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- Page navigation anchor for RE: Challenges presented by a custodian-based access systemRE: Challenges presented by a custodian-based access system
Dr. Persaud raises an interesting argument. In my opinion, antiquated laws that define the powers of health information custodians to control personal health information is the systemic problem that underlies issues with data interoperability and access to health records in Canada.
As defined by law, these custodians—such as individual practitioners, hospitals, pharmacies—are persons or organizations who possess custody or control of personal health information in conjunction with their powers or duties. They make decisions regarding access to records by third parties, including patients. The custodian-based access model made sense in an analog environment with paper records, whereby an entity was needed to store physical records securely and act as the point of access. However, digitized health records are easily copied and disseminated across a variety of platforms. Moreover, much health information is generated outside of patient-provider encounters, and, despite technologies like patient portals, remains largely inaccessible by the patient.
The current model of data transfer between siloed electronic medical record systems and various other databases places undue administrative burden on the custodian. Although custodians are generally given 30 days to respond, many are inundated with requests from patients, healthcare institutions, insurance companies and others for information that is increasing in volume daily, making it challenging to meet deadlines....
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: One EHR should not rule them allRE: One EHR should not rule them all
There is much hope in being able to leverage technology to improve healthcare, and understandably much frustration when it does not deliver as quickly as one hopes. However, as with any cycle it is important to avoid the lows as well as the highs. We should not lose sight of the goal and not forget to understand the underlying issues.
The author’s assertion that interoperability is an “unsolvable problem” that could be solved with a single company health record is not borne out with fact in the Canadian system. Health Information Exchanges (HIEs) like those in Ontario (Clinicalconnect, Connnecting GTA) are proof that records can, and are, being accepted and transferred between different sites. The Ontario Laboratory Information System (OLIS) stores and transmits information to a multitude of inpatient and outpatient electronic health records. The challenge is not to provide a single technological platform, but to break down the barriers to interoperability that are created when business models are threatened and privacy laws are outdated.
Our local experience in the implementation of a commercial enterprise-wide EHR has taught us that customization of a local instance of software leads to forks in the software that makes interoperability with other instances difficult, not solving the interoperability problem. This is not unique to our hospital; given the countless differences in everything from nomenclature to business logic between medical organizations, th...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: a National EHR for all Canadians: Another Way ForwardRE: a National EHR for all Canadians: Another Way Forward
I recently read the editorial by Dr. Nav Persaud on a national electronic health record. I share his perspective in support of an evolutionary change in digital health within Canada.
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As Dr. Persaud noted, health practitioners and service providers need better technology & collaboration to deliver better healthcare. “The lack of timely access to information means patients are at risk of harm from incorrect diagnoses and avoidable side effects on everything from prescription medications to the intravenous dyes radiologists inject when they do CT scans and other X-rays.” [1]
On behalf of innovators in the cybersecurity space, I want to let readers know that healthcare practitioners are not alone. Cybersecurity engineers and scientists with a mission to enable digital innovation have devoted time to developing identity and access management technology that radically moves digital healthcare forward as it solves the integration gap to connecting patients and service providers in Canada.
A federated identity solution differentiates by putting patients in control of their digital identity, and enabling secure access to their records. By putting patients first, an identity and access management solution can accelerate the speed and accuracy of healthcare delivery for patients without bringing hospital workflows and operations to a halt.
This type of solution provides the ability for citizens’ existing identity providers (e.g., Health Canada, Ministry of...Competing Interests: IdentityNorth conference - Page navigation anchor for RE: A national electronic health record for primary careRE: A national electronic health record for primary care
It is great to see all of the responses to this article. My feeling is that rather than choosing a single vendor solution the thing to do is to standardize on the data and the architecture of the records. A lot of work has been done on this by international organizations like HL7 and ISO. Canada participates at these meetings but the challenge seems to be on how to get that knowledge to the level of the EMR developers and to the EMR users. I have been to many meetings related to computer based health records where no one had heard of ISO 10781, 13606 or 18308. These documents provide extremely detailed information on health information standards. Physicians in general are only interested in having something that works. The problem is that while they be unhappy about how their system work they seem to be unwilling to spend any time informing their vendors about problems. There are many simple things that could be done to reduce some of the stress that these EMRs are causing but it seems to take decades to get anything significant done. A major problem are the organizations that produce the documents that are imported into physicians' EMRs. These systems were developed in the last century and there seems to be little pressure to get them updated.
I agree that physicians should not have to be involved with the deep in the weeds technical details. The problem is that the EMR developers have not really been involved either. There seems to be a preference to make thi...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: data interoperability is more far more valuable and feasible than single EHRRE: data interoperability is more far more valuable and feasible than single EHR
I agree fully with Dr. Persaud that health data should be stored and administered at a national level, or failing that at a provincial level. This would eliminate costly retesting, reduce medical error, improve the efficiency of health care provision, and allow for improved research and quality monitoring in the health care system. It is truly unfortunate that the greatest promise of electronic health records were never realized due the diverse set of incompatible systems implemented by siloed IT departments and care providers with no national or provincial direction.
The solution proposed by Dr. Persaud, however, is fundamentally flawed and lacks insight into the realities and complexities which have precluded such an approach in the past. For instance, requiring a single national EHR system would hold hostage all Canadians, health care providers, and institutions to a single corporate entity. Consider how all the varying requirements of every stakeholder would be collected and negotiated into a manageable service contract? Who would pay for voiding all existing EHR service contracts with providers who were not selected for the single national service?
We need to work towards alternative but feasible solutions to achieve the stated goals.
In my opinion, the best solution is centrally managed data with interoperability standards and requirements for querying and storing health data. EHR systems implemented across the country would be required and c...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: The future of EMRs in CanadaRE: The future of EMRs in Canada
What can the wealthiest person in the world teach Canada about the design of electronic medical record systems?
A lot.
Around 2002, when Amazon was still more or less an online bookstore squeezed by shrinking margins, Jeff Bezos issued a single mandate via email (https://plus.google.com/+RipRowan/posts/eVeouesvaVX) that set Amazon on the path to become the dominant online retailing platform in the world. The keyword here is platform: Amazon doesn’t sell everything itself, but it provides the interface between buyers and sellers. In one email he changed the culture of the company from one focused on products to one focused on services. In doing so he also made the company vastly more efficient, leveraged the ingenuity of third party developers, and turned cost items into revenue streams.
How did he do it? And what can we learn from this case to improve the efficiency of our healthcare system?
Essentially, the genius of the mandate was to make all of the teams of programmers working for Amazon communicate via the same interface, and to make the internal services that the teams provide to each other accessible to third party programmers outside the company at the flip of a switch. In this way Bezos drastically reduced the amount of redundant work the independent teams had to do. Instead of building it yourself, just look for it in the directory of services — chances are someone has d...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Canada's Lived Experience with a Single EMRRE: Canada's Lived Experience with a Single EMR
I was pleased to see the commentary by Dr. Persaud - A national electronic health record for primary care - and the resultant discourse that has arisen. Thoughtful debate about the best means of achieving health information interoperability is of central importance to the Canadian health service, as patient centric informational integrity is foundational to the delivery of quality care.
The notion of a single enterprise EMR as a means of solving the health information interoperability issue is not a theoretical premise in Canada. One need not look to the United States or Singapore to find such an instance. Just look north.
The Northwest Territories leads Canada as the most integrated health information system in the nation (see: https://cmajnews.com/2017/11/09/northwest-territories-leads-canada-in-el...). This was accomplished by deploying a single EMR on a single database through all services and all communities. In fact, this project goes beyond what is proposed by Dr. Persaud in that it unites not only primary health care providers, but specialists and allied health care service providers as well; virtually all health care providers in the Northwest Territories. And it works.
Although some may dismiss this success as a function of deployment to a small population of providers, the constraints faced in deploying the s...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: SINGLE EMR FOR CANADA: A SECOND OPINIONRE: SINGLE EMR FOR CANADA: A SECOND OPINION
The above editorial describes the author’s desire and need for a single national Electronic Medical Record (EMR) in primary care. He speculates that many of our problems in primary care could be solved by such an instance, from sharing of records between clinics, to research, to specialist access to notes. He cites single health systems in the US and Singapore as examples of how and why this could work. This is an interesting perspective, but one which may be overly simplistic and not shine light on the whole picture. There has been significant progress and development made in the digital health space in Ontario over the past ten years and this should be recognized and celebrated. This, coupled with a relentless focus on systems integration across the continuum of care, is where we should put our energy.
Although we have much in common as family doctors across the country, we all ask very different things from our EMRs. Practice environments are not the same in inner city urban centres, suburban practices, rurally, in university health clinics or aboriginal care centres. This delivery complexity needs to be appreciated. Nationally over 80% of family doctors already have purchased an EMR that works for them and are using it fulsomely. In Ontario this is over 85%. Physicians own their systems. They have made significant investments in these … financially, in time spent recording information about their patients, and in blood sweat and tears producing clinic...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Single EMRRE: Single EMR
I have been saying this for years and this is the main reason I have hesitated to have EMR. One system = no problems. L. Sadinsky M.D. Etobicoke, Ont.
Competing Interests: None declared. - Page navigation anchor for RE: common EMRsRE: common EMRs
The most expensive time consuming waste of money is taken up having to choose an EMR and then having to scan in reports and other patient information from other EMRs. This is the tragedy of health care EMRs a lack of willingness for provincial ministries to implement a common system. We recently had to threaten to sue a EMR provider to export his data to another EMR. Portability is a bad joke. We are too late for this. Who is going to buy Telus and the many other EMRs providers
Thank goodness the folly of our EMR history is highlighted by this article. Well done
Competing Interests: None declared. - Page navigation anchor for RE: A national electronic health record for primary careRE: A national electronic health record for primary care
It is sad to see that it is taking so long to get to where we have what could be called high performance electronic medical records. One important aspect must be the ability to exchange information without having to manually enter things. There has been a lot of work done at an international level that is largely ignored by EMR developers, Infoway and CIHI. There has been a strong preference to reinvent the wheel and a lot of time and money has been wasted on the development of rudimentary EMRs that are contributing to physician burnout. My experience has been that when a new EMR is being created the developer is very interested and willing to make modifications. After about 3 years once there is a bit of a user base the developer basically stops listening. Opensource products are an exception as evidenced by the enthusiastic user group meetings that OSCAR has had.
Various organizations have repeatedly produced 'high level' reports that describe some aspects of a desirable solution. The problem is that efforts to hammer out the details are typically deemed to be 'out of scope'. No organization has been willing to put the required effort into mapping out all the details that are required or to provide physicians with the funding to participate in a sustained effort to accomplish this. When efforts have been made to produce comprehensive specifications like the EMR 2 EMR work done in BC the vendors did not see that this could have provided guidance...
Show MoreCompeting Interests: None declared.