Hangzhou Health Bureau Hangzhou, China August 31, 2010 Evolution of RHNs Around the World and in China 1

About The Dorenfest Group Presentation Agenda About The Dorenfest Group Evolution of RHNs around the world Evolution of RHNs in China EMR evolution and its relationship to RHNs 2 2

The Dorenfest Group 40 years experience in H.I.T. Offer healthcare improvement services Focus on improving patient care and operational efficiency through better change management Work process improvement Management systems improvement Improvement in services for patients Improvement in quality of patient care

Some Dorenfest Hospital Projects

Dorenfest’s Investigation of China Healthcare in 2005-2006 Visited 17 cities in China Met 100’s of healthcare industry leaders in China Visited over 100 hospitals to review hospital operations and define opportunities for improvement Met provincial and city health bureau leaders in cities visited Met with many companies selling products and services to the healthcare industry in China Evaluated a group of hospital ownership and management opportunities and assessed viability of the Dorenfest “model hospital” in China Developed a strategy for bringing Dorenfest’s skill and experience to China

China Healthcare Leaders Want To “Leapfrog” the World 1. Chinese hospitals and health bureaus are making considerable investment in hospital improvement and information technology use 2. To do this, Chinese health leaders are working diligently to acquire the skills needed to make progress more rapidly by doing the following: Learning quickly from the global experience Doing more of what the rest of the world did right and less of what the rest of the world did wrong to avoid the mistakes that other countries have made Overcoming resistance to change Learning how to manage change

Examples of Dorenfest Projects in China Some health bureau clients for RHN and digital hospital planning Shenzhen Chongqing Some hospital clients Peking University Third Hospital Shanghai Changning Maternity & Infant Health Institute Rizhao City People’s Hospital Help clients from other locations bring their skills to mainland China Hong Kong Hospital Authority Microsoft Philips /

Hangzhou Health Bureau Evolution of RHNs Around the World

History of HIT Leading to the Beginning of RHNs in the U.S. 1. The U.S. began automating manual work processes in the late 1960s Financial systems was the area of emphasis until the later 1970s, when limited clinical systems began to be implemented Clinical systems, after first emerging on a very limited basis, began to proliferate in many clinical departments in the 1980s 2. By the late 1980s, there was lots of automated patient clinical data available on hospital and physician office computer systems with one person’s health data stored in many different automated systems at many different locations 3. This situation resulted in much duplication of data, as well as duplications of testing and treatments given to patients 4. This situation motivated the development of the idea of sharing data among the different healthcare facilities to make healthcare more efficient, and to produce a single electronic patient healthcare record. 5. This situation began the movement towards RHNs that started in the early 1990s 9

Government Reimbursement RHNs Began in the U.S. in the Early 1990s as Community Health Information Networks (CHINs) Hospital B Nursing Home Doctor’s Office Patient Data Outpatient Clinic Outpatient Clinic Government Reimbursement Insurance Payor Doctor’s Office Doctor’s Office Hospital A Home Health Agency Blood Bank Outpatient Clinic

The First Generation of RHNs in the U.S. Did Not Succeed 1. Community health information networks (CHINs) began in 1990 as the first generation of RHNs in the U.S. 2. CHINs were formed with a broad vision of sharing information among health organizations within a city or state, but failed for the following reasons: They lacked clear objectives Potential participants and stakeholders were not attracted to CHINs because they could not see their value While much money was invested by many CHIN projects, the net result was that none of them worked because the value to participants and stakeholders was not apparent to them 3. Integrated delivery ownership models emerged in 1993 as the hospital’s answer to the Clinton healthcare reform proposal 4. By the middle 1990s, integrated delivery systems emerged in every city in the U.S., and the CHIN concept disappeared by 1996 11

The Second Generation of RHNs, Referred to as RHIOs, Emerged in the Decade of the 2000s RHIOs were the second generation of RHNs in the U.S. Many different organizations promoted them in the early 2000s By 2004, national policy emerged through the Office of the National Coordinator for Health Information Technology (ONCHIT) In the ensuing several years between 2004 and now, almost 100 officially designated RHIOs emerged Heavy investment required to start up these RHIOs Many were unable to find a sustainable operating model and approached financial collapse Some long term successes emerged to share limited data 12

An Example of the Successful RHIO is the Indiana Health Information Exchange (IHIE) Project 1. Started in 2002 2. Now, any Indiana physician can get access to patient data from many data sources 3. The IHIE provides services that its participants and stakeholders in community healthcare organizations are willing to pay for happily and that benefit them, including clinical data sharing among many users 13 13

An Example of a Failed RHIO in the U.S. Is the Santa Barbara Project 1. The Santa Barbara County Care Data Exchange was once one of the most ambitious and publicized US health information exchange efforts. Eight years after its inception, and several months after providing some data, the Santa Barbara Project shut down operations. Despite its developed HIE infrastructure, participants found no compelling value proposition in initial HIE services. When external funds were ending, the project board voted to close down project operations. 2. Lessons learned: The project received a large grant and was viewed as a demonstration project for RHN forward movement. When the large grant funds were used, the project participants faced more risk than they were willing to undertake, given the unclear value proposition for the participants . The project lacked leadership and participants were passive while the money was spent and lacked interest in putting their own funds into the project The project lacked momentum and credibility. Delays in the project due to technical reasons dulled interest among community participants and created doubts about the project’s credibility The vendors providing software to the project overpromised what could be delivered Finally, and most importantly, the project lacked a compelling value proposition with appropriate benefits to key stakeholders, and therefore the stakeholders did not support the project 14 14

A Summary of RHN Efforts in the Rest of the World 1. RHN-type efforts have been taken on by many countries. Some of the leading successful examples include: Hong Kong Singapore Australia Canada England 2. In the next pages, we elaborate on Hong Kong and Canada as examples of worldwide RHN success stories 15 15

The Hong Kong Hospital Authority Success Story 1. The Hong Kong Hospital Authority was formed in 1991 when over 40 hospitals in Hong Kong were combined under a common management authority, allowing central decision making, which was a key to the success of the Hong Kong Hospital Authority IT efforts over the next 20 years 2. Hong Kong Hospital Authority manages all public hospitals and government outpatient clinics. HKHA started its IT program in 1991, including financial, HR, patient administrative and departmental systems. In 1994, it began developing its Clinical Management System (CMS). HA adopted a centralized approach in developing its CMS for clinical care, greatly reducing IT cost per hospital. 94, it began developing its Clinical Management System (CMS). Interoperability between different hospitals was one of the key aims in developing the CMS system 3. To date, the HA has spent 200 million USD on the development and implementation of clinical IT systems 4. The electronic patient record, (EPR), was first developed in 2000 using a unified information model. It provides a standardized repository of all clinical data collected throughout the HA and offers a clinician-friendly view into the comprehensive longitudinal lifelong record of the patient. Currently 9 million patient records are held in the EPR 5. The Hong Kong Food and Health Bureau established an EPR sharing project in 2006 to allow patient records to flow freely between different care settings in both the public and private sectors throughout Hong Kong. This program will use the core technologies of the Hong Kong Hospital Authority to help make the sharing with private hospitals a success. The program is well underway now 16 16

The Canadian Success Story 1. An independent non-for-profit corporation called Canada Health Infoway was established in 2001 to lead the national EHR efforts with all federal, provincial and territorial government as stakeholders 2. Canada created a national framework to guide the development of an interoperable EHR across all jurisdictions. Each jurisdiction determines its own implementation strategy. Canada has national agreement to use a distributed model approach with health data emanating from different operational applications within a given jurisdiction 3. In this model, the pan-Canadian EHR consists of many EHRs resulting in a peer-to-peer network of message-based interoperable EHRs deployed across Canada 4. The results of Canadian RHN efforts are substantial. Since inception, Infoway has approved 241 projects in the following targeted program areas: Diagnostic Imaging System, Drug Information System, Infrastructure, Innovation and Adoption, EHR, Lab Information System, Public Health Surveillance, Registries and Telehealth 17 17

What Are the Lessons To Be Learned from Failed RHN Programs Around the World? 1. There was a substantial amount of wasted investment in RHN type programs in the U.S. and some other countries. These programs failed for reasons described below 2. They started with broad visions, but had great difficulty creating implementable plans 3. The failed programs over-simplified implementation approaches to create flawed programs 4. Because of lack of clear objectives, stakeholder commitment could not be generated, causing lack of user interest in the efforts of these RHN programs 5. When success was accomplished, it was done through limited, well thought through first steps and strong stakeholder participation and support 18 18

Summary of Factors Creating Successful RHNs Around the World The common ownership factor with centralized decision making has been a key factor in some of the most successful RHNs around the world, such as Hong Kong 2. In successful RHNs without common ownership, a governance and management structure was created that worked very well to generate stakeholder commitment and support 3. Generate political support and strong coordination to involve the various stakeholders and users of the RHN to come together on the purpose, goals, and objectives of the RHN 4. Have clearly stated and shared goals and well-defined business models so that IT can provide effective support 5. Find good first steps. Good first steps will let health facility leaders see the benefits and become willing participants in the RHN 6. Select partners carefully and wisely 19 19 19

Hangzhou Health Bureau Evolution of RHNs in China 20 20

Evolution of RHNs in China 1. The Ministry of Health (MOH) guidelines for Health I.T. Development called for regional health networks and digital hospitals to be implemented throughout China between 2003 and 2010 2. This provided much momentum for RHNs a few years ago, as many health bureaus undertook regional health network and digital hospital investment 3. In the last few years data sharing has begun to emerge in China as some RHNs share limited data such as test/diagnostic results and some patient information 4. Healthcare reform calls for e-health records and RHN development and has provided substantial additional funding in a variety of ways, so it is expected that substantial additional progress will be made in the next few years 5. Much more activity and funding in many cities and provinces with even U.S. funding for one or two major planning projects, including the Sichuan Provincial Health Bureau EHR and Regional Health Network Project 21

We Studied Seven City RHNs in China to Learn Progress 1. Recently, we did an RHN consulting project in which we studied seven regional health network programs. The seven cities or provinces are listed below 2. The 7 cities or provinces are listed below: Dongguan, Guangdong Province Hebei Province Foshan, Guangdong Province Shanghai Shenzhen, Guangdong Province Beijing Xiamen, Fujian Province 22 22

We Studied Seven City RHNs in China to Learn Progress (Continued) 3. We dedicated our efforts in studying these 7 cities to answer the following key questions: What does the RHN do? What are the benefits so far? How much is the investment so far? Which vendor is used? What are the success factors and potential challenges? 4. From this study, we identified some common challenges these RHNs are facing, as well as some important success factors, which are outlined on the following pages. 23 23 23

Our Observations About the 7 City RHN Programs We Studied 1. Some common issues we observed are as follows: All have a large vision to implement an EHR, but first steps in execution were often unclear All are trying to do too many things at once The city or provincial government has made a substantial part of the initial investment for the RHN and plays an important role in planning and coordinating RHN efforts Technical issues do not seem to be obstacles preventing success in any of the 7 programs All 7 programs are in their early stages of execution, and it is difficult to forecast how successful they will eventually be. There is much more work to be completed than the work that has already been done 24 24

Our Observations About the 7 City RHN Programs We Studied (Continued) 2. There are key differences in the seven city RHN programs as follows: The first step in these city programs is different from city to city. Good first steps can get better stakeholders support. An example is that Dongguan provided a free Office Automation system and citywide appointment system to attract the hospitals to involve in the city RHN. The approaches to building the RHNs in these 7 cities are different. We think the reasons for the differences include the following: The more complex that hospital ownership and medical service resource distribution are within a city, the more stakeholders are involved and the more difficult it is to make progress If funding requirements are not large and can be provided by a single entity, such as the city health bureau, or the city government, then the whole program can be managed with a more centralized approach Cities that started their RHN pilot programs earlier have gained some experience, which has made these cities very aware of the importance of good planning and a more structured approach The amount of investment in the 7 cities has varied considerably. The investment depends on the city size, approach taken to the RHN, and whether or not a good plan is in place 25 25

The Best Approach to Building Success in an RHN Is by Building a Strong Foundation 1. Carefully define first steps, make them simple and beneficial, and gain stakeholder support 2. Limited data sets with high benefit to many stake holders would be advantageous 3. When first steps prove beneficial, more aggressive second steps can be taken

Hangzhou Health Bureau EMR Evolution and Its Relationship to RHNs 27 27

Opportunities to Improve Healthcare Delivery Have Been Pursued for Many Years Great redundancy of information High error potential Lack of timeliness High cost Organization complexity

U.S. Hospitals Have Sought an EMR Since the 1960s Through Four Generations of I.T. Systems Finance Systems (1960s and 1970s) Limited Clinical Systems (1970s and 1980s) More Advanced Clinical Systems (Late 1980s and 1990s) Electronic Health Records (2000s)

Current Status of EMR Adoption in U.S. Hospitals EMR adoption in U.S. hospitals is still limited According to 7-stage EMR adoption model of HIMSS Analytics: Stage 4 Is considered the minimum level an EMR is used effectively By the end of the second quarter of 2010, 83.7% of hospitals are still under stage 4. Only 16.3% are in stage 4 or higher US hospitals still have a long way to go in adopting EMR Data from HIMSS AnalyticsTM Database © 2010 (formerly The Dorenfest Integrated Healthcare Delivery System DatabaseTM) 30

The Stepping Stones to Paperless Community Based EHR EMR Hybrid Record Traditional HIS collects information Data sharing across the continuum of care, payers, patient, etc. Digital documents, common views, multiple access points, HIS and departmental systems Codified data in EMR integrated with other clinical systems Paper based files and workflow with some computers 31

Overview of EMR Status in China 1. EMR is critical to the long-term success of citywide data sharing in RHNs 2. Today, many Chinese hospitals have an EMR operational or in implementation 3. While some of these EMRs are working well, many of these EMRs are causing more problems and work for clinicians in the hospitals. Some reasons for this include: Data entry by physicians through CPOE has added time to their workday without providing offsetting benefits Methods of entering information into the EMR is often through straight typing with very little facilitation through assisters to make EMR entry easier In many EMR systems, it is difficult to find what is wanted, as compared to finding it in the manual record In many EMR systems in use today, erroneous data finds its way into the EMR, because of poor integration of a variety of software systems in use by the hospital 4. These problems have emerged because many EMRs were purchased without adequate clinician involvement and were implemented with poor clinician training 32 32 32

Some Suggestions for Creating Successful EMRs in Chinese Hospitals 1. Make a very careful evaluation of the EMR software products available. Take a careful look at how other hospitals use them in order to build up a solid foundation for the buying decision 2. Involve a large enough group of clinicians at various stages of the software evaluation so that they understand the differences between products and can contribute their wisdom to the buying decision 3. Use the clinicians who were selected to be involved in the buying process as super users during the implementation and as trainers of the other clinicians 4. Do not oversimplify your evaluation. Be sure and look carefully at how the EMRs are working at user sites to be able to understand what you need to do to be successful in implementing an EMR 33 33 33

Planning Hospital EMR and RHN Together by Using a Hospital Clinical Data Repository Can Be Beneficial RHNs in China are or will be sharing patients’ clinical data extracted from different organizations. The types of data shared or to be shared include, but are not limited to, lab test results, diagnostic imaging test results, and even the images themselves 2. These types of data are usually stored in different components’ clinical information systems. To be able to easily share this data, there is a need to have a consolidated database within each hospital. This type of database is called a Clinical Data Repository 3. The Clinical Data Repository can be used in the hospital to extract and store data from the EMR for hospital medical decision-making purposes 4. The Clinical Data Repository structure and data model can be made to have some common characteristics for all of the hospital EMRs so that the data sharing among hospitals is made easier 5. The citywide RHN data model can then be structured to draw data from the Clinical Data Repositories in each hospital 6. By giving this careful thought as the EMR strategies for the hospitals are further developed, the citywide RHN foundation will be stronger 34 34 34

SHELDON I. DORENFEST OR XIAO LIU THANK YOU. FOR MORE INFORMATION CONTACT: SHELDON I. DORENFEST OR XIAO LIU THE DORENFEST GROUP THE DORENFEST CHINA NBC TOWER, SUITE 2725 HEALTHCARE GROUP 455 N. CITYFRONT PLAZA DRIVE HUAIHAI EAST ROAD NO. 45 CHICAGO, IL 60611-5555 HUAIHAI PLAZA UNITED STATES OF AMERICA SUITE 908 PHONE: 312-464-3000 SHANGHAI, CHINA FAX: 312-467-0541 PHONE: 021-51001821 WEB SITE ADDRESS: www.Dorenfest.com E-MAIL ADDRESS: info@Dorenfest.com SHELDON’S E-MAIL ADDRESS: sheldon@Dorenfest.com XIAO’S E-MAIL ADDRESS : xiao.liu@Dorenfest.com 35