An E Health scandal? The real E Health scandal is that we don’t have an electronic health system. In an age of Google and 4G smart phones– the health system still functions largely with paper and fax. What we need is a fully integrated complex data system that not only has patient information in it and allows communication between all providers and institutions, but also can automatically gather, collate, analyze and compare data. Yes, we have some doctors using electronic medical record systems and many hospitals have developed their own systems for electronic data storage, but most of these systems cannot speak to each other. In this communications era, it’s the electronic equivalent of Dixie cups and wet string.
We claim that we want a health care system. We can’t have one, and won’t have one until that system has an integrated medical record and communications network. It’s important not just for patient care but also to understand how the system is or isn’t working, how much it is costing, and to be able to compare throughout the system. And this type of data collection needs to happen behind the activity, automatically. The recent Drummond report talks repeatedly about efficiency, analysis, and measurement – how can we do this without a comprehensive, integrated health care information system? What are the obstacles?
Collectively we’ve avoided doing it because we thought it would cost too much, because it was perceived as a luxury. At the same time, the banks, grocery chains, and cruise lines have realized that it isn’t a luxury. While electronic banking, monitoring of grocery sales, and cruise line card systems provide user convenience, they are there primarily to create efficiency, provide security, and save money. In the health care field we have failed to realize that an electronic data system isn’t just about patient care, it’s about system care – that we will save money by avoiding duplication of tests and imaging, reducing manual data collection, and identifying money saving solutions.
Some have raised privacy concerns – they are real, however these can and will be effectively managed.
We are past the era of choice. This is an electronic era and every provider and every patient in the public domain must be connected. The system itself should have been built a long time ago with a central data system and common interface. That doctors can decide they don’t want to have a computer, that lab and imaging results are not digital and provided to a central access hub, that a medication list for an unconscious elderly patient in an emergency department at midnight is not available – none of these are justifiable any longer.
An E Health solution? It’s not a luxury; it’s a necessity. Let’s stop trying to reinvent the wheel when other industries are already light-years ahead. I expect that if we went to the banking sector, the grocery sector, the cruise line industry and told them what we needed, they would likely already have it.
Let’s stop wasting time.
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Jonathan,
If I read your post correctly what you are suggesting fits very nicely with the plans of both eHealth Ontario and Canada Health Infoway are working toward. You might want to check out the “Connecting GTA project” (cGTA) being ran out of UHN. This project is working on an “interfacing hub” that will connect the different operating systems to a common set of databases (Ontario Lab, DI images and reports etc.). Another resource would be the CIHI eHealth Architectural map. My memory is that there is a perfect fit between your idea and their architecture.
I am not sure that this drives down the cost or eliminates the need for subsidies. cGTA does not reduce the core set of code required to produce an EMR nor the complexity of maintaining the core EMR, but rather adds the necessity to communicate with a separate online database. Further the cost of the cGTA project will need to be included as a part of the ongoing system costs. I worry somewhat about the ongoing costs of interface engines both in terms of dollars and in terms of the rigidity that the communication may cause. Hopefully this system will be done in such a way that improvements to the core EMR aren’t handicapped by the need to communicate with the Interface hub and databases.
What really matters is user functionality. If such a system doesn’t add value to the user needs it won’t get used, or will get used in some limited way.
The one area where I think there is enormous untapped potential is the PHR, especially if it is both comprehensive, and completely accessible to the patient. What would be the impact of having a diabetic patient match their comprehensive record of care against a best practice standard? I think the Mayo clinic already has the beginnings of an electronic tool.
The impact of consumerism on healthcare which is essential a knowledge transfer industry is a very interesting topic, and your PHR thoughts are worth watching.
Hi Lewis,
Thanks for the response.
Perhaps I am naive, but I think what I am suggesting is different than what you describe. It seems to me that you are saying they are building in extra layers of complexity into an already cumbersome system.
I am suggesting that we do the opposite and simplify things.
I am saying that we build a common database or receptacle. This database would be more comprehensive than the limited commonalities that you describe above (labs, DI, etc). I’m suggesting that the entire medical record of a patient be in such a common database. I’m also suggesting that the data from the rest of the healthcare system be in the database as well… such as a detailed database of doctors, hospitals, OHIP, etc… basically any data that could be needed by anyone anywhere anytime.
We then dump everything from the current electronic patient record into this database. We then build brand new electronic health record systems that are designed from the ground up to interface with such a database.
Now here’s where I get ‘radical’. I’m suggesting that we throw into the trash all the siloed electronic systems of today… THROW THEN AWAY.
I do not see the point of requiring complex interactions and communications in a Tower of Babel like project. This will be not only complex, but also expensive.
The key is that the data should not reside in individual systems but in a central database. This way it is not important for systems to communicate but only for an electronic record management system to interact with the database and the user.
In theory it should be very easy to use or switch systems and to build such systems.
What I’m saying is that we need to press the reset button. That would be the hardest thing to get people’s heads around. But again, perhaps I am being naive.
I’m happy to carry on this conversation with anyone in another vehicle online or in person.
Jonathan (jonathan_marcus@mac.com)
Mark and Lewis, I think we can have a system where doctors are ‘independent contractors’ AND we take a systemic approach.
I agree that we should have a common database but we don’t need a common interface. I don’t think it matters what system one uses to view and generate system data… as long as this data is able to be used by all other relevant players in the system. Levels of privacy could be set by users (doctors and patients) as necessary to foster communication and protect privacy.
I think an EMR should re redefined from it’s current form of being an electronic silo. An EMR should have three purposes: 1)read data from the system, 2) write data to the system, and 3) be an ‘operating system’ for the user.
3) ‘Operating system’ is what I mean by not requiring a common interface. It doesn’t really matter if one doctor uses a system with a different look and feel and organization as long as the data fields are common. Additionally, patient health records (PHR) could be different than the EMRs of physicians, yet still working with the same data.
EMR companies would build EMRs (and PHRs) with the above three specifications. If a user (doctor, patient, etc) didn’t like a particular system, it should be as easy as turning one off and turning another on as the data would be preserved.
This would drive the cost of EMRs down and would eliminate the need for subsidies, which paradoxically hinder innovation. EMRs would also become much easier to use due to competition.
This system would allow all users to stay independent contractors but have a much simpler and unified system that we would all be a part of, benefit from, and be responsible to.
I’m happy to discuss this further with anyone on or offline.
-Dr. Jonathan Marcus (jonathan_marcus@mac.com)
Hi Mark,
Thanks for your post. I enjoyed reading it.
My research is in the area of eHealth with a focus on Personal Health Records and Privacy. I definitely agree that although Privacy is a very important issue, it is something manageable. My personal opinion is that the privacy issue is often leveraged to make a point but without much evidence to back it – well, at least for PHRs. As Catherine kindly shared, there is a demand for patient access to their EHRs, and of what primary literature available shows, there is a willingness to trade off some privacy for access to personal records (especially for those who are sick). Hopefully we can get some privacy policy in place so that we can move on with the implementation/adoption of EHR and eventually PHRs.
Mark and Lewis
You have captured the essence of the current challenge for moving to a health care ‘system’ from the current patchwork of services.
Thankfully, the costs and performance of computer systems has improved exponentially over the past few decades. This opens many opportunities to rethink old challenges and provide real time high quality information that routinely supports the front line decision making where health care is actually provided to people. This requires pooling resources and efforts across traditional areas in order to assemble a sustainable and affordable health care system. It is amazing what dedicated and competent people can accomplish when they pull together.
Mark MacLeod you are brilliant! I wish you were the Health Minister!:) I’m not kidding!
I agree with you about EHRs and I always wonder why I can see my day to day banking details without any trouble and yet I never see my own health record details. I think the patient should also have easy access to their own or a loved one’s health record (ie Substitute Decision Maker) whenever the need arises. I have concerns about the power of healthcare providers to document in the health record and it should be transparent in my view to prevent those without integrity from altering it, embellishing facts or outright lying about patients in the health record. That happened to me and my late mother.
The other night I wrote a much more detailed response and I don’t have time to do so today, but in any case, thank you for writing your opinion which holds a mirror to mine and I suspect many, many others as well.
There is no plausible excuse why we cannot have a good EHR system properly connected and in place right now.
Mark,
Thanks for this post. Your comments are correct, and I would suggest that the debate be enlarged on two fronts. One the EHR is only useful as a starting point. What we desperately need to do in heatlhcare is use these tools to begin to build a standardized approachs to healthcare. Not just in planning where we can debate why one LHIN has 3% of post HIP patients transferred to inpatient rehab and another has 57% or why one LHIN has an age adjusted C-section rate of twice another. But we will get real value if we begin to use technology to standardize the front line processes, both administrative and clinical. The discharge process in one hospital that I looked at involved 75 forms and had a cycle time of 7 hours,regardless of destination and in my mind was a bigger contributor to ER backlog than ALC.
The degree of clinical variation is harder to control but much more important. While I understand that each patient is unique, a hip replacement in a 65 year old male with no complications should follow a pretty clear pattern, but as we know the treatment plan, costs, and outcomes vary significantly.
A shared EHR which is the current (as yet un-achieved) goal is not enough to solve those problems. We need a shared system that has common business processes. This would also make it possible to share resources much more efficiently, For example with a shared system a patient who needs an MRI could choose where to go based on their preference, close to home, quickest, near Aunt Martha etc. This would probably do more to solve patient angst over wait times than the money we have thrown at it.
The second point is that this decision requires provincial leadership that is willing to challenge the vested interests of the participants. I have a few scars from that battle, and am convinced too many leaders and managers in the system want to have these systems as strategic differentiator between their organization and the one down the street. orsee a shared system as putting their volumes at risk or have their business exposed to further scrutiny, or simply a loss of autonomy.
The Ontario history of incremental approach to change make this kind of change difficult, but I agree its the right thing to do.
Thanks again for the post
Lewis – I agree with all of your comments and I’m increasingly aware of the resistance to thinking that we are part of a system – individual doctors are resistant claiming they are independent contractors, hospitals are resistant wanting to protect market share and autonomy, providers and payers see themselves at opposite ends, labs and imaging clinics are virtual islands – all at the same time that we are trying to forge a system of so many disparate parts.