Dr. Glen Geiger paraphrases Victor Hugo: Nothing is more powerful than an idea whose time has come.
Geiger, chief medical information officer at The Ottawa Hospital, says that the health care system has finally reached the point where a shift to electronic medical records (EMRs) has become inevitable.
So much so, that 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.
The Ottawa Hospital went through a massive big bang in June 2019 in partnership with five other health care organizations: 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. The hospital’s switch to the Epic Health Information System was not without its challenges and its detractors; however, the hospital is now recognized as having made a significant leap forward.
For almost two decades, health care experts and analysts have promoted e-health and the EMR as ways to improve Canadians’ health care. But for the most part, the promise of information technology has yet to be realized.
Canadian hospitals are still struggling to harness computer technology for enhanced patient care. Governments have spent hundreds of millions of dollars incentivizing hospitals and medical offices to convert to paperless systems that house and manipulate medical information about patients. But only small steps have been taken, with scant evidence that patient safety and care are better off. Hospitals are languishing with half-built computer systems that cannot talk with one another and that are not yet sophisticated enough to perform the functions that clinicians and patients need.
In 2001, The Institute of Medicine (IOM), an arm of the National Academy of Sciences in the United States, released an influential document titled Crossing the Quality Chasm: A New Health System for the 21st Century. In it, the IOM called for development of an information infrastructure to support health-care delivery, consumer health, and quality improvement. It identified the need for automation of patient clinical information and drug-prescribing systems. The IOM suggested that strong commitment to such an endeavour could result in elimination of most handwritten clinical data by the end of the decade.
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.
Individual hospital organizations and health-care regions have continued to work toward establishing electronic health-information systems.
Most of these hospitals have slowly rolled out, over the past five to 10 years, various segments of an electronic health-information system, resulting in a hodgepodge of different systems.
“One of the challenges is that the systems don’t talk to each other particularly well,” says Rob Lloyd, chief medical information officer at Hamilton Health Sciences in Hamilton. “The systems are not mature to the point that they need to be” in order to achieve improvements in patient safety or care.
The other main challenge is the cost of establishing an electronic health-information environment. “The costs are just astronomical,” says Lloyd. Hospitals are facing costs of $100 million to $200 million to upgrade their systems.
Enter the big bang. The state of the health-information technology industry has now evolved. Chris Hayes, chief medical information officer at Trillium Health Partners in Mississauga, Ont., says that software vendors are now marketing “total business solutions” that involve holistic, large-scale electronic platforms.
“It’s really only in the last six or seven years that there’s been a really big penetration of these systems across North America,” says Lloyd. “We still don’t know the power of what they’re going to be able to do.”
By overhauling their existing health-information systems, hospitals hope to rapidly achieve the level of maturity and sophistication required to have an impact on patient outcomes.
This level is often considered to be Stage 6 in the Healthcare Information and Management Systems Society, Inc. (HIMSS) Electronic Medical Record Adoption Model, which is widely used to describe a hospital’s degree of adoption and use of electronic health records. It includes stages 0 to 7, in which level 6 involves all processes, such as medication administration, being completely electronic and paperless from end to end.
Most Canadian hospitals currently are at HIMSS Stage 3 or 4. Since introduction of the HITECH Act in the U.S. in 2009 — the Obama administration’s effort to promote adoption of health-information technology and the electronic health record — 70 per cent of American hospitals have achieved HIMSS 6. Less than five per cent of Canadian hospitals can claim such status, says Hayes.
Digitization requires concerted effort on the part of both the hospital and its clinicians. A culture shift is often required. Upfront investment of resources and capital is required to realize gains down the road.
And that road is often bumpy. It can take more time to input data than to write a note. “You get lots of doctors who are still going to just want to dictate their note,” says Lloyd. Doctors complain that they are being turned into robots, says Geiger.
A 2019 study in Mayo Clinic Proceedings revealed that doctors who found an electronic health record system difficult to use were more likely to report symptoms of burnout.
And while high-quality evidence is limited, there is consensus that well-developed health-information technology systems lead to benefits for clinicians, patients, and the health care system, particularly in terms of patient safety.
According to a 2015 Italian study by Paolo Campanella, use of the electronic health record has been associated with less time spent on documentation, better adherence to guidelines, fewer medication errors and fewer adverse drug reactions. Research in 2018 by Bridie McCarthy in Ireland demonstrated that implementing electronic nursing documentation in acute hospital settings is time saving and reduces documentation errors, falls, and infections.
The Global eHealth Executive Council in London, England, reported in a 2012 meta-analysis that full implementation of an EMR resulted in average time savings for nurses equivalent to 42 minutes for each nurse in every 12-hour shift in intensive care units and 54 minutes per nurse in medical/surgical units.
A 2018 systematic review in the Journal of Medical Internet Research by CS Kruse showed that health information technology had positive effects on a broad range of medical outcomes — including wound healing, quality of life, diabetes control, vaccination rates, depression, insomnia, eating disorder symptomatology, readmission rates and length of stay.
For patients, there is a strong push for a system that would allow them to access their own health data. “To really advance the idea of patient-centred care is to put the patient’s data back into the patient’s hand,” says David Chan, EMR software developer and professor emeritus in the department of family medicine at McMaster University in Hamilton.
Technology is creating new ways for patients to interact with doctors and the health-care system, such as patients reviewing their test results through electronic patient portals, booking appointments online and having online contact with care providers.
The age of health information technology is now upon us. “It touches everything that we do and it has the opportunity to improve and make more efficient everything that we do,” says Lloyd. “There’s no question in my mind that it’s going to be better.”
Alan Taniguchi is a Palliative Care Physician and Fellow in Global Journalism at the Dalla Lana School of Public Health
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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 https://www.lco-cdo.org/wp-content/uploads/2010/10/ACE%20DDO%20Walton%20Formatted%20Dec%202%2C2016%20LCO.pdf.
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?
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: https://www.cihi.ca/en/commonwealth-fund-survey-2019
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.
Paul
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.
“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 — https://www.thestar.com/news/queenspark/2016/11/30/ontario-auditor-general-exposes-litany-of-government-snafus-in-annual-report.html