Lessons from the Canadian national health information technology plan for the United States: opinions of key Canadian experts

A qualitative study of health information technology in the Canadian public health system

Background

Although the adoption of health information technology (HIT) has advanced in Canada over the past decade, considerable challenges remain in supporting the development, broad adoption, and effective use of HIT in the public health system. Policy makers and practitioners have long recognized that improvements in HIT infrastructure are necessary to support effective and efficient public health practice. The objective of this study was to identify aspects of health information technology (HIT) policy related to public health in Canada that have succeeded, to identify remaining challenges, and to suggest future directions to improve the adoption and use of HIT in the public health system.

Methods

A qualitative case study was performed with 24 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology.

Results

Identified benefits of HIT in public health included improved communication among jurisdictions, increased awareness of the need for interoperable systems, and improvement in data standardization. Identified barriers included a lack of national vision and leadership, insufficient investment, and poor conceptualization of the priority areas for implementing HIT in public health.

Conclusions

The application of HIT in public health should focus on automating core processes and identifying innovative applications of HIT to advance public health outcomes. The Public Health Agency of Canada should develop the expertise to lead public health HIT policy and should establish a mechanism for coordinating public health stakeholder input on HIT policy.

"Hidden" value: how indirect benefits of health information exchange further promote sustainability

BACKGROUND

Health information exchanges (HIEs) have already demonstrated direct value in controlling the costs associated with utilization of emergency department services and with inpatient admissions from the emergency department. HIEs may also affect inpatient admissions originating from outside of the emergency department.

OBJECTIVE

To assess if a potential association exists between a community-based HIE being used in hospital emergency departments and inpatient admissions emanating from outside of the emergency department.

METHODS

The study design was observational, with an eligible population of fully insured plan members who sought emergency department care on at least 2 occasions over the study period between December 2008 and March 2010. Utilization data, obtained from medical and pharmacy claims, were matched to a list of emergency department utilizers where HIE querying could have occurred. Of the eligible members, 1482 underwent propensity score matching to create two 325-member groups-(1) a test group in which the HIE database was queried for all members in all of their emergency department visits, and (2) a control group in which the HIE database was not queried for any of the members in any emergency department visit.

RESULTS

A post-propensity matching analysis showed that although the test group had more admissions per 1000 members overall (199 more admissions per 1000 members) than the control group, these admissions might have been more appropriate for inpatient treatment in general. The relative risk of an admission by the time of a first emergency department visit was 28% higher in the control group than the test group, although by the time of a second emergency department visit, it was only 8% lower in the control group. Moreover, test group admissions resulted in less time spent as inpatients, which was denoted by bed days per 1000 members (771 fewer bed days per 1000 members) and by average length of stay (4.27 days per admission for all admissions and 0.95 days per admission when catastrophic cases were removed).

CONCLUSIONS

Based on these results, HIE availability in the care of patients presenting to the emergency department is associated with fewer inpatient hospital days and a shorter length of stay, even when catastrophic cases are removed from the analysis. Although many factors can play a role in this finding, it is possible that HIE promotion of more appropriate hospital admissions from outside of the emergency department is one cause. Such "indirect" value shows that the return on investment found by HIEs may even be greater than previously calculated. Additional study is warranted to further the business case for HIE investment for the various stakeholders who are interested in supporting HIE sustainability.

Shifts in the architecture of the Nationwide Health Information Network

In the midst of a US $30 billion USD investment in the Nationwide Health Information Network (NwHIN) and electronic health records systems, a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internet-like architecture that encourages point to-point information exchange and private health information exchange networks. The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success, while making the NwHIN dependent on nascent technologies for community level functions such as record locator services. These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC's proposed changes in its strategy for the NwHIN.