Healthcare's Epic Fail - Paul Christopher Webster

online chart, hospital staff learned allthey needed about Morley’s complexmedical history. They reached a correctdiagnosis for her pain—intestinalblockage, best treated with medicationsvia IV—and opted against anunnecessary operation that mighthave had tragic consequences.Morley’s electronic records—which she suspects saved her life thatday in Mexico—were made availablevia MyChart, a website launched in2006 by Toronto’s SunnybrookHealth Sciences Centre. Through thesite, patients can retrieve lab results,ultrasound images and MRIs, andtrack prescription refills. They can setup appointments and email their doctors.Patients can also grant access toanyone they choose, including outsidephysicians, pharmacists andfamily caregivers.MyChart’s popularity—the site has15,000 registered users—isn’t a surpriseto Sunnybrook staff. “Criticswarn that patients may be overwhelmedby too much information,”says Dr. Andy Smith, the cancer surgeonwho treated Morley. “But that’soffset by the positives—patients whoare informed and empowered.”With the Internet revolution nownearly two decades old, electroniclinks between patients and health-careproviders such as those available atSunnybrook should be widespread inCanada. But that’s far from the case.Dr. Brian Postl, chair of the board ofdirectors of the Canadian Institute forHealth Information (CIHI), says Canadiansare often stunned to discoverthat basic information technologies areunavailable to public-health doctors. “Ithink the public thinks much moreexists than actually does.”There are at least three kinds of electronicrecords. The first is the PersonalHealth Record (PHR), to whichMyChart belongs. PHRs are co-curatedby patients, who can supplementthe clinical data uploaded by the hospitalwith other personal health information(migraine sufferers, forexample, can list dates on which theyexperienced headaches). Next is theElectronic Medical Record (EMR),used in private medical practices as asubstitute for patients’ paper charts.Third is the Electronic Health Record(EHR), which is a comprehensive recordof an individual’s medical history.According to a 2004 study by theCIHI, as many as 24,000 Canadiansdie annually from errors that electronicrecords could help prevent,such as doctors administering thewrong dose or prescribing a drug thatreacts dangerously with prescriptionsundisclosed by the patient. Anotherfederal study estimates that acountrywide EHR system could shaveas much as $6 billion annually fromour national health bill by eliminatingthe time Canadians spend chasingpaper records or redoing expensivetests at different clinics.Unfortunately, Canadians still havean easier time accessing their bank accountsonline than their medical records.To be sure, most provinces havestarted digitizing patients’ health informationin some way. Hospitals arealso getting into the act. Toronto’sPrincess Margaret Hospital usesInfoWell, a personalized health-informationwebsite, to give breast-cancerpatients access to test results, and tohelp them better interpret informationabout their treatment. But such a projectmight as well exist in an alternateuniverse for the nearly 70 percent ofCanadian physicians who still keeprecords in manila folders, communicatewith pharmacists via scrawlednotes and use fax machines (long obsoleteeverywhere else) to share testresults with colleagues.The achingly slow progress ofe-health in Canada hasn’t been forlack of trying. Ever since federal,provincial and territorialgovernmentsbegan discussing electronicrecording-keepingback in 1994, over$2 billion has beenplowed into buildinga national “infostructure”connecting82 r e a d e r s d i g e s t . c a 1 1 / 1 1 83

every clinic, hospital and physician inCanada. But this objective, mostlyquarterbacked by Canada Health Infoway—thefederal agency tasked in2001 with accelerating the countrywideadoption of health-informationAccording to a 2004study, as many as24,000 Canadiansdie annually fromerrors that electronicrecordscould help prevent.platforms—has been confounded bytechnological complications, missedimplementation dates and budgetoverruns. A defining moment of thisdysfunction was the 2009 spendingscandal that rocked Ontario’s eHealthprogram and led to the health minister’sresignation.Kevin Leonard, a University of Torontoe-health researcher, says thestakes for Infoway’s success couldn’tbe higher. Millions of Canadians sufferfrom chronic illnesses, such asheart disease and cancer, that demandconstant monitoring and consultationswith various specialists. “Patientswith chronic disease accountfor most of the public health costs,”he says, “and their numbers are risingsharply as the population ages.”As Leonard attests from his ownexperience battling Crohn’s disease,life for chronically ill patients canbecome a blizzard of files, referrals,prescriptions and not-infrequentmedication mishaps. Without a functioningEHR system that allows dataswappingbetween multiple doctors,efficient treatment may become closeto impossible, especially consideringour aging population. The chronicdisease tsunami on the horizon riskscrippling our medical system.“Lives depend on our ability to pulltogether and make the system work,”says Leonard. “Our failure to join theinformation age threatens everything.”The plan seemed simple enough. Giveevery Canadian an EHR and store itin a countrywide network of massivedatabases. Each province and territorywould house one or more ofthese “interoperable” digital hubs,which could be safely and securelyaccessed by health-care providersacross the country. The hope wasthat a senior citizen from, say, St.John’s, N.L., who falls sick in BritishColumbia while visiting relatives canexpect his complete list of currentmedications and drug allergies to beinstantly available to doctors in aVancouver ER.This vision made each jurisdictionresponsible for developing its ownEHR strategies, with Infoway payingup to 75 percent of the eligible costsof the approved projects. It was laidout in the 2003 Electronic Health RecordSolution blueprint, a documentthat pledged to “help governmentsand health-care administrations inCanada develop and deploy EHR systemsfaster and at less cost and lessrisk.”A decade later we still have thepledge, but few results. “It’s similar toconstructing a building,” is how Infoway,in its 2010-11 annual report, explainsthe fact that it is still buildingdata systems that few doctors nationallyactually have access to. “Thebuilding must be available before thetenants can move in, occupy and usethe space as it was intended.”To the ears of many observers, thisjust sounds like red tape.Karim Keshavjee, a Toronto-basedphysician and e-health researcher, isone of them. Keshavjee argues thatOttawa’s obsession with a top-downapproach has distracted the agencyfrom working more closely with theprovinces, resulting in dramaticallylopsided EMR and EHR adoptionrates. Infoway anticipated that theprovinces would design systems thatsuit their regional health authorities.Yet a lack of clarity seems to have lefteach jurisdiction in a guessing gameabout how to plan and monitor theirprojects, or fix problems when theyarise. Ten years after Infoway assumedcontrol of the EHR project, theresults are mixed at best. Albertaleads the country with 70 percent ofits doctors using electronic records;Yukon, Nunavut and Quebec, in contrast,lag behind.Infoway claims it has consultedwith hundreds of experts, includingmedical professionals. Critics say itfroze nurses and doctors out of theearly planning stages, and surrendereddecision-making to health-careexecutives without clinical experience.This, critics continue, is reflectedin the way the agencyimplemented its mandate, making patients’health information and historyaccessible to health-care providers,rather than building links betweenpatients and health-care providers.“Countries that rank highest one-health surveys,” says Keshavjee,“focused first on getting systems intothe offices of family doctors and specialists.There’s a good reason forthis: Health care is almost alwaysdelivered locally.” Building a nationalstorehouse of patient informationwon’t be much use to anybody,he says, unless you convince thecountry’s front-line health-care providers—whoalready store that informationon paper—to go digital.With only onedoctor on infoway’s13-memberboard of directors,physicians feelthey have but atoken presence.To get a starker sense of our predicament,we need only look abroad. TheNew York–based CommonwealthFund ranked Canadian doctors lastamong 11 wealthy nations in the EMRadoption rate. New Zealand and the84 r e a d e r s d i g e s t . c a 1 1 / 1 1 85

Netherlands have built electronichealth-care systems for a fraction ofwhat Infoway has now lavished onsoftware systems that, as yet, offerlittle benefit to patients or clinicianson a national level.Even Belize, a tiny impoverishedCentral American nation that spendsone twelfth what Canada spends perpatient, has built an electronic healthcaresystem far more comprehensivethan anything yet available in thiscountry—and much of its success isdue to Canadian innovators. Dr. MichaelGraven, assistant professor ofmedicine at Dalhousie University, codesignedBelize’s national health informationsystem. “Working indeveloping countries makes you developlean and mean work habits, “ hesays. “Infoway got very comfortablenegotiating among many vendors,with the focus only on software andhardware.” The salaries of hundredsof federal e-health officials and computerengineers consume over $22million annually—not far from the$30 million New Zealand spent toconnect all its doctors permanently.In the United States, e-health investmentsby major institutions areyielding better health care at lowercosts—and paint a picture of what apatient-centered EHR could accomplishin Canada. The Veterans Healthreadersdigest.ca/novemberPut your health first by reading up onthese invaluable hospital facts.Administration (VHA), a government-runsystem that serves over fivemillion patients, experienced anextraordinary turnaround afteradopting EHRs in the mid-1990s.Once saddled with the worst healthcarerecord in the United States, theVHA today is celebrated for its successin keeping illnesses such as diabetesfrom becoming full-blowncrises. This, in part, is due to in-homemonitoring devices that measure apatient’s vital signs and symptomsround-the-clock. The telehealth innovationharnesses the data in EHRsand allows staff to make timely interventionsthat prevent expensive tripsto the hospital for patients.Trevor Hodge, an Infoway vicepresident,acknowledges that Canadapossibly should have taken its blueprintto the whole clinical communityearlier in the game and worked harderto consult with health professionals.But Hodge notes that unlike pharmacists,Canadian doctors—particularlysolo practitioners—have been slow tospend money of their own on electronicsystems. In a 2010 article,Hodge wrote, “Physicians in communitypractice do not have a stronghistory of using information technologyfor clinical purposes.”Unsurprisingly, this rubs manydoctors the wrong way. In a recentarticle responding to Hodge, physicianand University of Ottawa professorDr. Mark Dermer, who servedon Infoway’s board of directors at onetime, notes that doctors have to payfor the hardware, software and implementationservices of EMRs. The investmentof time and money isgreater than any payback they cananticipate, so the business case forimplementing EMRs doesn’t exist.All this might have been avoided,critics say, if doctors had been allowedto drive the process. With onlyone doctor on the agency’s 13-memberboard of directors, physicians feelthey have but a token presence.Infoway has committed to fundingapproximately 300 health-informationtechnology projects across thecountry; planning for about 200 ofthose projects is complete. It alsonotes that approximately 50 percentof Canadian hospitals have core elementsof the EHR system already inplace. And Infoway has pledged towork more closely with physicians.Agency spokesman Dan Strasbourgsays that, over the last year, theagency has set aside $380 million tohelp physicians acquire and utilizeEMR systems, which includes personaltraining and on-site support.“Physician response to this decisionhas been positive,” says Strasbourg.Dr. Jeff Turnbull, president of theCanadian Medical Association(CMA)—which represents 74,000physicians—praised Infoway’s allocationof the money. “Infoway’s initiativeshows real commitment to putEMR support where it is neededmost: at the front lines of care.”But after all this, Infoway’s investmentstill represents only about 18percent of its $2 billion budget. Therest of the agency’s funding is earmarkedfor large-scale systems.Graven calls Infoway’s “vendorcentric”approach a “clear miss.”Graven’s experience in Belize hastaught him that an easy-to-use and“Our failure to jointhe informationage threatenseverything,” says atoronto e-healthresearcher.easy-to-deploy EHR system needs tobe “encounter-centric,” that is, focusedon the moment of doctorpatientinteraction.If Canada used this as a model,claims Graven, it could design a functionalEHR in six months and have itrunning three months after that.“Those few of us who have been apart of successful deployments—onlyten people have been through thismore than once, worldwide—knowthat it is possible to achieve thisschedule. It would help if Infowayfinally accepted input from peoplewho have actually done it before,rather than exclusively from thosethat have not.“Much of what was has been developedby Infoway,” Graven concludes,“can be retasked to serve thenew focus. But it needs to start overagain.”n86 r e a d e r s d i g e s t . c a 1 1 / 1 1 87