Today’s Digital Health Shift vlog is the third in a video series of OntarioMD CMO, Dr. Darren Larsen, speaking about the EMR Quality Dashboard. In this segment, Dr. Larsen discusses how leadership and collaboration amongst health care organizations are driving change to benefit patient care.
Submitted by Amanda Story, OntarioMD Practice Advisor
On April 11, 2017, at the Muskoka Algonquin Health Centre in Huntsville, my third child was born. Clark was a perfect 19 inches long and 7.7 pounds, with a full head of hair. But things quickly got scary, when his blood sugar and body temperature began dropping and his breathing became irregular. He was stabilized, and we were transferred to Toronto’s Sick Kids Hospital.
Little did we know our journey with Kabuki Syndrome was about to begin. Kabuki syndrome is a rare, multisystem disorder characterized by multiple abnormalities including facial features, growth delays, varying degrees of intellectual disability, skeletal abnormalities, and short stature. There’s also the potential for a wide variety of additional symptoms affecting different organ systems. Kabuki syndrome affects males and females in equal numbers, and specific symptoms can vary greatly from one person to another. The incidence of Kabuki syndrome has been estimated to be somewhere between 1 in 32,000 to 1 in 86,000 individuals in the general population.
Sick Kids Hospital was up and running on a computerized charting system, and was able to get all the test results from our local hospital quickly. It was amazing how hospital information flowed – physicians of all specialties sharing one chart, no test duplication, everyone knowing and seeing what had been ordered, what was pending and what the plan was. I was a stressed out, tired and scared mom, and I appreciated not having to repeat Clark’s history over and over again. When Clark would decide to throw a wrench in the plan, it was easy for the nurse and I to note it and a message was sent to the physician to get new orders and/or a new plan. The digital health system made it easy for the changes to be communicated to his entire team of cardiologists, respirologists, and endocrinologists.
Eventually Clark rallied, and we were transferred closer to home, to The North Bay Regional Health Centre. It was a big adjustment. We were surprised that communication between Sick Kids and North Bay Regional Health Centre was by paper and mail. When Clark regressed a bit, it was hard to compare results, causing duplicate tests and delayed treatment while phone calls were made to discuss results. We had experienced the power of digital health at Sick Kids, and appreciated how all the health care providers were connected. At the time, North Bay didn’t offer this – though it has since implemented a computerized system. It did offer video conference calls through the Ontario Telemedicine Network’s system, which allowed Clark’s entire team to connect and get his treatment back on track.
We finally made it home after a couple more weeks. Unfortunately, our stay at home was short. Within a couple of months, Clark caught a cold and a bad cough. We quickly took him back to North Bay Regional Health Centre, where he was admitted and put under observation. After the first 24 hours, Clark got worse. The following day, he went from needing a little bit of oxygen support to needing to be intubated and rushed to The Children’s Hospital of Eastern Ontario (CHEO), which had been consulted during his rapid decline. During transportation, his heart got tired and arrested from working so hard to make up for the decreased lung function. The amazing transfer team from Ornge was able to revive him quickly en route to CHEO. The Pediatric Intensive Care unit was ready and had pulled together a team to assess him and move him to extracorporeal membrane oxygenation (ECMO), which is a heart and lung bypass to allow him to heal.
CHEO had just implemented a computerized charting system called EPIC. It allowed the hospital to flow information around his care, similar to what we’d seen at Sick Kids. Everyone could see and use the same information in real time to assist with coordinating Clark’s care. His entire team at CHEO – Pediatric Intensive Care Unit (PICU), cardiology, vascular surgery, perfusionists, respirology, genetics immunology, infection control, physiotherapy and pain and symptom management, along with imaging and pharmacy, were all working in one chart around a single patient. This was digital health at its best – facilitating communications and transitions in care.
Our family physician was also kept informed through her office EMR, using Health Report Manager (HRM) to get Clark’s hospital reports quickly and keep up to date on his progress. I received many phone calls for support and counselling without having to give updates or go into details. It very much kept me sane during a very scary time.
When Clark was able to be transferred to recovery, the same chart, same information and same teams followed him. Even after discharge, the amazing efficiency of digital health still helps us to this day with his scheduled follow-ups. Each team can communicate and coordinate his appointments into clusters that help us save travel time, and tests and procedures can be grouped together to help minimize Clark’s discomfort.
I am very thankful for the adoption of digital health by Ontario hospitals and health care providers. I’ve seen the high level of accuracy and understanding it offered to everyone involved in Clark’s care. It made me feel comfortable and confident that the physicians had access to everything they needed all in one shareable electronic record. Clark’s medical information followed him wherever he was treated. Digital health has helped connect all the hospitals we visited with Clark, so they could share information and make the best decisions for his care. The digital health change in our health care system is also providing more information quickly and easily to family physicians everywhere in the province. Keeping physicians up to date to provide supportive care to caregivers and other family members is easier and faster. I am convinced that digital health is removing many barriers to efficient and effective health care in Ontario, and I honestly believe it helped save my baby’s life!
Clark is growing stronger daily. We have celebrated many “inchstones” such as regaining head and neck control and re-learning how to roll over, along with a few milestones such as pulling his socks off. He is a very happy baby that brings so much light into our lives.
This Digital Health Shift vlog is the second in a video series of OntarioMD Chief Medical Officer, Dr. Darren Larsen discussing the EMR Quality Dashboard. This segment focuses on how the EMR Quality Dashboard delivers Quality Improvement to patient care.
A recent survey from HealthCareCan found that more than 8 in 10 health leaders feel that Canada’s health sector is susceptible to cyber attacks. Also, 86% of respondents replied they have detected some type of privacy breach.
In the latest Digital Health Shift Vlog, OntarioMD CMO Dr. Darren Larsen explains the benefits of completing the OntarioMD Privacy and Security Training Module. Proper training can ensure that your practice is safeguarded against certain privacy breaches and security incidents.
Completion of the OntarioMD Privacy and Training Module is the final step to get connected to the ConnectingOntario Clinical Viewer.
In this Digital Health Shift vlog, OntarioMD Chief Medical Information Officer Dr. Darren Larsen discusses the need to help physicians move beyond simply focusing on patient care for individuals, toward being able to more easily analyze their entire patient population and proactively those at risk. OntarioMD is focused on improving population-based care through the development of EMR-integrated tools such as our EMR Quality Dashboard proof of concept, which translate EMR data through user-friendly visualization. And, through the ongoing development of our Quality Support Program, we’re providing the support and education physicians need to improve EMR data quality for efficient population-based care.
Dr. Darren Larsen is Chief Medical Information Officer (CMIO) at OntarioMD. As CMIO, Darren provides clinical advice to many provincial and national steering committees and clinician advisory groups and has been instrumental in forging system-level partnerships in many sectors. Darren is a tireless champion of optimization of EMRs and health informatics in empowering Ontario’s physicians, with a focus on quality patient care and practice efficiency. He provides a clinician perspective and guides all aspects of OntarioMD’s work to evolve and advance EMRs and digital health for primary care and community specialist clinics. This includes clinical practice change, quality improvement, data quality and analytics, and EMR maturity measurement. He recently shared his insights with RDP Associates on the state of innovation in Canada’s digital health sector.
Canada’s biotech and health-tech industries are among the most dynamic and innovative sub-sectors of the tech industry. But despite its dynamism, scaling up and go-to-market remain pressing challenges. Why is that?
Indeed, Canadian minds are anteing up some amazing ideas in the digital health space. We have such a strong well to draw upon for creativity and innovation. There is an endless need for new products, services and thinking in health care, for patients, providers and the health system, yet despite the demand, it is incredibly hard to bring innovation to market. I frequently say that real change requires resolution not revolution, and it is hard to maintain excitement and enthusiasm when the system falls short of the needs of innovators beyond the ideation phase. The reasons for this are complex, but some key issues that we could collectively work on to try to improve the situation quickly bubble up.
a) There is very low tolerance for failure in health care. Some of this is predictable, based on clinicians’ training in evidence. Some fall at the health system level, where even small failures lead to blame rather than learning, and it often becomes a story on the front pages of a newspaper. Some of this is even cultural. As Canadians, we do not trust our own innovators until they have been proven in another market or immediately hit the news.
b) Our classic public-sector procurement rules are complicated and hard to navigate. This leads to a bias toward established companies which have greater capability to persist and respond.
c) There is a basic distrust of business in our socialized health care system. The private sector is viewed with suspicion, and the introduction of profit motives makes those of us who believe and have invested in socialized medicine, somewhat wary. We must find a middle ground.
d) Regulatory issues abound in health-tech, from Health Canada medical device status rules, to technical standards often being vague, to privacy legislation being used as an excuse to stop innovation even when it is designed to permit it.
e) The investment/venture capital landscape is different and less permissive in Canada than it is in the US. It is frankly easier to find investors and backers south of the border than it is within our own country.
f) The desire to take a chance on promoting and partnering with new companies is low in Canada. We are guilty of “death by a thousand pilot projects” and accept this as the norm. Most pilots are created to test a very narrow product or service window of safety rather than facilitate scale and spread of the same. Unlike in the start-up space, in healthcare, we lack the “fail fast and fail forward mentality”, which is essential to the innovative process.
Many government grants are generic, but some are industry-specific such as those for clean-tech and agri-tech. Do we need specific grants that target biotech and health-tech sectors to ease some of the challenges they’re facing?
This might well be an option to try. The use of grant money could be tied to co-design or creative procurement that does not predict the final end-point for a product, but rather allows it to evolve organically until it reaches a desired state or value. Design thinking methodology could, and likely should be placed into the grant awarding process. Technology engineers, designers, and providers must align to ensure that they have created a product or service that is actually needed. Then, a shift to value-based funding and support might ensure ongoing success. Currently, many innovation grants do not consider scale and spread of an idea or product. There are incubators that provide in-kind expertise rather than cash. And there are investors who want to see successful companies move forward. The sweet spot is combining these in partnerships.
How would you describe the relationship between the government and Canada’s tech sector including its startup community? Where do health-tech and health care fit into their dynamics?
I possess a cautious optimism in this space. There is certainly an increase in the promotion of start-ups and a growing community of innovators who network and learn from each other. Also, we are seeing some fantastic government-supported or -partnered innovation hubs like MaRS, McMaster Innovation Park, the BMZ and DMZ at Ryerson University, and Velocity at the University of Waterloo, which are great as examples in Ontario alone (and more nationally: Ontario even has a Chief Health Innovation Strategist in the Ministry of Health and Long-Term Care, William Charnetski. These are great starts, but these are early days and this is still nascent work. It will take a long time to change a culture.
Are there sub-sectors of Canadian healthcare that conduct a significant amount of R&D?
I see a lot of progress in Canada now with the creation of health care “living labs“. These are unique spaces where partnerships are used to test products in working environments like hospital units (Mackenzie Health, Southlake Hospital) or human-centred design spaces (UHN Centre for Global eHealth Innovation, JLabs by Johnson and Johnson, Bridgepoint Active Healthcare) or digital health evaluation spaces (MEDIC at Mohawk College, WIHV at Women`s College Hospital). These serve as platforms for integrated thinking about solving clinical problems using integrated technology, not as siloed projects that are procured individually. I believe these may be our future.
What is your definition of a ‘value-based healthcare system’ and what are its key defining parameters?
Value takes many forms and changes according to who is looking for it and what their goal is. Certainly, from the government’s perspective, the value can be calculated in the ratio of quality (or outcomes) over cost. This is very important when setting budgets and ensuring that they are getting what they pay for. This is often the default value proposition in a publicly-funded health system, and it is indeed important.
Value, as measured by a patient, is a whole other proposition. They may value being listened to, having a concern demystified, or simply being told they will be fine.
The clinician perspective exists in the intersection of the health system and patient lived experience. We face the multifaceted challenges of unprecedented demographic change, medical system evolution, and continual demands to innovate every day. But on the positive side, this can challenge physicians in creating solutions.
Ultimately, the value can be only generated in trusted relationships. All three players in healthcare (funder, provider, patient) must work on mutual trust to achieve common goals. This is more than value; it is being valuable.
Do you think the newly revamped tax laws in the U.S could be incentivizing Canadian health-tech companies to move south?
Certainly, permissive tax rules may have an influence, but I believe that tech companies venture south before developing a strong presence in Canada for some far more basic reasons. The US market is much larger. An entrepreneurial spirit is deeply ingrained in American culture. There is greater degree of tolerance for failure. There is much more capital to draw upon from investors who are willing to take a chance on health-tech, knowing that they will win some and they will lose some. Still, there are challenges in the US too. It is a dog-eat-dog world in health care south of our border. Sometimes the stories of speed in success or failure are a distraction from a business purpose that enables longevity. Real change requires resolution rather than revolution.
This interview was conducted by Reza Akhlaghi, a digital content and social media strategist at RDP Associates.
Submitted by OntarioMD Dr. Adam Stewart
This blog post was originally published on April 22, 2018, on Dr. Adam Stewart’s website at www.stewartmedicine.com.
Information and data have value in every industry. The value of data in health care is only beginning to bloom. Who owns it, though?
Patients undoubtedly have rights with respect to their medical records. It goes unrecognized by most, however, that physicians own the value of data with their electronic charts.
Patients have rights to the content of the data within their medical records. The charts contain their personal information. This is unquestionable. However, the value of data comes from its structure and the organization, which is fully dependent on the physician who generates and maintains the medical record.
The organization of a patient’s chart may vary from being a barely legible handwritten paper chart to the other end of the spectrum of being a complex Electronic Medical Record (EMR) with the advanced data structure. Across the spectrum, the exact same patient information (content), can have widely different functionality and analyzability (value). This quality differential is entirely dependent on the physician and there can be extreme differences when comparing the charts, and thus data quality, of one physician to another.
Governments covet the value of the aggregate, even anonymized, data within EMRs for planning and policy purposes. Pharmaceutical companies share a similar craving for the data for marketing and development purposes. Innumerable interest groups and organizations equally desire data that relates to their agendas. (The legalities and ethics of sharing or selling data are beyond the scope of this article. Rather, the intent of this article is to identify and raise awareness of the value of EMR data that physicians possess).
As per College of Physicians and Surgeons of Ontario (CPSO), “patients have a right of access to their personal health information that is in the custody or under the control of” a physician.1 Patients can request copies of their charts. Even if the original chart was in EMR format, though, what the patient is entitled to and receives is either a printed paper copy of the records, or an electronic PDF document saved on a CD or memory stick, for example. In these formats, the data has relatively nil to minimal value because it is not structured in a way that is easily navigated and analyzed.
Physicians, and staff hired by physicians are the ones who input the notes and structure the data within their charts. Many physicians further build and customize tools within their EMRs to aid in the documentation. Physicians are the ones who pay for the EMR software, training, and vendor support. Physicians are the ones who are responsible for funding all of the computer hardware, technical support, and the physical space in which to house the infrastructure. Accordingly, in every sense, physicians own their EMRs.
One might try to argue that part of the payment to physicians from Ontario Health Insurance Plan (OHIP) for their services includes the generation and maintenance of the medical record.2 However, OHIP simply mandates and includes payment for physicians to “keep and maintain appropriate medical records”.3 It specifies nothing with respect to a standard of quality. The CPSO has more specific requirements.1 However, even a legible and complete paper chart meets those standards of care. Anything above and beyond the minimum baseline of those requirements has value, and that value is derived from, and therefore owned by, the physician who generates and maintains that chart.
There is obvious variability with respect to the quality of data within physicians’ EMRs. The difference from one extreme to another highlights the differences in the value of EMR data. Physicians own that value.
Patients have rights to the content of their individual data. Physicians own the organization, structure, functionality, and analyzability of the data. Physicians own their EMRs. It follows that physicians own the value of the aggregate data within their EMRs. These are careful and important distinctions.
Contributed by OntarioMD Peer Leader Dr. Yves Raymond
Recently, Newfoundland physician Dr. Thomas Hall contributed an opinion piece to CanadianHealthcareNetwork.ca, the online home of The Medical Post. Hall’s article – which can be read here (if you’ve registered for a Canadian Healthcare Network account) – argued that while EMRs are useful for connecting health care databases and analyzing patient data, using them during patient encounters risks the doctor being seen as distracted and lacking empathy.
I commented on the website that I find it interesting that we’re quick to blame technology when, in fact, it is how the user chooses to use the technology that is the real issue. In my comment, I also took the liberty to rewrite Dr. Hall’s article substituting paper charts for EMRs as evidence that his arguments could still be made if the medium were paper rather than EMRs. My version is below. Leave a comment below this post to let us know your take on this important issue.
Paper charting no doubt helps remember what you did, but what do they do to the more subjective nonverbal parts of our patient encounters in office?
Over the last number of months, I have been talking with both psychiatry colleagues in Newfoundland and with staff at the British Columbia Psychiatry Association about their thoughts on paper charting in a family physician’s office. Generally, they felt, and I agree, that paper charts in a physician’s private office as a place to write notes after an undistracted face-to-face patient encounter is potentially helpful. However, in my informal conversations with these physicians, they all expressed serious concerns about the possibility of being distracted and the perceived lack of empathy that may arise from their use of paper charts in the office while examining a patient. This is a serious problem, as most family physicians use paper charts in their exam rooms while seeing patients.
Also problematic is that a family physician’s day is approximately one-third to one-half filled with some components of psychiatric care. I often ask physician colleagues the question: “What do you think of a patient who checks their agenda during their appointment?” Almost exclusively physicians answer with words such as annoying, wasting my time, rude, or with even more intense expletives. This is just a normal human reaction when we think our time is being wasted or we’re not being taken seriously. We physicians have to be aware that the reverse is also true for patients who perceive similarly in encounters where the physician is constantly looking at and writing notes into a paper chart.
Apart from the obvious perceived lack of caring and empathy that paper charts in patient rooms may exacerbate, there also should be serious concerns about what a physician might miss by being distracted by writing notes into a paper chart. A small enlargement of one side of a patient’s neck, clubbed nails, thinning hair, a small facial droop, a facial expression crying out for help from a patient’s partner sitting across the room, etc. These subtle things will undoubtedly be increasingly missed as physicians are pressured to enter more notes that often serves no purpose other than liability coverage and administrative information.
Paper charts will eventually be in every physician office in the country but the “leaders” in our profession, who are often too removed from complicated day-to-day front-line patient care, need to be more proactive about policies that will minimize these pitfalls. As an example, here is some advice from Nobel Prize winner Dr. Lown, author of The Lost Art of Healing:
“Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures … Doctors of conscience have to resist the industrialization of their profession.”
Could rules be established by medical associations to suggest paper charting use be reserved to outside patient rooms? This would also require a potential increase in physician remuneration to manage the increased work that would result from extra notes entry at the end of the day.
OntarioMD’s EMR: Every Step Conference in London on April 12, 2018 will feature 11 sessions designed to inspire and educate clinicians on how to get more clinical benefits from their EMRs. These sessions have been certified by the College of Family Physicians of Canada’s Ontario Chapter for up to 7.5 Mainpro+ credits.
To see the full conference schedule and register, please visit https://www.ontariomd.ca/about-us/events/emr-every-step-conference-london-2018
Here is a glimpse of what you will learn at some of the conference sessions:
Pain, Opioids and Your EMR
Presented by Dr. Gordon Schacter, London Middlesex Clinical Lead, South West Local Health Integration Network
- A basic understanding of the issues in pain and opioid prescribing
- Knowledge of the minimum standards for assessment and management of pain and opioid prescribing
- How EMR tools can facilitate your ability to meet those minimum standards for assessment and documentation
- All the pain and opioid resources that are available to you: Self-Management, OntarioMD Peer Leaders, OCFP Mentorship, etc.)
EMR: Making Data Quality and Data Mining Exciting
Presented by Dr. Mario Elia, OntarioMD Physician Peer Leader
- The importance of high-quality data integrity
- An easy-to-use framework for clinical effectiveness in primary care across multiple domains
- Practical advice for moving forward with improving clinical data work in your office
Overcoming Wait Times for Specialists Using eConsult
Panelists: Dr. Anil Maheshwari, Chief of Family Medicine, Cambridge Memorial Hospital and OntarioMD Physician Peer Leader, Dr. Harpreet Arora, Board Member, Grandview Medical Centre, Dr. Sunjay Gupta, IT Physician Lead, Grandview Medical Centre
- Which types of issues are appropriate for eConsults
- The advantages (and disadvantages) of eConsults
- The steps taken to get both primary care physicians and specialists on board
- The actual referral process, the wait times for eConsults, the feedback from patients, family doctors and specialists
Switching EMRs: Lessons from the Front Lines
Presented by Dr. Stephen McLaren, OntarioMD Physician Peer Leader
- How to successfully transition your practice from one EMR system to another
- Best practices for data migration
- Other tips and tricks
Contributed by Hinna Hatif and Neil Faba, OntarioMD Communications and Marketing
As communications professionals with journalism backgrounds, we’ve both had a front-row seat to rapid change in the industry. In our case, we’re also focused on the changes that digital health has brought to the health care system. From the advent of online media to social media’s proven ability to put storytelling in the hands of those directly involved in the stories, the media landscape has shifted significantly over just two decades.
Twitter, Instagram and other social media platforms are shaking up many other industries, too, including health care. Today, many physicians and other health care professionals are active social media users, portraying their passion for the industry and its advancements in patient care via photos and videos, posts and tweets.
To better understand the way digital and social technology is shifting traditional and digital health care as well as journalism, we recently attended a panel discussion titled Healthcare Journalism in the Age of Twitter, hosted by Longwoods Publishing as part of their Breakfast with the Chiefs series. The panel included two journalists representing different generations and media institutions: Andre Picard a reporter and health policy columnist at The Globe and Mail for more than 30 years; and Rachel Browne, a Senior Reporter at Vice News who’s just a few years into her career. The discussion was moderated by Judith Jones, a patient advocate and communications specialist who was the keynote speaker at OntarioMD’s EMR: Every Step Conference last fall in Toronto. Andre’s name is almost synonymous with health care on Twitter, with more than 70,000 people following his account @picardonhealth. Rachel, who covers a broad range of health and other topics, is also a very active user as the author of more than 10,000 tweets on her account @rp_browne.
The discussion started out with some thoughts on how news agencies are faring in this changing landscape, while faced with cutbacks, financial pressures, and increasing competition to capture people’s attention. While The Globe and Mail and Vice Media have different histories and cater to very different audiences, the two journalists on the panel agreed that they share a lot of commonality when it comes to their struggles In the face of these challenges.
We’re living in a time where we have near instant access to more information than ever before. On the other hand, we’re barraged by fake news and incorrect information that is sometimes even reported by reliable news outlets because of the competition and demand the 24/7 news cycle brings.
“For people who know how to use the media, it’s the greatest time in history right now,” commented Andre Picard. “You can get everything you want and more. For those who are not interested, which is a growing segment of the population, it’s a waste land of fake news. It’s a dichotomy that’s troubling that one group is getting much larger and the other group is not.” As chilling as this sentiment seems, Rachel Browne offered a glimmer of hope: “there is a strong desire now more than ever for good quality content that’s different, that’s approachable, that’s informative, that’s going to stay and inform the reader beyond just reading the article, and maybe even inform policy decisions.”
Both Andre and Rachel agreed that for the public to get accurate, good quality information from media outlets – particularly when it comes to important subjects like health care where people’s lives literally hang in the balance – journalists need to be able to get their hands-on quality data on key issues like the opioid crisis. But this is often difficult, or – in the case of opioids where few reliable national stats exist – impossible. Rachel and Andre advised the audience – comprised mostly of members of the health care industry – to work closely with journalists, PR people and others to help fill in the gaps and tell the stories that need to reach Canadians.
The panellists offered some useful tips on how health care communicators and industry leaders could work collaboratively with journalists to help share information that can drive policy decisions:
- Form collaborative working relationships with journalists, to understand what issues are on their radar. Many large media outlets have project editors, who can share which topics are being considered for long-term reporting projects and can help organizations understand how they can help shape the story;
- Understand media outlets’ different audiences, and tailor pitches accordingly. With so many news outlets focused on specific target audiences, understanding how different media focus their reporting can help you tailor your messaging;
- Facilitate journalists’ access to patients who are willing to tell their health care stories, to add a human face to the issue. At the same time, it’s important that communications people prep those patients so they understand the extra attention they may receive by sharing their experiences.
To listen to the whole panel discussion, please click here.