@OntariosDoctors burnout report targets technostress

A white paper from the Ontario Medical Association (@OntariosDoctors) produced by a task force on physician burnout is one of the first in Canada to deal explicitly with the toll on physicians from practicing in a digital environment and identifying potential solutions.

A number of studies and policy documents from the US over the last few years have documented how use of electronic medical records (EMRs) and hospital point-of-care systems have contributed to physician burnout due the requirements for additional documentation and record-keeping.

While similar concerns have been voiced in Canada, country-specific data has been lacking, as have advocacy initiatives and proposals to address the issue.

“Healing the Healers: System-Level Solutions to Physician Burnout White Paper” deals with the issue head-on. One of its five recommendations for addressing physician burnout calls specifically for seamlessly integrating digital health tools into physician workflows. The first recommendation from the report concerning documentation and administrative work also addresses the burden placed on physicians by EMRs and hospital administration systems.

Chaired by physician health expert Dr. Mamta Gautam (@PEAKMD), the task force that prepared the document references the finding that physicians spend two hours on electronic documentation for every one hour of direct patient interaction.

To address this issue, the task force identifies the use of medical scribes as a means of relieving the burden on physicians by having someone else document patient encounters in real time. However, the task force notes that significant additional expense is involved with this approach and states that individual physicians should not have to pay for this means of reducing their incidence of burnout. The report goes on to note that “virtual scribes” or AI scribes might provide innovative solutions at a lower cost.

Finally, the task force discusses simplifying the multiple log-on process required for physicians to access a number of different systems as an effective way of saving a significant amount of time and frustration.

On the specific recommendation of integrating digital tools into physician workflow, the task force states this is essential to reduce the stress for physicians associated with using EMRs and other digital systems. More specifically the report recommends “implementing interoperability standards to ensure physicians can seamlessly access patient records and share patient health information among care providers.”

Another recommendation which hearkens back to the very start of the EMR era calls for physicians to be key partners from the start in the procurement, design, implementation, and ongoing optimization of digital health tools to ensure usability.

A third recommendation in this section dealing with change management, which had been a key tenet of the best physician EMR implementation programs in Canada in the 1990s and 2000s, is to “equip physicians with comprehensive and ongoing training on digital health tools.”

Better, but not there yet: Use of IT in primary care in Canada


When it comes to the use of information technology in primary care in Canada the best that can be said is that all the numbers have trended in the right direction since 2015.

Released by the Canadian Institutes of Health Information (CIHI) last week, the 2019 version of the Commonwealth Fund International Health Policy survey of 11 developed countries focused on primary care physicians and contains a wealth of data on the use of technology as well as on access and coordination of care.

At a time when Canadians and especially primary care physicians are engaged intense discussions about how to better use digital technology to improve care and better involve patients, what is most striking about some of the Commonwealth Fund findings is just how far many Canadian jurisdictions are from even having the basic tools to do this.

While the survey confirms the fact that overall Canadian primary care physicians have made huge gains in incorporating electronic medical records into their practices in the last decade (kudos to @Infoway and all the money put into enabling this in the 2000s), these gains are not evenly distributed. And when it comes to the use of health IT, Canada continues to lag behind other countries polled, in many instances badly.

While 86% of Canadian primary care physicians overall report using electronic medical records (EMRs), the 2019 survey shows only 1 in 4 (26%) are using EMRs in PEI while that percentage is 61% for primary care doctors in New Brunswick and Newfoundland.

Of course, the absence of an EMR makes any electronic engagement with patients or use of information technology to improve quality care a moot point.

As for providing patients with electronic access to their records or enabling electronic communication, Canada continues to also lag most other nations surveyed. Only 23% of Canadian primary care docs offered the option to ask medical questions via email or a secure website, and only 5% have the capacity to let patients see summaries of their medical record online.

These numbers fell far below the average among the other 11 Commonwealth Fund countries surveyed , which includes Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K. and the U.S.

We are also falling short when it comes to connectivity between physicians: The survey showed only 25% of Canadian family doctors used EMRs to exchange clinical summaries and 36% to exchange laboratory results with other physicians (Commonwealth Fund averages: 63% and 65%, respectively).

So, some good stats when looks at 2015 numbers provided for comparison, but many miles to go.

(Illustration: Cover of Future Practice magazine published by the Canadian Medical Association, May 2011)





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


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)

#HIMSS15 – Will the physician voice of angst be heard?

When it comes to the frustrations associated with health IT and the use of electronic medical or health records, U.S. physicians should know your Canadian colleagues feel your pain.
A national survey of Canadian doctors conducted last year (known as, wait for it, The National Physician Survey) with responses from more than 10,000 physicians documented many of those concerns.
While use of EMRs has grown rapidly among the Canadian physician population in the last decade there are still significant areas of the country where access to an EMR system is not available. More significantly, the majority of physicians continue to use a combination of paper and electronic records and many joke that the fax machine continues to hold sway in this country.
Perhaps what is more concerning is the percentage of physicians (17%) who feel the use of an EMR has decreased rather than increased their productivity and the high percentage of doctors who are only using their EMR as an electronic record keeping device rather than for any of the multitude of other functionalities that are available. For example, electronic prescribing in Canada still remains a vision for the future rather than the cornerstone of effective EMR use.
Interoperability continues to be the bugbear for both policy makers and individual physicians. in Canada. While Canadian doctors do not face the situation of U.S. physicians who having dozens of competing EMR vendors trying to sell to them most are still unable to easily exchange data electronically with the hospitals, other physicians, pharmacies or other providers in their communities.
Worse yet in the eyes of some physicians in Canada are the disappearance in the biggest provinces of government programs that paid the majority of costs associated with putting a computer on the desk and providing the software to digitize patient records.
“Meaningful use” has little meaning in Canada in the legislative sense but many Canadian doctors would sympathize as the U.S. federal government starts to implement the “stick” phase of the “carrot and stick” plan for encouraging use of electronic health records.
And don’t even start on the issue of patient participation as in Canada few patients can easily access their own record electronically and even fewer can communicate with their physician by email about their health concerns.
So, as speakers such as American Medical Association (AMA) President Dr. Robert Wah start to outline the challenges and opportunites facing U.S. physicians with health IT (in his address at the Innovation pre-conference symposium this morning) Canadians will be listening closely.
From the viewpoint of an external observer there has been a growing chorus of U.S. doctors recently vocally expressing why they are unhappy with the experience of using electronic health records – with even organized medical groups such as the AMA chiming in.
It will be interesting to see whether such concerns are heard in the evangelical atmosphere of HIMSS15 in Chicago this week.

And how was your visit?

For all its talk of equal and universal access, Canadian medicare is now an environment where every physician is offering a somewhat different experience to his or her patients which could be leading to dramatic variances in the quality of care provided
This may sound like an exaggeration. But consider the fact that for the first time in hundreds of years the fundamental process whereby a physician records the patient visit has changed.
It used to be – and in many instances still is the case – that you went in to see a doctor and he or she took notes with a pen or pencil and entered this information into your chart which was then manually stored in a big room with hundreds or thousands of other charts.
But since the advent of the electronic medical record (EMR) that has changed.
Physicians who use EMRs enter your medical information electronically and this is stored in a medical record which again is digital. EMRs are different, and absent enforced standards, the taxonomy by which that information is stored or portrayed can differ from practice to practice.
Now within that population of physicians who use EMRs, the degree of sophistication they apply to using that digital information varies across a huge spectrum. While some just store the data electronically and use it for basic record keeping, others use the available technology to improve the care they deliver such as sending reminders to patients who have been identified as requiring screening tests. Yet others are working with other health care providers and sharing the electronic record to provide integrated care or advanced disease management support.
But nobody mandates that they have to do any of this. Writing your medical information down with a pen and keeping it in a paper chart is still perfectly acceptable. And even with physicians who do use EMRs, the overall sense is that the majority are still just using the new technology for basic record keeping, albeit in a more legible form.
So, the adoption of EMRs which already varies widely depending upon which region in which you live and the practice characteristics of your doctor, is further varied by the degree to which the physician is using the functionality available.
The EMR may yet to prove a holy grail in the delivery of better patient care but until all doctors are using the technology equally well, we have a long way to go until we can ensure all patients are getting the standard of care available to them.