Canada Health Infoway (CHI) is investing billions in the architecture for a national electronic health record (EHR) system, which will likely be in place in most provinces by 2015, says Wayne Gudbranson, CEO of The Branham Group, an Ottawa-based technology research firm.
"Healthcare will change dramatically over the next five years," he says.B "It will be delivered in a more corporate fashion." Once the fundamental EHR building block and IT infrastructure are in place to share and aggregate healthcare information, economies of scale will create efficiencies in the system.
"Gone are the days of doctors as sole practitioners," he says. Instead, physicians will work in groups at major clinics. "The chief doctor will have regular Monday morning meetings with staff. They'll pull up data on the thousand patients they manage at the site, and look at trend analysis for say, their 25 diabetics to see how they're dealing with them."
This scenario is one future possibility, but there are other possible models, depending on what Canadians agree they want from their healthcare system, says Dr. Alex Jadad, director of the Centre for Global eHealth Innovation at the University Health Network in Toronto.
The lack of a shared, agreed vision is a central problem in Canada's approach to healthcare transformation, he says. "In Canada, we're thinking of the EHR first, without setting a clear vision of the redesigned processes we want. We don't have a unique vision that could be supported by technology - we're hoping technology will get things done almost by magic."
By contrast, Spain spent considerable time and effort in defining the shared vision of a revamped healthcare system at the outset with the public, physicians, policy-makers and other stakeholders before re-engineering it, he says. "It started in Andalusia, a region that has a population of 8 million. They re-engineered hundreds of processes, and they now have EHRs in place for them - and they did it all in less than 10 years with 12 billion dollars."
Ontario has spent 40 billion for a population of 12 million, and there is still no common EHR in place, he says. "Ontario's spent far more than Andalusia, and we're still asking for more physicians, nurses and beds. Little has been done to change our healthcare processes, and an EHR system is just going to automate them."
As a consequence, the incentives in the system are not aligned with outcomes, he says. For example, if the vision is a system that keeps people out of hospitals as long as possible, then the processes for keeping people healthy in clinics, home care and community settings need to change. "Instead, we have a system that's designed to wait for someone to be ill before doing something about it." The incentives in the system reinforce this hospital-centric model, but people pay lip service to wanting a different model, he adds.
Technology is another key area where incentives aren't aligned with the purported outcomes, he says. Uptake of more technology at doctors' offices, for example, is generally deemed beneficial. But the fee-for-service economic model for compensating doctors provides few incentives to embrace information technology. "If doctors only get $30 per visit no matter how much time they spend with patients, then it doesn't matter how much information they have. They'll send the diabetic to a nephrologist or other specialist. This is the reality, as doctors need to feed their families."
Jadad says this issue has come up in studies about the use of e-mail in doctor-patient dealings conducted by the Centre for Global eHealth Innovation. "We tried to send information via the Web about high blood pressure in patients to family doctors, but many said, 'I don't want to see that information.' In Ontario, there's no OHIP code for e-mail consultations or even phone calls, so they would have to do that on their own time. Patients have to go to clinics just to get lab results, and it could all have been prevented if we had the right incentives in place."
Doctors fear the Pandora's Box that technology may open, he says. "They imagine a world where they'll get 200 e-mails from patients daily, and their workload is already crazy as it is. Of course everyone wants an electronic system, but unless we address the lack of incentives, we'll be playing games forever."
There are many stumbling blocks that scare people in discussions about e-health innovations, which Jadad summarizes in the acronym CRAP. "Confidentiality of health information comes up, but banks are showing that information can be handled confidentially online and that it's not a deterrent. Reduction in the quality of care is another one - people say technology is dehumanizing, but they don't have a relationship with a doctor who can only spend five minutes with a patient. Absence of evidence about technology's ability to improve care - it takes years to do clinical trials to get that evidence, and by the time they're done, the technology's obsolete. Protection is the last issue: how to handle the legal issues if something goes wrong."
To avoid these issues, Canada should look at the model of systemic healthcare improvement offered by Spain. "In just 10 years, Spain is beating us on most indicators for half the money per capita. We might just have enough money, maybe even a bit more than we need. But we need a sense of urgency, and to translate that into urgent action. And we need more public involvement to make the right decisions."
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Autor(en)/Author(s): Rosie Lombardi
Quelle/Source: InterGovWorld, 16.07.2008
