Suppose you moved to a new city and with a few computer keystrokes your new family physician could access your entire medical history. Consider how beneficial it would be if you brought your child to a hospital emergency room while vacationing in another province and the doctor on call could pull up your son’s full electronic health record. Imagine the peace of mind you would have knowing that your elderly father, who has diabetes and several related health issues, is receiving care from a coordinated team of health care providers who all have electronic access to his medical information, laboratory results and daily blood sugar readings. These capabilities have been just a small part of the vision for Canadian health care in the 21st century for some time, thanks in part to the leadership of organizations such as Canada Health Infoway, a federal agency whose mandate is to develop standards and oversee the allocation of funds to e-health projects across Canada. The technology exists. But Canada is facing challenges that have made it difficult to keep pace with other countries in developing comprehensive provincial and national information technology-based health infrastructure.
The most recent setback has been the widely publicized controversy surrounding eHealth Ontario, the provincial agency tasked with improving deployment and adoption of information technology in health care. Questionable spending practices by consultants, contract sourcing irregularities, and a presumed lack of oversight now overshadow the key issues and steps required to advance the use of electronic record-keeping in health care.
The term e-health generally refers to any information technology-related initiative associated with creating a health record. An electronic health record is everything in your medical file – your history, conditions, treatments, drug prescriptions and any reactions – that pertains to your health over your lifetime.
At a time when several trends, in Canada and other countries, are putting increased pressures on the cost and delivery of health care, we are in a position to benefit greatly from an increased use of information technologies to begin reducing costs and improving the quality of health care delivery. Some of these trends include:
l An aging population – Increases in life expectancy also bring a rise in chronic diseases, leading to increased health care needs. According to the Canadian Institute for Health Information (CIHI) about 12 per cent of Canadians were seniors in 1998, 13 per cent in 2005, and by 2036, 24.5 per cent of Canadians are expected to be age 65 and older . This is significant as seniors age 65 and older consumed more than 44 per cent of all provincial/territorial government health spending in 2006, while only comprising 13.2 per cent of the population.
l Canadians expect more – Advances in medicine and technology have created an expectation that most illness is treatable, regardless of the costs and length of treatment. At the same time, the cost of many medications, research and testing is on the rise. In addition, as patients become better informed through a wealth of medical information easily accessible on-line, they are becoming savvy “health consumers,” with expectations of service and quality that can’t be met by the current delivery infrastructure. A typical example is emergency room wait times. In a 2007 survey by the Commonwealth Fund, CIHI reports that 46 per cent of Canadians waited two hours or more for care, the highest proportion in the seven countries surveyed. Ontario Ministry of Health data shows that hospital ER wait times average 8.7 hours, or 11.9 hours for complex conditions and 4.7 hours for minor conditions.
l Government’s ability to pay – Provincial governments are challenged to keep up with escalating costs and ballooning deficits. Canada’s provinces spend on average 40 per cent of their program budgets on healthcare. Health care spending from 1990 to 2005 grew seven per cent per year, while government revenues grew 2-4 per cent per year. Health care’s share of GDP will likely be 13 per cent in 2015, and more than 17 per cent by 2025.
Information technology has the power to create efficiencies and therefore create better quality health care that can be delivered at lower costs. The challenges of process standardization and automation are very familiar to IT professionals across other industries. Unfortunately, health care is still new at this, and in many ways, quite immature.
An example is the way Canadians consult with their physicians. While almost three quarters of Canadian adults go on-line to shop, e-mail their friends, and pay their bills, only 13 per cent of physicians reported communicating with their patients for clinical purposes . Understandably, physicians are concerned about time requirements, lack of reimbursement, and privacy issues. But incentives to routinely utilize secure email would be an easy way to reduce office visits and long commutes for conditions that do not require physical examination.
A more serious issue pertains to quality of care related to adverse drug reactions (ADR). For example, it is estimated that in Ontario in 2009 there will be 394,000 preventable ADRs, resulting in 240,000 physician office visits, 36,000 hospitalizations and 4,000 deaths . This especially affects elderly patients who may be on several types of medicines for different conditions. There’s little ability for drug information to be collected and shared among practitioners to provide a complete picture of a patient’s conditions, medical history, treatments and prescribed drugs. Many of these deaths could be prevented if we had better electronic health records and drug information.
Generally speaking, we are not faring well when it comes to the adoption of information technologies: Canada is behind other developed countries with universal access health-care systems similar to ours.
For example, virtually all Danish physicians use their computers to record clinical notes and to send and receive clinical messages. The Danish health network, MedCom, is used by the entire health-care sector – about 10,000 users across 4,000 organizations. Danish physicians can prescribe medication and order tests electronically. In Ontario, only about 20 to 25 per cent of physicians are using Electronic Medical Records systems (EMR), mostly for patient scheduling and billing rather than for management of clinical information.
When it comes to IT adoption, Canada fares poorly against countries like the UK, the Netherlands, Germany, Australia and New Zealand. Among the findings:
l In 2006, Canada had the lowest percentage of primary care physicians using e-patient medical records at 23 per cent. The Netherlands had the highest at 98 per cent. The US fared slightly better with 28 per cent .
l In 2007, Ontario physicians said that 9.9 per cent were using electronic medical records compared to 21.7 per cent in Alberta and 3.8 per cent in Quebec .
l In 2006, Canada also reported the lowest percentage of primary care physicians using electronic medical record systems to both share records with clinicians outside their practice and to provide patients with access to their records at six per cent for both activities. The Netherlands had the highest percentage, 45 per cent, of physicians who shared records electronically with other providers, and the UK reported the highest percentage, 50 per cent, of physicians providing patients access to their files .
In my view, deployment and adoption of information technology in health care faces three key challenges.
A Need for System Integration
There are a tremendous number of projects trying to move the e-health agenda forward. But one problem is that e-health is largely about integration. It’s not a problem of implementing individual systems. We need systems that talk to each other, with clear and consistent standards for all data collected and stored so the resulting interpretations are clinically valid.
Lifelabs is part of an e-health initiative that illustrates the issue of integration. eHealth Ontario’s predecessor, Smart Systems for Health Agency (SSHA), initiated a program called the Ontario Lab Information Systems (OLIS). Its goal was to create a provincial repository of all test results that had been delivered by both private and public labs as well as hospitals. The idea was that labs would send results to the central repository, which could then be accessed by care providers.
The infrastructure was built and Lifelabs was one of the program’s early adopters. For two years now Lifelabs has forwarded lab test information to the system. The information is sitting in the repository, but widespread access and clinical use are not yet a reality. Broad clinical use of this information can only occur once you create an environment that enables integration and physician adoption.
Lack of adoption and too many options of EMR systems are major issues that need to be addressed. One way to improve adoption is to create physicians incentives not just for the initial implementation of EMRs, but to also support and sustain their use over time in a way that is compatible and compliant with the workflow of doctors. As for too many options, the industry (particularly in the EMR space) would benefit from the kind of consolidation that we have witnessed in the ERP and business intelligence markets.
Adoption and Sustainability Require Incentives
There is a misalignment between incentives for medical practitioners to use the technology vs. what their objectives are. There is very little that anyone can do if physicians don’t adopt an EMR or clinical management system that allows them, in addition to billing and scheduling, to actually keep detailed patient records and use them to manage their care. The adoption rate for such systems in Canada overall is between 20 to 25 per cent.
Again, the technology exists. For example, there is a branch of the Ontario Medical Association, called Ontario MD, that certifies a number of commercially available EMR systems – there are between 15 and 20 on the market today – and also provides funding (in part through Canada Health Infoway) to assist with the purchase and initial installation of these systems.
Despite this support, adoption is low. This is partially because the systems don’t mesh well with physicians’ workflow, but the key reason is that physicians are not compensated and incented to utilize these systems in their practices for clinical use. Whether a physician uses paper or uses an EMR he gets paid the same. And if by using an EMR he takes more time to see people, he grosses less than if he were to maintain paper files.
In countries like Denmark, policymakers believe that the use of EMRs is important enough that they provide incentives. Physicians may receive an extra fee for using an EMR to its full potential, or they receive incentives for a certain number of years while they integrate a system into their practice, but they must be fully operational within a certain timeframe or they will not receive future funding.
There are incentives in place in other counties that are aligned with making sure physicians make EMRs part of their workflow. Once there are comprehensive systems in place, we can start talking about integration.
The Key Step is Leadership
Adoption and integration require strong leadership and single accountability.
When assessing how to integrate multiple systems it’s all about compromise, because no one system is perfect. If perfect systems exist in isolation in different medical settings without the ability for stakeholders to work together, then the power of integration is lost. For any CIO who has been challenged by the implementation of an ERP system (such as SAP or Oracle), it is easy to understand just how great this challenge is across so many disparate systems and so many stakeholders with diverging points of view.
Historical funding models together with an instinct to look after one’s own interests make it tough for hospitals, clinics, laboratories and other healthcare providers to want to come together out of their own volition and make compromises that may not be particularly advantageous to themselves, but may be beneficial to the overall provincial health care system. Decisive leadership is needed to create a vision that goes beyond the individual healthcare settings and to drive e-health integration forward, even at the expense of localized benefits.
Examples of such leadership exist in other countries and sectors. For example, President Obama recently appointed Nancy-Ann DePerle as health “czar” – someone who would consult with industry leaders and government, but who is ultimately responsible for driving the health agenda forward. A similar approach was taken in the U.S. auto and financial industries during turbulent times.
In Canada we rarely see this approach to leadership. Ontario tried with the establishment of eHealth Ontario under the leadership of its former CEO. The blueprint that eHealth put on the table was robust and made good sense. They were making progress, getting the message out, and clearly demonstrating who was in charge. They articulated a complex program and took the time to explain it.
We have to go beyond the kinds of issues that have decimated eHealth Ontario and move forward aggressively. We need to restore strong leadership to rise above individual interests, implement change and create a solid foundation for integrated, sustainable e-health. The technology exists, Canadians deserve that, and frankly, we are running out of time and options.