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“E” Is for Enabler

Network, Fall 2005

“Enabling One Person One Record” is the motto adopted by the Continuing Care e-Health Council. It alludes to an ideal vision of the future when the delivery of health care services will be streamlined by technology. The cornerstone of the e-health vision — some might say the holy grail — is the electronic health record (EHR), a single point of access to an individual’s complete personal health information. If you switch doctors, you won’t need to fill out another personal history. If you show up in the emergency department of your local hospital, or another hospital at the far end of the province for that matter, the nurses and physicians on staff will immediately know what medications you may be taking.

“Clients would like to know that when they go to see a professional they are recognized as a person,” says John McKinley, acting executive director of both the Acute Services and Community Health Divisions within the Ministry of Health and Long-Term Care. “Every time they walk into an office, or a clinic, or if they have someone coming into their home, they won’t have to go through their background and history again. There would be some way of capturing that information that would be available to them, so they won’t have to answer the same historical, demographic questions time after time.”

One look at Ontario’s health care system — encompassing everything from family doctors, hospitals, and neighbourhood pharmacies to medical labs, diagnostic imaging, long-term care homes, addiction services and community mental health agencies — is enough to suggest that creating an EHR is an incredibly complex task. Don’t expect to lay eyes on this particular grail for quite a few years to come.

In the meantime, several related e-health projects are well underway. Standards for financial information management are already in use by Community Care Access Centres and are now being implemented in the mental health and addictions sector. A secure communications network for sharing information has been built, and the Smart Systems for Health Agency is working feverishly to connect Ontario’s thousands of health care providers. User registration and access to secure e-mail, already a reality in the hospital sector, are coming soon to the province’s 1500-plus continuing care organizations. Drug and laboratory information systems are in development. And projects have been launched to create common assessment tools and a system for making e-referrals.

None of these e-health initiatives is considered an end in itself. Rather, the government views e-health as an enabler of its transformation agenda.

“Overall, the reason for the transformation is to improve health outcomes,” explains McKinley. “It’s timely access in some areas, it’s improved throughput, and it’s all for the client. As an enabler, e-health supports access to primary care.”

“It also leads to better evidence-based decision making, both on the provider side and for the ministry in its resource allocation models,” he continues. “Since we’re now moving to Local Health Integration Networks, where more local decision-making will be expected, they need good evidence of what does and what doesn’t work for their investment strategies into the future. That’s how I’d term e-health an enabler.”

Easy access to health information may indeed make life easier for health system planners and care providers, but the concept of an electronic health record also raises flags for anyone concerned about privacy. The issue of privacy is particularly important for consumers of mental health and addiction services, because of real fears about stigma and discrimination. The Personal Health Information Protection Act (PHIPA), which came into effect on November 1, 2004, places a clear obligation on health care providers both to protect personal health information and to allow access when necessary. The need to meet the requirements of PHIPA makes building an e-health system that much more complex.

Information and Privacy Commissioner Ann Cavoukian acknowledges that, as the use of technology increases, the need for privacy has never been greater. Multiple organizations are involved in providing health care to an individual, which underlines the need to integrate services. But the health sector in Ontario operates under a patchwork of rules, and some providers are currently unregulated. PHIPA spells out the ways in which health information custodians may collect, use, and disclose personal health information, and those rules apply equally to electronic records.

PHIPA requires that health information technology must enable the tracking of consent (so that health care providers can know whether the appropriate consents have been given and by whom), must allow the withdrawal or withholding of consent (the “lockbox” principle), and must enable clients to access their own personal health information and request corrections, if necessary. By building privacy requirements right into design specifications, using encryption, and minimizing the collection and routine use of personally identifiable information, technology can actually be used to help protect personal health information.

“The lockbox provisions are extremely challenging,” says McKinley, “and that is probably going to be one of the most difficult things to do. It is a very complex system and a very complex distributed information base, so it is not something that will be able to be implemented overnight. But it ispossible to do, and as technology moves forward and there are more and more options being created just by the development of new technology coming into the arena, maybe by the time we’re ready to come up with something there will be a much simpler solution available.”

The health care sector is certainly not the first to transform itself through technology, and there are lessons to be learned from other sectors that have already travelled this path and have faced many of the same challenges.

“If we look at examples in other worlds, other industries, what we’ll see is that transformation is a 10-year or 20-year proposition,” says Peter Catford, chief information officer at the Centre for Addiction and Mental Health. “My personal belief is that when you start along the road of e-health, there’s a very long adoption cycle, a very long learning cycle. It takes a long time for a strategy like this bear fruit, but you can have faith by looking at other industries.”

“The banking industry, for example, has radically transformed their business by moving to electronic client interactions with the bank. And it forced many services that traditionally had been very siloed and non-interactive to integrate and become very interactive. In my own bank, I can go to their website and get every piece of banking information and do every piece of banking that I need to do as a person, all over the Internet without ever going near a bank. But remember that they started investing in this technology in 1970 with this goal, and they only fully realized it in 1999 or 2000. I think the message is that adoption is a matter of faith and a 20-year decision.”

“Everyone can see the intrinsic value in creating an electronic health record, and the technologists tell us that it’s possible to do,” adds McKinley, “so the challenge now is to get from the ideal goal to something that’s practical and can be done. Ontario’s successes have mostly been in the hospital sector at this point. We’ve got movement on some base elements in the continuing care sector that will certainly serve us well as we move forward on this agenda, but I would say that there isn’t a fully integrated health record plan just yet. The overarching goal is there, the vision is there — enabling one person, one record — but there are many challenges to get through before we get there.”

“In frank terms, there is a certain amount of risk [when dealing with personal health information],” cautions Catford, “but we have a really good safeguard — and that is that health care providers have a professional ethic and a professional standard, and they handle this information with immense respect for the privacy of the client. That’s the safeguard, and as long we have that layer in our systems, then we will have a much greater confidence that our systems will protect people’s privacy. It may sound silly to say that people are what’s going to protect us, but I think, at the end of the day, they are the custodians and the system is just a tool that they use.”

Scott Mitchell is manager of the Knowledge Centre at CMHA Ontario.


Canada Health Infoway

Community Mental Health and Addictions Privacy Toolkit


Information and Privacy Commissioner of Ontario

Smart Systems for Health Agency

Transforming Health Care

» Return to Network, Fall 2005 – Contents