Final Report of the Federal Advisor on Wait Times

Chapter 4: Information Technology (IT)

The development and implementation of information and communication technologies have become key to ensuring quality health care. In health care systems the importance of technology is in its ability to allow health care providers to share crucial patient information easily and accurately. "Accurate information is crucial if patients are to have choice and receive the right care at the right time... to give healthcare professionals access to patient information safely, securely and easily whenever and wherever it is needed."^[33] In order to provide patients and professionals with the right information at the right place, at the right time, the federal, provincial and territorial governments, through Canada Health Infoway, are working together to establish a pan-Canadian health info-structure that will make information readily accessible to those who need it.

As discussed in Chapter 3, new business practices and system innovations have the potential to have a huge impact when applied to health care systems. "Health care has often been described as the last industry to be revolutionized by Information Technology and Information Management initiatives."^[34] The increased use of technology can serve to improve service in hospitals, clinics and at home through the use of tools such as: computerized patient registries, interconnected databases for drugs, diagnostic testing results and electronic health records, all of which allow patients and care givers in the health sector to have access to necessary information.

The goal of this chapter is to discuss and recommend IT solutions to improve timely access to health care. Specific IT tools and next steps that are being developed with the help of Canada Health Infoway are also described. These are, in my view, necessary investments in the transformation of health care systems in Canada.

4.1 Current state of the health info-structure in Canada

In September 2000 the First Ministers agreed "to work together to strengthen a Canada-wide health info-structure to improve quality, access and timeliness of health care for Canadians."^[35] As a result, Canada Health Infoway was established in 2001 to achieve the "desired future state of information technology for the Canadian health care system."^[36] As of 2004-2005, and since Infoway's inception in 2001, there have been 105 Infoway projects launched in all investment areas (infostructure, registries, diagnostic imaging, drug info systems, lab info systems, telehealth, health surveillance, interoperable electronic health record, innovation and adoption).^[37]

The term health info-structure refers to:

... the development and adoption of modern systems of information and communications technologies (ICTs) in the Canadian health care system which would allow the people of Canada (the general public, patients and caregivers, as well as health care providers, health managers, health policymakers and health researchers) to make informed decisions about their own health, the health of others, and Canada's health system.^[38]

An info-structure is the combination of technological tools and information provided by patients and practitioners that forms a base of knowledge which informs decisions made by all participants in the health care system. The ongoing development and use of this information structure will benefit the health system as a whole and provide an important set of tools to resolve wait time issues.

Each province is at a different place in the implementation of its information technology agenda, but there are visible common features developing:

• regionalization;
• creation of electronic health records;
• digitizing the process for collecting patient data in both hospital and non-hospital settings;
• automation of physician offices and placing the patient at the centre of care;
• in some jurisdictions, ensuring that all physicians have computer systems that are compatible with the provincial electronic health record; and
• others concentrating on the establishment of registries and other overarching systems.

4.2 Health care professional scenario

In order to illustrate the importance of information technology and how it can play a role in improving wait times, Canada Health Infoway has described the scenario of Betty Smith^[39] who, over the space of thirteen months, journeys from her first appointment with her family physician to the date of the surgery to address her hip pain. The scenario shows how, at each of the phases in Betty's care, information management and technology are critical to providing accurate and current details on Betty's status. It is not hard to imagine how Betty experiences her journey or to understand what doubts she may have with respect to the right information getting to the right person or place in the shortest time possible.

The same concerns exist for health care professionals involved in patient care. A family physician may see a patient, perhaps several times, adding notes at each visit to the hand-written and hand-filed patient chart in his/her neighbourhood office. Diagnostic tests are ordered and a receptionist makes appointments. The test results that are mailed or faxed back to the physician's office may be the only indication that the patient did indeed go for the tests. Test results are manually recorded on the test requisition and sent by mail, courier and sometimes by fax to the physician's office where they may linger in in-baskets or file folders until a physician has had a chance to review them and take further action.

Similarly, the physician's referral of the patient to a specialist will be booked by phone from one receptionist to another. The family physician may dictate or draft a letter that is typed and sent by mail or fax. The vast majority of physicians do not use email communication in their practice. Delays can and do occur; phone calls may not be made until the following morning or may not be returned for a day or two. The results of diagnostic tests or consultations can travel back to the family physician at a slow pace or can be lost or delayed along the way. As the patient engages with one or more specialists, the family physician may become disconnected entirely from the patient's care and receive the specialist's written report much later. Throughout this time the family physician is attending to others with unique needs and circumstances. The exchange of information from one person and place to another may be trusted to many people using many communication methods that are paper-based and susceptible to error or inefficiency.

4.3 Current issues in Information Technology

Hospital Care vs. Physician Offices

Across Canada, provinces are engaging in agreements and initiatives related to implementing technological solutions in the health care system. These efforts have addressed needs in both acute care and community care. Currently, the registries and databases that have been established for diagnostic images, pharmaceuticals and waiting lists are primarily available in acute care settings. However, physicians in their private practices also need to be connected to this system to enable the family or general physician to remain engaged in and contribute to specialist care.

Connectivity

Professionals in both acute care (usually in secondary and tertiary hospitals) and primary care settings need the ability to access health information regarding their patients. Provinces and territories together with Canada Health Infoway are attempting to address this need with the development and implementation of the electronic medical record (EMR). It must be noted that an electronic medical record is the record kept within a doctor's office that documents all tests ordered, results received, drugs prescribed, office visits and other individual information specific to that doctor. Developing this capacity simultaneously will guarantee that no data gap is created and that providers in the health care system will use patient information to add efficiency to continuums of care.

According to the report on Health Human Resources from Task Force Two, physicians treating a patient tend to use technology primarily for administrative rather than clinical functions.^[40] The Canadian Medical Association (CMA) has suggested that while physician use of technology is higher than many might expect, EMRs are not used to full advantage in Canada.^[41] Only 14% of practising Canadian physicians are currently using EMRs and only 3% of these users rely on them exclusively for patient information. Patient records continue to exist predominantly on paper and it is suggested that this will continue until "all providers adopt interoperable data systems that communicate with, and contribute to, a regional EHR."^[42] The electronic health record (EHR) is a system-wide record of an individual's procedures, doctor visits, medical care that relate to all physician contacts, hospital stays, and other activities within the provincial health system.

Informed consent

The issue of informed consent for the collection and storage of patient information has to be addressed while the EHR develops. Advances in information management and technology allow doctors and patients to be more informed about the patient's health history, current treatments and progression of diseases or conditions. This also ensures that patients are able to obtain necessary information to make choices about their health care and self-care.

Ensuring both patient and physician have a complete set of data allows them to make fully informed decisions and choices regarding treatment of the patient's condition. With this increased knowledge and understanding, a patient will be able to give his/her informed consent to treatment decisions or preventative measures suggested by their physician, which in turn will have direct impact on their health outcomes.

Privacy

Health information privacy is an important issue in wait time management - one that involves identifiable health information. An electronic health info-structure supports the health information privacy legislation already in place across Canada (e.g. different rules for managing consent). The wait time management solution would provide a foundation to this info-structure, rather than reinventing the wheel.

4.4 Technology tools

The adoption of e-health systems is a high priority in all health care jurisdictions. For each jurisdiction the main question that needs to be addressed is: How do we expedite a province-wide e-health system? IT offers solutions that support the infrastructures of systems using IT tools as the piers. An inventory of some, but not all, essential tools follows:

Tele-health

Tele-health initiatives are a feature of the e-health^[43] framework currently being implemented across Canada. Tele-health is defined as the delivery of health related services and information via telecommunications technologies.^[44] Clinical uses of telehealth technologies refers to:

• transmission of medical images for diagnosis;
• groups or individuals exchanging health services or education live via videoconference;
• transmission of medical data for diagnosis or disease management; and
• health advice by telephone.

Non-clinical uses of tele-health technologies include:

• distance education, including continuing medical education, grand rounds, and patient education;
• administrative uses, including meetings among telehealth networks, supervision, and presentations; and
• research.

Electronic Medical Record (EMR)

As discussed above, the EMR currently exists in some computerized clinics and physician offices. These records are similar to the EHR but have a smaller scope defined by the physician's involvement with the patient. An EMR can help inform and be linked to the EHR to provide more extensive information to the individual provider and patient.

Electronic Health Record (EHR)

One of the key tools for e-health implementation is the electronic health record. The EHR is designed to facilitate the sharing of data across the continuum of care, across health care delivery organizations and across geographies. This electronic file establishes a private and secure record of all episodic and historic care received within the system. The record is available anywhere, anytime to health care providers and patients in order to support access to care as required. An EHR is also an important means of reducing preventable medical errors by guaranteeing the practitioner has all the information available at the time of decision-making and increasing patient safety by providing quick access to this information.

In general, and to summarize, the benefits of an EHR in the health system are:

• increased access to integrated patient information;
• reduced duplicate tests and prescriptions;
• reduced physician prescription call backs;
• reduced patient and provider travel costs;
• improved vaccine management; and
• improved information management resulting in reduced costs.

Electronic health records can play a significant role in reducing wait times. "In essence, an EHR will increase productivity through efficiencies and care coordination at a level that is difficult, if not impossible, to achieve without technology."^[45]

Electronic health records are not used solely within a physician's office. Hospitals can contribute to and use the information that is within EHRs. However, as CMA has pointed out: "only 25 percent of Canada's hospitals have been able to afford electronic provider order entry for pharmaceuticals, only 15 percent currently have electronic systems for managing diagnostic images, and only 36 percent currently use electronic records."^[46]

Registries

Increasingly health care providers are moving from paper-based to electronic media to store pertinent information on patients in databases that are constructed to allow in-depth analyses of the information they contain. These databases are known as wait list registries^[47] and provide valuable information to both patients and providers. This patient data will help determine the urgency of and other pertinent details related to the patient's care. A wait list registry is essentially a list of patients waiting for a specific medical procedure or intervention. These types of lists have generally been paper based but this has limited the ability of care providers to analyze or compare information that has been collected. "Traditional paper-based recording and storage systems have long since ceased to support the health service in an efficient and effective manner. As a result, many general practice surgeries and hospitals now have some form of personal care record that can be shared internally."^[48] The ability to share information both internally and externally is an important advancement in technology.

Wait Time Websites^[49]

Many provinces, in an effort to provide more information to patients and providers have established wait time websites.^[50] These web pages provide varying levels of detail on the length of wait lists for different surgeries and procedures ranging from cardiac surgery to cancer radiotherapy.

Some of the wait time websites offer a wider range of information, including the average wait time for specific surgeries and procedures on a province-wide basis. Some sites provide outcomes data on individual surgeons that allow patients to compare their particular physician to others in the provinces. This information makes it possible for a patient to request another location or another physician in order to shorten their waiting time.

4.5 Canada Health Infoway

Canada Health Infoway Inc. is an independent not-for-profit organization that works in partnership with the public sector. Its role is to invest in, implement and reuse compatible health information systems that support a safer, more efficient health care system. Members include Canada's 14 federal, provincial and territorial governments and the board consists of all the Ministers of Health. To date Infoway Inc has funded over one hundred projects that have either been completed or are underway in all jurisdictions. These activities are "delivering electronic health solutions to Canadians - solutions that bring tangible value to patients, providers and the health care system."^[51]

To date Infoway has received $1.2 billion for the development of health information systems including EHRs, tele-health and public health surveillance systems. As of March 31, 2005, Infoway had approved $321 million in project investments. It expects to approve an additional $325 million in 2005-2006, which would result in an estimated cumulative $646 million in approved projects.

Infoway's ongoing mission is the development of an e-health info-structure across Canada. This will make patient information more readily accessible and put it in the right place at the right time for the benefit of patients and appropriate professionals.

Canada Health Infoway Analysis on Wait Times Solutions

In order to fully understand the implications of implementing a Canada wide system for efficient management of wait times, I asked Canada Health Infoway to conduct an analysis of the current state of technology in the Canadian health care system. Their analysis is included with this report (Report 2: Canada Health Infoway: Addressing Wait Times with Information Technology).

Wait time initiatives in Canada have varied from web-based reporting of wait times in selected surgical and diagnostic procedures to more focused investments that will increase capacity and redesign health system processes. Information and communication technologies have demonstrated their value in many of Infoway's efforts to date and will increasingly become crucial to supporting clinicians in providing timely and equitable access to quality health care for Canadians.

The use of information and communication technologies will result in the following benefits in the areas of access, quality and productivity:

Access

• support timely delivery of care - solutions to improve referral and scheduling processes and overall case management will help providers decrease the overall time between identification of need and treatment; and
• support equitable distribution of care - solutions for prioritization of resource usage will help ensure that care is delivered appropriately on the basis of need.

Quality

• improve appropriateness of care - standardized assessment and wait time prioritization will help providers ensure that the wait time is appropriate for the patient; and
• improve effectiveness of care - more timely access to physicians, specialists, diagnostic tests, surgical procedures, as well as after care services, will provide for improved health outcomes and reduced pressure on the system.

Productivity

• improve provider productivity - information technology will impact provider productivity in many ways, from ease of access to information to improved efficiencies (e.g. reduced call backs, reduced duplicate tests);
• more efficient resource use - solutions for scheduling will help managers optimize the use of scarce human and physical resources; and
• improve coordination of care - case management will allow a virtual team of providers to more easily coordinate the successful completion of a patient's treatment plan.

In order to better manage wait times an investment in referral management, scheduling, case management, wait time monitoring and reporting systems, location registry, physician electronic medical records and patient portal technologies is needed.

Technology costs will continue to increase over time. Delays in the implementation of health care IT solutions must be avoided. Future IT systems will build on existing work Infoway or government funded projects that have already taken place across Canada. The estimated time frame for implementation of the proposed systems associated with wait time management is three to six years. I propose that federal, provincial and territorial governments continue to work on both pan-Canadian and provincial information technology and management initiatives in order to take full advantage of the benefits that will accrue from this technology. Failing to do so will put patient care and our health care systems at risk.

4.6 Conclusion

An electronic health record infrastructure is a fundamental tool for the future development of wait time management tools. The wait time systems under development within the provinces and territories mark the beginning but could benefit from the functionality that Infoway is proposing. Canada Health Infoway's analysis shows the way to achieve a Canada-wide, interoperable electronic health record by 2009. In addition, the recommended wait time management technology can be implemented alongside the EHR so that when the wait time management systems are ready to come online, data will be available to support them. While it takes time for the adoption of technology solutions both systemically and by the end users, all jurisdictions need to push forward to ensure that delays are minimized. The sooner this technology is widely in use, the sooner we will see better management of wait lists and patient care in general.