Canada’s healthcare system came up smelling like a rose in Michael Moore’s documentary Sicko, his latest finger in the eye of the U.S. establishment, but many Canadians would liken the fragrance to something else entirely when contemplating the system’s long wait times for surgery, soaring costs and massive inefficiencies.
Few understand the problems in our healthcare system better than the IT executives charged with fixing them. But these executives face daunting challenges in trying to implement IT-based solutions, as we learned when we talked to a number of them about what’s ailing IT in Canada’s healthcare sector.
Our commentators (see below) identified three major causes of the country’s healthcare IT ills: lack of resources, problems with implementing change, and competing priorities. This article looks at each.
Commentators:
Mike Barron is CEO of the Newfoundland & Labrador Centre for Health Information, a crown agency tasked with integrating information systems across the province and implementing the vision of a pan-Canadian patient information system funded in part by the federal Canada Health Infoway initiative.
Linda Weaver is a 25-year veteran of the healthcare industry and is currently a healthcare IT consultant based in Halifax . As Chief Technology Officer at the Ontario Smart Systems for Health Agency she helped build a province-wide network linking over 20,000 entities.
Sarah Kramer is Vice President and CIO of Cancer Care Ontario. She played a lead role in developing the province’s Wait Time Information System (WTIS), which is helping to alleviate one of the system’s highest-profile problems. She was previously CIO at Nova Scotia's Department of Health.
Roberta MacDonald is Senior Manager of Consulting Services in Canada for healthcare management consulting firm Beacon Partners. Before joining Beacon last year, she was CIO at St. Mary's General Hospital in Kitchener, Ontario.
Donna Strating is Vice President of Information Systems and Equipment at Capital Health Edmonton. She has worked in the healthcare industry for 24 years in various capacities, including consultant, administrator, and hospital chief financial officer. This is her first CIO assignment.
Catherine Claiter is CIO at the Vancouver Island Health Authority. She was trained at the University of Victoria’s unique School of Health Information Science and began her career with the University Health Network in Toronto.
RESOURCE UNDERNOURISHMENT
On the face of it, the most debilitating problem facing healthcare CIOs is the painfully low level of funding for IT.
“IT in healthcare is hugely, hugely underfunded compared to other industries,” says Linda Weaver. “So very little of the infrastructure exists. Every time you try to go in and do something, you start from basically nothing.”
According to most estimates, hospitals and other health organizations spend on average just one to two and a half percent of their budget on IT. “That should be more like three to four percent just to maintain current levels,” says Roberta MacDonald. “Some private sector organizations spend closer to 25 percent on IT.”
Many hospital IT managers, as a result, “are just keeping ahead of everything crashing and burning,” Weaver says.
One reason for this is that most hospitals run deficits and many senior administrators still see IT as a non-essential extra. CEOs and CFOs too often are faced with stark choices between allocating funds for, say, two new nurses or a new clinical IT system. The CIO knows that implementing the system will mean that all nurses have more patient-facing time, but “it’s a harder argument to sell,” Weaver says.
“When you run a deficit,” she adds, “you sometimes have to slice and dice the things you can slice and dice. And often it’s not staff, it’s the IT and other infrastructures, which is why most of the IT funding ends up back in the government’s lap.”
That is a mitigating factor in the bleak picture around budgetary spending on IT. There are special funding sources for IT projects. Canada Health Infoway, an initiative whose main goal is the development of a network of interoperable electronic health record solutions across Canada, is an important one. Most provincial governments are also sinking money into healthcare IT infrastructure. The work of the Ontario Smart Systems for Health Agency, which electronically connects Ontario healthcare professionals to patient information, is a prime example.
The prognosis for funding is, however, improving. The perception of the role and importance of IT is changing, MacDonald says. Younger people who have grown up with technology are moving into leadership positions in hospitals and they are beginning to alter the funding dynamic.
Nor are funding levels entirely determined by blind economic forces. Some of it is in the hands of individual IT executives. For example, the CIO of one newly formed Local Health Integration Network (LHIN) in Ontario is pressing his C-level colleagues to develop a clear business vision and plan for the organization. From that, he believes, will naturally follow a properly funded IT plan.
That kind of clear business planning is also important for attracting outside IT funding. “Funders want to see that level of leadership and vision. They’re almost prerequisites,” says MacDonald, “because then you’re illustrating your readiness to be an early adopter. Otherwise, you’re at the bottom of the list.”
IT managers also need to do a better job of proving that the projects they undertake pay real dividends, according to Mike Barron. This can be accomplished by doing proper benchmarking and post mortem evaluations of project impacts. “CIOs have to prove that they’re not selling the government a bill of goods,” says Barron. “They’ve got to show that what they’re doing is improving the quality of healthcare. And that is not always done as well as it should be.”
Money isn’t the only resource issue. In fact it may not even be the most pressing issue going forward.
Sarah Kramer says that the tide is turning on funding – more investment is being made in IT. “Now you have to find people who know what they’re doing, and there just aren’t enough of them. It’s becoming almost a crisis in healthcare IT.”
Other commentators agree. “Designing the technology is pretty much the same as in any industry, but how you have to implement it is different. There are very few [in healthcare] who understand that and have done it successfully. So everybody is hunting for that same list of names,” says Weaver.
Training programs for healthcare IT professionals are now turning out graduates. “But you still have to wait two years for them to get up to speed with the healthcare environment, or with the particular software, or just the complexity of IT in the healthcare setting,” MacDonald says.
CHANGE CHALLENGES
Not all of our commentators put resource shortages at the top of the list of IT ailments.
“I think it’s the capacities of our organizations to change,” says Catherine Claiter. “Even if I had a significant new funding source, I’m not sure that we could add more projects to the plate.”
Donna Strating agrees. “Throwing too much money at a problem, unless you have the ability to make the changes that have to go along with it, won’t get you the return of benefits that you need,” she says.
Meanwhile there is the equally vexing problem of implementing and ensuring benefits from already approved technology-driven changes.
Part of the challenge is that healthcare, while monolithic in some respects, is never one cohesive entity. It’s a great many entities – regional health authorities, hospitals, clinics, private practice physicians, labs, naturopaths, dentists. Each has a different type of business, and each is paid differently.
“You’re not dealing with twenty or thirty thousand people that you can point to and say, ‘Go do that,’ and they will do it,” Weaver says. “Trying to get the health sector to agree on anything is an interesting set of dynamics. You don’t tell them what to do, you suggest that there’s something that would be best for everybody to do together, and then you spend time trying to reconvince them of that over and over again.”
Another part of the problem is that front-line health workers, who in many ways have the most to gain from the efficiencies IT could bring, are simply too busy to take the time to help IT professionals design new systems, or to learn new systems and processes when they’re introduced.
Some hospitals have tried to recruit nurses as superusers to help design clinical systems and push colleagues to use them, while expecting those same nurses to handle a full care load. “It doesn’t work,” Strating says. Getting doctors, the gatekeepers in the clinical realm, onboard is another challenge. As Weaver notes wryly, “They’re well educated and they’re trained to have opinions – that’s putting it gently.” Besides which, doctors don’t have time to put towards technology solutions.
Getting what she calls “physician leaders” onboard helps. They theoretically will influence their colleagues to buy in. But it may also be necessary to offer clinicians financial inducements to overcome their resistance – financial help to acquire systems and free personnel to help with process re-engineering.
Yet the clinicians are the business owners; they must be involved. The answer? Dedicate some of them to helping manage and speed the transition to new technology solutions. “It’s very hard to do. They’re some of your best people,” Strating concedes. But it’s necessary.
And to ensure success, it may also be necessary to leave change management analysts and other “hand-holders” in the project longer than they might be needed in other environments.
Ultimately, though, it just takes time and patience. “There is no magic bullet for this,” Weaver says. Adds Strating, “You can put a lot of money into the system, but unless you have lots of resources – whether it’s nurses to make the changes or IT teams to back it up – you can only move so fast.”
Which goes back to Claiter’s point that the biggest limiting factor in pushing the IT agenda in healthcare is the capacity of an organization for change. That capacity is finite, which means CEOs, CIOs, and macro-level decision-makers such as ministers and other funders, are continually forced to make difficult choices.
EMPOWERING THE PATIENT
IT is already driving major changes that will help reduce costs and care bottlenecks, but it must do more.
“We need to find ways to take care of patients differently than we do today,” notes Strating. “Whether that means taking care of them in their homes, or through chronic disease management, it’s a matter of managing them in a distributed manner versus saying that everybody has to come into a doctor’s office to get care. The question is: how can we use technology to create more of a virtual information framework to allow us to do this? I think that’s our big challenge.”
Distributing care will create new resource headaches for the sector, but despite its own personnel shortage, IT can provide at least part of the remedy. “There is not and will not be enough people to do the work, especially in the home care and community care settings,” Claiter says. “We have a staffing shortage of epic proportions looming, and we need to reduce the administrative burden on those folks as soon as humanly possible.”
The move towards more distributed care is radical enough, but some health organizations are also now talking about, and experimenting with, moving the focus of healthcare systems away from providers and towards patients – introducing a more customer-centric, service-oriented approach. This could mean giving patients access to their own health information over the Web, including lab results, which a few hospitals are already doing. It might eventually mean letting them book appointments online. And it could mean hospitals opening the kimono and publishing fatality and superbug infection rates on their Web sites, as some U.S. hospitals already do.
CIOs can play a proactive role here as well, Kramer says. At the very least, they need to have the necessary technology in place, or ready to be deployed, when the public starts demanding this kind of capability.
“That whole movement toward the democratization of knowledge, and consumerism generally, will drive some of the business-orientation changes that I think are needed,” Kramer says. It will also lead to less mystification around the practice of medicine, she believes.
Of course there will be resistance to giving more power to the patient, especially on the clinical side, with doctors arguing that lab results are too scientific for the lay public to understand, and too easy for them to misinterpret. Kramer concedes that 70% of C-level executives in healthcare would probably say patients should not receive information electronically, and in the clinical ranks, the ratio would rise to more like 80:20 or 90:10. Among her CIO colleagues, democratization of health information is not regarded as a bad thing in and of itself, but not all believe it’s a high priority.
“If patients are willing to use these kinds of tools, it’s certainly something we can do,” Strating says. “Do I put it as the highest priority in terms of benefits? No.”
COMPETING PRIORITIES
Deciding where to invest time and IT resources may be as vexing a challenge as any that healthcare CIOs face. As Strating notes, “There are lots of agendas, and it’s a question of how do we sort them out and set the priorities?”
How indeed? Clearly there is contention, even among our commentators. A major dividing line appears between those focused on big, infrastructure-oriented undertakings and those more focused on the day-to-day problems of delivering healthcare.
For example Barron’s organization, Newfoundland & Labrador Centre for Health Information, is dedicated to integrating patient information across several regional health authorities in the province and helping realize the vision of a national system that would allow clinicians to access patients’ health records wherever in the country they present themselves. He is clearly frustrated by IT efforts that don’t in some way support those goals.
“Unfortunately not all the investment [in the province’s regional authorities] is focused toward the bigger picture – that being the electronic health record and better healthcare delivery,” Barron says. “It’s not to say some of the things they’re doing shouldn’t be done, but sometimes [they’re done] just to meet short-term goals, or to show they’re doing something.”
Few would argue with the need for systems that allow clinicians to share patient information. “Without information, we can’t manage patients – that’s just a reality,” Strating says. “And you can’t move information around and monitor it if it’s not digital. You have to get there; it’s not an option.”
It’s clear that enabling this capability will mean building common structures and facilities. Otherwise each entity will have to make private arrangements with all others. And as Weaver says, “When you start getting into 20,000 different sites, as there are in Ontario, you can’t even imagine how to manage that.” Hence efforts like Smart Systems for Health and Canada Health Infoway.
But do those structures and projects need to be national or even provincial in scope? Claiter argues no. “Accessing patient information from another health authority is valuable in specific cases,” she says. “But it doesn’t represent the majority of patient care or the biggest opportunity for improving the quality and safety of care.”
Kramer also has reservations about the monolithic, infrastructure orientation of organizations like Canada Health Infoway, though for somewhat different reasons. “Business purpose and use should drive the building out of technology,” she argues, “not the other way around.” She specifically cites the electronic medical records project as an example of the other way around. “Until it is actually linked to a user application, it’s a very expensive white pages,” she says. “It doesn’t have a lot of value to anyone on its own.”
Instead, Kramer argues, the industry should be starting with business problems, such as wait times. Her own IT-based wait times project in Ontario is a template, she suggests, but others, such as work on chronic disease management in Alberta, follow the same approach. It’s an approach that has been successful enough recently that others are beginning to think it may be a better way to go, she contends.
Of Ontario’s wait times project, Kramer points out, “It got funded, it got pushed out, people took it seriously, and it didn’t drag on forever. And now it’s there with a very much larger residual benefit for all kinds of other purposes.”
The debate over where best to allocate IT resources is one that will not be resolved any time soon . As Strating points out, “We have a lot of competing priorities, and they’re all good. It’s difficult to say that any one of them is not the right thing to invest in. And that’s the problem facing IT: where do you put the time and the energy?”
The ills that plague IT in the healthcare sector – lack of resources, problems with implementing change, and competing priorities – are not dissimilar to those found in other industries. But one critical difference makes it imperative that we quickly find some cures. In healthcare, these ills may literally kill the patient.