In 2009, amidst the numerous eHealth boondoggle stories and negative sentiment, I began writing a blog for ITWorld. In one of my posts, I discussed the differences between an EHR and an EMR. I applauded the inroads that were made with Electronic Medical Record (EMR) implementations in primary care. However, I was critical towards the Electronic Health Record (EHR) for all Ontarians by 2015 strategy that seemed so far from reach at the time.
Well, 2015 has come and gone, and I thought it would be worth a look at where we are on the EHR strategy. To recap a little, an EHR is an integrated record that consolidates patient information across numerous providers into a single view. It is comprised of building blocks of information included but not limited to:
- Patient demographics (address information, next of kin, health card, family physician, etc.)
- Visit history
- Images (X-rays, MRI, EKGs, etc.)
- Lab results
- Drug prescriptions and administration
- Diagnosis reports (this could be progress notes, discharge summaries, interpretation of lab or image tests, etc.)
- Immunization history
The Canada Health Infoway (CHI) vision depicts the following conceptual view of a consolidated EHR:
Of course, when one sees the end product the question that is invariably asked: “Of course we should have that. It looks straightforward enough. Why has it taken so long?”
Well as the saying goes, ‘the devil is in the details’ and this is where, in 2009, it felt lost.
So let’s talk about what and who was needed to achieve the CHI concept and why it seemed a far cry from reality in 2009.
Some of the players include:
- Private labs
- Private imaging
- Community care and access centres
- Physician offices
- Software vendors for all of the above
- eHealth Ontario
- Ministry of Health and long term care
With such a broad set of players, let’s look at a use case of what’s needed and who’s involved to present information in an EHR. For our use case, we’ll focus on lab.
A patient could receive some lab work in a hospital and then may need to go to a private lab for further tests. The private lab will have their own systems, the hospital has their own systems and never before had there been a need to integrate with one another as information sharing was done through fax, phone or mail. So the ability to electronically communicate did not exist.
To compound this deficiency, consider the number of hospitals and private labs involved, all on their own standalone systems that do not integrate. Here is crux of the challenge. How do you consolidate all this information into a single view? How do you encourage all these different providers (both public and private), government bodies and software vendors to work together? Ontario’s answer was to build a consolidation repository known as OLIS (Ontario Lab Information System), but it doesn’t end there. As I said, the devil is in the details.
Data is meaningless if it doesn’t conform to a standard. When working with physicians in the past on technology solutions, one point that has been consistently raised across numerous specialties, institutions and practitioners was, “unreliable data is worse than no data”. What does this mean? Well, in the world of healthcare, if you are, “making decisions on poor data, then the patient outcome could be adversely affected.” Regardless of setting, patient safety always comes first. The message: proceed with caution and care.
This brings us back to that devil: the details. Data consolidation needs to conform to a standard. This means that a documented standard needs to be created and agreed upon, and then all the players need to conform to the documented standard or something needs to take their data and put it into the agreed upon standard. Considering all the moving pieces, the latter was the way Ontario decided to go. The result was a HIAL (Health Information Access Layer).
Using the HL7 message protocol, the various contributors would send information to the HIAL which would organize and parse data into the structure needed to meet the standard. The HIAL also validates and inspects data to ensure that it contains data necessary to be meaningful.
Now, let’s not forget our partner for our devil: proceed with caution and care. This meant years spent on securing agreement on standards, building infrastructure, testing infrastructure, convincing private entities to participate and public entities to spend the time and effort to comply.
Consider the complexity of the one use case and apply it to the other components that comprise the building blocks of an EHR. The journey was long, and progress came in dribs and drabs. This was and is the challenge when moving from standalone distributed systems to a consolidated view relying on building consensus, infrastructure and participation.
The above illustration is still an over simplification for illustrative purposes. There are numerous components and moving pieces that enable the transmission and flow of health data. Below is the depiction of the HIAL and its moving pieces, conceptualized by CHI.
CHI conceptual view of the HIAL
Now, to be honest, I’ve always found the CHI HIAL picture difficult to explain, so I’ll try and depict it another way.
I find this picture helps by illustrating the institutional flow of information and where it is consumed. Again, it is an over simplification. There are many other moving pieces., but I hope you find it somewhat helpful when trying to bring together the complexity. In this image, however, there are a couple of points to highlight:
- Providers contribute to repositories through a HIAL. This information can be pulled from the EHR to be viewed, it doesn’t go the other way (from the EHR to update systems).
- Data contribution can be viewed in a number of settings, hospital, primary care or specialist.
- Some of these repositories also can send results directly to an EMR, but not all data contained within repositories make it to EMR so it is a limited subset.
- Some notes on the acronyms used not referred to previously, DI-r is the Digital Image repository and the CDR is the Clinical Document Repository.
Throughout this blog you may have picked up a change in the language being used to discuss EHRs. Instead of ‘may’ or ‘could’ the language is ‘contribute’, ‘view’ and ‘known limitation(s)’. This leads to where we are.
The clustered approach and where we are
To deliver the 2015 EHR strategy, Ontario took a regional approach. This combined leveraging local capabilities and local expertise to help further the EHR goal.
This strategy would mean that progress wasn’t limited to a single entity building components while the providers across the province awaited its completion and their turn to participate. The clustered strategy enabled each area to progress independently.
Using a variety of local, regional and central strategies, Ontario now has EHR capability across its regions. Each cluster is at different stages in its progress. cSWO has a fully capable EHR leveraging the Clinical Connect solution pioneered out of Hamilton Health Sciences. cGTA and cNEO are leveraging a ‘built for purpose’ repository known as the CDR, or Clinical Document Repository, not all hospitals are online, but hospitals are actively contributing and the viewer is available to some in a limited capacity.
- Private labs
- Private imaging
- Community care and access centres
- Immunization history (served by the Ministry of Health’s Panorama)
- Medication history (from hospitals and through OHIP provided prescriptions served by the Drug Profile Viewer or Clinical Connect or cGTA portal depending on region).
So what does this mean to patients? Much of these changes are relatively transparent. Ontarians should see that lab and image results are available quickly to their healthcare providers. Ontarians should see the need to re-do tests minimized. When consulting healthcare providers, Ontarians should experience that through consultation providers know more about their medical history and ask more specific questions about their medical history. While in the hospital, there should be less waiting for information to move from department to department. Less people pushing around paper and care providers looking more at computer screens than file folders filled with paper.
As an emergency physician told me, “look if someone comes to emerge with a ruptured spleen, I’m fixing the spleen, not looking at a computer screen.” But in the same breath, “if a patient complains about symptoms I have the tools to look into a patient history and I’ve been able to avoid admissions, eliminate the need of performing duplicate tests.” For complex and long-term care patients, especially older demographics, a physician remarked to me, “every patient I see is a complex web. Much of it the patient themselves cannot relate or understand. By having tools I can piece together a patient’s story and help determine treatment strategies”.
Do Ontarians know this is happening in the background? Probably not, but it’s there. Something I was sceptical about in 2009 and happy to be proven wrong by all the players that have worked to get us this far on the EHR journey.
What the EHR isn’t and what’s next?
A couple of things to point out about what the EHR strategy is and what it isn’t. One thing that comes to mind is that EHRs don’t necessarily drive health system performance. An EHR may not improve Ontarians ability to receive Cancer treatment or an MRI. The EHR is about access to information quickly and securely to help clinical decision making. As mentioned, this will help reduce hospital admissions, duplication of tests, which are certainly a measure of performance. However, that is implied and more anecdotal. Initiatives, such as wait times and others, are more designed to drive and measure health system performance. This will be a topic of future posts.
Another important note is that the EHR journey is not complete. If you look back at the picture provided you’ll notice that the flow of data is all pointing toward primary care, an important capability. However, none of the arrows are coming from primary care. Although EMRs are well deployed across Ontario, EMRs are not yet sharing with these repositories. Therefore, although there is an EHR for Ontarians, the building blocks are institutional in nature and not private practice. As a result, the picture is not yet complete. This will also be a topic of a future post and the next large area of focus for Ontario in its EHR journey.