From across the Atlantic comes news of apparent financial maladministration at E-Health Ontario, the body charged with implementing the province’s e-health strategy. It seems to be the usual nonsense of untendered contracts, friends in high places, and chums helping chums. It is also an example where no one seems to have asked the simple question, “why would you do that?” — the strategy is a nonsense, and I am surprised that no-one challenged this before the policy had gone this far in implementation.
I would, naturally be more inclined to be concerned if the province’s e-health strategy were actually about e-health, or likely to deliver results worth having, but the $700 million or so per year will be spent on things like a diabetes registry, wait times, electronic prescribing/electronic health records. Only the last have anything really to do with e-health. The last can also be procured, so there really isn’t a need to make a supplier meal out of putting something in place. I will concede though that an EHR is a critical component of e-health, but it isn’t quite the same as e-health — it is a bit like confusing the foundation of a house with the home it will become. But having worked on eRx, the province’s failure to prioritise some sort of a patient-held smart card is a mistake as without this it is difficult to deal effectively with identity.
Without system redesign in the province, the e-health strategy is really just throwing good money away and given the current economic (and political) climate, this is no longer an option, if it ever really was.
Two things are of critical importance. First the province needs to have a thorough-going governance review of e-health Ontario, mainly to determine how to make sure it is fit for purpose in actually providing the leadership for development of an e-health infrastructure service delivery platform. Secondly, and this is the challenge, it is necessary to make sure that the e-health services are ones that the public will use and value. The province has failed on both counts. The next challenge though will be to find people to review e-health Ontario who haven’t been tainted by this scandal and benefited from the feeding frenzy e-health Ontario created. It may require looking further afield, to interested, but uncontaminated parties. They may even not live in Ontario — golly gosh, so much for made-in-Ontario mediocrity.
So, having vented on that last point,what would an outline e-health strategy look like for Ontario, assuming that some governance arrangements are put in place,. These are really just illustrations as certainly I would want to get a good understanding of priorities from interested patient groups:
- There are about 90 rural and small hospitals in the province. A good plank in an e-health strategy would be to enable them to become a single, integrated, but distributed healthcare provider, perhaps with some sort of local and shared corporate governance. A distributed healthcare provider, using e-health infrastructure technology would deliver specific outcomes to rural people, such as access to networked diagnostic imaging technologies, electronic prescribing and remote access to health records. I would certainly save people in Thunder Bay a lot of trouble getting down to Toronto for a scan. With a little bit of imagination and thought, this could work.
- About 60% of diagnostic facilities are located in Toronto, but which has only about 25% of the population; these are licensed clinics which often only offer a single procedure. Using networked imaging technologies, remote diagnostic telecare booths (you can buy one from Cisco) many of these suboptimal centres could be relocated either to the rural network, in the previous plank, or provide a more accessible urban service across the provinces main urban centres.
- Smart card technologies (whether a smart card or an electronic secure passport) would give a better reason for constructing electronic health records than ones focused on improving data access for health professionals alone. Patients, when given access to their health information, will have a vested interest in ensuring that the information is correct (my Ontario health record when I lived there had an error showing I had a condition affecting women, but I am a man — I still don’t know if the error was corrected; in an electronic system, that error would have been a problem, but I would have made certain that it was corrected, too). As an ‘auditor of one’ patients can make sure information is correct, and drive substantial service quality improvements. This is not to say that health professionals can’t do that, just that the evidence shows it comes slowly and is complicated by cartel-like professional practice barriers. Start by putting the e-health card in the hands of the heavier users of the health system, to better manage their healthcare, access to information, and gradually as people see their family doctor, or get born, migrate the whole population over. Of course, this will mean that family doctors, clinics, pharmacies will have to adopt some sort of information system.
- Don’t do what the English NHS is doing with Connecting for Health, by creating a large-scale government-led initiative. E-health Ontario’s predecessor took a look at Denmark, but failed to learn the lessons despite what they wrote in their sham of a consultation document — they missed the point partly because they appeared to have another agenda heading toward a particular solution. Denmark has shown how disparate stakeholder groups can work together to create an information system that works, and does things people value. Better that than spend vast amounts of money on a grand plan to nowhere.
The general plan is to build an infrastructure that starts with the patient/family as user. My experience in developing an interactive health television channel showed me the importance of starting there, and defining the benefits from that perspective. Change will drive from that end too. Finally, engage all the stakeholders (like the Danes did), find commercial partners with interesting technologies that do things that people value (rather than whizzy technologies), look for alternative systems to pay for healthcare services, as failure to develop a suitable and workable reimbursement system for e-health services is a barrier ( just ask Norway). Oh yes, don’t forget political will.