There is trouble in e-health land, at least in Ontario’s funny notion of what they might mean.  EHealth Ontario has been subject to an emergency audit of its procurement or not of an electronic health record [EHR] by the Auditor General of the province.  Apparently, somewhere approaching C$1 billion has been spent with virtually nothing to show for it.  The problems lie in a bad ehealth strategy, and inappropriate use of consultants.

There are lessons here for other jurisdictions, as they seek to embrace the benefits of EHRs, and ehealth more widely, in particular. Of course, what is an EHR for, is the core question.

One of my alma maters, McMaster University, has sprung into the fray saying it has an EHR called OSCAR that could be implemented for perhaps 2% of the estimated cost of a provincial EHR.  Their argument being that a lot of doctors are using it.

EHRs are not a tool for doctors, though.

EHRs are an integrated information repository to facilitate better healthcare.  Doctors are not the only oranges, and nurses, physios, social workers, pharmacists, OTs, oh, yes patients and parents, informal carers, too, need access to health records. In my view, patients should own and hold their own health record, to ensure high audit standards (would you let an error remain on your health record if you knew about it?).

Servicing the specific needs of doctors alone is not an EHR strategy worth having, and doctors themselves should be the first to say this. It is time they showed leadership within the wider healthcare system, and rejected self-serving models, such as McMaster’s, which automate obsolete information models. McMaster, too, should have known better.

The Ontario Ministry of Health has wisely rejected OSCAR’s offer, but for the wrong reasons.  Citing the need for doctors to choose their own systems, just shows their continuing logic of catering to the needs of a particular health profession, rather than addressing the systematic provision of patient information within an integrated decision-support system.

All this is being driven by beleagured officials who really need to think again about their priorities and why they really need an EHR.  Perhaps they are afraid to admit to having made a mistake.  Such hubris.

Clearly more work is needed to define the purpose of the EHR and the goals for an ehealth strategy in Ontario (and other jurisdictions of course), before more taxpayers’ money is spent on ehealth.

Oh yes, apparently Ontario are going for a tender on a diabetes registry. NYC has one. I fear the worst.

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

1. their capabilities and
2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.

From across the Atlantic comes news of apparent financial maladministration at E-Health Ontario, the body charged with implementing the province’s e-health strategy.  It seems to be the usual nonsense of untendered contracts, friends in high places, and chums helping chums.  It is also an example where no one seems to have asked the simple question, “why would you do that?”  — the strategy is a nonsense, and I am surprised that no-one challenged this before the policy had gone this far in implementation.

I would, naturally be more inclined to be concerned if the province’s e-health strategy were actually about e-health, or likely to deliver results worth having, but the $700 million or so per year will be spent on things like a diabetes registry, wait times, electronic prescribing/electronic health records.  Only the last have anything really to do with e-health.  The last can also be procured, so there really isn’t a need to make a supplier meal out of putting something in place.  I will concede though that an EHR is a critical component of e-health, but it isn’t quite the same as e-health — it is a bit like confusing the foundation of a house with the home it will become.  But having worked on eRx,  the province’s failure to prioritise some sort of a patient-held smart card is a mistake as without this it is difficult to deal effectively with identity.

Without system redesign in the province, the e-health strategy is really just throwing good money away and given the current economic (and political) climate, this is no longer an option, if it ever really was.

Two things are of critical importance.  First the province needs to have a thorough-going governance review of e-health Ontario, mainly to determine how to make sure it is fit for purpose in actually providing the leadership for development of an e-health infrastructure service delivery platform.  Secondly, and this is the challenge, it is necessary to make sure that the e-health services are ones that the public will use and value.  The province has failed on both counts.  The next challenge though will be to find people to review e-health Ontario who haven’t been tainted by this scandal and benefited from the feeding frenzy e-health Ontario created. It may require looking further afield, to interested, but uncontaminated parties.  They may even not live in Ontario — golly gosh, so much for made-in-Ontario mediocrity.

So, having vented on that last point,what would an outline e-health strategy look like for Ontario, assuming that some governance arrangements are put in place,.  These are really just illustrations as certainly I would want to get a good understanding of priorities from interested patient groups:

• There are about 90 rural and small hospitals in the province.  A good plank in an e-health strategy would be to enable them to become a single, integrated, but distributed healthcare provider, perhaps with some sort of local and shared corporate governance.  A distributed healthcare provider, using e-health infrastructure technology would deliver specific outcomes to rural people, such as access to networked diagnostic imaging technologies, electronic prescribing and remote access to health records.  I would certainly save people in Thunder Bay a lot of trouble getting down to Toronto for a scan.  With a little bit of imagination and thought, this could work.
• About 60% of diagnostic facilities are located in Toronto, but which has only about 25% of the population; these are licensed clinics which often only offer a single procedure.  Using networked imaging technologies, remote diagnostic telecare booths (you can buy one from Cisco) many of these suboptimal centres could be relocated either to the rural network, in the previous plank, or provide a more accessible urban service across the provinces main urban centres.
• Smart card technologies (whether a smart card or an electronic secure passport) would give a better reason for constructing electronic health records than ones focused on improving data access for health professionals alone.  Patients, when given access to their health information, will have a vested interest in ensuring that the information is correct (my Ontario health record when I lived there had an error showing I had a condition affecting women, but I am a man — I still don’t know if the error was corrected; in an electronic system, that error would have been a problem, but I would have made certain that it was corrected, too).  As an ‘auditor of one’ patients can make sure information is correct, and drive substantial service quality improvements.  This is not to say that health professionals can’t do that, just that the evidence shows it comes slowly and is complicated by cartel-like professional practice barriers.  Start by putting the e-health card in the hands of the heavier users of the health system, to better manage their healthcare, access to information, and gradually as people see their family doctor, or get born, migrate the whole population over.  Of course, this will mean that family doctors, clinics, pharmacies will have to adopt some sort of information system.
• Don’t do what the English NHS is doing with Connecting for Health, by creating a large-scale government-led initiative.  E-health Ontario’s predecessor took a look at Denmark, but failed to learn the lessons despite what they wrote in their sham of a consultation document — they missed the point partly because they appeared to have another agenda heading toward a particular solution.  Denmark has shown how disparate stakeholder groups can work together to create an information system that works, and does things people value.   Better that than spend vast amounts of money on a grand plan to nowhere.

The general plan is to build an infrastructure that starts with the patient/family as user.  My experience in developing an interactive health television channel showed me the importance of starting there, and defining the benefits from that perspective.  Change will drive from that end too.  Finally, engage all the stakeholders (like the Danes did), find commercial partners with interesting technologies that do things that people value (rather than whizzy technologies), look for alternative systems to pay for healthcare services, as failure to develop a suitable and workable reimbursement system for e-health services is a barrier ( just ask Norway).  Oh yes, don’t forget political will.

Central to all healthcare systems is the notion of the hospital.  Are these remnants of industrial-age or can they be rethought and refreshed for the post-industrial and information world we are likely to inhabit for some time?  Foucault spoke of the birth of the clinic (hospital); I will write about its demise.

The logic of hospitals has a lot to do with aggregation of technologies and brains.  It is easier to move the patient to the hospital where integrated systems kick in and provide care, than to have all that expertise go to the patient.  That paradigm is getting tired, but yet our thinking is still hospital-oriented.  What is the way out?

Evolution of artificial intelligence systems, for instance, points to the possibility of remote locations having access to clinical brains, either embedded in portable diagnostic technologies, or through distributed intelligent systems, or even more mundanely at the end of a telephone.  Perhaps it will take time to be comfortable with robotic surgeons, but remote manipulation of robotic surgical equipment is not inconceivable in daily use.

A rather interesting book from the early 1970s, by Maxmen, The Post-Physician Era, offered thinking about the direction of travel.  While getting many things wrong — we still don’t have shopping malls on the moon, he did, given the thinking of the day, accurately identify AI as a challenge to human diagnosis, and saw the obsolescence of the pharmacist through robotic dispensing.

The overall forces at work here are the migration of specialist human knowledge into devices and into software, that can be used by less-skilled people (i.e. not necessarily clinical professionals).  Self-diagnostic testing kits are just a primitive example.  Roll the clock forward with electronic health records, Web  2+.whatever, and advances in materials science, etc, and we have a constellation of factors which form a new pattern for healthcare service delivery.

And when will we build the last hospital?

It takes perhaps 3-5 years to plan a hospital and a couple to build one.  It is also critical in the design to take into consideration the evolution of use, changing demography, etc, to perhaps 20 years into the future.   I think by 2025 we will acknowledge that the existing hospital infrastructure should not be replaced, but slowly wound down as useful clinical environments.  Given the average useful lifespan of anything from 25 to 100 years, we need to be thinking the thoughts about the last hospital within the next 5 to 7 years.  There are, no doubt, hospitals in the early planning stages, that when built will be instantly obsolete.

Tempus fugit.