Greg Price was an athlete, an engineer and a pilot, much loved by family and friends. He died unexpectedly at the age of 31, shortly after receiving a diagnosis of testicular cancer. Between the onset of symptoms and his death, there were many breakdowns in Greg’s care, as the Alberta Health Quality Council documented in its study on continuity of patient care. As a result, Greg was forced to navigate a complex, often disjointed health ”œsystem” to try to obtain coordinated care. These gaps led to delays in potentially life-saving care and gaps in communication that led Fred Horne, then Alberta minister of health, to say in December 2013 that ”œthe system clearly failed this patient.”
Sadly, Greg’s experience is far from unique. To illustrate, in a 2011 survey of Canadian adults with health problems, 40 percent reported gaps in the coordination of their care in the past two years. Of those who had had surgery over this period, half indicated that there had been breakdowns in their postdischarge care.
We can and must do better " that is what patients and families expect and deserve.
Doing better requires leadership. Clinicians, health care organizations and governments must all go beyond their traditional ways of operating to embed transformational change in the health sector.
Nowhere is this more apparent than in the context of digital health. The digital revolution has spurred changes in almost all walks of life, from retail banking and shopping to instant communication. The same power and potential exists for health care, but it has only begun to be realized.
With paper-based processes it is simply not possible to ensure continuity of care for someone in Greg’s situation. It is not possible to reach out proactively to all patients who would benefit from evidence-informed preventive care. Nor is it possible to consistently prescribe and adjust medications for patients on complex regimes of cancer therapy or blood thinners. Information is the lifeblood of a high-performing modern health system, and patients, clinicians, managers and policy-makers need ready access to it.
Leadership, thoughtful innovation and a deep focus on value for individual Canadians are required to ensure access to quality care and a sustainable health system. It is not only " or even mostly " about putting computers on desks or apps on tablets. It is also about optimizing and integrating new capabilities into clinical workflows that will improve access and safety; engaging patients and families in new ways; enabling new models of care; and supporting transformation initiatives. This will mean major, if not radical, change in the way many clinicians orient their practices.
Of course, there are pockets of digital excellence in Canada that enhance patient-centred care and provide high-quality practice, but these impressive examples must become the norm, indeed the standard, of care. Alignment of reimbursement models, policy, legislation, education, regulation and other factors well beyond technology should be key components of progress. Failure to develop and implement policies to take advantage of the rapidly expanding digital world will disadvantage patients and damage the trust placed in providers.
Clinicians want the best for their patients. Information technology opportunities will enhance the role of clinicians, the quality of care delivered and the peace of mind of their patients. Clinicians who are well equipped with the most recent clinical knowledge and evidence and have ready access to important information about their patients and their care, and who also are happy and appreciated in their work, are almost certainly going to provide better care.
How then do we begin to position clinicians to manage the challenges of the digital world and the opportunities they provide to advance both the quality of practice and the enhancement of patient care? We will start by describing the digital information tools already available:
An important first step is to get free of the inefficiencies inherent in a paper office by adopting electronic medical record systems (EMRs), hospital clinical information systems and other point-of-care solutions. This creates in one place the ability to effectively manage each patient’s record and to take advantage of quality software to provide guidance in the management of each patient’s care. Good digital tools not only provide easy and quick access to the medical information but also provide flags and reminders about actions that can or should be taken by the clinician and the patient to avoid future problems, such as a schedule of screening tests based on age and profile, alerts related to new medications and a profile of the practice.
For patients with chronic diseases such as congestive heart failure, remote point-of-care testing and monitoring through electronic transfer of data would prevent unnecessary trips to physicians’ offices and emergency rooms and possible hospitalization.
Point-of-care tools such as EMRs open up opportunities for authorized health care providers to access shared repositories of health information such as lab tests, registries and pharmacy and public health information in the electronic health record (EHR), providing a more complete patient picture.
Personal health records provide patients with access to their own health information whenever and wherever needed.
Health services can be accessible 24 hours a day, seven days a week. Streamlined e-booking of appointments and the ability to make appointments online or with a mobile device make a win-win situation for both clinicians and patients, for example by reducing no-shows, filling cancelled appointment slots and giving an opportunity for the patient to outline the reason for the visit and provide a heads-up to the provider. Use of mobile devices can lead to speedier access to care and services by monitoring patients with chronic conditions and linking them to appropriate home care and other services, limiting the need for unnecessary emergency room visits and hospital stays. E-visits can increase physicians’ availability to assist patients and limit unnecessary travel; Canada is already a leader in providing quality telehealth support to remote areas, and there is great potential to expand.
Digital solutions support the development of integrated care, with the potential to provide a more focused and timely continuum of care. This can help avoid fatal delays in treatment and ensure that patients and their families, along with their health care teams, have the information and support they need.
There is an explosion of new medical information. The combination of good software and effective information management integrated into clinical workflow can provide an opportunity to keep abreast of newly developed guidelines and evidence in the relevant medical literature.
Considerable progress has been made, but Canada still lags behind some comparable countries. While not all digital tools are fully available in all regions of Canada, some are successfully in use in various locations.
There are pockets of digital excellence in Canada that enhance patient-centred care and quality practice, but these impressive examples must become the standard of care.
The benefits of the digital revolution go beyond the simple development of new business tools. The technology is less a limiting factor than the adaptation to and comfort with information technology solutions. The EMR is the first step in opening up a new world. As other professions and industries have discovered, this new world requires substantial changes in how business is done.
A 2013 study involving St. Mary’s Research Centre, St. Mary’s Hospital and McGill University compared paper-based medical practices with practices using electronic medical records. It showed a substantial difference in ability to efficiently and effectively manage patients’ care. The study asked practices to identify patients who would benefit from six types of evidence-based proactive or follow-up care, including immunization, follow-up care after a heart attack, cancer screening, diabetes management and medication recalls. Digital practices were able to answer these questions much more quickly than paper practices, and were more confident in their results. This raises real questions about opportunity lost and opportunity gained. One of the most telling results of the study was the ability of the electronic offices to quickly identify patients on medications whose indications had been revised " an almost impossible chore in a paper-based office! A substantial related benefit would be the value of instantly taking advantage of drug alerts. These examples and many others suggest that patients whose primary care providers don’t use electronic records or take advantage of their full functionality may provide a lower quality of care.
There are few better examples of the value of digital solutions than the management of drugs and prescriptions. Electronic prescriptions " including technological connections between physicians, pharmacists and hospitals " provide the potential for better health care and cost savings. The combination of evidence-based decision support and the professional sharing of confidential information by authorized providers of a patient’s medication profile provides an invaluable opportunity to address appropriate medication management, overmedication, inappropriate combinations of prescribed drugs and fraud or prescription abuse. The success of digital health initiatives in this area is already evident, with demonstrated patient safety gains and cost savings.
The synergy between the power of digital IT and the change in practice needed to bring full benefits to patients is well illustrated by the case of Greg Price in Alberta, as mapped by the Health Quality Council of Alberta. Even in this province, one of the most advanced in Canada in the availability of electronic medical record systems and the electronic health record, the council’s analysis shows there is a need to advance practice systems to provide the essential continuity and quality of care.
A key to patient-centred care is access. The Commonwealth Fund’s latest survey of 11 countries, for instance, found that Canadians over 65 were least likely to say that they had been able to obtain a same-day or next-day appointment with a doctor or nurse when they needed care. Less than half (45 percent) said they were successful in Canada, compared with 53 to 83 percent in the other nations in the survey. While most patients probably do not look at studies like that of the Commonweath Fund, those who do would find ample evidence to support the suspicion that they are shortchanged when it comes to access and that access issues are impacting emergency care and likely increasing the rate of hospitalization.
The principal barriers to patient-centred care can be found not in the technology but in the reluctance to engage in the change management required to integrate digital tools effectively into care. The logical extension of the digital advantage is to strengthen patient-centred teams or collaborative practices as an essential part of clinical delivery models. Physicians must adopt effective collaboration that supports a fully integrated EMR if they are to meet growing patient expectations for timely, quality care, while developing their skills and enhancing their own quality of life.
Improving access to care requires teamwork and digital information systems. Practices that feature shared accountability for access and care, along with enhanced IT for communication with patients and with other practice groups, are relatively new. Many existing practice models fall well short of real teamwork, beyond sharing call duties and administrative costs. This is one area where digital tools can have a powerful impact in providing greater access and quality. The EMR/EHR can enhance the ability of cooperative group practices, whether in family practice groups or specialty practice, to better serve patients while providing benefits to practitioners in terms of work-life management. Participation in telemedicine networks, appropriate tools to keep up to date on emerging evidence and incentive models that align with modern requirements for a high-performing health system are key.
Continuing education is important for the delivery of quality care. There is a blizzard of new information landing on physicians. The good news is that new information technology can embed relevant evidence at the point of clinical decisions that can aid in sorting through the volume. With patient information readily available, many serious problems can be addressed early and quickly, improving the quality of life for the patient and often avoiding more expensive and inefficient resort to hospital care.
The value of digitally enhanced teamwork is also underlined by the current trends in health care, which involve the movement from acute to chronic disease management, from hospital-based to home-based or community-based care, from individual-practitioner-based to team-based care and from independent to accountable care. These require a strong digital framework to support integrated networks of care.
Since medicare was introduced across Canada, there has been an intermittent but heated debate about two tiers of care: private versus public coverage. The term ”œtwo-tiers” describes the inequity that can arise between patients who have the advantages of receiving care from modern group practices offering 24/7 service, effective use of digital health and interprofessional teams, and patients who are still dealing with traditional models with paper records. Over time, this inequity will grow unless we embrace new models of care more rapidly, and the gaps will become more and more obvious to patients. This is far from theoretical. There are already many parts of Canada where these two tiers of practice operate side by side.
The issue of equity and inequity is more complex than simply who has the digital tools and who does not, as the system struggles with the 5 percent of Canadians who utilize 40 to 60 percent of health care resources. Special efforts are needed so that these complex patients can benefit from the advantages of digital health, such as identifying and managing their care with more sophisticated tracking and monitoring processes.
What should be done to prevent this emerging two-tiered health care system and ensure that we are efficiently reaching patients?
Nothing we have said here would be surprising to leaders in the medical associations and organizations, and in health departments in provincial and territorial governments. Indeed, these issues are edging into physician-government negotiations. The digital challenge isn’t about numbers, clouds and computers, it is about the need for substantial system change in service delivery to advance care for patients and give true meaning to patient-centred care.
There are several practical steps we recommend. Health ministries should develop a digital health strategy outlining their expectations for transforming the delivery of services and share it with provider organizations as the basis for system reform. Health care providers and the medical profession through their associations and regulatory bodies should advance new models of practice with digital solutions that would serve both patients and physicians better. These steps would provide a transparent and constructive basis for government, provider associations and the public to further develop courses of action to better serve patients. And at each step, the parties should be prepared to abandon the comforts of the status quo in a system that is becoming less sustainable while providing limited access.
Graham Scott is chair of the board of the IRPP. Among many other public service roles, he was deputy minister of health in Ontario. Jeffrey Turnbull is a specialist in internal medicine. He is also past president of the Canadian Medical Association and of the College of Physicians and Surgeons of Ontario.