Survival at the front lines of the health-care quagmire
A top-down bureaucratic approach has given us a system that just doesn’t work
I have been a family physician practising in this province for 30 years. It is a great joy looking after my patients. However, looking after them in the health care quagmire of disconnected information and bureaucratic silos is becoming a nightmare. It is alarming seeing my young colleagues bewildered so early in their careers, and new graduates of family medicine are afraid to set up practice.
The province is carved up into 14 Local Health Integration Networks and 76 sub-LHINs each seemingly reinventing the wheel while consultants analyze the same things over and over again. There is an obsession with accountability frameworks designed by this ever growing bureaucracy that has little idea about what we actually do and what tools we need to do our job.
Hundreds of millions of dollars have been spent on a huge array of electronic repositories and information systems that don’t integrate at the most basic level with each other years after they were built. Providers spend countless hours trying to locate who does what where and what hoops to jump through to get appointments. We fax long paper forms with lab and other reports that are somehow not available from these expensive repositories. We typically access each other by phone in the absence of electronic messaging capabilities.
Two Electronic Health Record (EHR) systems were funded that were supposed to provide immediate access to important patient information. They are so slow at times you might as well get a coffee waiting for a response. Our office systems can’t link to the EHRs so we log in to them manually.
I work in Burlington on the border of two LHINs that use different EHRs. If my patient shows up in Windsor with a heart attack I can access their hospital results immediately. If it happens kilometres away in Oakville I wait for the paper mail to come. I am only allowed to use one EHR and, of course, the two EHRs don’t connect.
In 2012 I was interviewed in a frontpage article of the Toronto Sun expressing my dismay. The health minister was quoted saying: “… I think all of us would like to have the magic wand where we have everything up and running tomorrow but it is a very, very big project.”
I was not aware that Google and Facebook were using magic wands for their very big projects. I thought they were using APIs.
An eHealth spokesperson was quoted saying: “Holmes’ frustration may reflect his own experience, but Ontario is leading the country in EMR adoption.”
“EMR adoption” was brought about in Ontario by a massively expensive subsidy program force-feeding systems into doctor’s offices.
Vindication arrived for me in October 2015 when the feature article of the Medical Post “EMRs: Islands unto themselves” also described expensive disconnected islands of systems managed by teams that never seem to be able or forced to collaborate.
It is 2018 and little has changed six years after the Sun article. It is difficult to envision how we will ever get to a modern paradigm in Ontario. Maybe we should look for a successful model elsewhere.
Denmark is light years ahead of us. No subsidies were paid and there was almost universal adoption of EMR systems very quickly in the 1990s. For over 15 years most Danish providers have been sending millions of messages and prescriptions across an electronic network. Patients visit their GP, then walk in to any pharmacy to access the prescription that was sent electronically. In spite of hundreds of millions of dollars of subsidies and the creation of huge agencies, we are nowhere close to doing these things in Ontario. We will be faxing for many years to come.
The difference between Ontario and Denmark has nothing to do with technology or access to smart people. The difference is leadership and governance.
In Denmark leadership brought all the constituents of their health-care system together into the same room. They defined all the interactions and created universal standards for interoperation. Firm deadlines were set and an effective governance framework ensured that things happened.
Whoever wins the provincial election needs to change what we have been doing in Ontario for far too long.
The top-down bureaucratic approach has created countless silos and primary care providers are tasked with stewarding patients through this “system” of silos.
It is becoming almost impossible and, when primary care is not sustainable, we are all in trouble.