Solutions for interoperability shortfalls

Many physicians remember the bumpy transition to digitized medicine at the start of this millennium. It was hyped as a modern form of record-keeping that would hone clinical investigations by making a unified patient chart accessible across jurisdictions.Instead, we got a forest of information silos, generally not interoperable.“On this interoperability issue, it’s a complex problem, but in the end, there were a number of different systems put in place,” said Michael Green, president and CEO of Canada Health Infoway, the independent, federally funded, not-for-profit organization tasked with accelerating the adoption of digital health solutions across Canada. “For example, family physicians—maybe they had one system and then the hospital had another and I think at that particular time, people didn’t fully consider the fact that these systems effectively speak different languages.”Different languages? There is some déjà vu in that, infrastructure-wise. In the 19th century, rival railroad companies determined their own gauges across North America, resulting in a lot of rail that didn’t connect. Canada’s tracks had to be relaid in the 1870s, when a standard North American gauge was finally established.The ED perspectiveDr. Fraser Mackay is the chair of the rural, remote and small urban section of the Canadian Association of Emergency Physicians (CAEP). He works emergency shifts in New Brunswick—a province with two health authorities (one English and one French) divided into seven geographic zones.Dr. Mackay said that in the health authority he primarily works in, there are “at least three different hospital-based systems” to navigate, within the seven zones.CAEP does not currently have a position paper on information system interoperability, Dr. Mackay said. “But we’d all agree the system sucks.”“The lack of interoperability is fairly consistent across the country,” he said. “It is simply variable in scale. Some provinces (Alberta, Quebec) are more integrated than others, but there is zero interprovincial operability and, more often than not, within provinces there are multiple silos of EHRs (electronic health records) and a big wall between hospital systems and private/out-of-hospital office/clinic systems.”New Brunswick has made an effort to make family physicians’ electronic medical records (EMRs) accessible through the province’s clinical information system. “That went about as well as it ever does when a government tries to tell doctors how to run their business,” Dr. Mackay said. He finds access to primary care EMRs to be hit and miss.In most other provinces, EMRs are landlocked within doctors’ offices—though there are efforts to change that. In Quebec, the provincial government recently earmarked $3 billion over five years to ensure that physicians choose an EMR that is fully interoperable.“Knowing there is (potentially important) clinical information that we don’t have access to, that’s probably adding to the burden for all of us,” Dr. Mackay said. “A lot of times we’re stuck reinventing the wheel. I’ve got to order blood tests, imaging; I’ve got to figure out what the best drug is when exactly that information will be sitting there prepackaged.”Does this lack of access potentially lead to poor outcomes? Dr. Mackay said there isn’t good data, but from an ER doctor’s on-the-ground perspective, “I think there’s really very little doubt about that.”Can we retrofit solutions?Switch to Canada’s west coast, where Dr. Joshua Greggain is the past-president of Doctors of BC. As a rural physician, he has worked emergency shifts in various parts of British Columbia—a province divided into eight health jurisdictions that got to choose their own vendors.That hasn’t been so good if a patient from a different health authority turns up in Dr. Greggain’s emergency department (ED) but things have recently improved. CareConnect was introduced in 2021, enabling secure sharing of information between provincial jurisdictions.B.C.’s CareConnect gives an emergency physician access to important information from “a multitude of settings” across the province, Dr. Greggain said. The information could come from B.C. Public Health, LifeLabs, B.C.’s PharmaNet or simply from another health authority. Physician EMRs’ data are not accessible.B.C. has also been developing another tool—B.C. Health Gateway—that unifies people’s facility-based medical records and makes them more easily accessible to physicians. It also serves as a patient portal that gives people access to that portion of their medical history. A number of other provinces are currently working on similar patient portals, in response to a 2023 push by Health Canada to create “a modern and connected, world-class health system where Canadians can interact digitally with the health system and access their own health data electronically.”Ideas for fixesDr. Greggain said that clinical information held in family physician EMRs should be accessible to ED doctors (with proper steps taken to safeguard security and patient confidentiality). He would like to see the government offer FPs a “free access point” that would integrate their EMR with the patient records on Health Gateway.“That might just incentivize people to use it,” Dr. Greggain said, pointing out that primary care clinics spend $500 a month per physician for their EMRs.Dr. Mackay has his own suggestion for making a patient’s medical record accessible in the right place at the right time. The information would travel with the patient. “Everyone’s got a medicare card with the magnetic information swipe on. Why can’t you swipe that in and boom, you have access to a portal that is accessible across the country?“There are three main issues,” he cautioned. “There’s privacy laws, which are extremely complex and variable depending on where you go. There is enormous expense. . . . And finally there’s the security issue. Cyber attacks on healthcare IT systems are staggering.”Time to get it rightGreen at Infoway believes Canada is at a critical juncture where there is the right combination of ramped up federal dollars, accountability, political will and crisis to finally overcome historic obstacles.He pointed to an international initiative the federal government, provinces, territories and Infoway are actively involved in, bringing International Patient Summary (IPS) standards to Canada. The IPS enables key information from patient records to be shared across regions and countries in a standardized way.As Canada moves toward adopting and localizing IPS, Infoway is supporting the development of a pan-Canadian Patient Summary Specification, aligned to international standards. Once the IPS is fully implemented, as hoped, a person’s health record would, indeed, travel with them. Ontario and Alberta are early adopters of the initiative, and it is expected to grow from there—especially as this work will advance bilateral agreements that have been forged between provinces, territories and the federal government, Green pointed out.It is going to take “a couple of years,” he estimated but Green believes there is a new urgency now: The federal government is demanding progress reports, and it expects results within five years.It's safer and doable“Even if you have just a 12-digit number that’s unique, you could provide that, or just provide a QR code,” Green said. “And all the (patient information) updates would happen seamlessly—for example, the visit you make to an ED somewhere in Canada or the world, when you go back to your own doctor, she would have that information as well and would have a record that whilst you’re away, you saw another physician.“One of our key focus areas (at Infoway) is to have seamless exchange of information. A patient should be able to access their own information. And then when they go and see a physician or nurse practitioner, they shouldn’t have to go through all their medical history every time. It should be available online, and that’s the goal.“We’re working with all of the EMR vendors,” Green continued. “There are a number that family doctors have. And then there are the big ones that hospitals use. And we’re working with all of those companies to make sure that the standards they use are the same.“I think that companies now recognize that it’s a benefit to be able to be flexible and share the information. . . . They know they need to do that. In the end, if you’re not sharing the information, it’s not really safe care, because someone could make a mistake. They may not spot the drug that someone’s using or they may not identify an allergy. And so it’s just common sense to have that information available.

Solutions for interoperability shortfalls

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