Data blocking impairing path to interoperability

Holding patient data “hostage” and requiring physicians to pay a hefty sum to get it when they switch electronic medical record vendors is one example of how data blocking is hampering the path to interoperability in Canada.

This example was recently raised by Dr. Ed Brown who noted one physician was asked to pay $6000 to obtain their patients’ records when they made such a switch.  Dr. Brown, founder and head of the former Ontario Telemedicine Network and now an advisor to Canada Health Infoway was speaking as a panelist at the last of a decade-long series of webinars on digital health hosted recently by the Sandra Rotman Centre for Health Sector strategy.

While billed as a discussion of the role of government in digital health, the virtual seminar saw a lengthy back and forth among panelists on the issue of data blocking after it was raised in the online chat.

With a person’s health data in Canada usually stored in a variety of individual physician, hospital, and laboratory electronic medical record systems (EMRs) – if it exists in an electronic format at all – few have any hope of being able to access their complete medical record in one place. Any reluctance of these various players to share the data they have with others makes tackling the problem even more complicated.

Not surprisingly, the blocking of or refusal to share health data or information by private vendors or organizations has been acknowledged as a significant issue in the United States for some time. However, attempts to address the issue have been made through federal legislation.

As the Public Policy Forum noted in its report released earlier this year on freeing the flow of health data in Canada, “we can learn from the U.S. 21st Century Cures Act, which knocked down the walls health-care operators erected between proprietary systems and set standards that enable the sharing of data across different systems.” 

“The Cures Act took on the challenge of interoperability … by prohibiting information-blocking and setting financial disincentives for noncompliance,” the Forum report continues. “As part of any credible reform, data blocking — whether by vendors, institutions or jurisdictions — must be outlawed and data portability guaranteed.”

In Canada, the issue of data blocking has not been given a high-profile in discussions around the need for interoperability of health data. But the challenge is well-recognized by community-based physicians who must often switch EMR vendors. In response to Dr. Brown’s example, one prominent Ontario physician noted on social media that this is a “huge” issue for community-based physicians as often their patient’s data is held ‘hostage’.

Asked by moderator Will Falk to provide a definition of anti-blocking, Dr. Brown said it means someone is prohibited from not providing data in an appropriate format when properly requested through a secure channel.

“We’ve got a mismatch between what we want and what exists out there,” Dr. Brown added because there are no universal standards or legislation to ban blocking. As a result, he said, there are some companies in Canada who have created “walled gardens” and will only release patient data if paid to do so.

“We need to legislate something that says, ‘you have the data, you have got to share the data.’ But it’s going to be tough. And the hardest part is going to be health providers because they’re going to have to standardize their own data on their desktops,” said Dr. Brown.

“No-one wants to share their data, lets be honest about that,” said Joyce Drohan, Chief Information Officer for the Ontario government and another panelist.

She suggested the use of a federated data sharing model where companies provide access to the data they hold to, for example, help train Artificial Intelligence (AI) algorithms without giving up control of the data itself. Drohan said this type of model is already gaining traction in the field of drug development and clinical trials.

#PrimaryCare2025 vision calls for better connectivity

Connected care through a better integrated digital health infrastructure in Ontario is a key part of the vision for a reformed healthcare system outlined this week in a white paper released by a group of primary care leaders.

Primary Care 2025 lays out a roadmap for health care in the province based on inter-disciplinary primary care hubs where providers would have responsibility for geographically defined populations. Linking primary care to all other aspects of care in the community would be facilitated by “an inter-operable electronic medical record (EMR).”

In discussing how care has been provided during the COVID-19 pandemic, the study authors note that the lack of shared EMR created a challenge of data access. “While adoption of electronic medical records in Ontario ranges, many physicians are still using EMRs in the same fashion in which they used paper records: as a standalone patient record accessible only to the family physician in that practice,” the report states.

“(A) robust cross-platform referral management modules would help coordinate referrals to eliminate costs or delays to care while helping to coordinate diagnostic workups to avoid repetitive and unnecessary testing. A shared database enables communication among providers as well as supporting systematic sharing of best practices. The economies of scale can be significant.”

The report goes on to say that implementing an EMR that contained both health and social care data by 2025 “would provide more seamless care for patients who require care by multiple sectors, facilitating collaboration between the primary care provider and providers working in home, community, mental health and addictions care.

The study authors point to a particular issue in Ontario with the separation of public health labs from primary care EMRs. “The inability to understand risk for a whole population for which primary care has a shared responsibility is a challenge that must be overcome in a post pandemic era. This is one example of the need to strengthen the connection between primary care and public health.”

The report as calls for the ability of all providers including those providing homecare to be able to communicate via instant messaging. “In the pre-pandemic era, most Ontarians did not have access to virtual care via phone or video appointment. Only small numbers of Ontario patients were able to communicate via email with their primary care team.” The report also contains a number of other recommendations intended to reform the system from medical education to more consideration of the social determinants of health

One EMR to rule them all: The @HQOntario #HQOchat

Recently, Health Quality Ontario hosted a lively and informative tweet chat (#HQOchat) on integrated care – and again and again the need for a shareable electronic source of patient information was mentioned as key enabler.

The chat featured a distinguished panel of moderators: Health Quality Ontario VP of Quality Improvement Lee Fairclough (@lfairclo), patient advocate Annette McKinnon (@anetto), University Health Network President and CEO Dr. Kevin Smith (@KevinSmithUHN) and Marathon, ON family physician Dr. Sarah Newbery (@snewbery1). With more than 100 participants, the discussion was wide-ranging and focused on what is already being done and what could be done better to integrate the care patients receive in Ontario.

The importance of a unifying electronic medical record (EMR) or source of patient information to allow patients and providers to better manage care and help ensure the seamless transition in care across different environments was raised repeatedly.

Those who have been following discussions about EMR and health technology over the last couple of decades will recognize this as a riff on the old theme of interoperability and the need for EMRs and other systems housing patient data to be able to communicate better with each other.

“Today it seems so possible, and (it’s) time to put focus on digital solutions to support integration,” was how one participant put it. Asked what integrated care meant to them, another responded “from a patient’s perspective, the whole team knows what it’s going on – there’s no need to repeat that story / circumstance over and over again,” to which a physician responded: “(we) need a way to have easy digital transitions of this info.”

In response to a question about what was needed to build a fully integrated health care system, Health Quality Ontario Interim President and CEO @annagreenbergON answered in part “patient and caregiver access to their own records. EHR. Virtual care.” Another participant answered: “A fully integrated system is 1 inspired by patients & caregiver needs, as articulated by them. Patients & caregivers are fully involved co-designers of that system. There is single portal where all medical data are held, synchronously accessible by patient & doctor.”

On the flipside, the lack of accessible electronic patient information was identified as a barrier to integrated care.

“ …. who can take lead in shepherding all providers into using common EHR (electronic health record) framework? It’s tragic that even hospitals across from each other can’t share easily. We also block innovative private partners who are lost/blocked from plugging into a standardized network,” one physician wrote in a post.

“…we don’t have access to our primary care records and even access to hospital records and lab results is uncommon. So, we need access to more info,” @anetto posted.

Another doctor tweeted: “I think the genie has already left the bottle to consider a single EMR – need instead to focus on joining up the info out there – Connecting Ontario is probably the best option to build on!”

“We need multiple options to access and share information,” stated one post.

And this post put some context to the discussion: “A province wide record would definitely be helpful, but I think it’s more than that. The technical solutions are important, but we also need to be mindful of things like relationships, good communication, & having time/skills to collaborate.”

 

 

Is failing to use an EMR unprofessional conduct?

It has come to this.

Some hospitals in Toronto are starting to use virtual reality in patient care (to help ease pre-operative anxiety). Yet, there are still family physicians in the province using paper charts to record and monitor the health of their patients: Not many for sure and far, far fewer than a decade ago an (an increase from 37% to 73% between 2009 and 2015).

But nonetheless, in an era where the health technology envelope is being pushed harder and faster than ever before, the most recent international comparison of use of electronic medical records (EMRs) by family doctors shows Canada continues to lag behind countries such as the U.K. and New Zealand where use is almost universal.

This finding comes from a study released earlier this year by the Canadian Institute for Health Information (CIHI) in partnership with the Canadian Institutes of Health Research, and with co-funding from Canada Health Infoway looking at data from the Commonwealth Fund 2015 survey of 10 countries.

Maybe the time has come to seriously ask whether the acceptable standard of care for family doctors practising in Canada involves using an EMR and that failure to do so could be seen as failing to maintain that professional standard.

It is a question that was first asked quietly more than a decade ago, back in the twilight era when only the most forward looking physicians and jurisdictions were using EMRs routinely. Now, when EMRs have hugely increased functionality and proved their value in efficiently managing the health of populations, the question can surely be asked with more authority.

Of course, nobody wants to force some physicians to use technology they don’t like, don’t understand, and which can sometimes lead to gross inefficiencies in the use of their time. In fact we can imagine there may be parts of the country where a physician still cannot even purchase a reliable EMR. And we in Canada still struggle with interconnectivity and many family doctors remain stranded on ‘electronic islands’ unable to use their EMR to communicate effectively with others in their community.

But the reality is that electronic storage of patient data is here to stay whether the medical profession likes it or not.  With almost three quarters of Canadian family physicians now using EMRs for patient care the time has to come to ask medical licensing authorities whether they need to apply more diligence to observing those doctors who choose not to rely on paper records.

The failure of family doctors to totally embrace electronic records is hindering both patient care management and population health management. Even of those who use EMRs, the CIH report notes fewer than half routinely use the system for at least 2 of the following: electronic alerts or prompts about a potential problem with drug dose or drug interaction; reminder notices for patients when it is time for regular preventive or follow-up care; alerts or prompts to provide patients with test results; and/or reminders for guideline-based interventions and/or screening tests.

Surely the time has come for this to change.

#Ehealth2016 – inquiring minds want to know

 

Canada’s premier conference on health information technology – #ehealth2016 – is now less than a month away.

That means it’s a good time to start to contemplate some of the big questions facing the health IT community in Canada and wondering whether this mega-meeting hosted in Vancouver.\, courtesy of COACH, Infoway and CIHI will provide any answers to these questions.

At its worst, this annual meeting can be an annoying combination of sometimes irrelevant keynote speakers and simultaneous sessions that do not live up to their titles/abstracts. But over the past decade e-health (however one chooses to write the name – hyphen, no hyphen, capital on ‘e’ or no capital on ‘e’ etc.) has become THE meeting for those interested in health IT to network, hear leaders in the field and gain insights into really interesting work going on at local/regional and provincial/territorial levels.

As an observer, I would suggest a few interesting questions this conference may help to provide answers for:

• With the death or evolution of the big dinosaur programs for funding physician EMRs (POSP, PITO etc.) what is being done to continue to involve and engage physicians in improving how they use electronic records to improve care?
• What is Infoway planning on doing with its new infusion of funding courtesy of the last federal budget?
• Is patient engagement a thing in Canada in health IT and if so what does it mean?
• Is the vendor space for EMRs and EHRs going to continue to consolidate ?
• And that interoperability issue – is anything substantive happening to better connect physicians and hospitals.
• Big data. (enough said).
• Are hospitals and practitioners adapting to the mobile revolution in health?
• Are these the correct questions to be asking? At HIMSS this year there was a big shift towards discussing digital connectivity beyond the electronic record and major discussions about data security in health. Should Canada be having those discussions too.

Inquiring minds want to know.

 

To the EMR … and beyond

For a conference that was about health information technology, it was all about health IT.

Allow me to explain.

The annual meeting of the Canadian Agency for Drugs and Technology in Health (@CADTH_ACMTS) is a showcase for health technology assessment (HTA) and the mission of the organization is to provide credible, impartial advice and evidence-based information about the effectiveness and cost-effectiveness of drugs and other health technologies.

What was noteworthy about this year’s meeting in Ottawa –  the largest yet for the organization with about 750 attendees – was the number of times electronic records (either EMRs or EHRs) were referenced as an essential feature for both gathering and for disseminating credible information to support evidence-based medicine.

Physician speakers repeatedly noted the need to have easy, point-of-care access at the time of the patient encounter, and to all of them this meant embedding that information in the electronic record.

More than one family doctor talked about being overwhelmed with guidelines and best practices and the need to integrate this information into the physician workflow to be useful – and EMRs as the natural place to do this.

The Canadian Association of Radiologists creates world-class clinical practice guidelines, but as Dr. Martin Reed, a pediatric radiologist from Edmonton told the meeting, one of the problems with these guidelines is that it is very hard to get people to use them.

He said there is now a feeling in the medical imaging community that the best way to do this is to integrate the guidelines into CPOE (computerized physician order entry) systems.

Given that some Canadian physicians still do not use EMRs and some (many?) hospitals are not using CPOE this could raise concerns about the quality of care being delivered.

On this information gathering front, the new focus on real-world data has placed an increased emphasis on the value of EMRs or EHRs to gather useful information to evaluate the effectiveness of drugs and technologies, the meeting was told.

“The starting point is having an EHR covering all of the caregivers. At that point the world is your oyster,” said Dr. Murray Ross (@murrayrossphd), leader of the Kaiser Institute for Health Policy in Oakland, CA.

Dr. C. Bernie Good (@CBGood23) who holds numerous roles with the US Department of Veterans Affairs gave numerous examples of how the extensive database gathered on VA patients through EHRs has helped support evidence-based drug prescribing.

And it does not end there.

As Anil Arora, assistant deputy minister in the Health Products and Food Branch, of Health Canada told the meeting it is not just the information being gathered in patient records that will need to be taken into consideration in the future – but also the wealth of patient data now being collected through wearables and other devices as well as through social media.

Given that we have by no means maximized the value of EMRs to gather this information in Canada, the challenges of extending the information sources to other digital repositories of patient information is currently problematic to say the least.

(Picture – Anil Arora. Courtesy CADTH)