Improving front-line health care - an update on eHealth Ontario

(Music)
(Music)
I think this is a good time to talk about how
an electronic healthcare system can improve the quality of care,
and the access to care, for 13 million Ontarians.
And this afternoon, I'd like to pose an attempt
to answer three questions:
One is, "Well, what is electronic healthcare,
and why is it so important?"
The second is, "What is eHealth Ontario's strategy
"for trying to implement electronic healthcare
in the province?"
And then the third is, "How is eHealth progressing?
What will patients see, and when will they see it?"
Now, as I start, I would like to acknowledge four special guests
at the head table who Nick has just introduced you to.
One is Jonathan Guss, the CEO of the Ontario Medical Association,
representing 24,000 physicians in the province.
The OMA are our delivery partners
in the process of wiring up doctors' offices
so that they're using electronic medical records.
They're doing an outstanding job at that,
and we now have more than half of our primary care providers
either using electronic records,
or in the process of implementing them.
And we've gained greatly from that partnership
and from your advice.
Um, Dr. Doris Grinspun heads
the Registered Nurses' Association of Ontario.
She represents 116,000 nurses.
And Doris and her colleagues have been very helpful to us
in looking at patient care through the eyes of nurses.
Who, after all, are very important front-line providers.
And we've learned a great deal in that dialogue,
in understanding what kinds of electronic tools nurses need
to be able to provide better care.
Uh, Camille Orridge is the CEO of the Toronto Central LHIN.
And in this, and in previous roles,
has been an untiring advocate
for pushing better-quality healthcare to the front lines,
and for the role that electronic health records
can play in doing that.
And Dr. Jack Kitts from the Ottawa Hospital.
The Ottawa Hospital has done a number of very innovative things
with electronic health records,
and they've actually been an extraordinary partner for us
over the past year, as we have tried out
some of our new systems and modules of capability.
Right now there are over 200 clinicians in Ottawa
who are working with OLIS, the Ontario Lab Information System,
which right now, contains over half the lab results
in the province of Ontario in electronic form.
That's a very important pilot.
And as we work the kinks out, we'll be looking for ways
to roll that out to all the practitioners in the province
as soon as we can.
So thank you all for being here,
and for your support over the past year.
So let's turn to the first question, which is,
"What is electronic healthcare, and why is it so important?"
And I'd like to start with two stories.
Something that's happened over the past year
is that from time to time, people say,
"So, what do you do for a living?"
And I say, "Well, I'm the new president of eHealth Ontario,"
and they say something just like what Nick said:
"Boy, you must really like a challenge."
In fact, that's one of the more enabling things they say.
(Laughing)
The second comment though is invariably something like,
"Oh, listen, I have to tell you what happened
to my uncle last year," or to "my mother,"
or to "our son."
And what follows is one of a list
of pretty distressing stories
about close encounters with our
paper-based electronic healthcare system.
And I'm going to share just two of them with you.
One was a woman who said to me that she and her brother
shared responsibility for taking care of their elderly father.
And it was necessary to take him into the hospital
for an exhaustive full day battery of tests.
And her brother said, "Well, I'll take the day off
and I'll take Dad in."
And they wheeled him around the hospital,
and he had all of these tests.
And a few days later they got a phone call
saying that more tests were required.
And she said, "Well, fine. I'll take the day off, I'll do it."
She wheeled her father around the hospital.
And during the day, her father kept saying,
"You know, I think I've been here before.
I think maybe they did that one before."
And she said, "Oh, Dad, you know how confused you get."
And they found out a short while later
that their father was right.
He had been sent back to the very same hospital
to have the very same series of tests administered,
one after the other.
And it was simply because one of his doctors had no idea
what another of his doctors were doing.
A second story was from a man
who rushed his 82-year-old father to the hospital,
found that he had rapidly-advancing pneumonia,
and his father had been in frail health for a number of years.
And in the course of the day in emergency,
they realised that he probably was not going to be able
to get ahead of the pneumonia, despite antibiotics.
And he then had with the ER doctor
one of those heart-wrenching discussions
that I'm sure some of you have had to have, which is,
when to shift from battling a disease
into a regime of palliative care,
which might shorten life, but would assure that a loved one
is as comfortable as possible in their final hours.
And so they agreed on it,
and his father was moved up to a ward in the hospital.
And when he and his family arrived in the ward,
they might as well have been visitors from Mars.
The staff in the ward had no idea who their father was,
they had no idea he'd been in ER all day,
they had no record
of what his progress during the day had been,
because they couldn't find the paper charts.
And the paper charts included the doctor's
express instructions on end-of-life care.
And they said, "Well, we're not authorized
"to do any of those things
without the doctor's instructions."
So the son ran back down to ER, tried to find the doctor,
he'd gone for the day, tried to find the charts, they were gone.
And when he got back up to the ward, he saw two things.
He saw his father
obviously in distress and uncomfortable,
and he saw his 80-year-old mother starting to fill out
a blank history page
so that she could give the staff some idea
what was wrong with her husband.
Later that night, they saw their father die
a needlessly painful death.
And if I seem a little bit more familiar with that story,
it's because the son in the story is me.
And that was the night my dad died.
Surely we can do better than this.
We have to do better than this.
Our vision at eHealth Ontario is that any time
any one of us is in front of a provider,
that provider has in front of them
all the information they need
to take the best possible care of us.
And it's not just information from their own files,
it's information drawn from any other provider
that you may have been visiting.
So, integrating records from disparate systems
so that any provider you visit can take better care of you.
A pretty simple notion.
Well, how hard could that possibly be?
Well, let me take you back a year
and describe my tour around Ontario as I began
learning about the healthcare landscape in the province.
And what I learned is that
we have about 155 hospitals in the province.
They all have hospital information systems,
they all create patient records.
And, generally speaking, the records created
in any one hospital cannot be read
in any other hospital in the province.
We have something like 6,000 doctors
using electronic medical records in their practices.
Those systems are provided by 11 vendors.
And, generally speaking,
the records created by a physician in their practice
cannot be read by the system used
by any other physician in the province,
nor can they be read by any hospital.
We have a community care and access system--
Uh, Community Care and Access Centre system in Ontario,
with 42 different locations,
with a very good system with patient information in it.
And that information cannot be read by physicians
or any of the hospitals.
So I took this job, thinking, as many Ontarians do,
that there are no electronic health records in the province.
What I discovered is the exact opposite.
The province is awash in electronic health records.
The problem is, none of them can talk to each other.
There's no way of assembling
a comprehensive and accurate view of any one of us.
And so our task is to find a way to do that.
So, how do you go about doing that?
Well, another thing I encountered early in my job
was this sense that the reason eHealth Ontario was here
was because we were a large
infrastructure manufacturing project.
And that somehow inside the agency,
we had a number of people busily stapling together
13 million health records.
And if we were lucky, there would be a day in 2015
when we could flip the switch on a giant server farm,
dozens of spindles would spin to life,
and out would fly 13 million health records for use
by providers and patients alike, and they'd all be perfect.
And in our industry,
we call that a high-risk approach.
(Audience chuckling)
So we began thinking of alternatives.
Well, one thing we noticed around the province
was that in certain locations,
typically clustered around larger hospitals,
there were already very innovative efforts
to try to combine records and to move them between hospitals,
and to move them out to the physicians
and family health teams in the area.
We saw an excellent demonstration
of a system like that in Ottawa.
There's a very good system in Hamilton that's doing it.
London, with their SPIRE project,
is doing a very good job.
Toronto has a system, Barrie has a system,
Sudbury has a system, Thunder Bay has a system,
and I'm sure I'm forgetting somebody.
And none of those systems is the same.
None of them follow common standards,
none of them use common technology.
And we were on our way to eight or nine
balkanized regions of the province,
with no ability to exchange records between them,
or have records follow you wherever you go in the province.
And so we had to think, "What sits between Ontario,
"which, with 13 million patients, is too big,
"and nine or ten regions, which feel a little bit too fragmented
"and too much like reinventing the wheel
if we try and deal with those locations"?
And what we feel will work
is three regional integration hubs.
We announced the first of these last week with ConnectingGTA.
We believe there should be two others.
One would be ConnectingSouthwesternOntario
and another will be ConnectingNorthAndEastOntario.
And each of these three hubs will pull together the records
of providers in the regions, who, after all,
tend to see the same patients.
They represent natural referral areas.
If you are a patient in-- Or an Ontarian in Windsor,
you probably have a family doctor in Windsor.
If you get sick, you probably go to a hospital
in the Erie St. Clair area.
And if you get really sick,
you may go to London Health Sciences.
But you're not going to Kingston,
and you're not going to Thunder Bay.
All the providers in that region have an incentive
to want to be able to see more information
about each of the patients they care for.
And so these natural referral areas are very good places
to start building integrated health records.
So let me talk a little bit about ConnectingGTA,
because it's the first of these hubs
that we announced last week.
The GTA is a pretty large natural referral area
with 6.3 million people-
it represents almost half the population of Ontario.
And any one of us living in the GTA could show up at any one of
about 700 different healthcare institutions seeking help.
So what we have to find a way of doing
is taking the electronic records in each of those institutions,
combining them into a unified view of each of us
that contains all the information necessary
to take better care of us, and make sure that there's a way
of getting it back to a provider when they need it.
So the way we're going about that in Toronto,
and I will spare you the technical details,
because I'm not sure I fully understand them yet,
but in my layman's terms, I think of it as a,
sort of a cross between Union Station and the Yellow Pages,
if I can mix metaphors for a moment.
What it means is that we need to be able to reach out to, say,
Toronto East General Hospital, and pull in a patient record.
And, against some master template of what all the things
an electronic health record for an individual could contain,
know where to put that information.
And also know where to put information
from physicians' files:
your history, your annual physicals,
the medications you're on, encounters with hospitals,
encounters with long-term care.
And you can see where all these things would go
in some master template.
And then realise how to map that record
back onto the legacy system that any provider
might be using who's trying to care for you.
And I think of that as using translation tables,
but I'm hopelessly dating myself in terms of technology
when I use a term like that,
because it's all going to happen in the cloud, when we get there.
So that's pretty complicated,
but the other way of doing this would be even more complicated.
What's happening at the centre of one of these integration hubs
is something called a "HIAL"--
I promise that's the only--
Almost the only acronym I'll use this afternoon--
A Health Integration Access Layer,
is that common standards are being used.
And one thing we need in Ontario
if we're going to have interoperable health records
that can follow you wherever you go,
is a set of common standards.
Well, one thing eHealth could do,
and I don't think this is a very good idea,
is that we could lock ourselves in a room with a big whiteboard,
breathing dry erase marker fumes,
and have a vision of common standards for the province,
and announce them.
And if we did that, we would have hundreds and hundreds
of CIOs around the province tearing their hair out,
because they've invested ten years and millions of dollars
in legacy systems that are working perfectly well
in their hospitals or their clinics
or their long-term care settings.
And what we would be saying is, now you have to retrofit those
to a common set of top-down standards
imposed by eHealth Ontario.
We don't think that's a very good idea.
We think a smarter idea is,
as we make these records interoperable,
as we find a way of combining them,
let's inject the common standards there.
Because the problems we have to solve are:
how do we tag records, how do we number them
so that we know how to put them together?
How do we make sure
that they're associated with a unique patient?
How do we know that they're safe and accurate?
How do we protect their privacy?
How do we protect their security?
How do we make sure that they're only accessed
by providers who should be able to look at them?
Right now in the province, we have literally
hundreds of different ways of numbering medical records.
We have all sorts of different ways
of figuring out who providers are,
who patients are.
We have many, many different ways
of managing security and privacy.
And we will not be able to build a province-wide system
that is safe and accurate and secure
unless we start to move to some common standards.
So ConnectingGTA is our opportunity to do that.
And what we want to do is do this as an open-book exercise,
with CIOs from around the province
involved in the decisions that are made.
Because, really, what we're doing is we're defining
the de facto architectural standard for the province.
So we figure out how to number records
and how to connect them together
and how to attach them
to unique individuals and other things.
We need CIOs from around the province looking on and saying,
"Yes, that makes sense.
"We're agreeing now to that becoming
"a common provincial standard.
"That will work in Southwestern Ontario,
that will work in Northeast."
So as we build ConnectingGTA, we know we'll be building a core
which solves the problem of how to make records interoperable.
And so when we go to start building
ConnectingNortheastOntario,
or ConnectingSouthwesternOntario,
that work doesn't have to be done again.
We can put that core technology in the middle and say,
"Please don't reinvent the wheel.
"This is the beginning of common standards,
"and if you build your hub following those standards,
"then we know at the end of the day
that all the records in the province will be interoperable."
And wherever you go in the province,
a provider that you present yourself to
will be able to look at your record,
because we found a way of making them move across the province
and across many different computer platforms.
Now, this is obviously a very complicated effort,
and it's important that eHealth Ontario
work with the smartest people in the province,
and from without the province, in order to get this done.
And so at eHealth, really, what we're engaged in
is a massive outsourcing operation.
We are a series of public-private partnerships
where we work with best of breed, healthcare providers,
their IT departments, and technology partners.
In fact, if you look at the budget of eHealth Ontario,
something like 80 percent of our budget
flows straight through the agency
and goes out to the private sector.
It goes out to the healthcare providers
that have the IT departments
that are capable of doing these things,
and much of it goes out to technology providers
that are bringing their experience,
much of it gained in other jurisdictions
who have already figured out ways of doing this.
And so, what eHealth does is several things:
we establish architectural standards for the province.
We write the blueprint, or the roadmap,
for how all this will come together.
We don't do it alone.
There's been a tremendous amount of consultation
with providers around the province over the past year,
to get their ideas, listen to them,
synthesize them, improve upon them.
And we now have a draft architecture
which we're beginning to syndicate
with the healthcare sector, which we'll improve.
But at the end of the day, we want to be releasing something
where most institutions in the province will look at it and go,
"Yep, they listened. That's what we talked about.
We recognize ourselves in that."
So architectural standards is one thing.
Establishing the common interoperable standards
we need is another.
Being a strategic investor
is a very important part of what we do.
Right now in the province there are many, many efforts
to make records move around and to push them out to providers,
but as I mentioned earlier,
we're reinventing the wheel in many different places,
and that means that we're using tax dollars
eight or nine times over
to solve the same problem in different locations.
We simply can't afford to do that anymore.
And so, as we develop the architecture and the roadmap,
we're going to be very thoughtful
about the way we spend taxpayer money.
And what we would like to do is build things once,
and then reuse them around the province.
So we'll be investing in projects which are scalable
and workable on a province-wide basis,
and that will converge.
But we will not be investing in projects
that are stand-alone and diverge.
We need to start pulling this thing together
if it's going to work and if it's going to be cost-effective,
and if we're going to get there.
So that's the role that eHealth plays.
The style with which we do this is something we like to refer to
as a "servant leader approach".
We start by listening.
We are constantly synthesizing the ideas we hear,
we're playing them back.
We're trying to pull standards together
using as much of the brain power around the province as we can.
But when we lock them in, we then need to enforce them,
and that's the only way we'll have a safe and accurate
electronic healthcare system.
So that leads me to the third question I posed, which is,
"What will patients see and when will they see it?"
Well, we should probably start with what they see today.
I mentioned that we have over 6,000 doctors
now using electronic records
or in the process of implementing them.
Right now in Ontario,
all images taken in hospitals are digital.
There is no more film.
X-rays, MRIs, nuclear medicine, mammograms are all digital.
And what that means is that we can send those images around
to hospitals and out to physicians electronically,
so they're accessible virtually immediately,
and there's no more waiting for the big yellow envelope
with the film in it, or worrying that it might get lost.
We have a Drug Profile Viewer
in most of the emergency rooms of the province.
And on that Drug Profile Viewer are the medications prescribed
to any senior citizen in the province of Ontario,
because they're funded by the Ontario Drug Benefit Program.
And it actually represents about 45 percent of the prescriptions
in the entire province.
So any time a senior's wheeled into the ER,
their drugs are on-screen and they're available immediately.
We are using Hospital Report Managers
to take important information from hospital stays
and push those out to physicians and other providers
who are the next stage of care for a patient.
So they could be radiology reports,
they could be medication changes while in hospital.
A very important form of that report
is a hospital discharge summary,
because it describes what has happened to a patient
while they're in hospital, and provides their next provider,
whether it's their physician or a long-term care home,
with better information with which
to take care of that patient.
Last month, we sent out 140,000
electronic hospital reports to the next provider.
Now, we have many, many more
that we have to figure out how to do,
but that's a good start, and we need to build on that momentum.
So, what will patients see?
Well, I think the main thing they're going to see
is that more and more of the providers they visit
will have computers in front of them.
They'll be using automated tools.
What the providers will see
is more and more of the patient on the screen.
So instead of right now only being confined
to the information that has originated
inside their practice,
or inside the four walls of their institution,
they'll be able to see
a much broader picture of their patient,
all of their encounters with the healthcare system,
and they'll have the information they need
to provide better care at a much lower cost.
In order to do it, we need to continue
to work on a very strong partnership basis
with the healthcare providers of the province
and with the technology providers.
I would like to think we're off to a good start at that,
in that we-- I'm sensing that there's a support
for this strategy from the healthcare providers,
and that they're already beginning
to work better together, and we with them.
But we certainly need to continue this.
There's no way eHealth Ontario can do this on our own.
We haven't the skills--
For one thing, we don't have the information.
Most of the information resides in the files
of the many, many different providers around the province.
But I believe we can do it.
I believe that if we can work as a unified front
of healthcare providers and technology providers,
galvanized by a common vision that we're going to provide
the best-quality care as quickly as possible,
and at the lowest cost possible, we will get there.
Now, at eHealth Ontario, we are deeply honoured
to be entrusted with so great a responsibility.
And here I really would like to acknowledge
the new management team at eHealth Ontario,
and some of our new directors.
They're at tables right there and right there.
So thank you. They really are the brains behind the operation,
and are doing great work on all of our behalves.
Um, we take this responsibility very seriously,
and we passionately believe that if we get this right,
and we will, that we can create
a healthcare system for the people of Ontario
that will be truly exceptional.
Thank you very much.