Executive Summary

Realizing Information Technology’s Promise to Improve Health Care

On October 20 and 21, 2010, the MUHC-ISAI, in partnership with Parkhurst Publishing, hosted its third annual conference. Over 150 clinical, government and administrative healthcare leaders from Québec and across Canada assembled to discuss the current status of health IT programs in Canada and abroad, and look at what the future might hold. The conference was chaired by The Honourable Arthur Porter, Director General and CEO of the MUHC, and Mr. Bernard Lord, Scholar-in-residence at the MUHC-ISAI, President and CEO of the Canadian Wireless Telecommunications Association and former Premier of New Brunswick.

The ISAI was formed in May 2007 to enable the MUHC, as an academic health centre, to contribute to the ongoing development of healthcare policy.

Purpose of the conference

“This year, the role of information technology (IT) in health care is of particular interest to the MUHC for a number of reasons,” said the Honourable Arthur Porter, Director General and CEO of the MUHC, in his introduction to the programme, “notably its impact on its vision for 21st-century medicine. After all, you cannot support worldwide epidemiological and research databanks, medical informatics, telehealth, and personalized health management platforms with a weak IT backbone. Despite this well recognized fact, the healthcare sector remains one of the slowest adopters of information technology. Why is that and what are the ramifications as regards the promise of improving health care with IT? What can we do to accelerate the evaluation and adoption of effective IT?”

The great debate

The opening session of the conference featured a debate between students from Queens and McGill universities on the proposition: “The best value we can get for the next $1 billion we spend in health care is in information technology.” The students stepped into the shoes of health ministers currently struggling with this challenge. The McGill side, arguing for the proposition, highlighted efficiencies that would result from the investment, along with improvements in quality and safety. Queen’s debaters, assigned the against stance, dwelled on the vast amounts of money already poured into this bottomless pit with only modest tangible results and argued that money would be best spent on the personnel and equipment that can relieve pressing challenges of wait lists and shortages.

The audience was asked to vote on the proposition before and after the debate and the winning title went to the team that succeeded in swaying opinion in the room to their side. The pre-debate poll found 66% of the room in favour of spending the next $1 billion on information technology, and 34% against. Following the debate, the percentage in favour grew to 73% and McGill was proclaimed the winning team.

What happened to the last billion dollars in health information technology?

Infoway: A progress report

In his keynote address on October 21, Richard Alvarez, President and CEO of Canada Health Infoway, traced the progress achieved to date in Canada. Infoway was created in 2001 as an independent corporation owned by federal, provincial and territorial governments to set standards for and support health IT investment. Jurisdictions present their projects to Infoway for review and, if approved, can receive up to 75% of the funding required. However, Infoway holds back 50% of its investment until the jurisdiction can demonstrate that the system is actually being used.

Alvarez described the significant progress made in several provinces, notably Alberta and Prince Edward Island, in implementing interoperable electronic health records and British Columbia’s success with electronic drug prescriptions, a measure that has seen a dramatic reduction in harmful drug interactions. Across the country, up to 80% of x-rays are now digitized and can be viewed immediately and transmitted from one doctor to another. And almost all of Canada’s northern communities now have telehealth capabilities to enable remote specialist consultation with doctors in urban centres, as well as other health services.

However, progress is lagging, notably in Québec’s provincial electronic record, and difficulties in achieving take-up of many health IT systems mean that Infoway has committed much more money ($2.1 billion) than it has actually spent.

Alvarez sees the public as key to the evolution of health IT: “We need to engage the public and build social capital that will carry the project,” he said. Infoway has started a TV advertising campaign to show people how electronic health records can improve care. And they have a web program, “Knowing is better than not knowing,” to drive home the benefits.

See www.infoway-inforoute.ca

Consumer solutions: A global health IT trend

There is still a vast amount of work to do before Canada’s health IT capabilities match those of leading countries. But looking toward the future, Alvarez predicted: “Consumer health solutions are clearly where the puck is going.” This vision was supported by health IT leaders from the U.S., the U.K. and Denmark.

Dr. Rob Kolodner spearheaded development of the electronic health record and personal health record at the U.S. Department of Veteran’s Affairs, went on to serve as the President’s lead for the United States eHealth Initiative and just last year left the public sector to found the consultancy Collaborative Transformations and join the international non-profit group Open Health Tools as Chief Health Informatics Officer.

Kolodner thinks we will soon see a democratization of health IT. “As technology becomes a commodity, it becomes faster, easier, cheaper for people with fewer skills to do more.” What starts as a specialized IT industry becomes consumer-driven and real innovation comes from front-line users as they adapt the system to their specific needs.

Health IT in the U.K. and Denmark

The U.K. is far in advance of Canada in having a national spine for health IT that is secure and allows all healthcare providers to plug into. In contrast to Canada, virtually every GP in the U.K. is connected to this system (connection is a pre-requisite for physician payment). They are also way ahead in using IT to put more power over health care into the patient’s hands. Every U.K. citizen has a unique identifier that links up their health information from many different sites. People can view their health record through a web-based application called Health Space, and they can choose a secondary care provider and book appointments using the Choose and Book national booking system.

Dr. Charles Gutteridge, National Clinical Director for Health IT at the Department of Health in the U.K., addressed the conference via videoconferencing the day after government announcements of half a million public sector job cuts across the U.K. The ideological shift that has come with the change in government aims to shrink the state and “place the individual in a much more prominent and self-responsible position,” Gutteridge said. This will put patients at the centre of healthcare processes and transactions. “No decision about me without me” goes the slogan of this new era. Patients will have greater choice of doctor and hospital, guided by web-based quality information.

Otto Larsen, CEO of Digital Health in Denmark, described his society as committed to the principles of free and equal access to high-quality health care paid through general taxation, and accustomed to state access to people’s personal information. The national health IT infrastructure created in Denmark allows for communication between primary and secondary healthcare settings. All messages between doctors are sent electronically through a secure closed system called the Danish Health Data Network. Common standards were established to allow communication between hospitals and home care provided by the municipalities. Prescriptions are electronic and the status of every prescription recorded.

A question of confidentiality

Danish citizens can access their health information through an e-health portal, using the same digital signature they use for taxation purposes and banking. The citizenry already accomplishes all of these tasks electronically and the state is used to a high degree of electronic communication with people. In contrast to the U.S. ethos of making the patient responsible for bringing their data to the doctor, Larsen says: “We have to have a system where you’re not dependent on yourself, but rather where society takes care of you. That’s our thinking.” The healthcare provider is responsible for collecting all relevant information to help a patient and has access to that information. People can opt out of sharing their data, but will have to do so at their own risk.

The unique identifier that enables people in the U.K. and Demark to access their health information has been so contentious in the U.S., according to Kolodner, that Congress has specified with every budget that not a single dollar go to the unique identifier, despite the fact that it was part of the 1996 law on health IT.

Canada wanted to avoid the debate that would ensue with a visible unique identifier, so, Alvarez said, made it internal to the system instead. The information can be brought together, but the data tagging system is invisible.

Is IT adoption slower in health than in other industries?

The short answer, provided by experts from the airline and banking industries, is no. Though health care has certain complicating factors, the perception that IT adoption occurred quickly in other sectors is misguided.

Dr. Yeona Jang, Professor at the Desautels Faculty of Management at McGill University, is a pioneer in implementing IT solutions in the banking and manufacturing sectors, mostly in the U.S. She stated that investment in IT, which doubled globally between 1987 and 2004 and reached $3.3 trillion in 2010, continues in spite of a high variance on implementation success rate for IT projects across all sectors and a highly variable return on investment. A stream of company and industry-level empirical studies has established a clear and positive relationship between IT investment and productivity growth. But, these studies also consistently found high variance around the positive mean. Nearly half of the projects failed to achieve adoption and their business cases within one year of going live. Even with successful projects, companies often experience an initial dip in performance after the system goes live. With experience, however, companies have gotten savvier about organizational change management in advance to minimize a dip in performance and drive adoption. The IT investment continues because those IT projects that succeed exert tremendous competitive pressure on other companies to survive in competition, driving innovation for doing things better, faster, cheaper, and smarter.

Lise Fournel, Senior Vice-President of E-Commerce and CIO, Air Canada, described the value of IT in the airline industry: “Information about customers allows us to plan our services in a way that maximizes revenue generation and optimizes efficiency.” Fournel recognized that customers need to get something in return for their information and what they really want is increased transparency and choice. “Customers also want to use e-commerce: 68% of our passengers book their own tickets online,” she said. People need the incentive to provide the information, and the industry needs the capacity to analyze this information and use it to improve productivity and processes.”

Jean Huot, CIO, MUHC and CHUM, faces these challenges in implementing IT programs in a sector that across North America spends less than half what other sectors spend on IT, and in Québec, spends only half of even that North American average. He sees added difficulties in the number of different stakeholders that need to be satisfied in health care, and in the highly autonomous status of clinicians. “They have to be involved in the selection of the system and the implementation strategy,” said Huot. “At the MUHC and CHUM we created the position of Chief Clinical Officer for the technological transition at both institutions. They report directly to their CEOs and are spearheading the implementation strategy.”

Bernard Lord, chairing the panel, contrasted the fact that IT has, through competitive pressure, become part of “core business” in some industries, to the meager investment health care is making in IT. “Is there a clearer business case in the private sector that gives an impetus we don’t feel in the public sector?,” he asked. Professor Jang related her experience in public utilities where a monopoly position meant there was no competitive pressure. The challenge without that, she felt, was finding strategies to motivate people to “change and get better.” The business case, managed by metrics, is increasingly being used in public and non-profit sectors.

Using IT to integrate the health system

Matt Anderson, President and CEO of the William Osler Health System in the Greater Toronto Area, has the rare insight that comes from experience in tertiary, secondary and community care. He held out hope that IT-enabled health system integration can make the system smarter and more cost-effective, primarily by directing people toward the most appropriate resource and avoiding unnecessary use of the most expensive care solutions. In the Toronto Central Local Health Integration Network (LHIN) he led until this year, 10% of all hospital beds were occupied by people who should have been elsewhere. Earlier initiation of discharge planning and better coordination with community resources, all dependent on interoperable electronic records and communication, stand to reduce the delays in transferring patients to more appropriate care settings.

Anderson focused on the benefits that could be achieved through better management of the 5% of people, many of whom have chronic diseases, who use 80% of health resources. “We can also have a huge impact by providing patients the tools to be active participants in their care,” Anderson believes.

He emphasized the importance of looking beyond hospitals when implementing health IT systems, and finding a way to enable exchanges of information between all sorts of agencies, whether primary care or community care. Standardization is key. “If the hospitals have five different systems, the community agencies will need to set up five different communications platforms.”

“We need to look at the big picture: work with primary care to keep low-acuity people out of the ER; move people through the system better (using tools such as Toronto’s Resource Matching and Referral System for access to secondary care); and improve the tools available to support people better at home.”

A new toolbox for health care

Exciting new tools are being developed, though the process of implementation is difficult. Dr. Luc Valiquette, Director of the Department of Surgery at the CHUM, outlined the strategy developed at Montreal’s two major hospital centres to incorporate the OACIS (open architecture clinical information system) in a step-by-step progression led by clinicians.

Lois Scott, VP, CareEnhance Solutions, McKesson Canada described telephone and web-based nurse-led programs to help people manage chronic diseases at home and get the most out of the care their physicians provide. She sees this type of program as essential in the shift from the episodic care model to a continuous care model suited to chronic disease. In Australia, where such programs are in use, Scott reported a sharp reduction in the use of ERs, hospitals and outpatient doctor and better compliance with guidelines for care. Patient and provider satisfaction improved.

Philippe Panzini, Chief Technology Officer, Medical MD, is working to connect ordinary people with physicians and physician-held information about themselves so they can form a personal health record. Platforms are available, and are multiplying, to enable that type of communication, but data needs to be strictly standardized and translated into popular terms. “SNOMED, for instance, is the most advanced technology [for standardizing health data] out there, but if you type in headache, nothing will come up,” says Panzini.

Joanne Desrochers, Assocate Director, Telehealth, MUHC, is developing telehealth within Québec’s Virtual Health and Social Services Networks as a new service delivery model that expands the possibility for resource matching and referral into very remote areas. Communities work to define their needs, and clinicians from many different centres collaborate to meet them.

Each of these innovators discussed challenges involved in implementing health IT solutions. Dr. Guy Paré, Canada Research Chair in Information Technology in Health Care, has spent many years assessing the success of health IT projects. “The real question,” he said, “is success for whom?” No single perspective will provide a complete picture. Health IT projects are unpredictable because their implementation impacts myriad processes and structures. “It is imperative to see and manage health IT projects,” he said, “as organizational development initiatives since we draw upon IT to generate new organizational forms of delivering care.”

Patient focus in a complex health system

Dr. Sholom Glouberman, Philosopher-in-residence at the Kunin-Lunenfeld Applied Research Centre at the Baycrest Centre for Geriatric Care and founder of the Patients’ Association of Canada, sees a patient focus as essential to health IT development given the growing importance of chronic disease that has transformed health care from a complicated to a complex system. To explain: A simple system is one where a recipe can be followed to get the same results time after time. A complicated system involves bringing multiple simple things together. Building a bridge, launching a rocket are examples of complicated projects. A complex project is one where the formula developed in accomplishing something the first time doesn’t necessarily work in subsequent attempts — like raising a second child.

Health care used to be complicated in that infectious diseases could be diagnosed, treated and in the end, prevented. It became complex when most diseases and deaths were due not to infections, but to chronic disease processes influenced by many different factors. People can do things to avert acute episodes, but something that works for one person may not work for the next. Today, everybody over age 65 has a chronic condition: high blood pressure, high blood sugar, the beginnings of heart disease or initiation of cancer. And the system people rely on to deal with these conditions is large, comprising some 3,000 organizations in the Greater Toronto Area alone.

This complex health system needs to be understood from the patient’s vantage point as the person moves from one care setting to another to fill a variety of needs. Patient wisdom needs to be tapped to fix some of the basic problems in health care and to ensure that they can access devices and programs that support self-care. Likewise, people electronic health record must have patient input because most of the diseases we see are chronic and information about food, sleep, pain and other subjective entries are needed to complete the picture and help people manage their condition. “We’re heading into more self-management aided by an expanding set of devices and information and communication technology platforms controlled by the patient,” concluded Dr. Glouberman.

Throughout the conference, the audience was polled on their views about different issues in health IT. See the results here.

A full report from the conference will be available soon, along with videos of some of the conference presentations. Look out for them in the weeks to come.

Detailed case studies on the implementation of health IT solutions are being prepared. Look for them on the Case Studies section of this website.

If you wish to receive a printed copy of the 2010 Health Innovation Report, including conference coverage, case studies, and the round table report “Medicine 2020: Portable, personalized, informed,” please send your full contact information to usher@parkpub.com

---

If you would like to submit an article or case study, please contact us.