Michael M. Rachlis MD MSc FRCPC

Health Policy Analysis 13 Langley Avenue

Telephone (416) 466-0093 Facsimile (416) 466-4135 Toronto, Ontario

Website: www.michaelrachlis.com E-mail michaelrachlis@rogers.com Canada M4K 1B4

June 11, 2009

Forget the Tim Bits and Bytes: Let’s not lose track of the big picture at eHealth Ontario

With the headlines screaming scandal at eHealth Ontario and the media and opposition sensing blood, Ontario risks falling further behind on electronic health records.

Of course I understand how people who are losing jobs and savings can be angry at the symbolism of consultants who make $300+ per hour billing for muffins. And, there has been a lot of money spent on electronic health records in the past without much to show for the expenditures.

But, let’s remember that so far we have allegations. Consultants usually have legal contracts which include payment for food on the road. Alan Hudson, Sarah Kramer, and her team were incredibly effective in their previous work at Cancer Care Ontario and the Provincial wait times initiative. And, they had already accomplished a lot in their first six months at eHealth including launching a pilot project to track prescriptions for 80,000 patients in Sault Ste Marie and Collingwood. Finally, topnotch private sector IT people make a lot more than Sarah Cramer ever did. Full disclosure: I have met Dr. Hudson and Ms. Cramer but never worked for or socialized with either of them. Now let’s take a look at the bigger picture.

You need high quality, integrated electronic records to run a safe, efficient health system. On a 1981 visit to a Havana community health centre I was struck that each doctor had a binder with lists of patients with different chronic diseases. In what might have been an apocryphal story, a physician told me that in his guerrilla days, Fidel Castro saw a child die from asthma. Fellow guerrilla and physician Che Guevara informed Fidel that the death could have been prevented with appropriate care prior to the attack. With a voice dripping with pride the doctor said that Fidel had created a world class health care system. And El Commandante insisted on the regular follow up on all patients with asthma and other chronic diseases to prevent unnecessary deaths, such as the little boy’s he had witnessed.

When I got back to my practice I bought a binder and started keeping track of all my patients who needed routine follow up. I discovered that I had more than twice as many patients with these conditions as I had suspected. My patients got better care. Probably some of them averted heart attacks, strokes, and kidney failure.

The following year, I visited Seattle’s famed Group Health Cooperative of Puget Sound. Established in 1948 and still run as a cooperative, Group Health has spawned innovation after innovation. In 1982 they had a fully integrated electronic health record with terminals in every office hooked up to an IBM mainframe computer. The possibilities astounded me. As I returned to my practice I thought it would be just a few years before I had an electronic system on my desk. It would track patients and automatically alert them and me about needed follow up care.

According to the Ontario Health Quality Council’s annual Report released on Tuesday, 27 years later only 25% of Ontario family doctors have electronic records compared with 50% in Alberta and 98% in the Netherlands. It’s even worse. Only 8% of Ontario family doctors use their electronic records to follow up patients. Thousands of patients with diabetes and other chronic conditions are dying unnecessarily. Thousands of x-rays are being re-done every year because the one done a few days earlier isn’t available. Fidel would not be impressed.

Why do Ontario and Canada lag behind other jurisdictions? First, electronic health systems cost money. Federal agency Canadian Health Infoway estimates capital expenditures of $10 billion for an integrated health record for the country. However, to put this figure in perspective, Canada’s health system spends that every three weeks. No Martha, we shouldn’t put electronic records back on the shelf for another 25 years and spend the money on more doctors and nurses working in an uncoordinated, unsafe system.

Second, Americans refer to our Medicare as socialized medicine. But we’ve really only socialized the funding. Most of Ontario’s 20,000 doctors are in private practice and Ontario’s 140 plus hospitals are still private, albeit non-profit corporations with independent boards. In the UK, the government paid for the electronic systems in hospitals and doctors’ offices. Providers and practitioners had little choice about their systems. Doctors and hospitals can communicate with each other. In Ontario the government has balked at paying. Over a dozen systems are approved for doctors’ offices but most will be unable to communicate with the various systems being bought by hospitals which in turn will be unable to communicate with each other.

Where do we go from here? Ontario and other governments have to suck it up and pay the money. Governments have to get together with providers and ensure nobody wastes money on any more systems unless they are fully interoperative. Regarding the muffins at Tims, let’s allow the Auditor General to do his good work. We need to ensure that every Canadian has a secure electronic record to keep their care safe and to sustain Medicare for the next generation.