E-Health: The Potential for Radical Change to Health-Care Delivery

Head Table Guests

John Sadler, Managing Director, Genoa Communications Management and Director, The Empire Club of Canada; Rev. Dr. John Niles, Victoria Park United Church; Alyssa Titus, Honour Student and President, Music Council, North Toronto Collegiate Institute; Donna Kline, President, Emerge Communications; Robert A. Dymond, Vice-President, Business Development, eHealth, MDS Inc.; Dr. Alex Jahad, Director, Program in eHealth Innovation, University Health Network, University of Toronto; Julie Hannaford, Partner, Borden Ladner Gervais LLP and Past President, The Empire Club of Canada; Kathy Kastner, CEO, The Health Television Network; Dr. Sami Aita, Chairman of the Board and CEO, Medcomsoft Inc.; and John Haslam, Director, Hospital and Pharma Sales, HoffmannLaRoche Ltd.

Introduction by Ann Curran

Tom Closson

Thank you very much Ann. I am very pleased to have the opportunity to present to you the potential for radical change associated with eHealth. I want to say at the outset the University Health Network is a name that is not particularly well known in health care. That is because it is relatively new. It is an amalgamation of three excellent organisations--The Toronto General Hospital, The Toronto Western Hospital and Princess Margaret Hospital.

I would like to start off with a chest pain scenario. A 55-year-old man with a history of heart problems feels pressure on his chest and pain while he is at work. They call 911. After two minutes he feels anxious because the ambulance has not arrived-it's rush hour. What should he do and how could the health system have better served him?

Well, here is what's possible today with the technology that we have, but it's unlikely to happen. In fact, I am sure it wouldn't happen. This particular patient, because he has a pre-existing heart condition, has a wearable monitoring device for continuous contact with the health system. There is two-way video to dialogue with the nurse or doctor until the ambulance arrives; his electronic health record is accessible to all the caregivers. At his office, there is a staff member that is trained in first aid and this staff member is able to attach a device to him that monitors 20 physiological variables and is also able to open an electronically tagged medication package for his potential heart attack. If it is likely that it will take longer than three minutes for the ambulance to arrive, the patient and the first-aid person can link to an on-line coaching protocol.

Emergency care specialists can join this two-way video conference and take the first-aid attendant or the patient through a protocol to slow down the attack and reduce the risk of death. At this point the patient's family is linked to the video conference and they can be reassured. The traffic is still delaying the ambulance so a community-based physician who has been following this by hand-held computer is on her way, assisted by satellite, to find the patient and attend to him.

Now, everything in that scenario is possible today, but unfortunately if you are a potential heart-attack patient, it's not going to happen for you. We have a health-care system that is quite fragmented. We have hospitals that are quite separate from each other. In a city the size of Toronto, we have many hospitals that all have different information technologies that in most cases don't link to each other. We are not very well linked with family physicians or other providers within the health-care system. The care that is provided is quite episodic, people tend to go to get health care when they are sick, and they get the care for that sickness and that's it until the next time they are sick. Yet many people have chronic illnesses, which need to be followed, and it is very difficult to access care providers 24 hours per day, seven days per week. If you phone most family physicians' offices this evening, in Toronto, you will get an electronic voice mail message that suggests that you go to the Emergency Department.

What do consumers expect? Well consumers want continuity of care. They want to know that if they have a chronic illness, somebody is following it and helping them. They want to have easy access to service, and they want to have access 24 hours a day, seven days a week They want to be assured that the latest drugs and the latest diagnostic technology are being used. But they also want a human touch and in fact, if you look at patient complaints of the health-care system, more often than not, they actually relate to the human touch side.

I thought I would define what I mean by eHealth. I am using this term to mean any electronic exchange of health-related data, voice or video. We could say data, which would be adequate, but I wanted to emphasise the video and the voice side as well. I have broken what I mean by eHealth into three major categories, because I wanted to talk about each regarding where we are today in the health-care system in Ontario with each of these areas.

I have broken it down to business eHealth, clinical eHealth and consumer eHealth. Business eHealth is the most fully developed. What I mean by business eHealth is electronic claim submissions-things like OHIP claim submissions, or claims for private or semi-private accommodation in hospitals and supply chain management-that is, hospitals being able to link with vendors to buy drugs or medical/surgical supplies. This is quite well developed, although it could be better. And there is a strong business case for it, meaning it's been easy for individual organisations to justify it, in terms of the savings that they can achieve.

This isn't the case for clinical eHealth. Although I gave you a scenario that includes many aspects of clinical eHealth, this is really the least adopted area in health care today and not just in Ontario, but generally throughout Canada and the world. I am using this term to include things like electronic medical records, where any service that I receive throughout my life is stored somewhere electronically, so that it can be easily accessed by anyone trying to provide care. I was speaking to my 20-year-old daughter last weekend about this issue, and was remarking that even at the ripe old age of 20, she has health records at four different hospitals in the Toronto area, a hospital in the United States, and with several family physicians. They are scattered everywhere. In fact, she doesn't even know where they all are and there is no way for her to bring them all together, unless she goes on a bit of a search mission and gets a good photocopier.

I am using the term clinical eHealth to also include clinical telemedicine. There have been some good pilots done in Northern Ontario through the North Project and from the Hospital for Sick Children. These projects show how we can use two-way video to have the physician and the patient in very different places and still have the physician provide care to the patient. In fact in Ontario, of the $20 million that is spent on travel grants to bring people down from Northern Ontario, three-quarters of it is spent on clinical consultations and only one-quarter of it on actually having a procedure done. So the idea of keeping the patient up north and having them use two-way video to have the consultation with the physician is clearly something that is technically feasible, and in fact, starting to happen, and it is happening in other parts of Canada as well.

There are major privacy and data standards issues in clinical eHealth which need to be addressed and these are major barriers to clinical eHealth moving forward. This is important because one of the things I have found in health care is that any time anyone has an idea to improve the health system, there is a group out there that says there are bad things associated with the idea. And these critics are the ones that end up being quoted in the newspaper, which makes it hard to move forward. Another barrier is that physicians outside hospitals have very inadequate information technology for the most part. There's a reason for that. Physicians are small business people who are concerned about what their expenses are and there is very little incentive for them in terms of payback to justify major investment in technology. Overall, there is a lack of a clear business case for many of these clinical eHealth applications, particularly if you look at them in a narrow way. If you look at them in terms of the whole health system, the business case can be quite compelling but given the fragmentation I talked about, the business case is very difficult for individual organisations or providers to justify.

Consumer eHealth, the third area, is expanding very rapidly. I was reading an article recently that suggests that there are 16,000 sources of health information on the Internet. So, if anyone is thinking about starting up a new health website, you have quite a bit of competition. There are additional functions that I have included under consumer eHealth; things like being able to order drugs through the Internet; provider/patient messaging-being able to send e-mails to your physician and have them answered. There is a big barrier to this right now because physicians don't get paid to answer e-mails. However, if you look at surveys of patients, they would like to be able to e-mail their provider. If you have ever tried to phone your provider when they are running a clinic, you're told they will phone you back, but e-mail is clearly a simple technology that people would like to use. Consumer eHealth also includes the storage of personal health records, which is something many consumers would like. They may be concerned about who has access to the records, but they would like the records to be brought together.

I have a wonderful quote from the Lalonde Report which was written in 1974 on A New Perspective on the Health of Canadians and I'll read it out. The year 1974 is 26 years ago; I only started my career in 1971, so it's my entire career. In 1974 Lalonde said: ""In spite of the great strides made in recent years, there are a number of difficult problems facing those with responsibilities for providing health-care services. There is a lack of a uniform and integrated system for maintaining health records for individuals. Essential data are scattered in many locations, in physicians' offices, hospital records, clinics, etc.""

Now this video clip I'm running shows you what it is like in most hospitals. You'll notice there is a computer in that picture, which is a good sign. But what we have in hospitals today throughout Canada is lots of paper-tons of paper. Paper being moved all over the place. It's not surprising that it's difficult for us to link with other hospitals and with family physicians when you see how difficult a time we have even keeping our own paper straight.

One of the reasons for this slow progress is demonstrated in this graph. It shows the percentage of revenues, worldwide for different industries, in terms of what they spend on information systems. You will see at the bottom of the graph that financial services companies spend 12 per cent of revenues on information systems and about half way down you will see that health-care providers worldwide spend just about 4 per cent. In Ontario health care, we spend less than 2 per cent. So we have a major problem in terms of how much we are spending in Ontario on information systems in relation to the likelihood of ever doing anything very significant in this field.

Nevertheless, I think there are some real drivers for change here. Although during the first 26 years of my career we haven't accomplished much, I think the next 10 will see major change.

Sixty-five per cent of Canadians have Internet access in their home or in their office. That is an April 2000 statistic. Health care is one of the most popular topics on the net; 77 per cent of users have searched for health information, 43 per cent of Canadians have made a purchase on the Internet and 20 per cent of Canadians are doing their banking on-line.

This is a fast-growing statistic. In my view the banking statistic is the one that will drive the change in health care the fastest. You have some of the same privacy issues in banking as we do in health care and yet we're up to 20 per cent of the people moving money around and paying bills on-line. Why not use the technology for health care?

I'll give you an example here-the Kaiser Permanente website-KP On-line. Kaiser Permanente is a very highly regarded health-maintenance organisation in the United States, probably one of the best regarded in terms of the health field. These are the kinds of services that you can get as a member of the Kaiser Permanente health-maintenance organisation. You can maintain your own personal health records; you would have access to information on all your test results and all the services you've received. You can order medication refills. You can request and schedule your appointments with family physicians or with specialists through the Internet. You can select customised health information. Kaiser has taken the 16,000 health websites and put the information into a form that makes it easier for you to find the information you need. You can access on-line support groups, so that if you have cancer you can get into chat groups with other people who have cancer and are members of your group. I've been playing around with chat groups myself recently, and it's interesting how that technology allows people to communicate from a distance at basically no cost. Finally, the KP website enables patient/physician communication, which is the ability to send and receive e-mails from your physician to get your questions answered.

Now there are many more things that constitute eHealth beyond what I have listed here, but KP On-line is a good example of what is already happening. Why isn't this happening in Ontario? Why isn't it happening anywhere in Canada? Part of the answer relates to the motivation for Kaiser Permanente. It's not just efficiency, although efficiency may be part of it. Another part of it is market share. Kaiser Permanente is trying to attract members in competition with other health maintenance organisations. With the way health care is organised in Canada, there is no competition to make organisations want to have market share. In fact it works the other way. I think most of us think we have too much market share already!

Now there are huge advantages to doing some real testing and evaluation in the city of Toronto about what could actually be accomplished in terms of eHealth. We're the largest city in North America with a single medical school: University of Toronto. It is one of the top three or four medical schools in North America and the expertise that it has is a remarkable advantage for us. We have the largest teaching hospital system in Canada doing a tremendous amount of research. In my organisation alone, we're doing $75 million of research a year on a budget of about $750 million. So 10 per cent of what we spend is on research primarily funded through research grants. There is a good technological infrastructure and there are good international links. We're home to major technology firms and we have communities here from over 170 countries. This suggests that we have an opportunity to do research that will allow us to be global providers. My view is that eHealth is going to make health care go global. In fact, it already has. Check out one of the 16,000 websites that provide health information; not very many of them originate in Canada. When you look at clinical telemedicine with the North Project or with what Sick Kids does, if you can provide specialist support to northern Ontario why not provide specialist support to Texas? I think the shortage of providers that we have today is going to encourage greater globalisation. You could make the argument that with the health human resources staff shortages, we can't even take care of our own people, so we should not try to take care of people in other countries. The fact is that the shortages tend to be in specific specialties and in certain geographic areas, so the technology will enable the provider to serve the patient regardless of where in the world the patient is. And with communities made up of people from 170 countries--where better to test out some of these technologies, than the city of Toronto? I was looking at demographics in the general catchment area that we serve; the biggest population groups that we serve are Portuguese and Asian. About 10 per cent of the population is Portuguese and about 10 per cent Asian. About 10 to 20 per cent of the people who come from those groups don't speak English. That's what our surveys show, so we've got the opportunity to test things out in our own backyard to enable us to look globally in the future.

So where do we go from here? I think there is lots of room for all of us in eHealth because it's just really beginning. We're starting the Program in eHealth Innovation at UHN (a joint partnership with University of Toronto) We recruited Dr. Alex Jadad from McMaster University to head up the Program. He is a physician with a special interest in eHealth who has been doing research into the use of eHealth in terms of patient/provider interaction. The Program in eHealth Innovation is trying to look at how we can use technology to improve the health and well-being of people worldwide. The way we are going to approach this is by looking at Toronto as being a mini model of the world. Toronto is the most multicultural city in the world and it's the perfect place, given all of the points I raised earlier, for this kind of initiative to occur. We want to promote the integration of all these technologies with the cultures of health and health care. We want to try and change the way health care is delivered.

So, in conclusion, I have several points I want to make. First, I think there is a major under-investment in informatics in health care in Ontario. Over each of the next few years, expenditures in health care in Ontario will likely increase at the rate of 6 per cent per year. Right now we are spending less than 2 per cent on information systems. If we took a one-year pause in putting extra money into providing service and invested the 6 per cent in information systems, we'd be up to 8 per cent in information systems. Think of the potential that would create in terms of new eHealth approaches. Now, obviously you cannot stop increases in health services spending entirely. But the idea of ramping up to get to a more reasonable level of information technology investment should be a major strategy initiative of any government.

A second point I want to make is that I believe there is potential for radical change in health care. The scenario I gave you at the beginning of this presentation regarding the heart patient is so different from what happens today. It just gives us a flavour of the kinds of things that could be accomplished with the technology that is already available. With this new UHN Program in eHealth Innovation I don't suggest that a year from now we're going to be able to provide all of this. Our Program in eHealth Innovation is a research effort to test out different approaches with private-sector partners and other public-sector partners. It will test out approaches that could be developed within Ontario and internationally.

And finally, I've stolen one of Alex Jadad's lines. Alex talks about enabling the health system to become a ""good travel companion."" This is very different from the way the health system currently works. When you go travelling with your travelling companion, you have someone to talk to, someone to share things with and, if you get into trouble, someone to rely on, 24 hours a day, seven days a week. This is very different from the way the health-care system currently operates. We believe that with the appropriate use of eHealth we can turn the health system into your travel companion. Thank you very much.

The appreciation of the meeting was expressed by Julie Hannaford, Partner, Borden Ladner Gervais LLP and Past President, The Empire Club of Canada.