Wednesday, July 02, 2008

Canadian Health Records Situation A Travesty

Janet French | The StarPhoenix | Wednesday, July 02, 2008

Canada's foot-dragging on embracing electronic health records is a flaw in the system as revealing as a patient's paper hospital gown, a longtime national health reporter says.  Globe and Mail public health reporter Andre Picard told a Health Quality Council conference on transparency in Saskatoon Friday the nation's lack of electronic health records is a "travesty" that helps make personal health information tricky to get and hard to understand once you do get it.

"Metaphorically, our butt-cracks are showing," he told about 200 conference attendees, who tittered at the remark.

Canada's health system needs to break out of the culture where basic health information -- including your blood sugar readings, blood pressure, cholesterol levels and how those numbers change over time -- is rarely shared with the patient and treated like a "state secret," Picard said.

"We're still in the era of paternalism," Picard said. "We're changing, but we're not changing quickly enough."

Picard gave the example of returning from a trip to Malawi with a parasite. When Picard asked his specialist what the name of the parasite was, the doctor was puzzled about why he wanted to know.

"Why do I want to know what's living in my body?" he said. "I just couldn't believe the arrogance of that. But it's not that uncommon, unfortunately."

The information in medical records belongs to patients, not health-care providers, he says. Standardized, electronic records available throughout the system would simplify access, Picard says. Patients might fare better if they approached health care like they shop for a vehicle, Picard said later in an interview.

"If you go to buy a car, you want the manual," he said. "If you get it fixed, you're not only going to get the bill, you're going to get an explanation of what went wrong and maybe you can avoid it happening the next time. It's the same philosophy."

Too many patients are compliant when they'd be better off asking questions, he said. "They have a great deal of respect for their physicians, which isn't bad, but it's taken too far. We just sort of take their word as gospel."

There's a bonus to inquisitiveness: Research shows engaged patients are healthier, less likely to experience a medical mistake and cheaper for the health-care system, he said.

"I think he's right," said Jean Morrison, the Saskatoon Health Region's vice-president of performance excellence and chief nursing officer, after Picard's talk. "We're a public institution, and people have the right to their information and they have a right to information about what goes on within public institutions."

Bobbylynn Stewart, the region's acting privacy commissioner, says it's "very easy" for patients to see their health records. The department will make copies at 25 cents a page and if an inpatient requests to see his or her chart, a staff member will explain what the jargon means.

Morrison admits many patients would not be able to understand their records without help. The region strives to eventually include a written analysis of tests in the notes to make records more comprehensible, she said. Although lab results, prescription information and diagnostic images are now computerized, Morrison estimates less than one quarter of the region's health records are electronic. The region would like to be paperless, but the provincial government will have to pony up the cash to make it happen, she says.

"Creating electronic records is a costly business because you are truly transforming the health system," Morrison said. "It's the software, the hardware, it's the training of the people, it's the way you do business. It's a multi, multimillion-dollar issue to do that. In the Saskatoon Health Region, we're talking tens-of-millions of dollars."

For skeptics who think information should be kept tightly under wraps, Picard points to Canada's tainted blood scandal, or the Newfoundland scandal where flawed breast cancer tests were done on women for eight years before the health authority admitted the errors.

"We can look at all kinds of elements that came into play, but No. 1, the starting point for that, was people covering up information and not being open about it," he said.

"In my experience, the price of secrecy and the price of paternalism is dead patients and wounded patients," he added.


Using “Virtual Reasoning” to redefine Healthcare

by Dr. Marlene Beggelman

The Internet is redefining the health care industry. Major transformations can be expected because Internet-based technology will deliver certain health care services more effectively and at lower costs. In the near future, much of the information that is currently imparted to consumers by clinicians will be delivered through and by web-based technology. If the web-based tools that deliver this information mature to the point of becoming reimbursable, beyond their current usefulness as value add-ons, the health care industry could experience a dramatic shift.

Early stage Health 1.0 information has predominantly been available in the form of an “e-pamphlet” with a one-size-fits-all approach. Subsequent generations of Health 2.0 tools are interactive and deliver personalized, and therefore more valuable information that is geared specifically to the user’s input. With the advent of advanced tools, consumers are no longer limited to being passive recipients of pamphlet-style information; in these milieus they interact with each other or with sophisticated software that analyzes cases on an individualized basis. Advanced tools are being used by Internet entities as bait both to drive traffic and to capture detailed user profiling data.

Several categories of interactive Health 2.0 tools are available, including advanced search engines that deliver more accurate results; social media sites in which individuals hone their medical knowledge through interactions with each other; and finally, expert systems - sophisticated software programs that analyze a consumer’s profile and, based on the analysis, pinpoint the most relevant educational information necessary to support the consumer’s health care decisions. Expert system tools basically simulate human reasoning.

Virtual Reasoning – a New Model
Speculation about where Internet health care might be taking us can be approached, in part, as a projection of the next generation of the most advanced web-based health care tools. If what consumers and payers want from health care is an acceptable cost-quality trade off, assurance that care is appropriate for the situation, that the diagnosis is correct, and that errors of commission and omission are kept to a minimum, web-based tools need to move beyond simple information retrieval to the level of analytic services – expert systems that are virtually capable of reasoning, rather than only presenting facts.

If Health 2.0 products bring you cholesterol guidelines, then virtual reasoning tools, in counter-point, should calculate your LDL (bad cholesterol) goal based on your level of risk for heart disease and assess whether or not you are taking the right medicine. If Health 2.0 delivers personalized information, virtual reasoning systems offer the equivalent of a virtual second opinion.

As virtual reasoning tools reach a greater level of maturity, they will represent cost-effective alternatives to certain health care services traditionally performed face-to-face by health care professionals. At some point, they will cease to function merely as value add-ons and become reimbursable, revenue-realizing businesses in their own right, augmenting some of the educational and analytic services now in the purview of health care providers.

The logical end-point of expert system and decision-support adoption will be a new reimbursable segment of the service industry in which lower cost services are rendered through technology solutions. When physicians are reimbursed to use expert system technology, they will have sufficient incentive to adopt electronic medical records (EMR/EHR) as well.

For tools to replace certain traditional face-to-face services they have to be integrated into the clinician’s normal workflow and electronic medical records systems. EMR/EHR companies will first incorporate expert system tools for much the same reasons as the PHR initiatives do – for the value-added benefits they offer to the customer base. In future models, though, fully integrated tools will sit “under the hood” of an EMR/EHR, continually combing the medical record data for errors and oversights as new data is entered. They will compare treatment to evidence-based recommendations, follow response to treatment over time, generate outcomes data, and generally function as an automated quality assurance system.

Physician Adoption
Physicians will ultimately be reimbursed for the time they spend administering care through the medium of information technology. Early pilots will likely be initiated by payers (large, self-insured employers) who believe that the potential for improved, more appropriate care will result in significant cost-savings. These technology adjuncts will free health care professional from the mundane functions of data gathering, recording, and administering; they will enable physicians to focus on the more rewarding cognitive aspects of medical practice. With more free time, physicians can move squarely into a consultancy role in which they help their patients assimilate and analyze increasingly complex choices.

Significant activity around tool adoption is already underway: Microsoft, Google and other Internet companies have been acquiring advanced search and expert system tools; programs in which web-based service delivery is reimbursed are being piloted; and Google Health has taken the first steps to make a large number of tools available on their platform. How quickly the process eventually unfolds depends on a number of factors that mostly revolve around any upcoming changes in health care financing and in the political climate. No matter how health care financing is structured, however, the need for tools that enhance health care quality and efficiency still applies.

Dr. Marlene Beggelman is the CEO of Enhanced Medical Decisions, which is the company behind