1. Summary
What is an electronic health record?
EHR is a summary of an individual’s health history and care
Conceptually, an electronic health record is a summary of an individual’s key health history and care. Ideally, such a record would be available electronically to authorized health care providers anywhere in Canada, at any time, and accessible online from many separate yet compatible computer systems within a network. The terms electronic health record (EHR) and electronic medical record (EMR) have recently gained widespread use, and are often used
interchangeably. Electronic health records allow health care providers to view a patient’s medical history, including laboratory results, diagnostic images and prescribed medication. An EMR, by contrast, is an electronic record maintained by a physician; it may or may not be shared with other health care providers.
An electronic health record is made up of information from a variety of sources including hospitals, clinics, pharmacies and laboratories (i.e., health care providers). The record contains several key data elements that are critical for treatment. This information is collected through a common system accessed by health care providers and stored in a series of databases.
What we examined
EHR consists of
many systems We assessed whether the Department of Health and Wellness has effective processes to manage the implementation of electronic health record systems for Albertans. Physically, an electronic health record exists in many systems that reside in many locations throughout the province, under the control and direction of multiple organizations.
The scope of our audit was limited to examining the components of the EHR systems that are funded using taxpayers’ dollars. Our audit did not include non-government entities such as clinics, pharmacies and laboratories. Nor did we examine systems in hospitals for collecting patient information. When we refer to the EHR systems, we are only referring to systems within the scope of our audit.
Auditing
concurrently with five other provinces
Concurrent with our audit of the Alberta EHR systems, five other provincial audit offices will audit how electronic health records are being implemented in their respective jurisdictions. In addition, the Office of the Auditor General of Canada is auditing Canada Health Infoway’s processes for distributing federal funds to each jurisdiction. The provincial audit offices will each report
separately; the Office of the Auditor General of Canada will issue a joint summary report on all of the audits in 2010.
Why it is important to Albertans
EHR systems should be efficient and cost effective
Increased costs of health care, the high level of interaction necessary between health care specialists, and the fundamental principle of responsible
management of taxpayers’ money, make it paramount to ensure that health care is delivered in the most cost-effective way possible. An electronic health record is a means to save money and improve health care by automating the collection and retrieval of critical health care information.
An EHR should be complete, accurate, available and confidential
Health care in Alberta has traditionally been a paper-based system. For
example, to treat one patient, physicians, nurses and physiotherapists each may create, and need to access, separate records. For this information to be effective for treating patients, it should be complete, accurate, and available when
needed. Patient information should also be protected so that individuals do not suffer as a result of misuse of their personal information.
Other countries already have EHRs
Many countries, including Canada, have looked at information technology as a solution for providing cost-effective and efficient health care. It is widely believed that fully functional EHR systems will save lives and reduce health care costs. Countries such as New Zealand, Denmark, the Netherlands, the United Kingdom and Australia have adopted an electronic health record for recording and tracking patient events.
What we found Accountability
No integrated delivery plan that connects
initiatives
The Department does not have a documented integrated delivery plan that connects the detailed plans of each of the many initiatives that make up EHR systems to the priorities of the strategic plan. Communication of strategic priorities and resourcing decisions was not always consistent and clear.
Reporting of progress to decision makers was not regular or complete—as a result, decision makers do not always have the information necessary to make informed decisions.
Governance of EHR is by committee
The Minister of Health and Wellness is responsible for health care in Alberta.
The Department of Health and Wellness has worked on developing and implementing a province-wide EHR since 1997. The governance of the EHR systems has evolved through collaboration of the Department, Alberta Health Services, and various stakeholders (physicians, laboratories, pharmacies, etc.).
The Department implemented a governance structure that includes
representation from all participating organizations. Governance of the EHR
systems is by committee, with the Deputy Minister of Health and Wellness chairing the EHR Governance Committee.
Collaborative governance requires common understanding
To ensure accountability, all parties must have a common understanding of the strategic priorities and decisions regarding allocation of resources. This
common understanding is typically communicated through a series of planning documents consisting of a strategic plan, an integrated delivery plan, and detailed project plans. In addition, to hold each party accountable for their actions, there should be thorough and timely reporting of progress made on all aspects of the EHR systems.
Project management
Project management practices should be followed
In the current economic climate, where dollars are scarce, and the government’s priority is to ensure that public money is spent on viable and effective
programs, it is important that appropriate project management practices be followed which clarify the benefits and costs of the significant investment in EHR systems.
Information on cost of EHR systems not shared
As of March 31, 2009, the Department estimates that it alone has spent
$615 million on building components of the EHR systems. The Department has cost information for each project within an initiative. However, that information is not summarized and shared. The Department has not calculated the total cost for all the EHR systems it funds (for example, the $615 million does not
include costs incurred by regional authorities on components that are part of the EHR systems). We noted in our audit that budgets and costs are managed at the project level, and not at an overall EHR systems level.
No current business case combining all projects
The Department was not able to provide us with a combined business case for the EHR components it funds—one that compares the total cost of the systems (i.e., the sizeable investment that the Government will cumulatively be asked to make) to the benefits (i.e., the anticipated cost savings and the improved quality of health care that will result once the EHR systems have been completed). This consolidated view should aggregate all of the many projects that make up an electronic health record, and show how changes or delays in individual projects impact the completion of the EHR systems.
Security
Shared
responsibility for protecting patient information
The Department shares responsibility for protecting health care information with all other custodians.1 That is, there is no one organization that is responsible for ensuring the protection of health care information. Security functions, like assigning access to Netcare (a web-based portal that allows users
1 As defined in Part 1 Section 1(1)(f) of the Health Information Act
to access patient information), monitoring what users are doing with their access, and auditing to detect unauthorized access, are performed in part by each stakeholder.
Monitoring of access to Netcare is reactive
We expected the Department would be reviewing Netcare access proactively and frequently, but found that monitoring was reactive. We also found that for a period of three months, no review of user access in Netcare had been
performed. Users’ access in Netcare was not always suspended or disabled as soon as the user no longer needed access.
What needs to be done
The Department needs to improve its management of the electronic health records project by:
• working jointly with Alberta Health Services and governance committee members to:
• maintain an integrated delivery plan that aligns with the strategic plan
• improve systems to regularly report costs, timelines, progress and outcomes (see recommendation on page 73)
• executing publicly funded electronic health record projects and initiatives in accordance with established project management standards (see
recommendation on page 75)
• proactively monitoring access to the Netcare portal (see recommendation on page 78)
• removing user access to the Netcare portal when access is no longer needed (see recommendation on page 80)
2. Background
Canada-wide initiative
Canada-wide
initiative In 2000, as part of the First Ministers’ Agreement, Canada’s political leaders identified development of an electronic health record as their top priority in health care. This commitment was subsequently reinforced in the 2003 Accord on Health Care Renewal and in the 2004 10-Year Plan to Strengthen Health Care.
Federal funds flow
through Infoway The Government of Canada established Canada Health Infoway (Infoway) in September 2000. Its mandate is to “accelerate the development and adoption of modern systems of health information and to define and promote standards governing the health info-structure to ensure [compatibility].” From Infoway’s inception to the end of 2006, the federal government provided $1.2 billion in funding for electronic health records, tele-health and public health surveillance solutions.2
All jurisdictions
participated Infoway membership consists of Deputy Ministers of Health from all 14 federal, provincial and territorial governments. Infoway coordinates the work of health ministries, regional authorities, other health care organizations and information systems vendors. Together, their goal is to develop a
compatible network of electronic health record solutions across Canada—
linking hospitals, clinics, pharmacies and other points of care.
Objective is to improve health care
The objectives for creating a Canada-wide electronic health record are to reduce wait times, increase patient participation in health care, make management of chronic diseases more efficient, improve access to health care in remote and rural communities, reduce adverse drug interactions, and improve drug prescribing practices.
Working towards compatible EHR systems
The Department is working with ministries from federal, provincial and territorial jurisdictions to create cross-jurisdictional EHR systems that are compatible with the electronic health records of all Canadian jurisdictions.
Canada Health Infoway, in the document EHR 2015 Advancing Canada’s Next Generation of Healthcare on page 62,3 has described the goal of the
Canada-wide approach as:
1. “Ensure the EHR elements are built with consistent standards, thereby enabling future interoperability within and across jurisdictions and simplifying the movement of knowledge and people across jurisdictions.
2. Serve as a catalyst for new infrastructure developments and ensure common platform quality across all jurisdictions.
3. Where possible, encourage cooperation, thereby eliminating redundancy and duplicative efforts in systems design, vendor negotiations, etc.
4. Reduce long-term costs and implementation time by leveraging scale and cross-jurisdictional knowledge.”
EHR is partly funded by Government of Canada
The development of EHR systems in Alberta is partly funded by the
Government of Canada through an agreement with Infoway. Each province or territory is entitled to receive funding from Infoway for eligible expenses. It is the role of the Department to propose projects to Infoway for funding and to implement the projects. Of the estimated $615 million that the Department has spent on EHR systems, $61 million was reimbursed by Infoway. Current funding agreements with Infoway allow for an additional reimbursement of up to $47.6 million.
3 Canada Health Infoway “EHR 2015 Advancing Canada’s next generation of healthcare” page 5
http://www2.infoway-inforoute.ca/Documents/Vision_2015_Advancing_Canadas_next_generation_of_healthcare[1].pdf
Key activities in development of EHR systems in Alberta
Some of the major activities that have been central to the development of the provincial EHR systems to date are listed in the following table:4
Year Event
1997 Alberta Wellnet, the predecessor to the EHR systems, is formed to develop and deliver province-wide EHR initiatives.
1998
Alberta Supernet, a province-wide high speed broadband Internet network, established to provide required Internet services is developed.
1999 The Pharmaceutical Information Network (PIN) was piloted and deployed as the Seniors Drug Profile.
2001
The Physician Office Systems Program established to lead the adoption of Electronic Medical Records within physician offices across the province.
2002
Premier’s Advisory Council recommended implementing
province-wide EHR systems, and PIN became the drug information component of the Alberta EHR.
2003 Alberta EHR systems were launched province-wide and physicians across the province were able to get connected.
2004
Capital Health launches Netcare, Alberta’s seven rural health regions form RSHIP (Regional Shared Health Information Program) and pharmacies begin to send drug dispensing information.
2005
The Premier announces that all Albertans would have an electronic health record by 2008; Calgary Health Region begins to implement an enterprise-wide single clinical information system.
2006
Alberta Netcare Portal 2006 deployment begins; the Provincial Diagnostic Imaging strategy is adopted and begins delivery;
Provincial Registries initiatives are underway.
2007
Legislation requires mandatory submission of dispensing information from pharmacies, system to system functionality begins to enhance the overall integration of physician offices and pharmacies with electronic health records, the Provincial Health Information Exchange (pHIE) initiative begins, delivering lab results electronically to physician offices.
2008
RSHIP, which represented the seven rural health regions, was disbanded; transition to a new model based on a North/South model (more in line with referrals patterns across the province) is underway.
2009 The nine regional health authorities are consolidated into Alberta Health Services (AHS).
Ministry’s strategic goals
The Ministry’s strategic goals for EHR systems are increased:
• accessibility of health services
• patient satisfaction with health services
• quality of care
• productivity of the health system EHR systems and repositories
The systems and repositories that make up the EHR systems include:
• registries—various systems that store patient, health care provider and health care delivery site information
• repositories—various systems that store patients’ drug, laboratory, diagnostic imaging and text report information
• health information exchanges—three systems that verify message formats and ensure reliable delivery of information (Provincial Health Information Exchange, Cloverleaf Regional Health Information Exchange, Calgary Regional Health Information Exchange)
• Netcare portal—system that gathers information from various other systems and allows users to view a patient’s complete health record online
• health care providers—various systems that store information that health care providers use, such as wait times management, public health, pharmacy, radiology, laboratory and physician information
• physical infrastructure—servers, networking devices and facilities Netcare portal
Netcare is central to the EHR systems
At the centre of Alberta’s EHR systems is the Netcare portal, a web application that brings information from a number of different sources into one location, allowing users of the portal to view that information easily. Netcare was first implemented by the former Capital Health Region to provide information on patients in the region. As Alberta developed EHR systems, the Department adapted Netcare to integrate health and demographic information on patients from all health regions.
The Department continues to develop the Netcare portal. In its current form, Netcare provides access to the following information submitted by providers:
• drug prescription information
• laboratory reports
• diagnostic images such as x-rays
• limited text reports of physician notes
• demographic information such as a patient’s health care numbers, address, age and gender
EHR data is combined from many sources
An electronic health record combines data from a number of different sources to provide an integrated view of a patient’s medical history through Netcare.
The Department often uses Netcare to refer to all EHR systems. For purposes of this report, we refer to the complex array of interrelated systems as the EHR systems and reserve the name Netcare for the portal through which users gain access to information in the EHR systems.
Main participants in the EHR systems
EHR systems are managed by many participants
For each of the data components of the EHR systems, several organizations within AHS may be responsible for developing and managing the systems that store the data. For example, AHS maintains three patient registries: one registry in Calgary and two in Edmonton. Although AHS is responsible for all health regions, each region continues to operate independently in its day-to-day operations.
Participants use different systems to provide EHR data
Various organizations (physician’s offices, pharmacies, labs, hospitals, etc.) use disparate systems to provide information for the electronic health record.
Furthermore, organizations that contribute information to EHR systems have a complex array of relationships with each other. Complex EHR systems require clear leadership in the form of direction on strategy, policy and standards from a central authority. The Government of Alberta has assigned this responsibility to the Department.
The Department and AHS share primary accountability and oversight for the outcomes of the EHR systems, with ultimate accountability residing with the Minister. Given the relatively recent establishment of AHS, work is underway to clearly articulate roles and responsibilities toward eliminating ambiguity and ensuring reliable accountability and oversight for EHR planning and
implementation.
Many systems are incompatible with each other
Managing a complex, interdependent EHR infrastructure is a significant
challenge. Alberta’s EHR systems have been built component by component as they have evolved. They have been built recognizing that the health system is a complex and diffuse operation with many key players, and with electronic systems that have evolved over a number of years. For example, legacy environments, such as incompatible electronic medical records in many physicians’ offices and incompatible hospital clinical systems have, and continue to require, costs of custom integration with the EHR.
Alberta is now focused on the development of an integrated vision, plan and roadmap recognizing the challenges of the distributed model and the benefits of an integrated vision and plan detailing the combined strategies, priorities,
Our review of the EHR systems focused primarily on information technology, governance, project management and security and privacy aspects. We have recommendations for improvement in each of these areas, as described in the following sections.
3. Audit objectives and scope
Audit objectives
Our audit
objective We conducted our audit to determine whether the Department and AHS have appropriate and effective mechanisms in place to guide, monitor and report on the implementation of EHR systems. Our audit considered:
1. Do the Department’s plans focus on developing consistent and compatible EHR systems?
2. Is the Department managing EHR projects based on a recognized project management methodology and are they achieving expected results?
3. Does Department management receive the information it needs to make decisions about implementing EHR systems?
4. Can the Department demonstrate that there are appropriate privacy and security mechanisms in place to access electronic health records?
Audit scope
Our scope Our audit evaluated the projects funded by the Department and partly
reimbursed through funding agreements with Infoway. These agreements set out the scope of work and criteria for eligibility of expenditures for projects such as diagnostic imaging repositories and Netcare.
Federal funding agreements do not cover all EHR projects. To evaluate if a consistent project management methodology is followed throughout EHR
Federal funding agreements do not cover all EHR projects. To evaluate if a consistent project management methodology is followed throughout EHR