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Impacts of EMR on healthcare performance: evidence from the Catalonian health care providers

Greta NasiSDA Bocconi School of Management

Agenda

• EMR systems: an impact assessment model

• The model’s methods for data collection

• Evidence from the Catalonian Health Providers

• Discussion and conclusions

Relevance of impacts of EMR systems

• Healthcare efficiency and effectiveness is becomingincreasingly dependent on information andcommunication technologies

• EMR systems promise to improve health care qualityto advance inter-organizational integration and datasharing across different health care providers, and toempower patients through greater access to personaldata

• However the variety and heterogeneity of potentialimpacts described in literature has not been framed into acomprehensive assessment model able to capture allrelevant dimensions of EMR impacts on health careperformance

The framework’s main dimensionsEfficiency includes impacts on the level of efficiency of internal processes which the application of the electronic medical record system has produced or will produce in the future in terms of time and cost savings and quality of information;

Effectiveness includes impacts in terms of improvement of the organisation as a whole measured as process integration, organizational effectiveness, risk management and better care processes;

Quality of service includes impacts on the overall care process, taking into account its performance, the continuity of care and the degree of empowerment of the patient;

Clinical Governance comprises the group of effects produced in terms of organisational culture, capacity for change as well as overall clinical performance.

The EMR assessment framework

Efficiency

Time savings

Cost efficiency

Information Quality

Effectiveness

Improvement of diagnostic and therapeutic activities

Risk Management

Effectiveness of processes

Quality of service

Patient Empowerment

Quality systems

Continuity of care

Clinical Governance

Service Value

Patient Empowerment

Efficiency of care

Quality Improvement

Accountability

Information management

Clinical Audit

Strategic management

Organizational effectiveness

Quality of service

Managing complexity

.

Diffusion

Pat

ient

wor

kflo

w

Methods for data collection

A mix of quali-quantitive methods have been defined and used for data collection. Here is a summary of the methodology adopted:“Self-completion questionnaires”, concerning information about the EMR system implementation which include:

• An assessment of the organization’s context;• The status of EMR system implementation and its functionalities;• Organizational impacts based on the four dimensions perceived by main

stakeholders including physicians, nurses, CIOs and controllers, Boards, patients

Semi-structured interview schemes to be used to interview key actors of the EMR system’ implementation project;Document scrutiny and analysis of other relevant information, as organizational and strategic documents, study reports

Some assumptions

After 6 years of EMR sys implementation

……. LONG RUN

Efficiency

Effectiveness

Quality of service

Clinical governance

After 1 year of EMR sys implementation

Pre-EMR system EMR system

Go Live

Data Collection

• A pilot data collection was carried out during in 2009 (March – September) in Italy and Spain to:

• Test the framework and methods;• Compare impact of EMR of new comers and

pioneers.

• An extensive data collection was carried out in 2010 to assess the impacts of EMR among Catalonian healthcare provider:

• 5 Hospitals and 10 primary care centers involved, selected based on network analysis

• Data collection: March to December 2010.

Organizations involved in the research

Data about respondents

• Three main specialties were interviewed (*):• Cardiology;• Gastroenterology;• Pneumology(*) Internal Medicine for Hospital General de l’Hospitalet

• A total of 220 questionnaires were retrieved:• 109 from Physicians;• 111 from Nurses.

• Data was gathered, based on network analysis, balancing hospital and “their” primary care centers

Findings: an overlook

Catalonian Hospitals Catalonian Primary Care Centers

EFFICIENCY

CLINICAL GOVERNANCE

QUALITY OF SERVICE

EFFECTIVENESS0246810

4,7

4,9

4,7

5,2

HospitalsEFFICIENCY

CLINICAL GOVERNANCE

QUALITY OF SERVICE

EFFECTIVENESS0246810

5,2

5,9

5,5

6,8

Primary Care Centers

EMR impact: comparing Italian and Catalonian cases

ITALIAN HEALTH PROVIDERS CATALONIAN HEALTH PROVIDERS

EFFICIENCY

CLINICAL GOVERNANCE

QUALITY OF SERVICE

EFFECTIVENESS0

2

4

6

8

10

5,0

5,4

5,1

6,0

Findings: Efficiency

In the long run, quality of the information prevails in terms of efficiency mainly due to of its clearness and completeness.

Lower perception of time and costs savings might be due to the routinization of the EMR in the respondents’ activities.

Time saving

Cost reduction Information quality

0

2

4

6

8

10

3,7

4,36,2

3,8

5,4 6,3

HospitalsPrimary Care Centers

Findings: Effectiveness Great enthusiasm for EMR

enhancement of diagnostic and therapeutic activities is enthusiastic in primary care centers thanks to more complete and reliable information.

• Hospitals' clinicians find that EMR does not necessarily contribute to reduction in the number of clinical errors.

• Overall, organizational and process is affected by the enthusiasm about the standardization of processes, and interchange of information among hospital departments and primary care centers.

Improvement of diagnostic and therapeutic activities

Risk Management

Process effectiveness

Organizational effectiveness0

2

4

6

8

10

5,6

4,3

5,8

5,2

7,1

7,1

7,0

6,0

HospitalsPrimary Care Centers

Findings: Quality of service Respondents appreciate

the integration of the clinical information systems and the all-day accessibility to the EMR.

Patient empowerment was not a priority in EMR implementation in Catalonia, this explains the results: patients cannot access their EMR.

Patient empowerment

Quality of service

Continuity of care

Quality system0

2

4

6

8

10

2,2

6,0

5,7

4,8

3,8

5,8

6,2

6,3

HospitalsPrimary Care Centers

Findings: Clinical Governance Increased levels of

accountability and good project management of the EMR - including training – is appreciated by the health care providers that took part in the study.

There is a need for a new wave of EMR to enhance how information is displayed

Clinical audit is effected by number of claims that health care providers still face.

Accountability

Information management

Strategic management

Clinical audit0

2

4

6

8

10

6,0

4,6

5,7

3,4

6,8

6,3

6,7

3,9

HospitalsPrimary Care Centers

Discussion and conclusion 1/3 • Overall the analysis shows positive impacts of

EMR on organizational performance

• Hospitals and Primary care centers showdifferences in results due to their different focus,degree of complexity and mission

• The more time has elapsed since the EMRimplementation, the more evident is the evolutionin impact perceived

• Different EMR implementation approaches havean overall effect on organization performanceresults

Discussion and conclusion 2/3 • Overall, Catalonian health care providers state that

EMR contributes to:• More reliable, comprehensive and complete

information about patient health history;• Standardized, integrated and efficient

processes;• Continuity of care and enhanced

communication;• Holding people more accountable for their

activities

This leads to greater organizational effectiveness

Discussion and conclusion 3/3

• Short term impacts tend to be forgotten and taken forgranted

• Some less enthusiastic respondents actually lookforward to new developments of the EMR systems

• Key actors are willing to further steps in ehealth

• A systematic assessment of EMR and complexehealth projects’ impacts might suggest the natureand direction of health care providers’ priorities andfuture strategies