e-Health -- new year imponderables

I had occasion to visit my local walk-in-clinic over the holidays and as usual, took the opportunity to observe what was going on around me; it was 08:00 on a Sunday and the waiting room was packed within 5 minutes of the doors being opened.
As I sat there, a slew of questions began forming in my mind, such as:

• why do doctors' offices close -- do we really think illnesses follow the concept of a "work-day/week" and observe statutory holidays?
• why do we still refer to the "family doctor", as if the latter is obligated to stay around to serve us until we depart planet Earth?
• why does the Ministry of Health (MOHLTC) seek so desperately to reduce hospital emergency room wait times, yet apparently has no coordinated plans to ensure 24/7 primary healthcare provider (HCP) coverage?
• why is the MOHLTC gung-ho on the EMR, yet we hardly hear any discussion on electronically linking healthcare facilities so patient data can easily be shared?

Of course, I not only thought about the questions/issues -- heck, I tried to solve them all by myself!

For example, I'm thinking that:

• using the FHT concept, primary HCP clinics should be staffed 24/7 and managed by the LHIN for any given area
• a hospital's emergency department should be for life-threatening situations only -- if you can get there under your own steam, you should really be visiting a primary HCP clinic
• we need to stop this nonsense about ownership of patients' records -- the latter should be electronically stored and managed by the LHIN with access allowed as appropriate (patients included); do we hyperventilate about ownership of our tax/banking/insurance records? Patients' records should simply be one of the tools used by HCPs/the MOHLTC to help provide best-of-breed care for Ontario residents

The more time we spend debating this, the closer we'll get to privatization (yes, I finally said the "p" word) -- there's no way our taxes can sustain the level of spending our healthcare system requires, for any appreciable length of time -- something's gotta give!

I'm hoping an election year will help spur on some badly-needed changes.

Wishing you the best for 2011.


Ernest A. James

President & CEO
Regal Informatics Inc.

e-Health -- a moment of clarity

I had the opportunity to attend the October session of the CE LHIN board meetings and I must confess to leaving the latter with a quizzical look and my mind running in overdrive; the Project Management Office gave an excellent overview of what the "rubber hitting the road" was like for them -- the latter was actually an inspiration for the previous post, in that I feel we need to hear more of the experiences of the folks on the front lines.

During the afore-mentioned presentation, I thought I heard something to the effect that efforts at implementing the various e-Health initiatives (such as a data center consolidation amongst the LHINs) were being stymied by the various hospitals bringing along their lawyers to the meetings.
On the way home, I began beating up on myself for not listening more attentively, for I determined there was no way LHINs could be shooting themselves in the foot by funding lawyers to, at best, slow down the progress being made with their projects, or so I thought...

Fast forward to November 30th, 2010 -- I was vegetating in front of the TV after a hectic day; flicking through the channels during commercials, I came across a TVO episode entitled "Patient-Centered care".
I quickly got back into listening mode and was taken aback at what I was hearing; stuff like "turf wars" amongst Healthcare Providers (HCPs) was vigorously being debated.
Elinor Caplan, a former Minister of Health for Ontario described one of her experiences that really had me shaking my head -- basically, she had met with two hospital boards that were planning the implementation of e-Health systems and pleaded with them to at least ensure compatibility was included in their specifications.
What did the hospitals do? They ignored her request, shored up their turf and ended up with systems that couldn't "talk" to each other, in effect creating more islands of information.

I have always contended that the state of e-Health in Ontario was not due to any lack of technology or security (systems that allow us online access to our income taxes or banking information are solid testaments), so the above discussions really put things into perspective for me.

So, what will it take to get some movement away from this "my patient data" way of thinking? Well, one way or another, it's got to happen.
Now, I'm not optimistic that HCPs will become altruistic and voluntarily begin sharing their data overnight, so I suspect we'll see something mandated by early 2012, at the latest.
I think we've had enough discussion -- it's now time for action -- the current state of affairs is unsustainable.

I wish you a safe and joyous holiday season and look forward to one interesting year ahead.


Ernest A. James

President & CEO
Regal Informatics Inc.

e-Health -- where is John Q. Public?

I normally look forward to attending the monthly Board of Directors' meeting for the Central East LHIN, but I always wonder why there's such a small (if any) representation from the rest of the community.
I've checked with friends from other LHINs and none of them has ever attended a meeting, so let's assume for the purpose of this discussion that my research is empirical.

There were only a couple occasions that I can recall where extra seating capacity (or a different venue) was necessary, and these were:

• the session discussing the realignment of COPD services in the Durham, Ontario region -- many of those living with the disease were out in full force to show their concern for aspects of the LHIN's plans
• the session regarding the reorganization of the PHRC

So, why the apparent disinterest?
As per the MOHLTC, "The legislation requires LHINs to engage their community, including physicians and other health care practitioners, on an ongoing basis..."
Now, I presume the mandate is being measured, so on this "engaged community" metric alone, the LHINs must be hurting real bad!

What could they do to counter this apparent indifference? I have a couple of ideas.

Firstly, why not market the LHINs to the point of ad nauseam?
Many Ontario residents I interact with have a fundamental lack of knowledge of what LHINs are all about -- I find this unfortunate since the latter funds their healthcare.
It's said that even tourists to Canada know the Pizza Pizza phone number, so why are we so conservative when preaching the LHIN gospel?

Secondly, I feel the level of interest would be raised considerably if someone from the front-line of our healthcare system would be asked to present at every board meeting.
For example, I may be interested in attending if it became common knowledge that the manager of the Emergency Department (ED) of my local hospital would be discussing:

• the serious effects on "wait times" of me showing up just because I have a cold 
• other options available to me, such as Telehealth Ontario

 My doctor would definitely have my attention if she informed me that she'll be presenting as to:

• why she and her peers are still not accepting new patients
• why she's recommending to all her patients that they assume a greater responsibility for their health
• how tools such as EMRs, EHRs and PHRs would help with the above

I think the optics for the LHINs would be greatly improved if they tried to connect with their communities more often at the grassroots level -- I've attended too many meetings where I've had to turn and ask the meaning of acronyms being thrown around by presenters.

Let's turn these board meetings into true "town hall" meetings -- that way there'd be no need to question the value of our LHINs.


Ernest A. James

President & CEO
Regal Informatics Inc.

e-Health -- should the user pay? Part 3

I was of the impression that this pay-per-use discussion was a done deal, but it appears to be otherwise; you see, the Quebec Minister of Finance, Raymond Bachand has made a decision not to go ahead with the implementation -- negative feedback from the public at large was just too overwhelming. 

However, he has also elected not to ignore the elephant in the room -- folks in Quebec will still be hit with a charge to their income-tax accounts of $100 beginning next year and escalating annually; after all, similarly to what we're experiencing here in Ontario, the health care budget issue will still have to be dealt with and giving in to public opinion doesn't simply make it disappear.

Speaking of health care budgets, it's interesting to note the pre-election rhetoric both from a Federal and Provincial level; for example, the leader of the Federal Liberal party (Michael Ignatieff) has promised an up-coming debate on health care in his recent Nova Scotia caucus address; he's also hinting at the types of changes his party would make if elected -- for example, prevention ("more health, less health care") would be a top priority; also, as indicated in an earlier post, user-pay would not be an option.

Provincially, Tim Hudak has promised to disband the LHIN system in Ontario if his party gets elected next year, using the money allocated to its administration for more front-line care.

Although we're not privy to the details, it's obvious to me that we're on the cusp of a revolutionary change in the way health care is administered throughout Canada -- I think we can all agree that the current way of doing business is unsustainable; elections in 2011 will probably be watershed events.

So, how do we mitigate the soon-coming upheavals? My suggestion is, as always, the use of technology; EMRs, EHRs and PHRs are tools that will both help us to take control of our health and ease the demand on our health care systems.

I think the need for change is superbly articulated by a comment I came across recently -- it states: "There's never enough money to pay for disease".

Ernest A. James

President/CEO

Regal Informatics Inc.

e-Health -- should the user pay? Part 2

So, I'm heading home after the meet/greet luncheon with Michael Ignatieff, feeling chuffed -- just had some good food, took a picture with a potential Prime Minister and got a definitive answer for my question.
However, I habitually try to play the so-called "devil's advocate" role and found myself asking, is it really a big deal if user fees became a reality in Ontario? And when it does, can there be any reasonably pleasant side effects?

After some searching, I realize this could potentially be the needed wake-up call for many of us; people like myself tend to abuse anything we do not have to pay for, at the time/point of usage -- OK, I admit, if I'm staying in a hotel, I may leave the tap running as I polish the ivories, but as you can imagine, my habits would change when I got home!
In other words, if I know I have to pay, I'll try my best to be frugal -- if it doesn't cost me anything immediately...

So being a realist, my suggestion to the Health Minister of Ontario would be to at least give those who make the effort to turn off the tap,  a tax break; for example, if an across-the-board $1,000 user fee was levied annually on working Ontario residents, and I also paid a $1,000 annual membership fee at my local health/fitness club (something that I used snow, rain or shine), at least make it revenue neutral to my tax account with an equivalent credit at year end -- something similar has been implemented for the use of public transportation, so why not healthcare?

I'd regard it as unconscionable if I made the effort to stay healthy whilst my neighbor simply slaps the alarm clock across the room at 06:00 hours and turns the other cheeks, so to speak! Yet, we'll pay the same user fees at year's end.

I'd also be doing a disservice if I were to be reticent with regards to the various options available before we got to the point of user fees; I was really disturbed by an article sent to me by a friend -- here are some of the eye-popping revelations I read:

• the most dangerous place in Canada is a public hospital
• one in every 152 acute care patients dies because of "preventable adverse events"
• two in 10 patients contract a hospital-spread infection or are given the wrong medicine
• no Canadian CEO could keep his job if his company’s "defect rate" was even a small percentage of that in our government monopoly health-care system

I passionately feel that:

• the inefficiencies should be removed from the system before user pay is even considered
• people should be given access to tools such as EMRs, EHRs and PHRs, along with constant reinforcement messages/education sessions to help them maintain their health. 

Only when the above efforts have been exhausted should the Health Ministry think about implementing user fees, along with the associated tax breaks to both reward and encourage us, of course!

As with any system, regular maintenance tends to prevent breakdown and the abuse of repair facilities.

e-Health -- should the user pay? Part 1...

I was thumbing through my weekly pile of reading material when the words "$25 fee per doctor visit" caught my eye -- apparently the Quebec Government wants to implement a user pay-per-visit healthcare system.
The above-noted article goes on to inform us that a "health contribution" will also be levied; to me, what's really interesting about the latter is the way it's being implemented -- apparently, you won't be dipping into your purse/wallet for this one -- oh no, for your convenience it's being shoe-horned nicely on to your income tax bill -- now, who could be upset at a government for being so understanding?
For this "health contribution", the plan is to charge Quebecers $50 in 2010, but since the budget was passed during the year, they get a 50% discount; for 2011, they'll reach for $100 and this doubles in 2012; sorry, but there are no prizes for guessing where it's heading after 2012!
This tax grab will further lighten the residents of Quebec's pockets by close to a billion dollars annually.

I love the following paragraph on page 22 of the 61-page report (my emphasis):

"The health contribution is a simple and effective way to provide substantial funding for the health-care institutions, but without demanding an excessive effort on the part of each taxpayer."

What this really means to me is that they need a quick and easy way to get more funding for healthcare; forget the effort required to find other means (e.g EMRs/EHRs/PHRs) of squeezing inefficiencies from the system -- heck, they should have this thing up and running in no time at all.

After I finally managed to get the remnants of my receding hair-line back in place, I filed the article and continued reading; curiously enough, another article soon catches my attention -- this one informed me of an upcoming visit by the leader of the Federal Liberal Party, Michael Ignatieff -- he would be the guest at a luncheon hosted by the Ajax/Pickering Board of Trade; ah, the wisdom of the Universe, I thought -- dropped right there in my lap was an opportunity to put a question to the man himself -- to get the official word on how the Liberal Party would deal with such a potential contravention to the Canada Health Act.
After all, one could be forgiven in thinking: this is Ontario, it'll never happen here; well, just remember that the Premiers meet on a regular basis and there's no reason to believe the "honey-pot syndrome" does not apply when they do get together!

So, on the day in question, I donned one of my best blazers, made my way to the convention center, and waited; soon the crowd became agitated as word of Mr. Ignatieff's arrival spread amongst the tables.
In he walks and my jaw drops -- he was dressed in the exact same style/color of blazer -- my immediate concern was: how would the luncheon crowd be able to differentiate between the two of us? Then it hit me -- it would be easy -- I was the handsome one, silly!
I relaxed, enjoyed the lunch and prepared to queue up behind the microphone, but alas the time for questions ran out, so I decided to wait outside the room and try to get his attention as he was leaving.

Let's continue this in part 2 where I'll discuss how I ruminated on the answer I received from Mr. Ignatieff; in the meantime, there's something that's demanding my immediate attention -- as I'm writing this article, the air is muggy and the sweat's pouring from my forehead, yet there's a story on the radio about stores in Toronto displaying winter coats; this is madness!

Photo credit: Dave Stell


Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- PHRs in the spotlight

Sounds of silence reverberated around the soccer world on the afternoon of Friday July 2nd, 2010; Brazil had just been eliminated from the FIFA World Cup of Soccer in South Africa after being beaten by the Netherlands, a team many thought didn't stand much of a chance to advance.
From the perspective of Personal Health Records (PHRs), I'd say something similar  (relatively speaking) occurred in Canada when Telus announced its entrance onto the e-health stage at the end of May, 2010.

A couple of weeks later (and unaware of the announcement), I attended a conference in Toronto where Telus management gave a keynote speech informing attendees of the company's portfolio of Information Technology (IT) products and services; from data center management to consulting, Telus is much more than the phone company I had envisioned it to be -- the media release therefore made a lot of sense when I did manage to read it.

This is huge; you see, Microsoft and Google already have PHR products, but one of the main concerns I regularly hear discussed is the fact that since their data centers are mainly located in the USA, customers' health data could be subjected to the vagaries of the Patriot Act -- people are basically concerned that their medical history could be searched, copied, destroyed or generally made unavailable should the government feel such actions to be in the best interest of the country.

Well, the Telus announcement has in effect eradicated all of those concerns; here we have one of the top 500 companies in Canada (heck, it's right up there with Rogers Communications Inc. and BCE Inc.) teaming up with Microsoft, one of the top ten software companies in the world to bring us an e-Health application that's geared to Canadians; based on the history of the players involved, it'll be secure, reliable and easy to use.

As a refresher, a PHR application will allow you to capture, upload, store, display and manage health-related information that's owned by you -- just imagine the following possibilities:

• you move to a new city and there's no need to purchase a CD/DVD of your history from your previous healthcare provider beforehand -- everything you need is as close as the nearest web browser
• you get home from a vigorous workout and you just have to plug the device that was strapped to your arm into your computer device to upload data that can include heart rate, blood pressure and distance traveled
• you need to record your blood pressure or other attributes daily -- don't worry, devices are coming that'll store the data and allow you to upload to your PHR at your convenience
• soon you'll be able to show off your superb physical condition to interested parties using your iPad/iPhone or similar device, because there'll be an app for that too

I predict that we're on the verge of an explosion of activity in the area of self-help health management; stay tuned -- my pledge is to keep you apprised.

Well, the games have ended; the team I was following just managed a place on the podium, but I predict vengeance will be exacted in Brazil in 2014.

In the meantime, I'm immediately putting in place a savings plan to ensure I can afford the Brazilian version of the vuvuzela.

Image credit: Salvatore Vuono

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- EHRs to the fore

I had volunteered to help out with a Rouge Valley Health System Foundation (RVHSF) fundraising activity -- we were tasked with selling raffle tickets at a Pickering Rotary event, to support the pending acquisition of a Magnetic Resonance Imaging (MRI) machine for the Ajax/Pickering hospital.

On the way to the park, it struck me that I knew nothing about MRI machines and should anyone ask me to explain the latter, it would be interesting to hear my response.
I resolved that Durham Region folks are a knowledgeable bunch and this would be a non-issue.

True to form, not one of the many people I met that day needed to know what an MRI machine was -- they either pleasantly declined or were happy to contribute and my allocation of tickets went quickly; I guess the combination of good weather, good looks, a great cause and pricing came together in a perfect storm, so to speak!

This got me to thinking about the day when Electronic Health Records (EHRs) and Electronic Medical Records (EMRs) finally become as pervasive as MRI machines -- I have no doubt it'll be soon! The next couple of paragraphs give me cause for such optimism.

I attended the Central East Local Health Integration Network Symposium last month and was pleasantly surprised at the emphasis the president of the Ontario Medical Association (OMA), Mark MacLeod (M.D.) placed on EMRs/EHRs; to paraphrase, he told us that EMRs is the grease needed to move patients through the system more efficiently; he went on to say that more work needs to be done to connect family doctors to hospitals.
Wow, I think for the top guy from the OMA to include such a topic in a major speech is very encouraging!

I also recently tuned into a webcast from the Institute for Functional Medicine's 17th International Symposium -- the topic was: "Looking Anew at Cancer"; I thought I'd be hearing some earth-shattering truths from the speaker, Jeffrey Bland (PhD, FACN, CNS), about how to easily prevent cancer.
However, I was soon overwhelmed by the complexity of the ideas presented, until he made a statement that made me sit up and listen even more intently -- in effect, he indicated that pattern recognition was a critical tool in cancer treatment and one of the best ways to collect, store and present patient data was an EMR; I wanted to say "Amen, brother" -- at that point I felt like I was in a choir, in church!

I continue to be amazed at what other countries such as Spain are doing with EHR technology -- checkout this CBC news article; I keep wondering how soon we'll be able to best their efforts; maybe I need more patience...

Until next time, if you love soccer like I do, checkout the 2010 FIFA World Cup on CBC television -- the host country, South Africa, made a great start by scoring the first goal of the event -- a spectacular effort!

Photo credit: Ernest A. James and Heather Montague (Special Events Officer for the RVHSF), at the 3rd annual Pickering Rotary Ribfest.
Photo by: Jennifer Collins

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- CE LHIN going for gold!

Last month I was invited to a store opening in Pickering at which time I had the opportunity to meet our 2010 Vancouver Olympic Silver Medalist, Shelley-Ann Brown, amongst others.
As you can see, I jumped at the first photo op I got and was also able have a short discussion with with her.
The impression I got was of someone dedicated to winning -- when not attending the various media events, or lending a helping hand (for example, with the Haiti reconstruction), you'd probably find her training hard for her next competition.
To me, she's not done until that gold medal's dangling...

This got me thinking about a comparison with our Local Health Integration Network (LHIN), the Central East LHIN (CE LHIN) -- you see, I'm yet to be convinced of the utility of inter-LHIN collaboration; to me, our LHIN's a huge bobsleigh team working to give the residents within its area of accountability, the most efficient healthcare possible. Sure, there are others (LHINs) in the Ontario healthcare system, so the whole idea is for the CE LHIN to acquire a place (and remain) on the podium for healthcare in Ontario.
I'd imagine that Shelley-Ann and Helen were aware of other competing teams from Canada -- I'd also hazard a guess that they weren't collaborating for ideas either -- they were too busy executing their own plan.
After the race (or at some other appropriate time), ideas may be exchanged, but during the competition, each team is sequestered -- the driver and the brake-person each concentrating on getting familiar with the nuances of the course.
So it should be with our LHIN -- we should be too busy trying to understand the unique requirements of residents to be involved with other LHINs,  other than what's legislatively required.
Of course there will be opportunities for a meaningful exchange of ideas (for example, conferences and the like); Shelley-Ann and Helen probably had a discussion with the Kaillie Humphries/Heather Moyse team after the competition to ascertain what the latter did differently to win gold!

My point is that collaboration between LHINs may not be conducive to the proper execution of their respective mandates -- participants are predisposed to ensuring their "home team" comes off best; in Olympics parlance, I'm sure the Shelley-Ann/Helen team would rather win the gold medal and leave the silver for Kaillie and Heather!

Funny -- seems like the Premier McGuinty team may be thinking along the same lines because as I write, I'm hearing on the news that pay for performance is being legislated for Ontario hospitals: http://www.healthzone.ca/health/newsfeatures/article/803818--hospital-ceo-pay-to-be-tied-to-performance?bn=1 -- it'll be interesting to see what impact this has on inter-LHIN/hospital collaboration!

In the meantime, while I continue searching for ways to help improve the operation of my LHIN, I think I'll also check around to see if someone could come up with a functional neck brace/ornament for Shelley-Ann and Helen, 'cos wearing both the gold and silver medals simultaneously could sure end up doing some serious neck-muscle damage -- those medals are heavy!

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- retrospectively

During a lunch session with a friend last month, it was suggested I restate some of the main points I have blogged about to date; thinking about the utility of the idea, I decided to do a "compare and contrast" on my current position vis-à-vis my first blog article.
What I've found is that although my strategy is still focussed on e-Health systems (Electronic Medical Records (EMRs), Electronic Health Records (EHRs) and Personal Health Records (PHRs)), I'm definitely blazing a new trail.

For example, I distinctly remember when I first started, I was all gung ho to set-up my office in Queen's Park (the Legislative Assembly of Ontario) and help enact new legislation mandating an EMR system in every doctor's office in the Province within a couple of years.
I soon realized this would be counterproductive, since doctors are not Information Technology (IT) specialists -- sure, the various organizations such as OntarioMD would be assisting procedurally and financially to set things in motion, but when the implementation party is over and the doctors are left on their own to manage the various aspects of their systems, the shine could disappear pretty quickly in a busy practice!
This could result in the necessary processes for backups, security, and software updates for the EMR system being given a low priority -- not a good thing if you want to maintain patient data integrity and privacy.
A rather severe thunderstorm struck the Greater Toronto Area (GTA) last summer; it convinced me that the Application Service Provider (ASP) model should be the way to go (this is where the vendor hosts the application and the doctor accesses it using a browser -- see my August 2009 article for more details) -- at least the burden for data security would be offloaded -- or so I thought!

I was derailed again late last year following my attendance at a seminar on the "OSCAR" EMR system -- someone made a comment to the effect that handing over the management of patient data to vendors could be akin to putting a kid in a candy store and expecting them not to be interested in sampling the wares; in other words, you can't expect vendors to have access to such a huge database and not be interested in legally selling it for research and marketing purposes.
So basically, I was back to square one -- the EMR system was back in the doctor's office...

However, a couple of months ago, I had an epiphany; it struck me that I did not maintain an E-mail system, yet I'm able to read my business/personal mail on a daily basis -- I simply use a browser to log on to the hosting company's web site (e.g. Google Mail) and manage my mail effortlessly and reliably via a process known as Software as a Service (SaaS -- see my February 2010 post).
It begged the question: Why can't healthcare providers have similar functionality without losing control of their patient data/privacy? Why shouldn't it be possible for your doctor to enter the exam room with say, a tablet (an iPad is an example of what's in the marketplace), sit next to you, tap the device a couple of times to access your healthcare record and start having a meaningful discussion, all without having to worry about the activity occurring behind the scenes?

This is where I'm at today -- my passion is now geared towards removing the management aspect of IT, but adding the functionality to enhance the provider/patient relationship.
In other words, we need to remove the computer hardware and it's associated software components from the front line of patient care (e.g. the exam room) and replace it with a non-intrusive mobile device that uses a simple web browser interface as an enabler to superb patient care.

The technology described above is available, so why are we still encouraging healthcare providers to become IT experts?
Well, a comment was added to my last article that I found succinct -- it was suggested that what we really need is political leadership!
With the size of the debt/deficit these days, I think it's only a matter of time.
We got off lightly this fiscal year (at least from a healthcare perspective) because elections are looming on the horizon, but watch out, 2012 may prove to be really interesting!.

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- integrated

Oh Canada! What a country, eh! Whilst I was out earlier today (Monday, March 1st), I noticed many people walking around, chests puffed up like show budgies; no surprises there -- after all, we're coming out of a relatively mild winter, and one of the best Winter Olympic Games ever, has just ended -- what a way to start the year!
What's next, my favorite movie "The Hurt Locker" cleaning up at the Oscars, or a 10% increase for healthcare spending in Ontario for the upcoming fiscal year? Well, let's stay tuned!

As I promised last time, I'd like to spotlight integrated healthcare; based on an article that the Obama administration is said to have used on numerous occasions during recent discussions on healthcare costs. Although we do not have identical models of healthcare, I found the article a worthy discussion point.
It came about when  Atul Gawande, did some research into why McAllen Texas is the most expensive place in the US, in terms of healthcare costs, yet it doesn't stand out for its quality in delivery.


Despite its length, I feel the article should be mandatory reading for everyone involved in healthcare delivery on the planet!


Mr. Gawande argues McAllen shows that:

• an unhealthy population and high healthcare costs do not necessarily correlate
• costs are inordinately high because people got more of the expensive stuff and not necessarily what's needed
• there's an overuse of medical care -- health providers tended to maximize revenue
• universal care is not feasible/sustainable unless costs can be controlled

He then goes on to suggest that the Mayo clinic-style of integration will be the future of universal healthcare; their tenet is: "the needs of the patient come first...", not the convenience or revenues of healthcare providers.

Two notable quotes for me are:

• the most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do
• when doctors put their heads together in a room, when they share expertise, you get more thinking and less testing

Recent events have me questioning where we're really heading, healthcare-wise, in Canada; for example, the media on both sides of the border jumped on the story of Newfoundland's Premier Danny Williams' trip to Florida for a heart procedure -- it was even referred to during President Obama's televised health summit.

It begs the questions: does this reflect on the quality of our healthcare? Are we at the two-tier stage where if you can afford to, you can get better care, faster, elsewhere?

I agree wholeheartedly with Atul Gawande's argument that the Mayo clinic model of healthcare (that of integration) has got to be our beacon for the future, if universal healthcare is to survive.

Admittedly, it has piqued my interest mainly because one of the underpinnings is the use of Information Technology (IT) to share everything -- patient information, expertise, ideas etc.

That's it for now and until next time, perhaps you should start working on mothballing the snowblower and preparing the lawnmower, hedge-trimmer and golf swing -- won't be long now!

Article: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- the shoe-maker needs new soles, part 2

Let's continue the discourse begun last article by considering the following statement:

The current Canada Health Infoway/OntarioMD Electronic Medical Record (EMR) systems strategy is flawed.
The above-noted organizations support doctors installing their favorite EMR application on their computer systems, be it from vendors such as xwave, Practice Solutions, Nightingale or the Open Source product, OSCAR -- heck, the two organizations even go as far as to fund the process!

The fundamental question that's been avoided is:
... does your doctor really have the required resources (time/expertise) to maintain his/her system?
Let's take a hard look at some of the things that are required on a regular basis; your doctor needs to:

• ensure the system is secure
• ensure daily backups are successfully completed
• ensure these backups are rotated off-site in case a catastrophic event occurs
• ensure the hardware systems in the exam rooms are maintained
• ensure tested procedures and resources are available to rebuild following a catastrophe

The list goes on...

To be honest, although these stand-alone applications do an excellent job, I'd much prefer my doctor taking the time to master the relationship between good nutrition and health, as opposed to delving into the intricacies of maintaining computer systems.

Sure, your clinic may be able to fund Information Technology (IT) resources (take for example, the Oshawa Clinic), or your doctor may have gone the "Application Service Provider" (ASP) route whereby the system is located at the Ministry of Health data-center with clinic staff connecting through a browser; however there still remains the fact that all they've done is to automate an island of information; if all health provider offices in the Province were EMR'd, (in-house or ASP), they'd still be inaccessible by other clinicians -- we'd still have:

•  instances of hospitals not being able to discharge patients because critical health information is locked up on some hard drive
• letters of apology being sent to individuals when computer systems (or components thereof) containing health information go missing
• doctors not knowing in a timely manner when their patients have been admitted/discharged to/from the hospital
• no efficient means of summarizing health data for trending/funding exercises by the Ministry of Health and Long Term Care (MOHLTC)

In other words, we'd still be missing the infrastructure to link these automated islands of information!

I can almost hear the question:
OK, you've always been a proponent of EMRs -- what's going on? What alternative do you suggest?
Glad you asked -- well, what we need each of our Local Health Integration Network (LHIN) organizations to do, is host an EMR system as a "Software as a Service" (SaaS) application -- the latter is where a hosting company provides the services of any application (could be EMRs, mail or Microsoft Word/Excel/PowerPoint functionality) accessible via a browser; this could be funded either by ad revenue or by a direct charge to the user on a time/use basis.
To read my E-mail, I log on to Hotmail or GMail via a browser -- I don't really care where the servers are located -- I just expect the mail service to be available; there's no need for me to be concerned with backups, updates to mail programs and the like -- that's all taken care of by the hosting company. If there's a an outage, a need for an update to be applied, a catastrophic event -- no problem -- I just sit back, relax and wait until the service becomes available. Why shouldn't our EMR systems follow a similar process?

Picture the situation whereby each LHIN runs it's own data-center and serves up a SaaS EMR accessible through your favorite browser! Every authorized clinician (doctor, nurse, paramedic, specialist etc.) around the globe now has access to the same patient record! Eureka!
My point is that generally, doctors don't do their own accounting, they don't service their own vehicles or their office equipment; so what's so special about IT?
When a police officer pulls you over on the highway, s/he just needs your documents to access your personal/vehicle record -- surely healthcare should be no different -- my health is just as important as my security!

To those doctors who have so far controlled the urge to implement an EMR system, I applaud your prescience; with the advent of netbook computers sans Microsoft Windows, the Apple iPad and similar tablet offerings from other manufacturers, something's gotta give pretty soon!
Let someone else look after the IT work in the back-end -- you concentrate on the front-end, i.e. the best patient care possible.

Next month we'll discuss integrated health care -- a process that's working very well in the US; in the meantime I'll let you get back to organizing your Super Bowl party. Be safe and enjoy!

Ernest A. James

President/CEO
Regal Informatics Inc.

e-Health -- the shoe-maker needs new soles

I hope you had a wonderful holiday and the effects of L-tryptophan have long since dissipated; so now you're ready for the Ontario Winter Games -- you know the ones where you compete to see who can get the longest slide on black ice without falling, who can throw snow the farthest clearing up after a storm, or who can clear the snow jammed into driveways by the plow, the fastest.
Winter's upon us, obviously, and I sure didn't miss the irony of the situation after I'd just purchased fuel in -25 degree wind-chill weather and my favorite singer Dee Dee Bridgewater begins singing the song "Cherokee" with opening lyrics of "Dreams of summertime..."

Anyway, apologies to those readers living outside the boundaries of the Central East LHIN (CE LHIN) -- the posts for January and February may not be as generalized as previous articles; I'd like to suggest however, that what's discussed is by no means unique.

I received a "December-update" alert from the CE LHIN concerning current e-Health projects and the following items really piqued my interest:

• the Hospital Information System (HIS) being terminated due to a lack of resources -- this project appears to pertain to CE LHIN data consolidation standards; I presume this means the end of the project, since it's obviously inappropriate to continue the next phase if the previous one is incomplete
• a business case to consolidate 33 hospital data-centers will be presented to the various CEOs at an all-day session in our region -- I also presume the CE LHIN is spearheading this
• the CE LHIN is joining forces with 5 other LHINs to develop a Patient Health Information (PHI) system that will enable data sharing
• we're also involved in a Resource Matching and Referrals (RM&R) project with 7 other LHINs whereby information will be shared between the various "Care" centers 

I received another alert shortly thereafter informing me that the Peterborough Regional Health Center ("a cornerstone of our LHIN" as per the Chairman of the CE LHIN's Board), after being in a deficit position for the past 13 years, is this time projecting a $35 million whopper for the 2010/2011 season.
Things have gotten to the stage that the LHIN is sending in a peer review team to fix the situation!

To me, the above begs the question: Why are we involved in so many projects with non-CE LHIN participants (and terminating internal ones) when our infrastructure is tumbling, or about to?

I'm suggesting the CE LHIN, at a minimum, consider the following options:

• all projects involving other LHINs be mothballed -- let's hunker down and get our house in order -- let the shoemaker have a chance to re-sole his shoe, so to speak
• get our LHIN's hospitals' data-centers consolidated within the region and change the way we pay for and use software; this will not only save huge amounts of money on the licensing front, but will also facilitate information sharing (think EMRs/EHRs) -- the current lack of which I feel is a big contributor to the ongoing deficits

At this point, I'd like to hold the discussion until next time when I'll get into more details.

Think the above is a tad unworkable? Well, let's get your ideas/comments posted -- we're gonna need all hands on deck; the next couple of years will no doubt be painful since budget cuts (which inevitably translate to service reductions) will be an ongoing reality, but if we do things right we could come out of this with a much more efficient operating model that can be proudly shared with other LHINs.

Wishing us all a safe, healthy, challenging but productive year ahead.

Ernest A. James

President/CEO
Regal Informatics Inc.