The time has come…health care makes the push to go digital

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  • Judith Wahl says:

    I agree that Electronic Health Records must become the standard. However its of critical importance that the system used reflect the Ontario law on health decision making . By this I mean that the electronic records need to use the right terms for things like Substitute Decision Maker, include the hierarchy list of SDMs as in the Health Care Consent Act and not just “attorneys” , NOT include references to “advance directives” which are not in Ontario law but may include references to “patients wishes, values, and beliefs ” that impact their health decision making , include a warning in that section that the wishes etc are not informed consent and that even if wishes about specific treatments are included in the electronic records that the health practitioners can rely on those wishes only when treating the patient in an emergency. Otherwise the health practitioner must get an informed consent before treatment from the patient if capable or the incapable patients SDM. The electronic records must include space to confirm that the health practitioner offering a treatment did assess the patient’s capacity to consent , some notes on why the patient was found incapable to consent, gave the info required by the CPSO and the health care consent legislation if they did find the patient incapable, and to whom the health practitioner got informed consent from if the patient was incapable for this purpose. These are only a few examples. .

    I realize that the bulk of the records are about the actual treatments and care delivered BUT the records must comply with all the law that is applicable including the Health Care Consent Act, Mental Health Act, Privacy legislation and so on.

    I assume that the the Ottawa Hospital , the Ottawa Hospital Academic Family Health Team, Hawkesbury and District General Hospital, Renfrew Victoria Hospital, St. Francis Memorial Hospital in Barry’s Bay and the University of Ottawa Heart Institute made sure that any necessary changes to comply with Ontario law were made to the Epic platform as EPIC is based in Wisconsin . I will be contacting all these health organizations to try to find that out as I don’t know if they did do that as part of this adoption of this electronic records system. I hope I will get replies to my inquiry as I am again researching this same issue if I can get access to enough of the electronic records formats that are being used in various places around the province.

    If you are interested in reading a research paper on whether health records in Ontario health facilities and organizations do reflect Ontario law , see the paper commissioned by the Law Commission of Ontario for their Last Stages of Life Project — Judith A. Wahl, Mary Jane Dykeman, Tara Walton:Health Care Consent, Advance Care Planning, and Goals of Care Practice Tools: The Challenge to Get it Right,Released December 2016

    In this paper, the writers reviewed 100 sets of forms, policies, documents etc related to health care consent and advance care planning that were being used at the time of the research by hospitals, health teams, long term care homes and other health facilities and organizations. The forms etc were requested by the researchers directly from the health organizations and were volunteered by the health organizations knowing that these would be reviewed and possibly included as examples in the research paper . The writers agreed to keep confidential the source of any particular record either critiques or lauded unless specific consent was obtained from the health facility to reveal the source. On review, NOT ONE SINGLE SET of records was completely correct in respect to the legal references or practices described. Most include some good and legally correct information and references but it was obvious that some used documents and forms and policies from other jurisdictions that have different laws or had misinterpreted the Ontario law. .

    I know from my former legal practice at the Advocacy Centre for the Elderly ( I am now retired from that legal clinic), I frequently saw forms and documents , including electronic records, that did not reflect Ontario law. This caused many problems for both my clients as well as the health practitioners because proper informed consent was not being obtained particularly if the patient previously had completed some form of “:advance directive” “living will” or “statement of wishes” or whatever such document was called at the particular health organization. Health practitioners were not getting consent from appropriate people when the patient was incapable because the form or record display did not include the SDM hierarchy as in the Health Care Consent Act which has been the law since 1996 but instead included terms like “family member” “attorney” “guardian” . This is only one example of the problems records that do not reflect Ontario law may cause.

    So.. I think that changing over to more electronic records is a good idea BUT since so many paper or simple electronic records forms and systems failed to comply with Ontario law, the new electronic records system , even if purchased from suppliers from other jurisdictions must be revised to reflect Ontario law. At one health conference I had the opportunity to speak to an American supplier of such a product and ask whether certain lines / boxes etc could be changed on their product to reflect terminology used in Ontario health decision making legislation. He said that was possible since hats also an issue across the US because of state specific legislation. So why do I see that product used in Ontario health facilities as is and without appropriate changes made?

  • Paul Gallant, CHE says:

    Interesting article and I appreciate Dr. Alan Taniguchi’s sharing of what’s occurring in Ottawa. I wanted to add my two cents especially on the following section.
    “..some Canadian hospitals are preparing for the big bang. Rather than building digital health-information management systems piece by piece, they plan to implement new comprehensive computer systems all at once, often on a single day. And they hope these new systems will help them provide better care to patients.”

    My opinion:
    Certainly there are some hospitals, health care organizations and health regions in Canada are “integrating” some health information management systems instead of a big bang approach or building piece by piece. Meaningful patient-provider focused and thoughtfully implemented technology has improved many areas of patient care and continues to do so in parts of Canada. There’s significant room for improvement, though as mentioned in your title, health care makes the push to go digital.

    We need to look beyond any one group of hospitals towards comprehensive regional and provincially integrated systems (primary through acute care) and dare I say eventually nationally. We also need to look far beyond USA comparisons and measures. For example, recent CIHI/Commonwealth Fund (Jan. 2020) reported “65% of Canadian primary care physicians think that better integration of primary care with hospitals, mental health services and community-based social services is the top priority in improving quality of care and patient access.” Also “the proportion of primary care physicians who have electronic access to any regional (e.g., hospital/hospital network), provincial or territorial information systems where they can see patient information from outside their practice” is below the Canadian average in BC, Ontario and Nova Scotia.”
    More here:

    I completely agree that “The age of health information technology is now upon us.” The reality of big bang re. information systems, may be continued investment in technology without the desired improvements or outcomes patients, public and clinicians’ expect. Therefore, with cautious optimism, it’s possibly going to be better when we meaningful include clinicians and patients in Canada’s priority setting for better integration of information systems including a national health record.

    Healthy Debate, Thank-you for continuing to create and share such pertinent articles.

  • Darren Stevens says:

    I agree that technology improvements in health care are beneficial to patients and caregivers alike – I would even say essential, but I strongly disagree that big bang is the necessary approach.

    Big bang is fraught with risk, excessive costs, missed objectives, and restarts, as examples included in this article illustrate.

    No single monolithic system can ever be best of breed in all areas. Thus it is necessary to have integration between systems. Once integration is recognized as a necessity, best of breed systems can then be chosen for each health domain, and each can be installed iteratively and in isolation without negatively impacting the overall health system.

    Such an evolutionary approach mitigates the risk, costs, timelines and associated pains of adoption that big bang causes, such as years of lowered practitioner productivity and risk to patient safety, as has occurred on too many of these projects.

    Modern hybrid integration technology is able to adapt existing systems from “outside the box”, so that they can safely and cost-effectively become integrated components that share information across a broader ecosystem, regardless of their existing API capabilities. By isolating the systems behind the middle tier, the systems become loosely coupled, meaning that they become “black boxes” behind interface facades that mirror those ancient or proprietary APIs. Those interface facades can then be transformed at the middle tier into protocols compatible with other applications, like HL7 v2, v2 and FHIR; in fact, legacy applications can be easily adapted this way to provide support for the needs of multiple connecting applications, which often reduces or eliminates the motivation for replacing the system in the first place.

    Once this straight-forward step has been taken, older systems can then be replaced with newer systems, and the middle tier can adapt the communications from the old to the new, usually without modifying those existing legacy systems. In this way, each system that requires or provides information to that deprecated system can remain unaware that the deprecated system is being replaced. This is fundamentally important. Additional strategies also become available, such as reading from multiple existing deprecated systems and writing to only the one newer system, again, allowing a low-risk, low-pain evolution into digital transformation.

    Perhaps best of all, this strategy allows existing teams to divide and conquer to solve the problem, uplifting a nation’s health systems in a natural, non-disruptive, evolutionary manner, in contrast to putting one’s eggs all in one mega-vendor’s basket.

  • Mike Fraumeni says:

    “In Canada, response to such recommendations led to the establishment of government agencies such as eHealth Ontario. But by 2009, the Ontario auditor general released a scathing report stating the provincial government had wasted $1 billion in taxpayer money on eHealth Ontario and that little progress had been made in achieving an electronic health record.”

    I guess the Ontario government didn’t practice what it preaches that in order to prevent spending such large sums of money that turns out to be wasted that you do evidence based analyses first and foremost. Typical I suppose of many governments. From the Toronto Star a few years ago:

    “The initiative has certainly advanced since our last audit in 2009. However it is still not possible to say if it is on budget because the government never set an overall budget,” she said.
    “In effect, we cannot say if $8 billion is a reasonable figure.”
    That amount includes $3 billion spent by eHealth, $1 billion by the Ministry of Health and agencies like Cancer Care Ontario, and $4 billion by hospitals, community care access centres and other clinics across the province.”

    Source: Ontario auditor general exposes litany of government snafus in annual report —


Alan Taniguchi



Alan Taniguchi is a Palliative Care Physician and Fellow in Global Journalism at the Dalla Lana School of Public Health.

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