With the recent announcement of a new eHealth CEO as well as Federal blunders when it comes to eHealth oversight it is important to understand what the new CEO is inheriting as well as where eHealth has delivered against the CHI roadmap.
The recent criticism of CHI and their lack of oversight in Ontario and British Columbia is not just a result of faulty management or control mechanisms, but is symptomatic of a larger problem. The direction is ambiguous and lofty. It is difficult to apply controls on something that is more academic than actual.
The CHI EHR has been divided into a number of categories, below is a list of categories as well as where Ontario is in relation to the road map.
It will be incumbent on the incoming CEO to decide whether to continue along the path of CHI, or start focusing on outcomes. The challenge is investment vs. reward. The investment in the CHI roadmap does not necessarily result in immediate outcome, which is partially the reason for the inappropriately labelled ‘boondoggle’ that has dogged eHealth in recent months. Without being able to site immediate improvement to patient outcomes it will take a strong willed visionary to stay the course and hope that the CHI roadmap can achieve its utopia.
The other option is to start to focus on projects that have more direct link to patient outcomes. The result might not be a fully operational EHR by 2012, but improving the delivery of care should be able to combat critics. When looking at the list below it may be debateable whether a fully operational EHR is even possible in Ontario’s current healthcare structure. But that is for a separate debate.
Registries have been divided into two categories by CHI:
Client Registry: A directory that lists all patients and their relevant personal information (names, addresses, etc.).
Provider Registry: A comprehensive directory of participating authorized health care providers; each authorized health care provider will be authenticated to ensure that he or she is authorized to access electronic health records.
The primary challenge delivering registries is the participation at the provider levels. Each hospital has their own complex IT infrastructure. This infrastructure was built to support the hospital, not exchange information with other entities. Historically these infrastructures were set up to inhibit the exchange of information and be as secure as possible. Attempting to integrate with all healthcare providers requires considerable investment both at the hospital level and the centralized service provider level.
A secondary challenge with registries is the overall vision. Currently Ontario is working on a registry that doesn’t fall within either category and is more specialized. The insinuation of a client registry is that it is all encompassing and subsequent modules can be build upon it. If this is not the case then what is the intrinsic value? The diabetes registry project will certainly improve the quality of care, but it seems to be diverting from the overall roadmap that CHI has produced.
Where is Ontario?
Complete: A client registry has been implemented. This registry contains all records and their personal information. It has been integrated with the majority of hospitals in Ontario
Coming: The diabetes registry. This is a form of client registry that tracks all individuals with diabetes their interactions with the health care system in Ontario and the care they have received.
Diagnostic Imaging Systems
DI Systems will electronically collect, store, manage, distribute and display patient radiology images and reports – such as X-rays, ultrasounds, MRI and CT images – entirely in digital format, without the need for film. To be fully effective, CHI recommends that DI Systems be supported by modern digital archiving technologies, known as Picture Archiving and Communications Systems (PACS). As a result they are proponents of hospitals acting as hubs for smaller facilities.
With a transformation activity so large the major challenge will primarily be time and cost. There is considerable effort associated to digitizing the large amount of records that exist. In addition there is a large cost to enable the secure storage of these images. These two don’t even consider the logistical issues associated to transferring data from film to digital media, or centralizing existing digital media which might require change in standards. Finally the transport of such data and applications that they interact with provides another layer of complexity.
Where is Ontario?
Complete: there are no current provincial sanctioned systems or standards associated to DIS. That said many hospitals have some DIS capabilities.
Coming: DIPACS to act as a central repository for digital images.
Drug Information Systems
For each prescription, a DIS will check for allergy alerts and drug-to-drug interactions against a complete medication profile. These systems will dramatically reduce the number of adverse drug reactions by providing physicians and pharmacists with information to support appropriate and accurate prescribing and dispensing.
Much progress has actually been made on this front. Some of the key challenges have been integrating with pharmacies and various client systems. Although there is significant functionality available it hasn’t been integrated with an EHR. There is no current integration with client registries. This latter step could be a costly endeavour if true application integration is sought both from a custom development and timing persepctive.
Where is Ontario?
Complete: Drug Profile Viewer a system that enables ERs to ensure that conflicting medications are not prescribed. The DPV has been used in emergency departments in 177 hospitals, so health professionals can quickly access information for seniors. In September, the system was used to view drug information more than 95,000 times
Network connectivity between eHealth and pharmacies enabling the secure exchange of patient data.
Coming: Provide pharmacists with access to Electronic Medical Records (EMRs) to view pending prescriptions and a subset of clinically-relevant information. This will contribute to the quality of care that Ontarians receive. They can expect to get their prescriptions quicker, without conflict and less errors.
Laboratory Information Systems
When a patient is tested, whether at a clinic, hospital or other facility, Laboratory Information Systems will enable laboratory technicians to enter the results into a database accessible to authorized health care providers. Test results will be linked to individuals’ electronic health records, providing additional resources for diagnosing and treating patients.
Labs aren’t a necessarily government run. As a result obtaining participation can be challenging as this component of an EHR doesn’t necessarily improve lab profit margins. In addition building consensus amongst labs has historically been challenging often holding progress hostage. Finally centralizing data is a complex endeavour attempting non-willing participants to modify their existing systems to comply to a standard.
Cost and time have been the major challenges associated to the Ontario Lab Information Systems project/program. Also known as OLIS this project has been in existence for more than 12 years. The good news is there is a working system in place although it isn’t integrated with client/provider registries. Considering the challenges faced to get as where they are now, additional integration could prove very challenging.
Where is Ontario?
Complete: Ontario Lab Information System hosted centrally for labs. This respository enables labs to centralize information and allow subscribing heath care providers the ability to access information.
Coming: Integration with additional systems
In order to access specialized care, residents of remote and rural areas are often forced to travel long distances, which can mean significant cost, inconvenience and, in some cases, aggravation of underlying medical conditions. Telehealth is designed to provide support to remote patients as well as perform some initial triage to alleviate pressures on emergency rooms and physicians.
Telehealth has grown in popularity and application. As a result additional functionality like video conferencing and regional data has placed a growing pressure on system size and capabilities. This translates into additional infrastructure spend to support growing capabilities and demand.
Where is Ontario?
Complete: Fully functional telehealth system.
Public Health Surveillance
In March 2004, taking into account the lessons learned from the SARS outbreak, the federal government assigned Infoway the task of developing a Canada-wide communicable disease surveillance system in partnership with the provinces and territories.
This implement resulted in the application known as iPHIS.
Challenges: Integration with other portals make it challenging to ensure that all health providers and consumers are going to the same resources for accurate information.
Where is Ontario?
Complete: iPHIS the Public Health Information System is used extensively for disease management and communication. Recently used for H1N1 as well as a measles outbreak in mid-2009
Coming: Panorama – a solution that has larger integration and access to systems.
Innovation and Adoption
Canada Health Infoway’s Innovation and Adoption investment program supports projects that can:
- Drive the adoption of electronic health records (EHRs) across the country
- Help achieve an interoperable EHR for more than 50% of Canadians by 2010
- Be rapidly deployed
Messaging is a primary challenge. Just looking at the implications associated to all the systems that are required for an EHR is setting up these initiatives for failure in the public eye. Each of these areas have varying degrees of implementation within each hospital. Enforcing standards and compliance has really not been part of the process. Funding is provided but rarely monitored.
This is not to slight the hospitals and providers their primary concern is delivery of care not upgrading an HIS (Hospital Information System) to HL7 3.5 or to be web services compliant. This has impeded the ability to have interoperability in Ontario. In addition rapid deployment is not a realistic expectation. If using bench marking the OLIS application has been underway for over 12 years. How can other areas that have received little attention expect to be done quickly?
The old triple constraint of Project Management dictates that if you need something done quickly it will take more money. There isn’t the workforce in place to be able to achieve this goal in Ontario at all the levels required and still be able to deliver health care.
Where is Ontario?
Complete: Client Registry, Ontario Lab Information System, Telehealth and Drug Profile Viewer.
Coming: Diagnostic Imaging, Diabetes Registry, and Panorama.
Canada Health Infoway's (Infoway's) Infostructure investment program supports jurisdictional projects that will develop common solution standards and architecture, ensuring that Canada’s electronic health record (EHR) systems are interoperable.
Building consensues, monitoring compliance, workforce dedication and broad scope have all been challenges in this area. The Infoway infrastructure is a complex blend of application and infrastructure that requires compliance to set standards to function:
Where is Ontario?
Complete: 2 Data Centres geographically diverse to withstand a disaster.
A dedicated health network connecting all hospitals and many providers to enable the secure transfer of data.
Coming: HIAL – Health Information Access Layer has been long discussed to help interoperability between systems and providers. The challenge is being able to deliver such technology that is interoperable with all existing systems, some of which are quite aged. The result is to enable interoperability investment needs to be made at the provider level before integrating to a centralized structure, which puts conflicting pressure on delivery.
Patient Access to Quality Care
Providing Canadians with timely access to quality care is an important goal of Canada's health care transformation. To address this, Canada Health Infoway’s Patient Access to Quality Care (PAQC) investment program supports innovative jurisdictional projects that will leverage existing electronic health information technologies in order to improve access to quality care and reduced wait times.
PAQC projects which have been selected can demonstrate the potential to accelerate transformation initiatives that reduce wait times. Technology deployments include consumer health solutions such as chronic disease management tools, patient portals and scheduling.
They key challenge here is measurability. Wait Times is a system that is designed to provide metrics. However, how do we evaluate the impact to Quality Care that OLIS, iPHIS or DPV has? Intuitively we know that these systems should have a positive outcome to patient care, however assigning metrics to measure the impact they have had is a challenge.
Where is Ontario?
Complete: Wait Times system – this has proven to reduce wait times. It enables patients awaiting care to be prioritized and redirected to other providers if certain thresholds are exceeded. Some systems mentioned earlier: Drug Profile Viewer, Telehealth, OLIS, iPHIS, as well as other applications that are not listed on the CHI roadmap such as Oral Care, Autism, Healthy Baby/Children, EMR systems, all of which improve the delivery of care.
Coming: Diabetes Registry, Diagnostic Imaging, DPV enhancements and Panorama
An EHR is a secure, integrated view of a person’s medical records from all systems in the network; it provides a comprehensive view of a patient’s medical history. A network of interoperable EHR solutions in Canada – one that links clinics, hospitals, pharmacies and other points of care – will help improve Canadians' access to health services, enhance the quality of care and patient safety, and help the health care system become more efficient.
This definition is not in substitute to the other categories listed here. It is rather envisioned that this will tie all of these things together into one graphical view/interface that has access to all data.
Now this is a pretty picture, the problem is something like this requires the following Infostructure (or Infrastructure) to support it:
The above is a large and complex technology challenge that doesn’t just include the build out of infrastructure, but interoperability of disparate systems. Interoperability is a challenge both of antiquated systems at provider levels as well as software incompatibilities as a result of competition between vendors. These are the real issues that face the ability to acheive a fully functional EHR in Ontario, regardless of timelines.
Ontarians should receive some solace that it is not all doom and gloom. Yes Ontario does not have a fully operational EHR, but they have made great strides. It will be interesting to watch the new CEO and his ability to communicate achievements, progress and strategy that Ontario health consumers can expect to receive over the next couple of years. He will certainly be scrutinized along the way as this is likely to be one of the major campaign discussion points in a not too distant election.