, not more funding. We would spend better, not spend more.
For Case Study #1: Healthcare in British Columbia, we now have the following elements of our transformation project, which has two initiatives to improve the performance of our health system (improved accountability, improved information management). We used our High-level Service Model to identify a Support Service (MIMS) that was missing in our enterprise, remapped responsibility for information management and technology from patient-facing services (clinicians) to the support service, and standardised the COTS application used to access and maintain a central information repository for primary care information. We’re spending better, not spending more.
Performance Measures and Improved Accountability to Patients and Healthcare Workers
Improving Primary Care with improved Information Management
A New Day in Primary Care (scenario)
greg
A secure, authoritative, and complete information respository accessible by authorised individuals where and when they need it is a beautiful thing.