Letter to W. Edmund Clark: Valuing public and private assets with respect to Ontario’s digital health strategy
Many thanks for inviting us to speak with you on October 19. We had an excellent conversation and as requested we are following up in writing.
On October 7, Health Minister Hoskins released an open letter to you, seeking a value assessment of Ontario’s e-health assets and recommendations on maximizing the value of those assets “by improving how care is delivered, the patient experience in interacting with the health care system and, indirectly, through the economic value that is created for Ontario's economy.” You were approached in your capacity as the Premier’s Business Advisor and Chair of the Advisory Council on Government Assets.
Ontario’s registered nurses, nurse practitioners, and nursing students will follow the results of your review very closely because they recognize the potential of e-health to further enhance health systems and health services delivery. Nurses are very keen to support the development of a comprehensive, fully integrated e-health system in the province. This would enable us to focus more of our time on health service delivery, have access to the patient’s relevant history, and be supported by robust information. This will lead to enhanced practice and better outcomes for Ontarians – especially if also accompanied by adequate health human resources and evidence-based practice.
Significant progress in e-health has been realized on a number of fronts:
- Health professionals now have fuller and quicker access to health records, particularly in the hospitals. Much more remains to be done across all sectors to get access to necessary data and other electronic health tools.
- Public awareness of electronic health records has increased markedly in recent years, and most individuals’ primary care providers have electronic systems in their offices.
- Portals from health centres are in use and telehomecare is widely used and very successful for cardiac and transplant patients.
- Mental health apps are now available. The population is embracing technology, and that presents an opportunity to engage and empower people to be more involved in their own care.
However, e-health adoption in Ontario lags behind other jurisdictions, particularly those in Europe. A major challenge is getting legacy electronic health information systems to interface with each other. For example, nurses often are unable to obtain significant clinical information about patients when they are admitted to the emergency department. As a result, resources may be wasted rerunning tests because the results of the original tests ordered by primary care providers are not readily available.
Efforts such as the government’s Bill 41 -- Patients First Act, 2016 -- place an increased emphasis on facilitating effective transitions throughout the health system and the co-ordination of care. Since 2012, RNAO has advocated for a primary care co-ordination model for all Ontarians through our Enhancing Community Care for Ontarians (ECCO) model. The existence of an interoperable electronic health system was identified as a key enabler to ensure that primary care is supported to fulfill a vision of patient-centred, safe, coordinated care. Timely access to and exchange of clinical information is imperative to achieve this vision.
It is important to continue shaping our e-health system to be consistent with health transformation goals. We refer you to ConnectingOntario as a project which is doing just that. An initiative of eHealth Ontario, it is working to integrate health records for three provincial regions and make that information available to providers. It is incorporating not just electronic medical records (EMR) from primary care, but also clinical reports from hospitals, the community, diagnostic imaging, lab results, and drug information. It covers most but not all health sectors: acute care, community support services, complex continuing care, long-term care, mental health and addictions, primary care, and rehabilitation. There is much to learn from the successes and challenges of the ConnectingOntario project. We urge you to recommend that Ontario realize the planned integration province-wide of Connecting Ontario, and that as intended, the integration be scaled up to the national level.
We also advise that you review the recommendations of the Hospital Information System Renewal Panel. They apply to the hospital sector; however to meet Ontario’s Patients First strategy they could be used to provide guidance for system-wide recommendations on integrating e-health systems across the province. The long-run objective must incorporate all relevant client information into the provincial electronic health system and all e-health data into a consolidated e-health data system. Otherwise, inefficiencies will continue creating quality and cost impacts.
Ontario must also take the next step to fully realize the potential of well-designed technology to enable clinical best practices through such features as e-Decision Support, e-Clinical Practice Guidelines such as RNAO’s nursing order sets and e-tools to help providers to predict and monitor their patients and enable better care transitions. And it must support nurses and other health providers to transition to a practice that fully utilizes those tools and processes. Getting e-health right will not by itself deliver a successful patients-first strategy, but it is a necessary step.
We know that provinces can learn from each other. For example, based on Canada Health Infoway’s quantification of the benefits of the province’s extensive digital health system which includes: telemedicine and telehomecare; EMRs; diagnostic imaging systems; and drug information systems. Ontario would appear to be advanced relative to its counterparts in the area of telemedicine and telehomecare, and lagging in drug information systems. These domains remain siloed and must be integrated into an electronic/digital system of care.
We are optimistic about the potential directions of your review, and want to provide our advice, expertise and resources to ensure that the impact will be beneficial to patients, nurses and other clinicians. In our view, it will be important to continue with the task of improving the e-health infrastructure so that it maximizes the health of Ontarians and effectiveness of the health system. We don’t want that objective to be subsidiary to creation of economic value and/or privatization. Therefore, we advise against using as guidance the mandate of the Premier's Advisory Council on Government Assets, which was to examine “how to get the most out of key government assets to generate better returns and revenues for Ontarians.” We are concerned that such a focus could be incompatible with improved care and better patient experience.
In that regard, an immediate concern is the privacy of health information, and we take some assurance in the minister’s emphasis on the protection of personal health information in his letter. We are encouraged by your statement that selling digital health assets is not on the table. These are both important assurances and we urge you to maintain these commitments. More generally and as I stressed during our conversation, RNAO would strenuously oppose any privatization of electronic systems or software and/or reliance on sole-source proprietary programs as that would make the health sector hostage to exorbitant fees for services to update those systems and software. On the other hand, RNAO would support any electronic systems or software that are developed with our public dollars and run on a not-for-profit basis.
In keeping with these assurances, our request is that your assessment provide advice on changes to the e-health infrastructure to that will:
- enhance the patient experience and make the health system co-ordinated, fully integrated and person-centred; and
- improve the quality, safety, timeliness and efficiency of health service delivery.
As we note above, this is not just about realizing the full benefits of comprehensive and accessible EHRs, but it is also about realizing the full potential of the e-health system to transform practice in the digital age with electronic knowledge-based practice, virtual care management, and data analytics. In such a digitally enabled health care system:
- health providers can connect to robust information and clinical best practices at point of service to enhance clinical practice and outcomes;
- Interprofessional teams can connect to enhance communication, collaboration and patient care (many patient adverse events may be traced to communication problems);
- patients can connect to e-information tools to improve self-care and be fuller partners in their own health journey; and
- clinicians, health organizations and funding agencies can connect to the required data analytics that are needed at the clinician level, management/organizational level and provincial and national level to achieve the triple aim of ‘better health, better care and better value.” This includes precision clinical/practice where technology will enhance the relationship between research, practice and a continuous quality improvement feedback loop with evidence.
Most Ontarians want to, and must have an active and informed role in their own health and health care. The RNs, NPs and nursing students of this province are excited about the prospect of being better able to nurse though clinical interventions as well as to educate, coach, empower and otherwise support their clients -- enhanced by the promise and capacity of robust technology. That will require a roadmap and investment not only in software but also continuing to actively engage nurses, and other professionals in the design and use of technology to support patient self-management and enhance the care they provide.
From a fiscal point of view, it is important to address the above health system imperatives while maintaining or improving cost effectiveness, and protecting Ontario’s long-run fiscal capacity. In fact we believe your review can examine routes to the creation of economic value, precisely by examining how Ontario’s ehealth vision can meet the above criteria and objectives. The inquiry must not be led by a quest to create economic value. It is far more pressing to help Ontario catch up with leading countries in e-health, by leveraging its current domain investments, enabling enhanced e-functionality and achieving an integrated and interoperable digital health system. Ontario must then take that second step to use e-health to transform clinical practice and population health management. There will likely be significant economies from scaling up of system integration, and there will be significant economies from transforming practice; both will greatly enhance the value of e-health to Ontario.
Ontario’s nurses are very committed to advancing health and safe, quality, evidence-based health care and see technology as a critical component in system transformation. We respectfully request that you keep these goals as a focus in your inquiry. We look forward to continue our active participation in the inquiry, and are pleased to offer our advice, nursing and ehealth experts, and other resources, that will certainty enrich your work.
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT
Chief Executive Officer, RNAO
Copy: Honourable Kathleen Wynne, Premier of Ontario
Hon. Eric Hoskins, Minister of Health and Long-Term Care
Jeff Yurek, Progressive Conservative Health Critic
France Gélinas, New Democratic Party Health Critic
Get the letter with full references below