Dr. Glen Geiger paraphrases Victor Hugo: Nothing is more powerful than an idea whose time has come.
Geiger, chief medical information officer at The Ottawa Hospital, says that the health care system has finally reached the point where a shift to electronic medical records (EMRs) has become inevitable.
So much so, that some Canadian hospitals are preparing for the big bang. Rather than building digital health-information management systems piece by piece, they plan to implement new comprehensive computer systems all at once, often on a single day. And they hope these new systems will help them provide better care to patients.
The Ottawa Hospital went through a massive big bang in June 2019 in partnership with five other health care organizations: The Ottawa Hospital Academic Family Health Team, Hawkesbury and District General Hospital, Renfrew Victoria Hospital, St. Francis Memorial Hospital in Barry’s Bay and the University of Ottawa Heart Institute. The hospital’s switch to the Epic Health Information System was not without its challenges and its detractors; however, the hospital is now recognized as having made a significant leap forward.
For almost two decades, health care experts and analysts have promoted e-health and the EMR as ways to improve Canadians’ health care. But for the most part, the promise of information technology has yet to be realized.
Canadian hospitals are still struggling to harness computer technology for enhanced patient care. Governments have spent hundreds of millions of dollars incentivizing hospitals and medical offices to convert to paperless systems that house and manipulate medical information about patients. But only small steps have been taken, with scant evidence that patient safety and care are better off. Hospitals are languishing with half-built computer systems that cannot talk with one another and that are not yet sophisticated enough to perform the functions that clinicians and patients need.
In 2001, The Institute of Medicine (IOM), an arm of the National Academy of Sciences in the United States, released an influential document titled Crossing the Quality Chasm: A New Health System for the 21st Century. In it, the IOM called for development of an information infrastructure to support health-care delivery, consumer health, and quality improvement. It identified the need for automation of patient clinical information and drug-prescribing systems. The IOM suggested that strong commitment to such an endeavour could result in elimination of most handwritten clinical data by the end of the decade.
In Canada, response to such recommendations led to the establishment of government agencies such as eHealth Ontario. But by 2009, the Ontario auditor general released a scathing report stating the provincial government had wasted $1 billion in taxpayer money on eHealth Ontario and that little progress had been made in achieving an electronic health record.
Individual hospital organizations and health-care regions have continued to work toward establishing electronic health-information systems.
Most of these hospitals have slowly rolled out, over the past five to 10 years, various segments of an electronic health-information system, resulting in a hodgepodge of different systems.
“One of the challenges is that the systems don’t talk to each other particularly well,” says Rob Lloyd, chief medical information officer at Hamilton Health Sciences in Hamilton. “The systems are not mature to the point that they need to be” in order to achieve improvements in patient safety or care.
The other main challenge is the cost of establishing an electronic health-information environment. “The costs are just astronomical,” says Lloyd. Hospitals are facing costs of $100 million to $200 million to upgrade their systems.
Enter the big bang. The state of the health-information technology industry has now evolved. Chris Hayes, chief medical information officer at Trillium Health Partners in Mississauga, Ont., says that software vendors are now marketing “total business solutions” that involve holistic, large-scale electronic platforms.
“It’s really only in the last six or seven years that there’s been a really big penetration of these systems across North America,” says Lloyd. “We still don’t know the power of what they’re going to be able to do.”
By overhauling their existing health-information systems, hospitals hope to rapidly achieve the level of maturity and sophistication required to have an impact on patient outcomes.
This level is often considered to be Stage 6 in the Healthcare Information and Management Systems Society, Inc. (HIMSS) Electronic Medical Record Adoption Model, which is widely used to describe a hospital’s degree of adoption and use of electronic health records. It includes stages 0 to 7, in which level 6 involves all processes, such as medication administration, being completely electronic and paperless from end to end.
Most Canadian hospitals currently are at HIMSS Stage 3 or 4. Since introduction of the HITECH Act in the U.S. in 2009 — the Obama administration’s effort to promote adoption of health-information technology and the electronic health record — 70 per cent of American hospitals have achieved HIMSS 6. Less than five per cent of Canadian hospitals can claim such status, says Hayes.
Digitization requires concerted effort on the part of both the hospital and its clinicians. A culture shift is often required. Upfront investment of resources and capital is required to realize gains down the road.
And that road is often bumpy. It can take more time to input data than to write a note. “You get lots of doctors who are still going to just want to dictate their note,” says Lloyd. Doctors complain that they are being turned into robots, says Geiger.
A 2019 study in Mayo Clinic Proceedings revealed that doctors who found an electronic health record system difficult to use were more likely to report symptoms of burnout.
And while high-quality evidence is limited, there is consensus that well-developed health-information technology systems lead to benefits for clinicians, patients, and the health care system, particularly in terms of patient safety.
According to a 2015 Italian study by Paolo Campanella, use of the electronic health record has been associated with less time spent on documentation, better adherence to guidelines, fewer medication errors and fewer adverse drug reactions. Research in 2018 by Bridie McCarthy in Ireland demonstrated that implementing electronic nursing documentation in acute hospital settings is time saving and reduces documentation errors, falls, and infections.
The Global eHealth Executive Council in London, England, reported in a 2012 meta-analysis that full implementation of an EMR resulted in average time savings for nurses equivalent to 42 minutes for each nurse in every 12-hour shift in intensive care units and 54 minutes per nurse in medical/surgical units.
A 2018 systematic review in the Journal of Medical Internet Research by CS Kruse showed that health information technology had positive effects on a broad range of medical outcomes — including wound healing, quality of life, diabetes control, vaccination rates, depression, insomnia, eating disorder symptomatology, readmission rates and length of stay.
For patients, there is a strong push for a system that would allow them to access their own health data. “To really advance the idea of patient-centred care is to put the patient’s data back into the patient’s hand,” says David Chan, EMR software developer and professor emeritus in the department of family medicine at McMaster University in Hamilton.
Technology is creating new ways for patients to interact with doctors and the health-care system, such as patients reviewing their test results through electronic patient portals, booking appointments online and having online contact with care providers.
The age of health information technology is now upon us. “It touches everything that we do and it has the opportunity to improve and make more efficient everything that we do,” says Lloyd. “There’s no question in my mind that it’s going to be better.”
Alan Taniguchi is a Palliative Care Physician and Fellow in Global Journalism at the Dalla Lana School of Public Health