Canada’s health information strategy is overly focused on the development of a national infostructure and underserves the needs of physicians and patients, provincial administrators say following release of a major new study of electronic medical records (EMRs) in Ontario.
In focusing it efforts on electronic architecture, Canada Health Infoway, the federal agency working with the provinces on designing and financing the national health infostructure, hasn’t given physicians the tools they need to adopt and use EMRs, says Brian Forster, chief executive officer of OntarioMD, a subsidiary of the Ontario Medical Association, which manages the provincial government’s $386 million EMR Adoption Program. “If you look at Infoway’s blueprint, not much of it is available to physicians.”
David Ludwick, manager of the Sherwood Park Primary Care Network in Alberta adds that “there’s been a lot of time and money invested in a national infostructure.” But given that the bulk of patient demand is local in nature, the time has come to refocus on investing in delivering ehealth solutions “that help patients equip themselves,” he says.
After almost a decade of work and $2.1 billion invested by the federal government, Forster worries that Infoway continues to underserve patients and physicians in its focus on patching provinces and regions together along an “interoperable” national health information highway.
He argues that the results of a new survey of Ontario physicians indicates that investments in EMRs at the physician level are more effective in generating improvements in care (www.cmaj.ca/earlyreleases/4theRecord.dtl).
The survey indicates that EMRs help physicians improve their efficiency and increase personal incomes while improving patient care, particularly through preventive care measures, which ultimately reduces future demands for health resources.
The success of EMRs in propelling physicians to improve practice management and patient care by adopting electronic tools indicates that federal and provincial governments need to place far greater emphasis on “building from the middle-out” by directing more of Canada’s multi-billion dollar health infostructure investment toward doctors and patients, Forster says.
Infoway’s current blueprint, released in 2006, makes no mention of linking patients to physicians (www2.infoway-inforoute.ca/Documents/EHRS-Blueprint-v2-Exec-Overview.pdf). The agency does, however, list “patient access to quality care” as one of its 10 main priorities on its website. But a map of the 182 largest investment projects indicates that only eight address the theme (www.infoway-inforoute.ca/about-infoway/infoway-projects-map).
Rather than investing in a national system “where every Canadian has their health information move with them, no matter where they receive care in the country,” the primary focus should be on local, often inexpensive, health information solutions that connect doctors and patients, Forster suggests. He adds that the United Kingdom government has dramatically refocused its national ehealth plan on local solutions, and away from creating a complex, expensive national grid.
Forster’s “middle out” idea draws from the experience of New Zealand and Australia, where clinicians, not bureaucrats, crafted the world’s top-ranked EMR systems according to a Commonwealth Fund survey (http://content.healthaffairs.org:80/cgi/content/abstract/hlthaff.28.6.w1171).
“The top-down approach of many national programs for healthcare information technology (IT) may be at the heart of their current problems,” notes Enrico Coiera, director of the Centre for Health Informatics at the University of New South Wales in Sydney, Australia. “The medical-industrial complex loves a big procurement, and the contracts do not get much bigger than for building nation-scale health information systems … [but] government should avoid doing what it is not good at, like designing, buying, or running IT.”
There’s now a need for Canada to rebalance federal and provincial ehealth investments and refocus its EMR approach, argue Ludwick and Allan Brookstone, a Vancouver, British Columbia physician and publisher of CanadianEMR, which rates products.
“The investment strategy has been weighted in the wrong direction,” says Brookstone. “
But some experts say it may be premature to say that investments at the local level necessarily yield improvements in patient care.
Robin Tamblyn, scientific director of the Clinical and Health Informatics Research Group at McGill University in Montréal, Quebec, says the Ontario survey warrants follow-up research.
Because it is based on survey responses from a subset of Ontario users, the study might not be usable “for an argument on return on investment,” she cautions.
But the finding that physicians widely endorse EMR usage should prompt closer investigation of how the use of EMRs affects such things as medical testing procedures, pharmaceuticals and specialist referrals, she adds.
Similarly, Anne Holbrook, principal investigator on a series of electronic health research studies at McMaster University in Hamilton, Ontario, cautions that the OntarioMD survey data is drawn from “only a portion of all docs using EMRs” and contains “a major response bias” in that respondents had all received funds from the survey manager. As well, she warns that OntarioMD is in a potential conflict of interest “as their survival depends on this evolution of EMRs.”
Nonetheless, the results of the survey “make a lot of sense,” she says, adding that EMRs appear to be performing the basic functions they were intended to perform.
Holbrook also notes that surveying physician attitudes, alone, is not an indicator of improvements in patient care. “It is much more important to actually measure whether quality of care is improved and whether patient safety is improved. This requires prospective, unbiased studies looking at clinical patient outcomes.”
Canada Health Infoway declined interview requests on whether its strategy should be revised to focus more squarely on programs that promote use of EMRs at the physician level.