Health's digital divide: electronic health records

Canadian health-care providers are spending millions on electronic health records.

Dr. Rob Fowler leans in for a closer look at the patient tucked into the starchy white sheets of the hospital bed. It's a milder-than-usual January morning and the 30-year-old man has shown up in the neurosurgical intensive care unit of Sunnybrook and Women's College Health Sciences Centre in Toronto, with bleeding in the brain. The patient, transferred here the day before from the hospital's emergency room, had originally complained of a bad headache, and a scan performed hours later confirmed a hemorrhage in the space between his skull and brain. “Have you had a chance to look at your CT scan yet?” says Dr. Fowler, addressing the man and his wife, who is perched in a chair beside her husband. With that, the 36-year-old doctor wheels a fancy-looking computer cart–complete with a 19-inch touch-screen monitor–to the side of the man's bed, where he's able to pull up a large digital X-ray of the patient's brain. The neurologic injury is clearly visible on the screen. As Dr. Fowler calmly explains possible treatment options to the couple, the anxious patient begins to relax.

Nicknamed the COW, short for “computer on wheels,” this $8,000 cart is one of about 60 that will eventually be spread out across the 1,115-bed hospital. With the click of a mouse, clinicians will be able to have immediate, and in many cases bedside, access to high-resolution digital images, laboratory results and medication histories, all viewed through a wireless server-based hospital information system. As Dr. Fowler explains later, accessing the CT scan at a patient's bedside in the old paper-based system would have been “near impossible. With this, you have all the info you can't remember or write down, at arm's length,” says the assistant professor at the University of Toronto, who also practises critical-care and general medicine at Sunnybrook and Women's. “This system saves me at least half an hour [per session] of medical rounds.”

Across the country, health regions and hospitals such as Sunnybrook are pumping billions of dollars into technology, upgrading their antiquated paper-based health records systems into flashy new electronic health records (EHRs). Instead of lengthy delays waiting for a paper chart or X-ray film from the radiology department, orders and results can be viewed online, digital images accessed electronically and medication histories made available with a few simple clicks. By 2009, Canada Health Infoway predicts that whether you're in a hospital in Charlottetown or a doctor's office in Vancouver, 50% of Canadians (through their physician) will be able to access their own electronic health records, everything from immunizations and drug histories to allergies and digital X-rays. The goal, of course, is simple: if doctors can access health records instantaneously and make more informed decisions about diagnoses, it will save time, money and, most importantly, lives. The process of getting there, however, is anything but simple.

With multiple computer systems across different provinces that don't yet “talk” to each other, lack of funding, and ongoing debates over who should “own” the data in the system, creating digital databases of patient records across hospitals and physicians' offices is an ambitious–and pricey–target. Although a pan-Canadian EHR system is projected to save about $6 billion annually, it'll also cost Canadians an estimated $23 billion in capital and operating costs over the next 10 years. This is not exactly a drop in the bucket–especially considering the amount represents more than half of the $41 billion in health-care funding promised to Canadians in September 2004, at the first ministers meeting on the future of health care.

In the meantime, the few Canadian health-care IT companies that have managed to carve out a niche for themselves in this growing market are hoping to cash in. It won't be easy.

Most of the electronic health record software in major Canadian hospitals or health regions comes from large U.S.-based multinationals such as Cerner Corp. Not surprisingly, these companies' ability to pour millions more than their smaller Canadian competitors into research and development is a unique strategic advantage. More money also means more marketing and greater visibility thanks to more extensive lobbying efforts. In many cases, it also means a final product that is more sophisticated than some of the Canadian software out there: products such as Cerner's PowerChart, combining a clinical database, user-friendly interface and tools for clinical ordering and documentation. But as several of Canada's smaller niche players point out, bigger isn't always better. Buying health-care technology from the United States often means expensive customizations and back-and-forth wrangling with vendors when things go wrong.

That the publicly funded health-care system in Canada is stretched to the limit doesn't help. A recent report by the Canadian Institute for Health Information projected public-sector spending to reach $98.8 billion in 2005, up from $74.7 billion in 2001, with the majority of that spending going toward hospitals and physicians. Given this, continued support of health-care IT waxes and wanes. Why not use extra funds to buy more drugs or hire an additional nurse, instead of another piece of expensive software?

Hospital and regional health-care executives, however, point to tangible benefits that have already been realized from EHRs. Hundreds of thousands of dollars are saved by dramatically reducing paper health-record retrieval and storage costs; use of expensive lab tests is down considerably; and adverse medical events (unintended injury or complication due to mismanagement of a patient's condition) are reduced because of online alerts that warn doctors about the possibility of potentially deadly interactions between medications. For example, in Edmonton's Capital Health region, one on-call doctor–otherwise unfamiliar with the patient–was able to access crucial medical data from a web-based system at his home.

But implementing these technologies and reaping the benefits, argue health-care administrators, takes time. As for the oft-cited comparison to the banking industry, which was successfully automated almost 25 years ago, Sunnybrook's chief information officer, Sam Marafioti, has this to say: “You can't walk up to the health ATM, stick your tongue in it and get a health check. The ATMs have been pretty successful at showing how somebody can get their balance anywhere in the world and draw money. Health doesn't work as simply as that.”

In fact, says Richard C. Alvarez, president and CEO of Canada Health Infoway, a not-for-profit organization that invests with its public-sector partners in compatible health-information systems, “These are multimillion-dollar projects that have never been done before. In a lot of cases, we don't have the expertise in Canada to pull these off successfully.”

As a result, many of the clinical information systems installed in Canadian hospitals, health regions and community-care access centres today are procured from large U.S.-based multinationals, including GE Healthcare and Meditech Inc.

The irony of software developed in the United States landing up in Canadian hospitals–countries diametrically opposed when it comes to the health-care payer model–has not been lost on Mark Groper, president and CEO of Dinmar, the 120-person Ottawa-based health-care IT solutions company that developed and installed Sunnybrook's Oacis EHR system and that recently won major contracts in both Montreal and Ottawa. He is encouraged by the increased business, but says companies like his continue to face roadblocks.

“I think there's two things. One is the funding. It still isn't there. A lot of the money that Canada Health Infoway has, still hasn't been spent,” he says. “The other is the procurement practices and policies that make it very difficult for companies like ours to secure the business. The U.S. companies we compete against are much larger, and they spend a lot of time lobbying the provincial and federal governments. A lot of [buying] decisions aren't necessarily made on the basis of what's the right product.” The “right product,” adds Groper, is one designed with Canada's unique EHR needs in mind–one that supports a bilingual population and allows information sharing through web-based viewing portals or integrated systems.

The flip side of hospitals going digital with patients' records is that, in order to fully integrate the system, doctors' practices and community health centres ideally need to go digital with their records, as well. There are companies that cater primarily to such markets; their products are called electronic medical records (EMR). But for such EMR vendors as Toronto-based MedcomSoft Inc. (TSX: MSF), the relative immaturity of the Canadian market space for health-care IT and lower adoption rates among physicians' offices adds up to a much more lucrative market south of the border. Although the company's billing and scheduling software is installed in about 500 sites across Canada, MedcomSoft chairman and CEO Sami Aita says it has no intention of doing any EMR business here at home. “There is no [financial] incentive for EMRs, whereas…since 1998 the U.S. has been introducing legislation, making EMRs an absolute necessity.”

This, however, is starting to change, as smaller niche players such as Calgary's Clinicare Corp. and Markham, Ont.- based Nightingale Informatix Corp. edge their way in. Company representatives say the trend toward automating patient charts, billing and scheduling has meant a slow, steady, increase in business.

“Last year was a bit of a turning point for us,” says Nightingale's president and CEO, Sam Chebib, whose publicly traded company (TSXV: NGH) has seen 100% year-over-year revenue growth since it launched the web-based MyNightingale suite of outpatient clinic software products, in 2002. The 120-employee company recently secured an exclusive relationship with Toronto's Mount Sinai Hospital to automate its outpatient clinics, and is also working on EMR initiatives in Nova Scotia and Alberta.

Clinicare's president and CEO Dennis Niebergal agrees. Electronic medical records are becoming “front-and-centre,” he says, thanks to concerns over efficiency and patient safety and the Alberta government's 2001 decision to offer financial incentives to doctors who install EMRs. So there's demand–the challenge is to keep it going.

“Think of it this way,” says Stephanie Saull-McCaig, director of acute-care information management at the University Health Network, a Toronto-based consortium of three large teaching and research hospitals. “Ontario's got 159 different hospitals with 159 different CEOs, all looking for an IT solution.” And that's just Ontario.

In fact, the one province that seems to get the idea of integration is Alberta. Edmonton's Capital Health region, for example, launched Canada's first regional electronic health-record system in 2004 and is set to unveil the second, $10 million province-wide phase of the project–Alberta Netcare–in May. The web-based portal, which will eventually link every doctor in the province to a patient-centred electronic record that can be reviewed securely from any location, also links to the provincial drug database, giving staff up-to-date information on medication and allergy history.

“We needed to find a way to bridge all of the different islands of information, and we knew we couldn't rip out all the technology and [put in new systems] that fast,” says Donna Strating, the region's chief information officer. “We're integrating key pieces of information through this portal.”

In Ontario, by contrast, the move toward regionalization and integration is only starting to kick in with ministry-designated local health integration networks. So progress has been slower, particularly among smaller institutions.

At larger institutions such as Toronto's University Health Network, which uses a computerized patient record developed by Raleigh, N.C.-based Misys Healthcare Systems to link to some of its six local partner organizations, vice-president and CIO Matt Anderson says the benefits of integration are clear. For example, X-ray films are now shared seamlessly between institutions using archived digital viewing systems. So-called runners, who used to race between hospital floors to pick up and drop off lab orders and results, have been replaced by online viewing systems. BlackBerry messages are automatically generated by the emergency department's information system and sent to a community-care access co-ordinator if a home-care referral is needed. And the Toronto General Hospital site is currently working on a project with Ontario paramedics with the potential to have patient information collected in the ambulance and sent electronically to the ER before the patient even arrives.

Anderson says each of these “small wins” creates a more efficient system that increases patient safety, improves the quality of care and frees up time for doctors and nurses to see other patients. He says further links among Ontario's local health integration networks will result in even greater efficiencies. “Cost justification for IT gets easier if you look at it from a regional or population-based model as opposed to if you look at it from a single institution,” says the 37-year-old executive, who was named one of Canada's Top 40 Under 40–an award that recognizes movers and shakers in Canada's workplaces–by the Caldwell Partners in 2004.

Anderson says he is happy with the University Health Network's Misys system, but adds he'd like to see more “made-in-Canada” EHR systems. He also worries about the implications of Canadian health-care institutions buying software from non-Canadian companies.

“If we're buying our product from multinationals, we're a small market, how are we going to influence the R&D?” says Anderson. “Theoretically, one solution would be to find a [medium-sized EHR vendor such as] Dinmar, work with the Canadian banks to invest and have Toronto, Edmonton and Vancouver move onto that product. This could actually allow us to develop it in such a way as to support the Canadian marketplace.” Music to the ears of those operating Canadian companies like Dinmar, Clinicare or Nightingale.

Still, this is health care, where change is often slow, and cures aren't discovered overnight. With spending bottlenecks, a lack of co-ordination among Canada's key health-care players and (for now) continued reliance on U.S. technology requiring time-consuming customization, Canada's health regions, hospitals and doctors' offices remain much more than a click away from the end goal–providing patient-centered EHR coverage from coast to coast to coast.