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Medical and health care writer and editor. Views are my own

Canada Health Infoway (@Infoway): Back to the Future again

Infowayaccess

How you greeted the news last week of Canada Health Infoway’s rebranding and new campaign to mobilize support for digital health will probably depend very much on how you have viewed the success of this pan-Canadian federally funded health organization to date.

Over its 17 years of existence, Infoway has had more than its share of detractors for either failing to do enough with hundreds of millions of dollars it was charged with co-coordinating to bring digital health to Canada, or for focusing on the wrong things at the wrong times. Or take electronic prescribing: That Infoway’s PrescribeIT initiative has now spread to three provinces will be viewed as a major success by supporters of the organization. However, detractors will point out Canadian is many years behind other countries in ePrescribing, PrescribeIT involves few physician practices,  and at least one major national pharmacy chain has evidently failed to endorse Infoway’s funding model.

Part of the conflicting views of Infoway can perhaps be traced to the way it has radically reinvented itself over the years.  In his address to the Infoway Partnership Conference in Montreal last week, Infoway President and CEO Michael Green acknowledged that over the course of its existence, Infoway’s role has radically shifted focus; from building the infrastructure to support digital health, to providing clinician tools, and most recently to driving access for Canadians to digital health.

The latest iteration of the driving force behind Infoway – ACCESS 2022 sees the organization firmly positioning itself as an advocate for building a coalition committed to promoting “a future where all Canadians have access to their health information through the availability and use of digital health tools and services, which will empower patients and improve health outcomes.”

“ACCESS 2022 will bring together the collective expertise of an agile technology sector, the knowledge base of health system experts, and the insights and experiences of patients and caregivers, to ultimately meet and exceed the demands of Canadians in the 21st century…We are asking all Canadians to join us in this movement,” Green said.

Unveiled with touques for all and the music of Stompin Tom Connors at the Montreal conference, it was all very archetypically Canadian – and once again was doubtless viewed with either enthusiasm or cynicism depending on how you view Infoway.

We actually have a credible objective assessment of the organization presented in Fit for Purpose, a report published in March by two highly respected health policy experts Drs. Danielle Martin and Pierre-Gerlier Forest.  At the request of the federal health minister, Martin and Forest assessed all 8 federal pan-Canadian health agencies including Infoway.

They noted that Infoway has had several signature successes, including:

  • Driving the digital health agenda in Canada by creating pan-Canadian leadership
  • Parnering with all jurisdictions to achieve “close to” the 2004 federal/provincial/territorial health accord goal of 100% availability of electronic health records thereby resulting in $19.2 billion in cost savings and efficiencies since 2007
  • Initiating a patient engagement framework that “provides Canadians with access to their health information and digital health solutions that empower them to be more active members of their care team.”

However, while not criticizing Infoway directly the report goes on to identify significant shortfalls in how Canada is doing with digital health:

Data currently exists that could be used to improve care in hospitals, primary care environments, community settings, and health regions across the country. Unfortunately, the underlying architecture to support this meaningful use and enable continuous improvement across health systems does not yet exist in Canada. Infrastructure has been built and electronic health record systems purchased across the country, but two key outcomes are still missing: an inter-operable set of electronic systems and a “single” accessible electronic record for every Canadian patient as a critical means to achieving coordinated, integrated care.

How successful Infoway is in addressing this – and it is clearly committed to doing so  – will very much determine how it is viewed in future years.

(Image from Access2022.ca website)

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MyHealthNS – A perplexing patient portal poser

MyHealthNS

“Most QI (Quality Improvement) programs don’t incrementally ascend, but often fail. Many QI projects never work out at all and of those that do, almost all have real failures, along the way. But failure is not bad and contains within it the seeds for future improvement.”

Dr. Joshua Tepper, former president and CEO of Health                                                             Quality Ontario and now CEO of North York General Hospital

Those committed to bringing a patient portal to the residents of Nova Scotia should take heart from these recent remarks by Dr. Tepper. While he was talking about quality improvement initiatives, the comment speaks directly to the Nova Scotia situation and is probably more relevant than people would acknowledge to all aspects of digital health and health technology innovation.

Surely, nothing seemed better set up for success than the MyHealthNS portal intended to allow patients to communicate with their physician virtually, receive laboratory results, book appointments, and allow physicians access to Econsultations and Ereferrals. Canadians have overwhelmingly indicated that this – in some ways more than anything else – is what they want from digital health.

Yet despite government backing and strong early support, MyHealthNS has enrolled only a small number of Nova Scotians. And while the initiative is by no means dead it must, to date, surely be judged a failure.

The reasons behind this are informative and speak volumes about the importance of local variables and the challenges of bringing change to a complex system such as health care.

The MyHealthNS story was told recently by Dr. Stewart Cameron, a family physician and advocate of the portal, at the Canada Health Infoway (@Infoway) 2018 partnership conference in Montreal. A very, very abridged version of that follows:

MyHealthNS was piloted in 2012 with about 30 family physicians and 6,000 patients. Results were overwhelmingly positive and a full provincial roll-out of the portal was initiated in 2016 (and again in 2018 and again in?).

Two important points:

  • Enrollment in MyHealthNS is done through family physician offices which made it easy to authenticate patient identities but has had negative consequences leading people to question whether this is the right model.
  • Physicians involved in the pilot project noted that the portal must be integrated with their EMRs to be successful and that a payment model was needed to remunerate physicians for using the portal. In fact, one physician involved in the pilot saw their income drop as a result of participation.

Fast forward to this year.

In February 2018, only 13,782 patients were registered with the portal out of a provincial population of approximately 1 million people (that figure is now up to about 20,000, according to Dr. Cameron). Of these only 10% had accessed the portal at all in the month prior the evaluation in February. Additionally, only 250 practitioners had registered with the portal and of these only 35% were using the portal actively.

The reasons behind these poor numbers can be traced to two key reasons:

  • Payment for physicians for enrolling patients or using the portal is still not part of the master fee agreement although physicians can now receive a stipend for involvement.
  • While the portal is now integrated with most EMRs in the province, one major system is not integrated directly. Further, many physicians are currently migrating to different EMRs and are reluctant to take on the extra burden of enrolling patients in the portal during this time.

Of course, with physicians acting as the gatekeeper for patient enrollment it is obvious their reluctance to be support this initiative actively is a huge barrier to success. At a time when family physicians are under increasing stress and many suffer from burnout, embarking on such an initiative must produce tangible, immediate benefits to attract them.

Not only are family physicians reluctant to enrol their patients (which must be done face to face or by phone) but many residents of the province currently lack a family physician and so have nobody to sign them up.

What must have been a source of frustration for Nova Scotia delegates to the Infoway meeting was that the same meeting heard how Quebec has already signed up 300,000 people to their portal in a short time using a direct enrollment model.

MyHealthNS has failed to date but that is no indicator of future failure as long as those involved with the project learn from their experiences to date. In the words of Dr. Cameron: “This is going to happen. It’s inevitable.”

(Image courtesy, the Government of Nova Scotia)

 

Digital health: The flying car of health care reform

Flyingcar3

Building a flying car is now relatively easy – it’s building the floating road for it to drive on that’s causing all the headaches.

Flying cars have been a mainstay of science fiction and futuristic thinking almost since the advent of the automobile itself. And for some, the prospects of digital health having a significant impact on how we deliver health care seem to stretch back almost as far – and the divide between our wishes and reality almost as wide.

Remember the information superhighway at the beginning of the millennium and how this was going to transform the Canadian health care system by using the internet and nascent electronic medical record (EMR) technology to make it easy for physicians to deliver and patients to receive the health care they needed? Remember the promise behind the hundreds of millions of dollars invested through Canada Health Infoway (@Infoway) in building the infrastructure to deliver digital care.

Well, the superhighway never materialized, and most Canadians still cannot access their medical records electronically nor can most communicate with their physician in any manner other than face-to-face.

As we approach another Canadian Digital Health Week next week (#thinkdigitalhealth) it is worth noting that, integrating digital health into the mainstream of Canadian health care remains in many ways the flying car of health care reform – always part of our future but never our present. I know this is an overly simplistic and pessimistic picture and it is true that some digital innovations such as PACS (picture archiving communication systems) have transformed how health care (specifically medical imaging in this case) is organized.

But the reality is that transforming our health care system through the use of digital health tools and platforms has been a long, slow slog.

And if one listens to Australian health quality expert Dr. Jeffrey Braithwaite (@JBraithwaite1) this should be no surprise. Dr. Braithwaite was recently a keynote speaker at the Health Quality Transformation conference and the Quality Improvement and Patient Safety Forum in Toronto and he had tough messages for those wishing to implement widespread system change.

His view is that health care is a complex, adaptive system with several interdependencies. As a result, change does not occur in a linear or predictable fashion meaning you can’t just dedicate funding and lots of effort and assume it will change something. For those who have seen have the launch of major initiatives to implement digital health this must surely resonate. Time after time we have seen pilot projects using digital technologies that have had early promise but fail to stick. In other cases – such as the use of EMRs in primary care – we have seen widespread implementation efforts that have seen an incredible backlash from the physicians who are supposed to be using them.

Digital health care will – eventually – transform how we deliver or receive care but as Dr. Braithwaite points out, probably not in ways we anticipate and not without a lot of effort.

Regarding implications for digital health, Dr. Braithwaite had one other point of significance and that is the importance of listening to physicians and others working on the front lines of care. He talked about work imagined – how policy makers and external observers think the health care system works versus how work actually gets done. Physicians can tell you exactly how and why EMRs are not having the desired impact and are making their lives miserable.

Listening to them and making changes in how EMRs are designed, function and are integrated into practices must surely have a positive impact. The same is true for virtual visits or e-mail communications between doctors and patients– mandating that it occurs will almost certainly not be successful unless both patients and physicians are consulted on how it can happen in a way that works for both.

Image courtesy of Pal-V

 

Patients at #HIMSSEurope18: From ‘a’ to ‘the’

Sitges2

To have the patient voice presented articulately from the podium isn’t all that unusual at medical and health conferences these days.

However the fact that this occurred at a major digital and health information technology conference – until recently the domain of companies and organizations wanting to do things to and for patients (often for money) rather than with them – is worth noting.

To its credit, the HIMSSEurope/Health 2.0 meeting in Sitges, Spain did not just have prominent patient advocates such as Marie Ennis-O’Connor (@JBBC) and Anne-Miek Vroom (@annemiekvroom) speaking at plenary sessions but throughout it also reflected a new paradigm of providing health care services and products that patients want, delivered where and when they want them.

Although some feel more can be done: “The most powerful force in health care innovation (the patient) is yet to be unleashed,” said Ennis-O’Connor.

“To me, empowerment is not just having an app with all your health care information, it is about being part of the system,” said Miquel Bru, VP of business development for Made of Genes, during a session on precision medicine. As Vroom pointed out in her address, you don’t need a program or project to work with patients, just ask their opinion and incorporate them into the workflow.

It was Vroom who also pointed out that while virtual care, mobile apps, and telemedicine innovation are all being applauded as breakthroughs for patient care they do not automatically improve the patient experience and can still be challenging for those with disabilities.

In his keynote address, Dr. Robert Wachter, chair of the University of California, San Francisco department of medicine and oft-time critic of electronic records and their impact on physicians, noted that the “perfect patient” ready, willing and able to adopt digital tools to manage their care is not common. Instead, he said, digital tools and information will have to be customized to accommodate patient preferences and knowledge levels.

“There is no such thing as a ‘one size fits all’ patient,” said Ennis O’Connor who also noted there is some concern about the growing gap between digitally literate and engaged ‘super patients’ and those who are not.

While the conference was filled with speakers discussing tailoring their digital solutions to what patients really wanted, Ennis O’Connor challenged people to act on truly involving patients in their work. She said that patient engagement has become a leading theme at conferences (including this one) but said there has been no significant movement to change this rhetoric into a tangible reality.

However, Lucien Engelen (@lucienengelen), a global digital health strategist and patient engagement champion, who served as master of ceremonies for the Sitges meeting said he perceived the tendency to involve ‘token’ patient has been decreasing while meaningful involvement of patients at conferences has been increasing.

And while the yardstick may not have moved as much as patient advocates may wish there was a definite sense here that digital health innovators, policy makers, and providers are starting to view patients as partners and not simply subjects for the next shiny new digital healthcare toy.

Something is happening here … #HIMSSEurope18

Sitges1

You try so hard but you don’t understand
Just what you will say when you get home
Because something is happening here but you don’t know what it is
Do you, Mr. Jones?

                                             Ballad of a Thin Man: Bob Dylan

The problem with a Health Information Management Systems Society (HIMSS) meeting – any HIMSS meeting – is that there is so much going on at one time that it is impossible to craft it into one coherent narrative.

That is the challenge with HIMSS Europe 18 currently underway here in Sitges near Barcelona, Spain as hundreds gather to discuss the latest in digital health and health information technology and to network, network, network. And it’s doubly challenging as this meeting is being held in conjunction with Health 2.0, the health innovation conference recently purchased by HIMSS.

(Now wait a minute, wait a minute you say – you get to go all the way to a resort hotel in Spain, with a clothing optional beach within 5 minutes walk, where they serve wine at the some conference buffet luncheons, only to cop out and say you can’t write coherently about it. Patience please).

As a social media ambassador here and lively live tweeter I can supply you with an endless number of insightful tweets or sound bites from just the first 24 hours. For example:

“We have gone from a paper world to a digital world in a short period of time”: Dr. Robert Wachter

“There is a lot of tokenism in health(care) innovation, and some think you can change or even fix health(care) overnight. It is not about technology, nor about the process, it is about changing the culture of an organization”: Lucien Engelen

“Pay patients and value them as the experts that they are”: Marie Ennis-O’Connor

But while I think these tweets provide a useful running commentary of the meeting they – and even the twin meeting hashtags #HIMSSEurope18 and #health2con – provide only a partial and episodic picture of what is going on.

Individual presentations or sessions are also noteworthy. For instance I have never heard as passionate a presentation supporting the role of nurses in the future digital world as that given by Angelien Seiben and Shawna Butler from Radboud University Medical Center. And Dr. Jordi Sorreno Pons a GP and CEO of the Universal Doctor app jammed so many ideas into his 8 minute presentation on future developments in medical innovation that it was almost incomprehensible.

The big subject areas – patient engagement, big data, artificial intelligence – are all given their own sessions or streams here.  But in the time available they tend to focus on specific projects or regional initiatives.

Certain things have changed from HIMSS or eHealth meetings held 15 or 20 years ago. The digitization of patient records is now a reality and not a vision and patients are not only discussed but included (#patientsincluded) as presenters in their own right.

But as to what all of this means for the future of digital health in Europe or worldwide – we are too much in the moment to have a clear picture given the complex nature of health systems and the endless number of variables that impact such systems.

For the numerous people here with an start-up to promote or an niche application to profile the meeting is a far simpler place.

(This is the first of what we hope will be a series of posts from Sitges)

A parliament of medicine no more: @CMA_Docs changes its governance

 

CMA

The Canadian Medical Association (@CMA_Docs) is not immune to the dramatic changes in governance impacting governments and organizations around the world.

At its annual gathering this August in Winnipeg, the CMA’s General Council will cease to exist as “the parliament of medicine” and a major policy making body, and will be substituted with a healthcare summit aimed at attracting a much more diverse audience to advance the debate about health care in Canada.

For those who have sat through decades of often intense debate by physician representatives from across the country, on issues as important as abortion, physician aid in dying, and the future of medicare, this is a dramatic change. But, frankly it is not a surprising one as the CMA has been transitioning its policy-making processes for a few years now.

While CMA General Council often made great theatre and was guaranteed to attract front-page news for the organization, the issues discussed where often not within the strategic framework of where the organization wanted to head. The CMA has been clear it wants to broaden the funnel for collecting new policy ideas from a council of 200 plus selected representatives from its provincial and territorial associations, to the membership as a whole.

The elimination of General Council will be perhaps the most obvious but, given various announcements on the association’s cma.ca website, certainly not the only governance change being planned by the organization and voted on this year.

For instance in order to better align the CMA with its new mission statement as “empowering and caring for patients”, the CMA Board of Directors wants to add a non-physician to bring the patient representative to its Board of Directors. While a radical step for the CMA, this is in keeping with what many other medical organizations are doing.

That’s not the only change envisaged for the Board. Rather than allocating numbers of Board representatives based by number of physicians in a jurisdiction each province and territory would have just one Board member. This would shrink the size of the Board from the current size of 26 to 18 or 19 members including ongoing representation from students and residents.

The annual general meeting which was always held in conjunction with General Council will continue to expand its role for ratifying business decisions and after this year will move from August to the spring in 2019.

Those who will remember the extensive CMA governance review process that culminated in 2008 with arguably minor changes to governance will appreciate just how much and how fast the world is changing, to see what CMA will be doing this year.

Sir Charles Tupper may not be rolling over in his grave but it will be very interesting to see how CMA members do in keeping up to the speed at which their organization is moving.

Radiology and AI: An algorithm took my job

Radiology18

Radiologists and those who love them sometimes seem to be some of the most insecure people around and radiology seems consistently voted the specialty most likely to be made defunct by modern technology.

In Canada, this perception has been voiced repeatedly over the past decade or two, first with the perceived threat of radiologists on the other side of the world working during our night to interpret scans and provide results when Canadian radiologists are sleeping, and now with the widespread attention given to artificial intelligence (AI) and deep learning and its potential uses in health care.

At last year’s annual meeting of the Canadian Association of Radiologists (@CARadiologists) I pondered whether this year’s meeting of that organization would be leaving it too late to discuss the significant issues revolving around AI and radiology (see my post “(A) I, Radiologist”) given the speed with which the field is advancing.

I need not have worried.

Last week the CAR released a white paper on the role of AI in radiology in advance of its annual meeting this year to be held April 26-29 on the theme of AI in radiology with the learning objectives including: discussing the recent changes that have occurred in imaging as a result of the implementation of artificial intelligence, deep learning, and machine learning in imaging workflows and; discussing the opportunities of big data and artificial intelligence to improve on the diagnostic performance and predictive value of imaging.

As an extensive overview of the topic, the CAR document squarely confronts the main issue at hand, namely that “recent breakthroughs in image recognition introduced by deep learning techniques have been equated in the media with the imminent demise of radiologists.” The authors go on to state rightly that the work of radiologists goes far beyond that of just correctly interpreting images.

“… the complex work performed by radiologists includes many other tasks that require common sense and general intelligence for problem solving–tasks that cannot be achieved through AI. Understanding a case may require integration of medical concepts from different scientific fields (eg, anatomy, physiology, medical physics) and clinical specialties (eg, surgery, pathology, oncology) to provide plausible explanations for imaging findings. Such tasks accomplished by radiologists on a daily basis include consultation, protocoling, review of prior examinations, quality control, identification and dismissal of imaging artifacts, cancer staging, disease monitoring, interventional procedures for diagnostic or therapeutic purpose, reporting, management guidance, expertise in multidisciplinary discussions, and patient reassurance”

However, the white paper’s authors also fully appreciate the potential of AI and state that “to remain current Canadian radiologists will need to follow and contribute to health care AI research and development, embrace the changes in workflow that will be required to support the implementation of clinical AI and adapt to changes in their practice that will improve care of their patients.”

So, while the demise of radiology (again) does not seem imminent, the white paper will bear close reading by Canadian radiologists who wish to remain relevant with some of the most significant and fundamental advances in medicine currently underway.

(Image courtesy of the Canadian Association of Radiologists)