Purpose/Objectives: Healthcare organizations across the globe have made large financial investments in the implementation of eHealth solutions. Many have not achieved the intended benefits. A plethora of reasons have been identified including the complexity inherent in these undertakings, sub-optimal leadership and staff with limited informatics knowledge and skills. Evidence-based resources are required to adequately prepare healthcare leaders, clinicians and others to effectively lead and support these initiatives. Yet, there is a paucity of such resources. This presentation reviews the results of one of three systematic reviews that were conducted to inform the development of a best practice guideline intended to enhance the informatics capacity of individuals involved in these types of initiatives. This systematic review identified individual and organizational factors that influence the implementation and adoption of eHealth solutions.

Methodology/Approach: Major medical databases were searched to identify relevant studies published between 2006 and 2016. A total of 178 studies met the search criteria. The data was categorized using the dimensions of the Clinical Adoption Framework and analyzed to determine the quality, consistency, generalizability and limitations of the evidence, making this the first comprehensive systematic review of its kind.

Finding/Results: A total of 173 factors were identified from the 16 articles that met the inclusion criteria. The two most commonly reported individual factors that impacted the implementation of eHealth solutions were technical competence and end-user participation. The organizational factors reported most often were training, usability and workflow integration. Fifteen individual/organizational recommendations were developed from these sources of evidence and published in the Guideline.

Conclusion/Implications/Recommendations: The individual/organizational factors and recommendations reviewed in this presentation will have relevance for healthcare leaders, clinicians and others who are involved in the implementation of an eHealth solution regardless of their role or setting. The recommendations outline evidence-based strategies that contribute to better design and adoption of eHealth solutions, enhanced clinical decision making, improved patient outcomes and health system transformation.

140 Character Summary: This presentation highlights key individual/organizational factors derived from a systematic review intended to enhance the adoption of eHealth solutions.

Purpose/Objectives: When clinicians deliver services to patients and families distant from their own clinical environment, new clinical, operational and technical systems must be designed both at the consultant site, and the patient site – a two pronged approach. For many telehealth visits, new clinical relationships between providers at BCCH and providers in community are created. In order to make the virtual clinical event as close to in-person visit as possible and meet the same health goals, there must be thoughtful and collaborative work at both patient and consultant ends. For the Children’s Virtual Care (CVC) sites across BC, the capacity and context of the system in the patient’s community must be combined with the capacity of BCCH Children’s, to meet the needs that can be unique to children and families. This presentation will describe the challenges and successes in building a system for pediatric virtual service in diverse BC communities, some of which have limited capacity and exposure to children with complex health challenges.

Methodology/Approach: Service need for pediatric subspecialty care is the primary driver for Children’s Virtual Care (CVC). With one Children’s Hospital, about 1 million square kilometers, and 1 million children, providing equitable access to pediatric subspecialty care in BC is an ongoing challenge. Analysis of access by health service delivery area and knowledge of the child health service system helped clarify the targets for virtual care, both in location and volumes. Using the Child Health BC Tiers of Service Framework for Children’s services, including the regional health authorities’ capacity for the support of children and families having telehealth visits, a feasible plan was developed for each CVC site. Children’s Virtual Care sites are those where staff at the patient site can support a number of clinical and operational requirements of a child’s virtual visit. CHBC worked in collaboration with technical, clinical and operational teams across the health authorities to develop CVC sites in regional health authorities and with the BCCH subspecialty teams to identify and meet specific requirements are needed to provide a visit as close to one at BCCH as possible.

Finding/Results: 19 Children’s Virtual Care sites in BC have been supported to gain the operational, clinical and equipment capacity to support pediatric subspecialty visits, and provide the specific requirements in 26 different subspecialty clinics. The CVC sites have child friendly environments, pediatric medical equipment, clerical support for reception and registration, processes for diagnostic testing when needed, nurses who can assist with assessment if required, and for some, pediatricians to collaborate with a pediatric subspecialist. Subspecialty BCCH teams are integrating virtual visits into their triage process, scheduling and booking , and workflows so that virtual visits are not a system separate from the system and processes that support in person visits. Rather the Virtual Care incorporates the multiple components within the health service system to increase effectiveness, efficiency and to ensure the satisfaction of children, families and their providers. 98% of families surveyed reported they agreed, or strongly agreed they would like telehealth for their child’s visit again. According to parents who participated in this survey, telehealth also prevented two parents from missing work, children from missing school and reduced the negative impacts of travel.

Conclusion/Implications/Recommendations: The two prong systematic approach to support clinical telehealth visits for sub-specialty services, systems and supports, will ensure an effective children’s virtual visit that is integrated into clinical processes, and the patient, family and provider satisfaction that leads to growth in the use of virtual services.

140 Character Summary: CHBC creates a sustainable pediatric subspecialty virtual care system for visits as close to in-person as possible, improving access care.

Purpose/Objectives: The Electronic Health Record (EHR) is central to British Columbia’s eHealth strategy to increase the quality and safety of patient care. However, the implementation of EHRs is a challenging, transformational change that involves the complex interaction between health care professionals, processes and technology. To support the successful adoption, use and optimization of EHRs for the benefits of patient quality, safety and the patient/provider experience, there is a need for a comprehensive framework/model to understand the variables that contribute to EHR adoption, use and benefits realization. Currently, such a comprehensive framework/model does not exist in the literature. However, an EHR Adoption and Use (EAU) framework/model is critical to informing evidence-based planning, implementation and evaluation of EHRs at the local, provincial, national and international levels. To inspire bold action in EHR adoption and use for benefits realization, Island Health embarked on the development of an EAU Model. The purpose of the EAU model is to guide EHR adoption and use planning, as well as to inform formative EHR evaluation at Island Health.

Methodology/Approach: A literature review of existing technology adoption/use and quality frameworks was conducted from May to June 2017. The variables/constructs and dimensions of each of these frameworks were extracted. Similar constructs and definitions were combined and an overarching framework was developed. To operationalize the model for measurement, relevant metrics related to patients, caregivers, health care providers, the health care organization and population health were extracted based on literature reviews and prior EHR evaluation knowledge for each construct. Methodologies, methods and instruments for evaluating the metrics were also identified.

Finding/Results: Ten technology-adoption-and-use frameworks/models were included in the development of the EHR Adoption and Use (EAU) Model: (1) the Unified Theory of Acceptance and Use of Technology (UTAUT); (2) Canada Health Infoway’s Benefits Evaluation Framework; (3) the UVic eHealth Observatory’s Clinical Adoption Framework; (4) Island Health’s Quality Framework; (5) the BC Health Quality Matrix; (6) The Clinical Systems Transformation (CST) Benefits Framework; (7) the Agency for Healthcare Research and Quality (AHRQ) Domains of Health Care Quality; (8) Health Quality Ontario’s Quality Attributes; (9) Accreditation Canada’s Dimensions of Quality Care; and (10) the Clinical Adoption Meta-Model. As the most cited and rigorously tested framework internationally, the Unified Theory of Acceptance and Use of Technology (UTAUT) was used as the core framework for the EAU Model. In total, 42 constructs and sub-constructs were included, and multiple metrics at the patient, health care provider, health care organization and population health levels were developed for each construct. The EAU Model can be seen in Figure 1. The validation and testing of the metrics and evaluation methods is currently underway. Figure 1 EAU Model

Conclusion/Implications/Recommendations: The EAU model combines evidence-based variables/constructs of technology adoption and use with universal quality and experience benefits that can be measured for EHR benefits realization. The EAU model can be used by health care organizations to guide the planning, implementation and continuous evaluation of EHRs at the local, provincial, national and international levels.

140 Character Summary: The EHR Adoption and Use (EAU) Model is an evidence-based framework to guide EHR planning, implementation, continuous evaluation and benefits realization.

Purpose/Objectives: Telehealth is defined as being the virtual organisation of service networks, professional collaborations with or without patient intervention using information technology in order render at a distance professional training, patient teaching, assistance, monitoring, clinical coaching, consultation and follow-up. A new Ministerial Telehealth Framework has been proposed in the province of Quebec. The Ministry intends to review the telehealth governance in order to recognise telehealth as a service delivery model, to anticipate the clinical needs that justify telehealth services, to agree on an integrated plan for the development of telehealth services, to have an overview of the telehealth services and projects over the province, to optimise telehealth services and resources and to measure the impact and benefits of telehealth. Given this context, a telerehabilitation clinical project was developed in a Montreal-area health network. More specifically, the objective of the telerehabilitation project was to develop a model of delivery using modern technologies in order to improve the access to specialized and ultra-specialized rehabilitation services (evaluation & intervention) and to measure its effects.

Methodology/Approach: With changing demographics, increased prevalence of chronic diseases, limited health care resources and health network reforms, it is essential to consider alternative methods of rehabilitation service delivery in order to optimize recovery across the continuum of care. The telerehabilitation clinical project implemented remote services using innovative technology in three major rehabilitation centers. Using a systematic project management approach, clinical needs were assessed, appropriate technologies identified, implementation progressively undertaken, patient and clinician satisfaction was assessed and potential cost savings estimated.

Finding/Results: Close collaboration with an industry-partner was essential to develop the remote telerehabilitation applications that will be presented. An in-house evaluation process allowed us to measure several indicators such patient and client satisfaction, types of interventions and the potential cost savings with the use of the telerehabilitation modality. The factors impacting on telerehabilitation implementation and routine use are presented, with regards to the technology itself, the organisations (including clinician attitudes and beliefs), and the context within which the organisations function. The strategies to overcome barriers throughout the implementation process are also discussed.

Conclusion/Implications/Recommendations: Integrating telerehabilitation innovations into routine clinical care is a complex process. Despite the anticipated benefits of telehealth, its implementation in healthcare remains challenging. Findings from this clinical experience, as well as more long-term studies of telehealth use in different contexts will allow us to better understand the factors which impact on telehealth implementation as well as its routine use in clinical practice.

140 Character Summary: Implementation of Telehealth Services Across 3 Rehabilitation Centers in Montreal Canada

Purpose/Objectives: This presentation will focus on the successful adoption and current use of HEALTHe NL, Newfoundland and Labrador’s electronic health record (EHR). Including: ? Implementation of Orion’s EHR solution - HEALTHe NL ? Current state, in relation to Canada Health Infoway’s EHR Blueprint ? Adoption metrics ? Current usage ? Governance and future plans

Methodology/Approach: This presentation will highlight the adoption strategy for HEALTHe NL. This includes the strategic focus on target groups based in a phased approach as informational components of HEALTHe NL became available such as: ? A focus on physicians in the Eastern Regional Health Authority (RHA) when only Eastern RHA laboratory information was available ? Nurses completing medication reconciliations based on the robust medication profiles ? Clinicians in remote areas referring patients to the tertiary care centre, that would otherwise not have access to that information, for health care services including; cancer care, Janeway (children’s hospital), cardiac and vascular services.

Finding/Results: This presentation will highlight the current state of adoption for HEALTHe NL including the following information:: ? Total active use ? Top signed on user groups (eg. nurses, physicians, pharmacists) ? Top departmental users (eg. medicine, surgery, emergency room, nursing) ? Unique medication profile data

Conclusion/Implications/Recommendations: In conclusion, this presentation will provide recommendations with regards to the success of the adoption strategy employed. In addition lessons learned speaking to challenges and future areas of focus will be shared. The presentation will also highlight next steps based on stakeholder engagement and enhancement consultations with both end users and Orion, the HEALTHe NL vendor. Future plans and opportunities: With active use, comes increased requests for product enhancements and integration. We are currently working with numerous stakeholders to review and priortize opportunities for expansion of the HEALTHe NL viewer including eNotifications, eReferral, eConsult and eOrdering.

140 Character Summary: Newfoundland and Labrador's provincial electronic health record: HEALTHe NL success stories

Purpose/Objectives: Pulmonary embolism (PE) is a serious condition that can be fatal if diagnostically missed. The aim of this study is to evaluate the impact of integrating a clinical decision-support system (CDSS) on diagnosis of PE in an inpatient hospital setting.

Methodology/Approach: This is a mixed-methods study with an observational pre-post design. A CDSS for the diagnosis of PE has been designed to represent best practices in data visualization and uncertainty in presence of disease. This CDSS will be integrated into the computerized provider order entry system and set up to be triggered at key points in the PE diagnostic workflow at two hospital sites. Data will be accessed from clinical information systems and consist primarily of information about tests commonly requested for PE diagnosis and provider decision-making steps. Data will be collected for six months prior to deployment of this CDSS and again for six months after deployment. This data will be analyzed to determine pre- and post-intervention physician adherence scores. Adherence scores will be compared to determine what impact, if any, the CDSS has on physician adherence to diagnostic guidelines for PE. Similar data from a third hospital site will be collected and incorporated into the final analysis. This third hospital site will not have access to this CDSS for PE diagnosis and is designated as control site for outcome comparisons.

Finding/Results: Based on previous work, the research team expects to see increased provider adherence to diagnostic guidelines for PE in settings where the tool has been implemented.

Conclusion/Implications/Recommendations: Clinical decision-support systems have the potential to improve patient care and safety as a result of increased provider adherence to existing evidence-based guidelines. Work on PE is not the only condition for which diagnostic error is of concern, but this research may produce a template for the use of decision-support with other conditions. This pilot study is expected to launch in early 2018 with preliminary analyses available by late 2018.

140 Character Summary: Pilot clinical study of the impact of a clinical decision-support system on provider adherence to guidelines for diagnosis of pulmonary embolism.

Purpose/Objectives: The purpose of this presentation is to discuss the adoption of Telemental Health Services in a Regional Mental Health Centre. We will also discuss the high level of satisfaction our patients and providers experienced with this service.

Methodology/Approach: Background: Historically, access to mental health services for patients in the rural regions of our Eastern Ontario catchment area have been a challenge due to the long distances between our rural patients and the urban location of their mental health service providers. Objectives: To mitigate this access barrier to mental health services we created a plan to establish rural mental health clinics throughout our catchment area. Methods: We employed various strategies to ensure the clinicians and clinics we recruited adopted and retained the practice of providing Telemental Health Services from clinicians based at an urban tertiary academic health centre to patients located in 14 rural primary care clinics. Results: Our ten-fold increase in patient volumes and the high levels of patient and provider satisfaction indicate that the methods we employed to create a Regional Telemental Health Service have been successful. Conclusions: Employing the correct change management strategies can allow for the rapid adoption and development of Telemental Health Services in a catchment area where rural access to conventional specialized mental health services is a challenge.

Finding/Results: Our ten-fold increase in patient volumes and the high levels of patient and provider satisfaction indicate that the methods we employed to create a Regional Telemental Health Service have been successful.

Conclusion/Implications/Recommendations: Employing the correct change management strategies can allow for the rapid adoption and development of Telemental Health Services in a catchment area where rural access to conventional specialized mental health services is a challenge.

140 Character Summary: We will describe the adoption of and satisfaction with Telemental Health services in the context of an Ontario regional mental health centre.

Purpose/Objectives: As the healthcare industry has become more complex, the lag in the sophistication of approach in change, transition and sustainability has become more acute. The change communities in the country seek to better understand the problem, the gaps and look at how A2B Change Process can be relevant and applicable in the continuously evolving healthcare change landscape.

Methodology/Approach: This particular research is part of an informal survey, which assessed the current National Change Management Framework and its six core elements (1) Governance and Leadership (2) Communications (3) Training & Education (4) Workflow Analysis & Integration (5) Stakeholders Engagement (6) Monitoring & Evaluation using a 5-question survey. The survey was open to all Change Management Network members on both LinkedIn and InfoCentral virtual communities.

Finding/Results: Early respondents with combined practitioners’ anecdotal contribution and further literature search conducted is supportive of the A2B Change Process with solid foundations on Transitions to Operations and Sustainability Planning as part of the change journey. The results also are reflective of lessons learned as shared by the interview respondents. Oftentimes, in our attempt to manage change that we are forgetting that change and transition DO NOT 'start and stop' during 'Go-Live'. "Go-Lives' are just events in the change process, and the real change and transition management is continued well beyond 'Go-Lives'. A well-thought out 'hand-off' from project teams to the business teams is required to ensure sustained success. Note: Research is still in progress.

Conclusion/Implications/Recommendations: According to Albert Einstein it is “Insanity: doing the same thing over and over again and expecting different results.” As our environment evolves and so must we to remain relevant. As organizational leaders, we have the responsibility to manage change efforts along with the process of transition to minimize the negative impact on frontline stakeholders. It is important for practitioners to include transition components; (1) Transition to Operations (2) Sustainability into the change process or in any methodology of choice. This approach focuses the change as well as the transition. Change and Transition are not interchangeable and they must co-exist in conjunction with one another to ensure successful and sustained digital health implementations. Change is an event and Transition is a process and so as sustainability. To date, the informal survey received from 29 peer-respondents. It is expected to see an increase of 50% from current survey rate of participation. Although further numbers are expected to add to the results of the research, it is unlikely to see a change in recommendations. The story of CHANGE and TRANSITION can be summed up by 'Make a Plan, Ensure Commitment & Move on' one person at a time.

140 Character Summary: Overall, the study clearly demonstrates that a more sustained outcome results when transition components are included in the change & transition management approach.

Purpose/Objectives: Telemonitoring has a demonstrated ability to ease the burden of managing heart failure by facilitating self-care for patients and decision support for clinicians. A smartphone-based telemonitoring program was launched as part of the standard of care in a large hospital-based heart function clinic. The objective of this study was to identify the technical and contextual barriers and facilitators to implementation and to determine the success or failure of this initiative.

Methodology/Approach: A mixed method, single case study design was employed. Quantitative data included objective measures of implementation success (feasibility, cost, fidelity, and penetration). Qualitative methods included semi-structured interviews with adopting and non-adopting clinicians (N=9) and other program staff (N=4). Interview guides were developed based on the constructs of the Consolidated Framework for Implementation Research (CFIR) with the intent of eliciting responses with regard to factors known to impact implementation success. In addition to the interviews, patient and clinician-reported issues documented by telehealth staff were analyzed. Quantitative and qualitative data were collected at 4 months and 12 months to explain implementation success longitudinally over a 1-year period.

Finding/Results: By August 23rd, 2017, 98 patients had been enrolled in the program. Excluding equipment costs, the cost of implementation as measured by telehealth support time expended, was higher than initially expected. Minor problems with fidelity, which is the degree to which a program is implemented as intended, were reflected in issues documented by patients and clinicians. Penetration (i.e., integration) of the program within the clinic increased over time with an increase from 3 to 7 clinician users. Several barriers and facilitators were identified. Barriers included (1) difficulty in documentation due to lack of interoperability with the hospital EMR, (2) managing system alerts for unmotivated patients, (3) communication challenges among key stakeholders, and (4) the lack of clear implementation strategy. Facilitators included (1) characteristics of the implementation setting (i.e., a clinic that values innovation, teamwork and patient-centeredness), (2) a strong clinician champion, (3) a telemonitoring system that was easy to use, (4) pre-implementation work related to identifying a service design that minimized disruptions to clinician workflow, and (5) a general perception from clinicians that the telemonitoring program has had positive impacts on patient care. Despite increased support staff requirement and minor issues related to the system, participating stakeholders placed more weight on the facilitators and pointed to the voluntary adoption of the system by other clinicians when concluding that the implementation of the telemonitoring program was a success.

Conclusion/Implications/Recommendations: To date, no comprehensive implementation studies on smartphone-based telemonitoring programs have been conducted. By using a longitudinal and theory-based approach, our study could map barriers and facilitators experienced throughout different phases of program implementation. Findings are discussed in such a way that they are transferable to diverse settings. Understanding the factors that influence the implementation of telemonitoring systems is a necessary step toward meaningful scaling of these innovations.

140 Character Summary: This presentation will discuss results from the implementation evaluation of a smartphone-based heart failure telemonitoring program.

Purpose/Objectives: Fast Healthcare Interoperability Resources (FHIR), the newest standard coming out of HL7 International has been gaining a lot of traction since its early beginnings in 2012. A number of countries have already embraced it as the interoperability solution of choice for the HIT field. At the same time early implementations have found that the promised benefits can only be achieved when best practices are observed. What needs to be true for this new technology to have a chance of becoming the panacea of Canadian interoperability?

Methodology/Approach: Just like any new technology, FHIR is not immune to the hype surrounding its launch. We set out to look beyond the hype, examining how the standard is created, early adopters on the international scene, emerging trends for its use and new technologies springing up at its fringes. The challenges associated with its early adoption and the mechanisms needed to facilitate broad scaling of solutions based on its use have been investigated.

Finding/Results: FHIR is truly an international standard. Experts from around the world are contributing time and content to its continuous development. While at the surface it appears as the most user friendly standard ever to hit, the complexity associated with healthcare has never disappeared. This complexity is driving a continuous change in the very fabric of the standard as well as in the resources that are its building blocks. This change has significant repercussions on version control, large scale, long-term adoption strategies, harmonizing across international boundaries, semantic meaning and the overall project management approach those considering implementing with FHIR should consider.

Conclusion/Implications/Recommendations: There is no denying that FHIR is the path forward. Recognizing this truth does not change another one - every journey destined for successful outcomes requires the necessary due diligence. A transparent, scalable FHIR-based interoperability in Canada includes an examination of the threats, opportunities and viable strategies that does not place us at odds with the rest of the world and place us on a path to true interoperability.

140 Character Summary: FHIR will revolutionize the world of interoperability. What needs to be true for it to become the panacea of Canadian interoperability?

Purpose/Objectives: The role of Clinical Informaticists (CIs) is to bridge the gap between clinical practice and information technology to facilitate patient care. CIs work in various capacities; for example, CIs provide health care information system (HCIS) application support for clinicians; CIs develop and provide end user (clinician) education; and CIs collaborate with stakeholders to design, develop, and implement HCIS solutions. Newly hired CIs face a staggering learning curve as they transition into their new role; for example, trading in a stethoscope for a laptop and learning a new language, including numerous acronyms, which may be proprietary or organization specific. Moreover, developing CIs as mentors can prove challenging as one cannot assume all experienced CIs would make good mentors. This may be because CIs may not have formal education/training in mentorship, may not have the skills needed to be a mentor, and the mentorship process may not be clearly defined. The purpose of this project was to apply a cognitive apprenticeship model to guide the mentorship, orientation, and professional development of newly hired CIs.

Methodology/Approach: The Cognitive Apprenticeship Model (CAM) (Collins, Brown, & Newman, 1989) emphasizes the facilitation of knowledge acquisition through situated learning and discussion of cognitive processes between mentee and mentor. I utilized the CAM as a mentor to five new Clinical Informaticists hired between July and October 2017. I focused on the following CAM components: 1) Modelling (ex. user set-ups and resolving user issues), 2) Coaching (ex. observing and giving feedback to mentees’ teaching), 3) Scaffolding (ex. daily check-in time increased or decreased), 4) Articulation (ex. Socratic method for questions), and 5) Reflection (ex. Competency, Assessment, Planning, and Evaluation tool). As the mentees progressed with their learning and knowledge acquisition, I modelled, coached, and articulated less and gradually removed the structured support (scaffolding); for example, with user set-ups and teaching. However, because clinical informatics practice is dynamic, professional development is ongoing, and at any given time, I may be utilizing the CAM components for each mentee; there is no end to the CAM as there is no end to learning.

Finding/Results: A ten question survey and anecdotal feedback indicated mentees' satisfaction with their mentorship, using the Cognitive Apprenticeship Model (CAM). All mentees were able to achieve department expectations with defined timelines; for example, by week six, new Clinical Informaticists are expected to teach a four hour order entry class and complete user-setups independently. An unanticipated finding was an increase in staff recruitment/retention as two of the mentees were hired into temporary positions and have since been hired into permanent positions.

Conclusion/Implications/Recommendations: Mentorship in clinical informatics is often informal and may have an undefined process. Without a framework/model for mentorship, mentors may neglect to improve and/or may negatively affect the orientation and professional development of new Clinical Informaticists (CI). The application of a Cognitive Apprenticeship Model (CAM) in this project was successful to guide mentorship and ease the challenging transition from clinician to CI. Therefore, it is recommended that an approach such as the CAM is used to facilitate mentorship in CI practice.

140 Character Summary: Cognitive apprenticeship in clinical informatics practice facilitates the mentorship, orientation, and professional development of Clinical Informaticists.

Purpose/Objectives: Background: Since the rollout of inpatient EMR in 2013, the outpatient nephrology (off-site clinic and hospital-based dialysis unit) remained on paper. The nephrology program wanted to move away from a hybrid state to address inefficiencies with continuity of care (e.g., duplicate work efforts, transcription errors and often delays in patient care). After considering the resources in-hand, the decision was taken to leverage the existing inpatient-EMR to meet nephrology outpatient needs. The implementation included Computerized Provider Order Entry (CPOE), Bedside Medication Verification (BMV) and electronic Medication Administration Record (eMAR), integration of dialysis machines with the EMR and automation of data collection for Ontario Renal Reporting System (ORRS). The project started in October 2016 and EMR went live in April 2017. Objective: To evaluate the implementation of hospital’s inpatient EMR in an outpatient nephrology by comparing pre and post go-live states.

Methodology/Approach: We proceeded with identifying and analyzing nephrology care areas that went through the transformation. We also focused on complex care processes, such as, the transfer of chronic kidney patients between care sites and related medication reconciliations. Analysis on the transformation impact on people and processes was also performed on a sample of nephrologists, nurses and renal pharmacists; in which a pre and post implementation efficiency matrix was created to evaluate expected benefits.

Finding/Results: Findings: With use of CPOE, BMV and eMAR, order processing was found more reliable, faster, accurate and auditable. Integration of dialysis machine proved to be efficient in care delivery. The process of ORRS report finalization showed better data acquisition. We also observed few inefficiencies, such as medication reconciliation between inpatient and outpatient visits, dialysis prescription reconciliation, combined trending of inpatient and outpatient labs and medications over time, tracking of outside referrals, labs and medications. We also observed occasional slowness/non-responsiveness from provincial data source (i.e., Connecting Ontario.) leading to temporary manual processes. Results: Based on the evaluation matrix, there is an overall improvement noted in the program’s performance and patient care quality and safety. However, we also observed some inefficiencies due to inherent limitations in inpatient-EMR for outpatient areas.

Conclusion/Implications/Recommendations: We conclude that implementing an inpatient EMR in an outpatient setting may prove to be a better alternative to a paper-based environment; however this is heavily dependent on the flexibility of options in EMR and careful reengineering of patient care processes.

140 Character Summary: Careful implementation of an Inpatient EMR in an outpatient setting brings overall efficiency.

Purpose/Objectives: A project to move from paper forms for documenting patient encounters in a provincial emergency health services organization to an electronic patient care record (ePCR) system prioritized frontline paramedic engagement. This approach ensured the delivery of a solution that meets end-user requirements and which is being readily adopted. This presentation will provide an overview of the project’s paramedic engagement strategy.

Methodology/Approach: Paramedics have been involved in the electronic patient care record project from the beginning. Paramedics held a seat at the table during the procurement process to select a vendor. Ten paramedics participated in a usability evaluation to ensure the lead proponent’s solution was learnable and usable. Paramedics also completed an evaluation of the lead proponent’s software in parallel with a crew using paper to validate that the solution would work in a live setting. Paramedics have also been engaged throughout analysis and design. Paramedics sit on the core project team. Over 20 workshops have been held across the province, collecting feedback on the application from hundreds of paramedics, and all feedback is documented in a product backlog. Paramedics sit on a planning committee to drive prioritization and decision making on the application. All paramedics are invited to regular project demos to view the updates being made as the project progresses. During the execution phase of the project there has been twofold engagement. First, the support model involves non-paramedic project team members riding along with paramedic crews during their first shift using the system. Project team members have now spent hundreds of hours in ambulances, providing an unprecedented opportunity to observe the system being used in the field. Second, paramedics have been hired as deployment team members to provide peer support. This twofold approach has fostered a trusted partnership between IT and frontline paramedics working towards a single, shared vision.

Finding/Results: Building paramedic engagement deeply into every aspect of solution selection, training and delivery has ensured that the right decisions are being made by the right people. Paramedics helped select their new documentation tool and have driven project decisions; for example, they selected a device with a physical keyboard based on usability study findings. The workshops have identified unique regional requirements across the province. Paramedic-driven decision making in planning meetings ensures the most important updates are prioritized. By working in the field, project leads better understand the solution, and are more responsive to questions and feedback. The paramedic deployment leads add credibility to the project and deployment. As a result of engagement, paramedics have taken ownership of their solution, creating excitement around the implementation.

Conclusion/Implications/Recommendations: By making paramedic engagement core to every aspect of the project, the project has delivered on a large, complex mandate while successfully meeting end-users’ needs. This level of heavy engagement requires significant investment of time and a willingness to give up some decision making on product priorities, but the end result is worth the upfront effort. Regardless of the type of project, engaged frontline staff is a critical component to enabling change, adoption and successful delivery.

140 Character Summary: The project will present on the importance of paramedic engagement through all phases of a successful electronic patient care record implementation.

Purpose/Objectives: Fraser Health has launched a key initiative to reduce high frequency usage at their 12 Emergency Departments – Familiar Faces. Utilizing the Unifying Clinical Information (UCI) solution, Familiar Faces Care Management Plan can be accessible by Acute and Community care disciplines to provide integrated care. The vision is to improve patient experience and health outcomes for high frequency users of the Emergency Department (ED) – ensuring that each receives the right service, at the right place, at the right time to meet their needs.

Methodology/Approach: Frequent users or ‘Familiar Faces’ of Fraser Health’s ED often represent vulnerable populations who would benefit from coordinated upstream interventions that would both improve care and lower congestion. Patients/clients are identified as Familiar Faces based defined criteria. The Familiar Faces Care initiative recognized the challenges associated with coordination of care amongst health care teams, and with access to community-based health and primary health care services. These challenges were further compounding the problem of frequent ED use. If an individual is identified as Familiar Faces; the clinical team works together to develop the Familiar Faces Care Management Plan. The Care Management Plan is an integrated and shared comprehensive outline that illustrates the deliberate organization of care activities, resources and services for the Familiar Faces client when presenting to the ED. The Familiar Faces Indicator flag is used to identify patients who meet the Familiar Faces criteria. The Care Management Plan is entered in Meditech (used in acute care settings) or Paris (used in community care settings). There is only one Care Management Plan per patient/client to avoid duplication. In addition; the Indicator flag is entered in Meditech and Paris to ensure acute and community staff are aware of an active Care Management Plan available to view in UCI. Due to the lack of integration between Meditech and Paris; the UCI solution was selected to share the Care Management Plan between acute and community settings. The UCI solution provides a holistic integrated view of the patient across Fraser Health including Provincial Lab, Provincial DI and information from the Vancouver Coastal/ Providence Health/PHSA (VPP) CareConnect solution.

Finding/Results: The Familiar Faces initiative has been implemented in Meditech and Paris. Familiar Faces Care Management Plan from Meditech and Paris are both accessible in UCI for all Fraser Health users. In addition; the Paris Indicator flag for Familiar Faces is also viewable in UCI.

Conclusion/Implications/Recommendations: As a result of this key initiative, Fraser Health has achieved the following objectives: Familiar Faces alerts and care management plans developed in Meditech and Paris Consistent care and messaging for the Familiar Faces client at all points of care Emergency Departments have established links with various community services Easier access to care management plans in UCI by clinicians The following current initiatives that are currently in progress and future state: Meditech Indicator flag integration with UCI Sharing Care Management Plan with BC Ambulance Services Integration of VPP Care Management Plan with Fraser Health Implementation of Care Management Plan and Indicator flag in Profile (used in primary care settings)

140 Character Summary: The Familiar Faces initiative was introduced to reduce the high frequency users in the Emergency Departments by utilizing the UCI solution.

Purpose/Objectives: The primary objective of this literature review was to understand the commercialization landscape relevant to eHealth and mHealth in Canada. In the recent few years, eHealth and mHealth focused apps have been growing at a significant rate and that has brought in a unique set of challenges in a knowledge-driven economy like Canada. This literature review will help to further identify those challenges and the kind of opportunities can come out of it from the discussion. As well as, this research will help bridge the gap between various important key stakeholders such as the academic world, clinical practitioners, and the medtech industry itself. The ultimate motivation for this discussion is to enable further collaboration among the key stakeholders pertaining eHealth and mHealth in Canada

Methodology/Approach: 1. Scoping review of eHealth and mHealth publications with the focus on commercialization of such technology within the different healthcare systems in the world. 2. Interview key stakeholders who play a key role within Canada for commercializing new eHealth and mHealth technology. 3. Use Levac’s methodology to identify papers which describe barriers and opportunities to commercialization of eHealth and mHealth focused solutions in Canada

Finding/Results: The initial literature searches have identified several gaps that have limited the commercialization of mHealth technology: 1. Lack of consistent terminology defining eHealth and mHealth technology within literature and in work practices, 2. Lack of definition between go to market tools vs. wearables vs. EHR’s vs. efficiency in Canadian and North American Markets, 3. Not enough multidisciplinary insight on mHealth and eHealth technology success in the long run in the current healthcare system. This literature review and discussion would be developing recommendations related to 1. How eHealth and mHealth are defined in what context, 2. What are tools, resources, and organizations in place within Canada to foster eHealth and mHealth focused innovation within the healthcare system? 3. What type of strategic initiatives need to take in order to foster longer implementation plan for new innovative eHealth and mHealth solutions to be better integrated.

Conclusion/Implications/Recommendations: eHealth and mHealth technology use in Canada, both in the research and industry domains, have been increasing significantly in the last ten years. Such use of technology has shown to help various parts of the population be better aware of their health, help the healthcare team able to remotely monitor the patients’ vitals, and help the overall healthcare system become more proactive. Public healthcare in Canada is a very complex system and there are various stakeholders that play key roles when it comes implementing and deploying a new form of technology on a systems level. In this project, we are finding the current barriers and opportunities that are prevalent with implementing eHealth and mHealth within the Canadian landscape by doing an initial literature review and as well as interviewing key figures within the field in order to bring together relevant information for innovators.

140 Character Summary: Understand how commercialization of mHealth and eHealth works within a public healthcare system like Canada, exploring barriers and enablers.

Purpose/Objectives: The Canadian health care system is a cherished institution in Canadian society. Universal access to care is viewed as a basic right for all Canadians and this historical institution is internationally recognized and envied as a model for health care delivery. In Canada, medical records can be generated and maintained in a variety of ways. Different care providers throughout the patient’s journey will create their own local charts and, because of the complexity this system, transference of this information between providers in the circle of care is slow, cumbersome, and often reliant on inefficient modes of communication, such as paper facsimile, or images on a CD-ROM. This can result in an increased risk to patient safety, privacy breaches, miscommunication, and costly repetitive administrative processes. This fragmented system of digital health records increases the burden on our healthcare system and patients. In terms of the experience for the individual health-seeker, the current system is disempowering because knowledge of their own personal health information is obscured through lack of access and transparency.

Methodology/Approach: Leveraging the use of systems thinking and design principles, a comprehensive current state analysis was conducted to illustrate baseline performance, and a future state ideation was generated. In order to find solutions and innovations that will translate into actual applications, a literature review was conducted with a focus on the Canadian healthcare context. For the literature review, promising components of digital health, proposed innovation, impact, and barriers were explored. Additional research included interviews that were limited to brief probes of professionals in the field to better understand context and applications.

Finding/Results: This research began by first understanding the current context of digital health records in Canada. Due to multiple types of health records, each governed by a different set of ownership, data is fragmented, out-of-date, incomplete, and cast across a network of regions and provinces. Owing to this, data can be redundant and difficult to access resulting in duplication or error that ultimately leads to unnecessary cost to Canada’s healthcare system. Patients are also left at the mercy of this system, either by having to transmit their data at multiple, various touch-points or simply left disempowered; unaware of their current health status until the next care provider is available or a health crisis arises. Furthermore, the lack of comprehensive datasets negates opportunity for research to formulate disease-preventing interventions that target specific areas of Canada’s population. Thus, it is clear that a need exists for reform in the area of digital health records, particularly in unifying digital health records and providing patient access.

Conclusion/Implications/Recommendations: The rise of personal data management in health care suggests patients prefer more autonomy over their personal health data. The popularity of mHealth portals and wearable devices is growing at a fast pace and presents tremendous potential. This self-generated data, in the purview of the patient, could play a role in the future alongside traditional health records to simultaneously aid in disease prevention for the patient and assist care providers in delivering improved, holistic services.

140 Character Summary: Patient data, in the form of wearables and mHealth applications, can augment a Universal Digital Health Record, made available to both patients and care providers.

Purpose/Objectives: To propose a new approach to interoperability in healthcare. Current technological approaches to interoperability generate increased effort for end-users, are costly to implement and do not provide sufficient value to stakeholders that they would pay for it out of their own pockets or contribute to its sustainability. We suggest that by introducing an economic value-based approach to data exchange, we can create a more compelling opportunity for adoption across multiple stakeholders. Using diabetes as a use case; we determined the economic value that accrues to the healthcare system that is associated with exchanging a single data element.

Methodology/Approach: We used the British Design Council’s Double Diamond design method to identify and define key high value use cases. We identified screening for diabetic retinopathy as a use case due to the increasing burden of diabetes on the Canadian healthcare system. We developed and used an economic framework that assesses the Net Present Value of a stream of current costs (and savings by not screening 30% of patients) and compared them to the savings generated by increased screening (and associated costs).

Finding/Results: Approximately 59% of the 3.4 million patients with diabetes in Canada have some form of diabetic retinopathy (DR), and 1.5% of those patients have vision loss due to DR (30,000/year). We identified that exchanging information on whether a diabetic patient completed their annual eye exam allowed for prevention, early detection of DR and timely treatment. Using our economic framework, we calculated the value of exchanging a single data element. (By definition, constraining exchenge to a single data element minimizes costs and minimizes effort.) This allowed us to find that the overall cost savings associated with exchanging one data element between optometrists (who provide eye exams) and family doctors (who provide care to patients with diabetes) would equal approximately $140-210 million per year.

Conclusion/Implications/Recommendations: The implication of this method is to highlight that current interoperability approaches do not sufficiently incentivize stakeholders to exchange information. Interoperability is perceived as an end in itself; but our value-based approach suggests that it should be used only as a means to an end, in order to better support care planning, program design, and clinical decision support. As we have found, it is not necessary to exchange hundreds of data elements amongst stakeholders. Rather, sharing just one high-value data element for diabetes can benefit thousands of patients and provide cost-savings to government, with minimal data collection efforts from vendors and physicians. We believe we have found an alternative approach to solving the interoperability challenge.

140 Character Summary: We undertook to find out why interoperability in healthcare is so elusive. We believe we have found an alternative approach to solving the interoperability problem.

Purpose/Objectives: Health technology solutions are too often implemented without a true understanding of the system-level problem they seek to address, resulting in excessive costs, poor adoption, ineffectiveness, and ultimately failure. Prior to implementing or adopting health care innovations, stakeholders should complete a thorough assessment to ensure effectiveness and value. Our panel will describe how to evaluate the impact of health technology innovations through the four dimensions of care outlined by the Quadruple Aim Framework, using established remote consultation services as case examples.

Methodology/Approach: The panel will draw on the implementation experiences of different remote consultation services who are at different stages of implementation. Remote consultation refers to a service that allows primary care providers (PCP) to connect with specialists via an electronic medium in order to receive advice regarding a patient’s care. Services may be synchronous (i.e. occurring in real time) or asynchronous (i.e. through text messages stored on a server and accessed by the other party at a later time). Through the presentation, panel members will demonstrate the evaluation of remote consultation services, provide an overview of their current data, and highlight challenges in capturing metrics for all four dimensions of care outlined by the Quadruple Aim framework: patient experience, provider experience, costs, and population health.

Finding/Results: Panel members will highlight key data as guided by the Quadruple Aim framework. Examples of metrics from the four dimensions are as follows: Patient experience: specialist response times, rate of referral avoidance, patient satisfaction, wait times. Provider experience: PCP satisfaction, PCP description of service benefits, type of questions asked, specialist satisfaction. Costs: total system costs, per capita cost, direct and indirect savings. Population health: health outcomes (e.g. mortality, morbidity, health status), population served, patient safety, equity of access.

Conclusion/Implications/Recommendations: Panel members will conclude with a discussion of the importance of evaluating new innovations in order to ensure long-term sustainability and growth. Members will provide advice on how to evaluate healthcare innovations, reflect on challenges faced, and offer their assessment of Quadruple Aim as a lens through which to view healthcare innovations. Differences in experiences between services will be explored.

140 Character Summary: Our panel will describe how to evaluate the impact of health technology innovations using the Quadruple Aim framework's four dimensions of care.

Purpose/Objectives: To develop an authoritative list of IT management issues facing executives in Ontario hospitals and examine their evolution since 2010.

Methodology/Approach: The ranking-type Delphi survey, which involves a set of linked questionnaires, was used to elicit the opinion of three panels of experts (IT executives) through an iterative process: brainstorming, narrowing down, and ranking (Figure 1). Out of 39 participants who agreed to participate in the study, 33 completed phase 1 representing around 85% response rate (Figure 2).

Finding/Results: The responses in Phase 1 were consolidated by two researchers (inter-coder reliability of 88%), resulting in a list of 26 key issues. The issues with a mean rating of importance above 4.5 ([1-7] scale) were retained in Phase 2 yielding 21 issues in the academic panel, 19 in the community panel, and 19 in the rural panel. Two rounds of ranking were conducted due to low consensus, but the final agreement level remained low: W (academic) = 0.235; W (community) = 0.254; W (rural) = 0.381. 5 out of 9 common issues to all hospitals identified in 2010, persisted until 2017. The reported issues in 2017 may be categorized as external/provincial, technological, and organizational (Table 1). Limited funding remains the no.1 issue for hospitals, paralleled by an increasing cost of technology investment, maintenance and support mostly for community and rural hospitals. Importantly, the need for provincial leadership in relation to standardizing policies and agreements, and outlining a provincial IT investment strategy, was reported as necessary to enable collaboration and information sharing across providers. Technology-related issues (e.g., evergreening, external security threats, privacy of information exchanged between providers) emerged, compared to 2010, given the increased connectivity and information sharing over wireless networks/platforms. Organizational issues (e.g., recruiting IT staff, time/cost of training, meeting end-users expectations) persisted to a variable extent in the three panels.

Conclusion/Implications/Recommendations: Low consensus consistently observed in the three panels is an indication of the diversity and varying complexity of issues faced by hospitals in Ontario. Provincial leadership and funding support are needed to support hospitals and guide their efforts to implement sustainable IT solutions and develop partnerships for shared IT resources and services.

140 Character Summary: Financial constraints, provincial leadership and technological issues with enhanced connectivity/wireless platforms are leading issues in Ontario hospitals.

Purpose/Objectives: Following-up on the 2017 eHealth Conference presentation, Manitoba’s Home Clinics: Aligning Continuity of Care, ICT, and Remuneration, the results of Manitoba’s implementation of the Comprehensive Care Management Tariffs will be shared.

Methodology/Approach: The development and implementation of the Home Clinic model in Manitoba has been a collaborative effort including Manitoba Health, Seniors and Active Living, The College of Family Physicians of Manitoba, Doctors Manitoba, Manitoba eHealth, fee for service clinics, and Manitoba’s Regional Health Authorities. In 2015, a new Comprehensive Care Management Tariff, designed to support the adoption of the Home Clinic model, was negotiated that focused on the provision of comprehensive care to “Enrolled” patients with complex needs. The Tariff came into effect as of April 1, 2017. The annual management tariff encourages a team-based approach to care and requires that fee-for-service physicians use an EMR that can submit Manitoba’s Primary Care Data Extract. This extract leverages the Primary Care Quality Indicators and includes prevention, screening and management of chronic diseases, based on CIHI’s primary care indicators. In return for submitting data on the Primary Care Quality Indicators, Home Clinics will receive value-add analytic reports that combine information submitted from the Home Clinic’s EMR with other administrative data sets, including hospital and emergency department information, and provide comparative analytic data from other Home Clinics to support continuous quality improvement efforts. The intent of these efforts is to empower Home Clinics to leverage data to make better informed decisions about the provision of healthcare services to the populations they serve. In addition, Manitoba has established the Manitoba Primary Care Indicator Advisory Committee, led by clinicians, to elicit feedback and recommendations on existing and new indicators, and to ensure that the indicators are aligned with the latest clinical evidence and care guidelines.

Finding/Results: The launch of the Comprehensive Care Management Tariff was successful, and resulted in more than 60% of eligible physicians registering with a home clinic and enrolling more than half of the Manitoba population within the first six months. The focus of this presentation will be on the initial findings regarding data quality, adoption of the value-add reports, and feedback from Home Clinics regarding their utility.

Conclusion/Implications/Recommendations: Manitoba continues to promote Home Clinics, Enrolment, and the Comprehensive Care Management Tariffs areas part of the evolution towards more comprehensive, continuous, and coordinated care for Manitobans. This next phase focuses on leveraging the information from EMRs to support clinical information sharing, and evidence-informed continuous quality improvement activities to promote access to continuous, comprehensive quality primary care for Manitobans.

140 Character Summary: Manitoba’s Home Clinics: aligning continuity of care, ICT, and remuneration to support continuous quality improvement through health analytics

Purpose/Objectives: The eHealth Centre of Excellence (eCE) in Waterloo, Ontario, recently led an innovative procurement process for securing a vendor to facilitate the development and deployment of an electronic referral platform for the Waterloo Wellington Local Health Integrated Network (LHIN). Part of the innovative procurement process was an agreement that included a Proof of Concept (POC) and a decision point based on the outcomes of the POC to proceed with the selected vendor in a long-term contract, or to go back to market to consider alternative options (Go/No Go decision). With little to no existing frameworks to draw on related to a POC Go/No Go vendor decision, the Benefits Realization (BR) team at the eCE developed a model to ensure that the decision-making process was fair, transparent and evidence based. Attendees will hear about the process that was developed to support the innovative procurement POC evaluation.

Methodology/Approach: This evaluation process included partnering with a third-party consultant firm to develop a vendor evaluation framework that focused on six domains: 1) Solution Quality; 2) Implementation; 3) Service; 4) Engagement, Training and Knowledge Transfer; 5) Vendor Team; and 6) Project Experience. This evaluation was conducted in the Spring of 2017, and the results were combined with the results of other evaluation activities that were conducted simultaneously, all of which provided a rich source of evidence for the program governance to base their decision on.

Finding/Results: In this presentation, the data sources that were gathered as part of the evidence base development, the step by step process for making the decision, and who to involve in each step will be explored as well as on overview of the key lessons learned.

Conclusion/Implications/Recommendations: This model for evaluating vendors as part of an innovative procurement process should be considered as a best practice for other health care organizations to leverage.

140 Character Summary: An evaluation process to support a decision to proceed with a vendor in a long-term contract following a Proof of Concept or to explore other market place options.

Purpose/Objectives: Health organizations are often at a disadvantage when procuring niche telemedicine peripherals available only from a limited number of vendors. Jurisdictions typically go to market alone for solutions, setting the stage for inconsistent agreements and service contracts between provinces. However, using collaborative technologies establishing a united front is quite literally just a click away. Collaborating with a pan-Canadian RFP team is efficient and worthwhile; allowing members to deepen the knowledge base in a specialized field.

Methodology/Approach: Telehealth in Canada has benefited from an established network of specialist colleagues across the country that maintains strong relationships and shares insights into common problems. In the spring of 2015 it became clear that a number of jurisdictions were each pursuing the same goal: Find a new application to support remote auscultation. The complexities of coordinating a national procurement process seemed daunting but the opportunity to share the workload and gain economies of scale toward a common goal were attractive benefits deemed worthy of the effort. The team embarked on a mission to draft a national RFP to acquire competitive pricing and increased functionality for a telemedicine auscultation solution. A lead procurement jurisdiction and a separate lead project management jurisdiction were selected. Splitting the workload across the two jurisdictions proved to be a great strategy to manage effort and ensure an efficient process. The team agreed to a re-occurring meeting schedule using a feature rich web-conferencing tool allowing team members to regularly collaborate face-to-face. The visual connection proved key in enhancing the collaborative atmosphere for team members scattered across 6 time zones. Complex technical and clinical requirements were gathered, discussed and agreed upon. RFP terms were reviewed, signed off and shared. Evaluation tools were jointly created, locally deployed and comparatively assessed. And all of this achieved without direction or guidance from an external party or project manager. And… without any cost to the organizations involved apart from the participants’ time.

Finding/Results: Over the 18 month journey our dedicated team learned a few things, including: - Joint RFPs at a national level take time. Coordinating 7-8 provinces requires patience and a minimum 12-18 month runway. - Regularly scheduled checkpoints using a rich media collaboration tool helps a team feel like a team. - Industry changes quickly – there were many changes in market during the RFP process. - Senior leadership buy-in is important to have resources available. - Success doesn't mean getting what you asked for…. . - As different as we think we are we are more alike than we think.

Conclusion/Implications/Recommendations: Strength in numbers is expressed not only in economies of scale but also in knowledge and experience. The complexities of a dispersed team were diminished with the use of visual collaboration technologies and the value of a deep specialist knowledge pool outweighs burden of facilitating an endeavor like this. The team realized that having regular touch points with colleagues across the country allowed for sharing of information well beyond the scope of the RFP.

140 Character Summary: Unite and conquer! Leveraging strength in numbers across Canada to drive down costs and improve features in a niche market space. A national telemedicine approach.

Purpose/Objectives: Purpose: As digital innovations continue to transform health systems in Canada, it is important to examine registered nurses’ readiness in informatics. The purpose of this study was to determine self-perceived informatics competencies, and factors associated with competency amongst practising nurses in Alberta.

Methodology/Approach: Methods: An exploratory, descriptive, cross-sectional survey using the Canadian Nurse Informatics Competency Assessment Scale (C-NICAS)—a 21-item comprehensive measure of nurses’ informatics competencies based on the Canadian Association of Schools of Nursing’s entry-to-practice informatics competency requirements—was employed.

Finding/Results: Results: 2844 nurses completed the C-NICAS. Nurses’ self-perceived informatics competency was slightly above the mark of competent. Perceptions of competency were highest on foundational computer literacy skills and lowest on information and knowledge management competencies. However, overall informatics competency mean scores varied significantly in relation to age, educational qualification, years of experience, and work setting. Regression analysis showed the quality of informatics training and support, offered by employers, contributed the most to variance in mean scores of total and sub-domains of informatics competency. Other factors—age; educational qualification; work setting; previous informatics education; access to internet; use of health technology; access to supporting resources; informatics training; an informatics role; and continuing education in informatics—also contributed to variance in mean scores of total and sub-domains of informatics competency; in varying degrees.

Conclusion/Implications/Recommendations: Conclusion: Findings provide a basis for actionable policies to address informatics educational needs and support requirements for nurses practising now and in the future.

140 Character Summary: A survey of 2844 nurses revealed a number of factors impact perceptions of informatics competency. Actionable strategies are proposed.

Purpose/Objectives: The Canadian health care system presents a challenging environment for innovation in digital health. Tool development and research promotion often occur in parallel, but rarely intersect in an efficient way. This lack of an integrated infrastructure to foster success in the Canadian marketplace leads to an unfortunate result: the acquisition of promising Canadian technology by other countries. The purpose of this study was to identify (1) current challenges and barriers to digital health innovation, and (2) identify existing resources that should be leveraged to promote digital integration.

Methodology/Approach: A purposive sample of participants (n=60) were invited to participate in a symposium representing a broad range of players within digital technology and health sectors. The entirety of the symposium was audio-recorded and transcribed, and detailed field notes were taken throughout. Thematic analysis of resulting qualitative data allowed for identification of themes to be shaped into priorities for a digital health innovation strategy.

Finding/Results: Themes highlighted ongoing challenges faced by innovators and health system gaps that present opportunities to encourage digital health innovation. Challenges Misaligned incentives: The Canadian fee-for-service funding model has no mechanism to incentivize individual clinicians to reduce in-person visits and hospital readmissions. There is a resulting tension between financial gain (realized at the organization/system level) and the critical role clinicians play in operationalizing digital solutions. Fragmentation of digital health initiatives: Numerous organizations in Toronto are working to promote digital health innovation including incubators, governmental departments, research organizations, and industry. This fragmentation creates unintended competition, resulting in an inability for any one organization to achieve their objective. Organizational barriers: De-centralization of system oversight has created layers of complex bureaucracy, with differing requirements between institutions. This precludes both a clear entry point into the system and an ability to efficiently scale solutions system-wide. No access to big data: Health data is often retained solely within the health institution that collects it, with no degree of interoperability between organizations. This decentralization is a barrier to comprehensive access, which would inform areas of system need where digital health technology could provide a solution. Opportunities Improved collaboration: Cross-sector relationships between organizations in the digital health space can optimize the likelihood of successfully integrating digital technology in the healthcare system. Training and education: The overarching need for a culture shift among clinicians presents an opportunity for Universities to develop innovative approaches to education that train professionals in health, computer science, engineering, and design. Need for innovative evaluation methods: Digital health tools interact with contextual factors to produce their effect and are constantly updated in response to user feedback; therefore, traditional evaluation methods utilized for pharmaceuticals and clinical trials are not feasible.

Conclusion/Implications/Recommendations: There is need to build partnerships to link ongoing initiatives and align the limited resources invested in digital health innovation. The overarching consensus called for collaboration between developers, researchers, academic institutions, and health system partners to align priorities and streamline innovation infrastructure. Participants suggested that net new initiatives in the healthcare sector involve the explicit integration of digital health to ensure progression with respect to innovation.

140 Character Summary: Identification of system challenges and opportunities to improve digital health innovation and integration in Ontario using qualitative methods.

Purpose/Objectives: This presentation reports on an business case tool designed to generate cost-effectiveness profiles for national-scale digital health infrastructure investments. The work was initially undertaken in collaboration with the Asia eHealth Information Network (AeHIN) and with support from the Asian Development Bank and UNICEF. The spreadsheet-based business case tool that was originally presented and workshopped at the AeHIN General Meeting in Naypyidaw, Myanmar in February, 2017.

Methodology/Approach: The digital health investment case tool leverages health enterprise architectural models and implementation approaches informed by current best practice in low-resource settings. The overall cost profile for a national-scale digital health infrastructure investment is developed by generating 3 linked sub-profiles: 1. sociotechnical costs associated with digital health strategy, enterprise architecture, norms and standards, governance and programme management 2. shared infrastructure costs associated with implementing and operating a national-scale health information exchange service 3. point-of-service solution costs associated with rolling out digital health solutions at facilities (e.g. hospitals, clinics, labs, pharmacies, health outposts) and within community care workers that provide public health and curative care services across the breadth of the care delivery network. Specific cost profiles may be developed that operationalize underlying care workflows that are particularly "high value" (in terms of their health impact). To establish the health impact of a candidate care intervention, the model leverages the Lives Saved Tool (LiST) that has been developed by Johns Hopkins University with WHO and Gates Foundation support. Using LiST, the health impact of a particular care intervention can be determined and, leveraging published literature, the industrial engineering impact of digital health on improving the effectiveness of the particular health intervention can be modeled. For a particular health intervention, the digital health investment case tool associates the a national-scale, 10-year "total cost" profile with the health impact (and, potentially, the cost-efficiency impact) that would accrue from implementing digital health. What-if scenarios and sensitivity analyses can be applied to the resulting CUA and CBA outputs. In this way, MOH leaders can make construct the "business case" that supports their digital health investments.

Finding/Results: The tool was employed to develop an example investment case for an electronic immunization registry. This use case was explored at the 2017 Myanmar workshop. The presentation will step through this use case to illustrate the business case regarding digital support of childhood immunization. In conclusion, updates from country uptake of the tool will be reported.

Conclusion/Implications/Recommendations: The tool enables ministries of health in low and middle income countries (LMIC) to develop a cost profile for a national-scale digital health implementation and to associate this cost profile with a benefits profile (expressed in economic terms and in terms of health impact). A cost-utility analysis may be generated that expresses the "value" of the digital health investments in terms of disabilty-adjusted life years (DALYs) per dollar. By developing a second benefits profile expressed in economic terms, a cost-benefit analysis can also be generated and used to determine the relative opportunity cost of the proposed investments. In this way, evidence-informed digital health investments can be advocated for.

140 Character Summary: DALYs per Dollar: what is the steely-eyed business case for making digital health investments in low-resource settings? As Jerry McGuire says: "show me the money!"