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Why aren’t Canadian family doctors embracing e-communication?


In the last decade, technology has revolutionized the way we live and work. We email and text more often than we phone or fax. We share photos with friends using Facebook and debate with colleagues in real-time using Twitter. We pay bills, book plane tickets, and buy clothes on-line. We can effortlessly post opinionated blogs in cyberspace for all to read.

But, if you have a question for your family doctor, chances are you still have to pick up the phone – perhaps wait on hold—and then negotiate with a receptionist a convenient time to come in – likely during the middle of a work day – to speak in person with your physician.

If your family doctor has a question about your care, they send a fax to a specialist requesting an appointment for you. Sometime after you see the specialist – perhaps days or maybe months – your family doctor gets a fax or letter in the mail with “an answer”.

iTunes can tell you which songs you might want to buy based on your purchase history. In contrast, most of our electronic medical records aren’t sophisticated enough to alert physicians when a patient is overdue for a test or would benefit from a certain medication.

It seems that we’ve become complacent and just accepted that this is the way it is in healthcare. Change is too hard. Ensuring privacy is too important. We can still deliver high quality care, right?

But, a new Commonwealth Fund study finds that Canada lags far behind other countries when it comes to using information technology in primary care. In 2009, Canada was dead last among ten other developed countries when it came to the percentage of family doctors using electronic medical records. Three years later, Canada is still dead last among these countries.

Only 56% of family doctors in Canada use electronic medical records but even worse, only 10% are able to use them in a sophisticated way – to guide clinical decisions or generate summary information of their practice. In contrast, 98% of primary care doctors in the UK use electronic medical records and 68% of them use them in a sophisticated way. Not surprisingly, only a minority of Canadian practices routinely receive and review data on the quality of their patient care.

Canada also ranks last when it comes to exchanging patient information electronically between doctor’s offices. And we are least likely to allow patients to request appointments online, ask for prescriptions refills online, or email their practitioner with a medical question.

Perhaps it’s not a coincidence that Canada is at or near the bottom of the pile when it comes to providing after-hours care or same or next day appointments. Embracing new technologies would no doubt free up physicians’ time to see the patients who need to be seen.

The good news is that 82% of primary care physicians in Canada were satisfied or very satisfied with practicing medicine. But how satisfied are our patients?

Perhaps we are old and set in our ways. When a group of first year family medicine trainees at the University of Toronto were asked about ideas to improve the health system, near the top of their list was a desire to communicate with their patients using technology. Not just email, but twitter and text messaging.

We need to stop making excuses for not using communication technologies in healthcare that are commonplace in every other aspect of our life. And perhaps, we need to hand over this file to our new physician graduates, who are more in touch with our patients and the changing ways of the world.

Tara Kiran is a family physician and researcher at St. Michael’s Hospital. She also works part-time as a Primary Care Advisor for the Toronto Central Local Health Integration Network. Follow Tara on Twitter @tara_kiran.

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12 comments

  1. Nick Ragaz

    I’m glad to see attention paid to this topic. My company makes secure patient-physician communication possible for a growing number of practices in and around the GTA: https://wellx.ca/

    There are definitely still barriers (chiefly, workload concerns) but they are not technological or legal, and forward-thinking practices are seeing great results in both patient satisfaction and efficiency.

    • Trevor Jamieson, MD

      Agreed.

      I think there’s a bit of wishful thinking to the notion that we’ll somehow create an info exchange backbone so that everyone can see everyone else’s labs/notes/etc and magically things will improve. I would worry that in fact this will lead to info overload, no time to sift through it all anyway, and the relevant info being lost in a sea of irrelevant data. Like this post by Daniel Sands (Cisco/Harvard), I tend to believe that connecting people is as (if not more) important: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605126/

      There are a few issues:
      1) Time – MDs perceive that this will take more time when they are already busy. The hope would be that this time of communication could actually save time in the long run by shifting some care from the office to the electronic sphere (and hopefully with the use of applications that fit smoothly into a workflow, i.e. no crazy 5 minute login processes, etc)….however…see (2)

      2) Money – Unfortunately, the truth is that a large number of people out there aren’t paid to do this (and aren’t paid nearly enough that it justifies decreasing your in office visits by a significant percentage in those instances you could). I find this is especially true for specialists, who are vital links in proper care coordination, but outside some very specific areas like oncology, aren’t paid for this longitudinal shared care model.

      3) Legal – Personally I think that a properly documented and verbatim record of a conversation with another MD or patient/caregiver is protective, but many still fear it. In addition, unlike the office/phone where you can be backed into a corner and give opinions you’re not 100% sure of, with email, you have time to think/research first. (As well, there is the fear that patients use it for emergencies, but I think that just amounts to proper consent/selective use)

      4) Security – I think the very conservative lens with which patient privacy is viewed actually does patients a disservice (iTunes, can, after all, only give you recommendations on what to buy because you’ve voluntarily waved some of your privacy). I think younger patients understand that waiving some privacy can be empowering (see patientslikeme.com for an example)

      Overall, I think we need to accept that the way we do business is changing, and that communication is vital.

      “Teams” of MDs currently operate much like a 4x400m relay team; one member has the baton and everyone else is watching or waiting. We need to operate more like a well oiled hockey team; yes, only one person has the puck, but the rest of the team is constantly moving into a supporting position. That requires communication and more than episodic involvement (especially for our more complex patients)

      Trevor Jamieson

      • John Moore

        Dr. Jamieson nailed it-

        “Teams” of MDs currently operate much like a 4x400m relay team; one member has the baton and everyone else is watching or waiting. We need to operate more like a well oiled hockey team; yes, only one person has the puck, but the rest of the team is constantly moving into a supporting position. That requires communication and more than episodic involvement (especially for our more complex patients)

        The relay analogy (I call it ‘sequential care’) leads to a focus on transitions- which leads to the discussion about more easily (electronically) sharing records.

        But, especially for complex patients (the 5%), care is not sequential, and requires collaboration, and a coordinator. Health Links may provide the coordinator- but we need to focus on how to support the collaboration (electronically). Phone and fax won’t be sufficient.

        The collaboration system is probably more important than “an info exchange backbone so that everyone can see everyone else’s labs/notes/etc”, but would provide the ability to exchange records. (the patient and alternate would be part of the collaboration.)

        John Moore
        @moorejohned

  2. Ken Collins

    The crux of this problem is that all EMRs available to physicians in Canada are downright awful. I have yet to use one that can operate in a “sophisticated way”. There’s not something inherently different between British and Canadian family physicians; the difference is in the environment. We operate in multiple different provincially-administered healthcare systems versus their National Health Service. I believe they also have more outcome-based requirements for physician remuneration, the tracking of which is made easier by the use of EMRs. With such comparatively small markets, EMR vendors have minimal incentive to build something good.

    CanadianEMR had a three-part article written by a software developer which explains why EMRs in Canada are terrible, which also helps explain their poor uptake by family doctors. It’s available here:

    http://blog.canadianemr.ca/canadianemr/2012/10/emr-in-canada-a-developers-perspective.html

  3. Cynthia Sunstrum

    Thanks for speaking out on this topic. Privacy protection is often cited as the limiting factor. Surely if banks who use electronic records and communication extensively can protect our financial assets, the same can be done in health care. Yes – sometimes breaches in security and privacy happen. They happen in paper based systems as well what with faxes that go missing and records that are misfiled. I am willing to take certain risks regarding the safe-keeping of my medical information if it means that better coordination and communication among health practitioners will improve the quality of my care and increase the efficiency of the system. Performance of EMR systems is indeed another significant factor. I have witnessed my own physician navigating the EMR system in his family medicine clinic. It was painfully slow and complicated; all the pieces did not connect. Once again using banks as an example, if I can e-transfer money to someone across the world with ease and speed, I know the technology must exist. Where there’s a will there is a way! I can only assume that it’s the will that’s missing or that there is a lack of understanding of how we can all benefit by embracing these technologies. We can and must do better!

  4. Health Council of Canada

    Great post, Tara. This year’s Commonwealth Fund health survey has yielded some interesting results allowing for some great insights into the performance of our health systems. At the Health Council, we’ve also been busy analyzing the survey results. For some years now, we’ve been a co-funder of The Commonwealth Fund’s annual international health policy surveys.

    Watch for our results in January 2013 – Bulletin 7 in our Canadian Health Care Matters series. Our bulletin will focus on several key areas of health system performance – access to primary care, coordination among health care providers, as well as the uptake of information technology. We’ll also report on the use of incentive payments to drive improvements in primary care and on primary care physicians’ general perceptions of the system and the care their patients receive.

  5. Dr Clare Liddy

    Thanks Tara for a great overview. Whilst I agree we are lagging behind other countries I am optimistic that we will catch up. I think doctors are very willing to adopt technology when they see immediate high value to a system. In our region, we have had great success using electronic communication ( eConsultation) between the primary care doctor ( and Nurse Practitioner) and the specialist community. Our system has grown organically in the last year and now has over 200 primary care providers who are using the system to consult with a large variety of specialists. Face-face consultation has been avoided in 43% of the cases. Overall satisfaction with the eConsultation system is very high!
    This type of approach could be transferable to the patient -primary care interface and I would imagine would also result in avoidable visits for the patient. Given that many primary care providers are now in capitated models, perhaps we will see more movement towards this type of communication. I do agree that current privacy legislation is burdensome however if the demand for access is driven by the consumer we will be able to find solutions.
    Let’s keep challenging the status quo and drive health care innovation forward.

  6. Harry Zeit M.D.

    As a physician psychotherapist working primarily in the field of trauma, I find e mail communication with my patients invaluable. The potential risks are very much outweighed by the significant benefits. The attachment system can be soothed, and a sense of being in the therapist’s mind can be maintained during difficult passages.
    Some patients move away, while still desperately needing to continue therapy, and e mail communication can sometimes bridge the logistics of less frequent sessions.
    Sadly, despite admonishing physicians to utilize e mail, the government refuses to fund it. Maybe part of the reason is that this would open the process up to a lot of abuse.
    For now, I consider that the hour or two a week I devote to this activity is part of my service, which – in fact – gives it a slightly different flavour than the funded work in my office.
    I do believe that having access to e mail is a very important part of doing psychotherapy with patients with post-traumatic and dissociative disorders.

  7. Doug Maynard

    I love how what is a patient issue is continuously framed and discussed as an MD issue. Patients would benefit greatly from electronic records and electronic communications, full stop, but the discussion always ends up shifting to how hard it is for MD’s.

    A patient-centred approach to the issue would tell us, from endless survey and research data, the Canadian public wants the health care system to embrace e-health, and is willing to accept the privacy consequences, in the same way that they have for the banking industry.

    A patient-centred approach would show us that the burden of trying to navigate an ‘analog’ health care system is too onerous, particularly for families with children with disabilities or complex needs. Children may or may not be dying as a result of a cumbersome system, but their families are spending/wasting much of their lives dealing with paper and process, and their children are often not receiving optimal care as a result.

    We see Canada continue to fall in international rankings, we continue to acknowledge that the status quo isn’t good enough, yet change comes at a snail’s pace. What is needed is for Canadian patients to be empowered and to have more power to demand these changes to the system.

    The current system imposes a burden on patients, yet leaves the patient holding all of the consequences of a poorly run system. The consequences of continuing the status quo should be on the policy makers and administrators of the system, not on the patient.

  8. Lee Taylor

    Another factor impeding electronic communication is, who decides the standard? With multiple EMR software companies out there, and little standardization, who is responsible for the merging of the various offices – the docs? The government? eHealth Ontario was footing the bill for some of the connectivity, but that disappeared this year – this was a huge step backwards.

    Our office of 40 Family Physicians now has hospital report downloads and eprescribing because we have a physician champion pushing the accepted boundaries of what can be done with technology. This has been hugely beneficial to the 50,000 patients in our region. But we are encountering further expansion problems because other systems and other hospitals don’t use the same nomenclature. There has to be standardization, but who decides? And who pays the bill for the homogenization of the data? It is easy to say that communication needs to improve between offices, but without the integral structure – the “info exchange backbone” if you will, to support such communication, follow through is difficult.

    With the British National Health Service, and other successful single-service system, the government arbitrarily decided which system everyone would use. But this would never happen in Canada – we are too afraid of offending someone to impose a standard without choice.

  9. Abhishek

    Hello Tara Kiran,

    Thanks for bringing light into one of the core issues of public interest that is often ignored. I believe that the basic fundamental in development of technology is completely ignored in the discussion of healthcare IT in Canada. I believe health Canada have been trying to update e-health from decades now and the requirements that were relevant a decade ago are now obsolete.

    The problem is in the era of rapidly developing technology if there is a gap between inception of an idea and implementation of the application, the idea becomes practically useless.

    Moreover I see public perception in dealing with healthcare, at least in Quebec, is still outdated. I have seen examples of clinics in Quebec, which in spite of offering an advanced technology in managing medical appointment and communications are experiencing very limited shift in patient’s from traditional method. It kind of discourages clinics to change if the change is not embraced for those who they are serving to.

    I think updating healthcare technology by focusing on the clinics and MDs is just one half of the solution. I have rarely seen any organizations, including EMRs, even considering inputs from the patients end and mostly focusing just on filling the gaps on the services they are offering now. Health Canada must equally invest in increasing patient awareness and participation in what is being developed for the future.

    Abhishek @abhishekkumaran

  10. Peter De Wolfe

    I am not a physician, i am a patient. I have benefited greatly from e-communication with my psychotherapist. Without going into a lot of details, it has “brought me back from the brink”.

    Often patients go to their appointments days or weeks after making the call for a visit and enter the white, hygienic office of their physician and become intimidated by their surroundings or afflicted with “white coat syndrome”. E-communication could help remove this wall and allow patients to open up more regarding their medical situation. The information provided would benefit the physician greatly in providing a more informed response to the issue and may result in more effective treatment.

    A slight digression:
    Some physicians currently use programs within their office to manage patient records. I know EMR’s have been discussed to store patient records and potentially allow record sharing between health care providers. EMR’s are still a work in progress in Canada. There are many obsticals to overcome and a lot are political in nature. E-communication would assist in providing an argument of why EMR’s are crucial to better health care.

    E-communication could also be used in issuing prescriptions to pharmacies. This could be done while the patient is still in the office. This would benefit the physician, the patient and the pharmacist.

    Some physicians see e-communication as i creasing their workload. I see it as decreasing their workload in some areas. No more script writing. No more lost scripts that need to be re-written. No more calls from pharmacies requiring clarification of un-legible prescriptions!

    When it comes to e-communication, think outside the box. What are the benifits in both time and financially? There is potential for support both financial and political to assist in making e-communication a billable service. It would also support the urgency of EMR’s and a more homogenous set of rules across provinces and territories.

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