New warning on health records

Posted on April 27, 2010 in Health Debates

Source: — Authors: – Opinion/Full Comment – Auditor-General report suggests costs and benefits will never be known
Posted: April 26, 2010.  By Terence Corcoran

Auditor-General Sheila Fraser’s report last week on Canada Health Infoway and the federal-provincial pan-Canadian Electronic Health Records initiative failed to generate much news. The report, “Electronic Health Records in Canada: An Overview of Federal and Provincial Audit Reports,” is an alarming portrayal of a multi-billion fed-prov program that’s at risk of running off the rails. Apparently, however, the AG’s report didn’t contain enough sweeping statements to satisfy media practitioners who prefer to have their boondoggles served up fully diagnosed and ready for surgery.

In summary, the report concluded that Canada’s Electronic Health Record (EHR) program, as implemented so far by Infoway and the provinces, has no overall cost controls, no total cost estimate, no numbers on total costs to date, no way of measuring benefits, no way of determining whether budgets are being met, has lacked strategic planning, has a high risk of not achieving objectives, and there are questions about how the project will be funded through to the end.

For a program that was once estimated to cost more than $10-billion, the AG’s brief and general assessment should be more than adequate warning that the great planning benefits of electronic health records may come at a price that overwhelms the benefits. For one thing, the cost estimates are out of date, based on a 2005 consultant analysis that claimed the $10-billion in spending would generate $6-billion in annual benefits.

Those benefits were based on the idea that if every Canadian’s individual health record were available electronically, the health-care system would save billions by speeding diagnoses, avoiding prescription errors, and streamlining health-care delivery, including drug delivery systems that pushed generics. In a 2005 report for Canada Health Infoway, the federal-provincial agency set up to promote computerized health records for every Canadian, the consulting giant Booz/Allen/Hamilton produced a big number: $98-billion over 20 years. The return on invesment was said to be 8:1 on each gross dollar invested.

Ironically, the big selling point for EHR is cost control. Electronic records will save billions by making sure patients are using generic drugs and reducing duplication in lab tests and other procedures. Cost control, however, doesn’t figure in Ottawa and the provinces that are now spending uncounted and uncountable billions attempting to develop the EHR system. Infoway, using federal money, has allocated $1.6-billion to subsidize provincial EHR programs, with another $500-million allocated in the last budget. Beyond that, nobody seems to know. “All provinces have not consistently tracked their total costs,” the Auditor-General said. “Therefore, the total costs to date of the EHR initiative are unknown.”

And they will never be known. Ontario has spent more than $1-billion, most of it apparently now lost, in part because the province rushed into the program without a strategic plan. Ontario also suffered from “inadequate oversight of project expenditures and deliverables, and significant scope creep (expansion of the original scope).” Other provinces experienced varying degrees of inadequate planning, governance issues, failure to make clear business cases for initiatives and lapses in cost control.

With little sign of control over costs, carrying out cost-benefit analyses gets a little tricky. The AG’s report is useful here:

“There is limited public reporting on progress at the provincial level. Provinces are hampered by the lack of comprehensive information, including costs, baselines and performance measures for the overall initiative. However, there are some initiatives underway. For example, Nova Scotia is participating in a joint initiative with two other Atlantic provinces to develop performance indicators, and Alberta has made progress in developing key benefit-evaluation components, although no benefit evaluations have been performed…. As a result, the provincial ministries of health and the public are currently unable to assess whether the initiative is achieving its goals and objectives, on time and within budget.”

Even Infoway, the federal-provincial agency that’s on the brink of topping $2-billion in spending, is quoted by the AG as saying “the risk of not achieving the goal is high.” The goal being to get 100% of Canadians’ health records in accessible electronic form by 2016—available to hospitals and other health-service providers, but not patients.

The AG raised questions about the $6-billion in annual benefits that are supposed to accrue to the sytem. “Will the cost savings and efficiencies be realized for Canada? What will be the other benefits? When will jurisdictions establish baselines to start measuring benefits?”

That last point is interesting. A determination of benefit implies knowledge of what it is one is trying to improve, a baseline for comparison. The AG’s comment implies that such baselines do not now exist. This suggests the great EHR experiment may not be able to determine what benefits have been achieved. All that exists is a couple of consultants’ reports on speculative savings and benefits, with no way of measuring real savings.

The AG report concludes with a series of reviews of contentious issues. For example, it wonders about the role of individual doctors. About 80% of Canadians interact with the health-care system through their doctors, but the pan-Canadian EHR program is aimed at hospitals, pharmacies and clinics. “Unless there is a significant increase in the number [of doctors using computerized systems], the potential benefits of EHRs will not be fully realized.” Infoway responds the funding has now been allocated to the role of doctors.

Where all this is going, nobody seems to know. The AG wonders where the money will come from. “Finally,” the report says, “questions remain about how the initiative will be funded. What will be the total cost to complete the EHR initiative?” In the United Kingdom, the total cost ran to $19-billion and the Financial Times recently reported that there is now agreement that a fully operational interactive patient record will not be achieved in the foreseeable future.

The future remains unforeseeable in Canada too.

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