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Lydia Lee, Vice President and Chief Information Officer, talks about where technology is going in the health care sectors.
1. You recently talked to the Medical Post about what a wired, or electronic, health care system would look like. Do you think it's possible to go completely electronic? How long will it take and how far are we along that spectrum already?
Absolutely, yes, it's possible.
UHN is currently working on a strategy called "Advanced Clinical Documentation" (ACD). It is a core aspect of our new corporate strategy, and it's envisioned be about a five-year journey. I think that at the end of that five years, we will be the majority of the way there, if not completely done with making our patient record electronic. There will always be little bits and pieces that are going to be paper-driven, such as documents coming from external agencies or doctors.
We have several key objectives for ACD. For one, we want to create an electronic set of tools that allow people to enter data at the point-of-care. So that not only do we have the information in the chart available to clinicians and the entire disciplinary team for when they need it, at the point-of-care, but it's also going to be created in a way that data on the backend is available to us in a structured way. This is a key thing for us, and it's one of the benefits I'll talk about later—because we're a research hospital, it's not enough for us to have text just in a PDF file. It needs to be more dynamic, so we can do analysis and research with it. So we can tell ultimately if what we're providing and doing for patients is helping their outcomes. We're not just scanning a sheet of paper into the computer—we're transforming how that previously static data is used. This is all about whether we're providing the maximum value, from a health care point-of-view, towards patient outcomes. So that's the end-game for ACD.
Think of everything we've done at UHN in terms of the electronic patient record—we've done all of the admitting and discharge and scheduling, we've done the lab and result-reviews for clinicians, we've done order-entry now. So the last key module, or part of it, is clinical documentation. This is the last major stretch for us.
Another thing to think about in terms of how long it will take, is not just as UHN but as a health care system—when I think about what is happening in Ontario and Canada, and in North America in general, there's a sort of "race to finish" the electronic chart for most health care providers and hospitals in particular.
There's actually a model, developed by the Healthcare Information and Management Systems Society out of the US, for implementing electronic records—HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM). The Canadian average right now is in the 2 to 2.5 level (it's a 0 to 7 scale). UHN is at a 4.75. There are other hospitals in Toronto that are at 5. With ACD, I want to get us to 6 within the next three years, and hopefully at 7 by the five-year mark.
2. How doable is that within the broader health care system? If UHN gets to 7, but other hospitals don't or health care providers that our patients deal with, how does that work, when it comes to transferability of records?
This model that I'm talking about is organization-specific. It's an industry standard model though, so it's a race to the top right now—in the US there's a competition for those hospitals that get to a 7.
The thing that's tricky for us is that not only are we worrying internally about whether we have the information we need to provide patient care, but UHN also looks across the continuum. So we're working with a lot of partners to try to make sure our information can be extended outside the walls of UHN and vice versa. UHN has a strategy to not only think inside the walls, but also across the continuum of care, and our part in helping drive change across the continuum. A lot of the work that SIMS does is to support the corporate strategy outside the walls, by working with eHealth Ontario and the Ministry of Health and Long-Term Care. So we have to do both, which is why we're not done yet with our EPR.
3. "Going electronic" is an easy catchphrase—intuitively, most people would agree that it's a worthwhile goal. But can you talk more specifically about the benefits to both patients and health care workers?
The easiest way to talk about benefits is to understand some of the challenges with paper charting. Right now, if the chart is on paper, then the information is distributed to only the people that have it in their hands at that point in time.
The second problem is that because it's only available to whoever has it in their possession at that point in time, and it's not shareable, then there's a lot of work just to get that information into someone else's hands—faxing, photocopying, scanning.
And the third problem is that the information is static, meaning it's just sitting there and it has to be read and interpreted. So those are the challenges of dealing with a paper, or hard-copy, chart.
So think about the flipside—what are the benefits of going electronic? One of the most obvious and biggest benefits is that multiple people in the care team—and I'm defining care team very broadly, so it could go outside the UHN walls—can have access to the chart at the same time. That's important because patient care isn't just delivered in sequential steps by individuals. It's people working together, making joint decisions, and then they work in parallel to provide care and treatment to a patient. So having parallel access, or simultaneous access, to the information, facilitates the care process. The information can move and it can be viewed by multiple parties at the same time.
It can be distributed in a quick and timely manner to care providers, not across UHN, but also to other people outside. And relatively easily when it's in electronic form, because you're not spending hours chasing paper, and scanning and faxing.
The problem with static information on paper is that it's up to you to interpret what you're looking at. The benefit of technology is that you can use algorithms and intelligence, so that based on what's in the electronic data, the system itself can actually flag, alert and remind to prompt action. So even if you may not be thinking about a particular thing, if the system is prompting you—"Hey, pay attention to X or Y" or "Be aware of this condition"—you'll consider it. Those are things that a system can enable in a consistent fashion.
We're inundated with information—no matter how intelligent any of us are, there's just tons of data coming at people all the time, and you can't possibly be expected, nor would we expect, people to remember everything. In a research hospital too, there's not just the day-to-day clinical information, but people are reading research journals and best practice guidelines, and taking in a lot of information.
The last benefit is particular to UHN—when you have paper, you can't do anything with the paper unless you go through a very onerous process of extracting the information. In particular, with our ACD project, we want to have structured data on the backend, so we can actually do high-quality research, analysis and quantitative reviews, that we don't have complete access to right now.
We have lab results, we have medical orders—we have that today, in structured data. What we don't have is some of the data on the process of care that normally gets documented in notes—progress notes, flow sheets, etc. This is the "What I did to the patient today" part—the clinical documentation. So when you structure that information, then you have information tying "What did we do to the patient today?" with "How did they do at the end of their stay?" So, the idea here with ADC, and really with electronic health records, is that if we know that certain patients have a functional status of X when they get out, or a functional status of Y when they get out, we can ask, "What are the circumstances that drive a patient to X vs Y? How do we modify our processes of care to make everybody as best as possible from an outcomes perspective? And we can't do that unless we actually analyze the process of care. And that's very difficult if the data's trapped in a big blob of text in a PDF somewhere.
So those are some of the key benefits from a hospital standpoint. So not only does it help the care team understand what they're doing in a more granular way, but obviously the intent here is to capture this information in a more structured way overall, so we can understand better how to continuously improve the model of care to improve the outcomes for our patients.
4. As a society, we have very high expectations of technology—a lot of that is about the speed and ease with which these things should happen. Anyone can set up a blog within 30 minutes, and so we assume that adapting new technology should be that easy in every area, including health care. What are some of the challenges SIMS faces when considering new technology for UHN?
This is a great question, because things have changed dramatically over the last two to three years even, in this area. For sure, anybody can go and set up a blog in 30 minutes or I can get on Twitter and start tweeting. So absolutely, those things are all possible on an individual level.
The challenge is that my job is not to just manage your individual technology. My job is to look after 12,000 staff, and provide technology to support their work in the most productive way possible. And that's about change, fundamentally—trying to change the way people work at an individual level, and then multiple that by about 12,000. It's thousands of people that have to be considered when we make changes. So it's not just about how easy is it for you when we have to make changes, but how easy is it for all of us, under every circumstance that we could potentially think about.
And when you are trying to be a responsible leader for an organization of this size, we have to not only think about the specific wants and needs of every person that works here, but the policies that will help enable a move forward in a responsible manner. Policies have to be looked at, the security and architecture has to be looked at. So it's tough when you have to look at it on an enterprise level. It's very easy when you're looking at it on an individual level, it's tough when you're looking at it across an entire organization. And every program and every service across every department has slightly different needs, slightly different interests, slightly different tolerance for control—all of that has to be considered.
I'm making it sound highly bureaucratic, because it is in some ways. From a responsibility standpoint, we have to look at those things. We have many people who are super tech savvy and many who are not. And we have to manage everything and anything in between.
It's an easier thing to make a change for a couple hundred people instead of a couple thousand—but the scale makes it more challenging. That's just the way it goes. It requires that we have a level of rigour in our planning for IT changes that smaller organization can be more flexible about.
The other thing that's important to understand is that IT resources are very precious—the dollars are very precious. So we have to do planning 1-3 years out for changes that we're going to make.
5. So how do you plan, considering how fast technology changes and becomes obsolete?
That's just it. We're planning 1-3 years out for things that we know are not turn-on-a-dime initiatives, so that leaves very little room and dollars—although we do try to set some aside—for the things that come up that we can't anticipate. And things that we have to respond on a dime as much as possible. There are far more calls on the investment dollars than we've got. So we plan very carefully.
It's tough for an organization like ours to turn on a dime. We do set aside a little bit for what I'd call R&D money in SIMS, but relative to things like ACD, which is planned way in advance.
So all of that said, it's harder for a larger organization to be super nimble and flexible, although we are trying to build some of that into our planning.
6. Does patient privacy play a role in that?
People sometimes throw that up as a barrier, but I personally don't think that's the case. I think the role of privacy for us is simply understanding what about privacy, or security, or the law for that matter, are we obligated to make sure is there to protect? We incorporate that and then move forward.
Privacy has never been a barrier for us at UHN. I get crazy when people suggest that, because it's not. We just have to be careful and make sure we understand all the implications and what we're trying to do. And in fact, the rules are even clearer today than they were five years ago before the Personal Health Information Act, or PHIPA, so it's actually even better now, because we know what we have to do.
7. What do you think the daily life of a health care worker in the hospital is going to look like in five years?
First off, it's not dissimilar to the patient answer. I do see the role of IT being very significant. Even more so than it is today. I think that for health care workers there may be a day when it's as important to understand the clinical environment and bring those skills, as it is to understand how to use technology. Because if that's a fundamental tool to do your job in the future, there will be a higher level of expectation in the future to be using technology. People here are not only comfortable with technology, for the most part, but they've got ideas on how to make it even better. So that will just carry on.
8. We recently ran a story in UHNews about a nurse who accesses a lot of health care tools through her iPhone and uses that in her daily work. Where do you see the role of personal tech fitting into the health care landscape for staff?
I think that will become very prominent for us. The good news for us right now is that we're going through this transition to a new IT outsourced vendor program. This new provider will give us some flexibility and we'll be able to support a larger variety of devices—so we won't have to say no all the time to people who want to bring in an iPhone, for example.
We're trying to test everything and anything we can get our hands on right now. We have to look at security, and the form factor (can people actually see what's on the screen) and whether it will be a problem from an infection control standpoint. There are lots of aspects you have to test physically—does it break the second you drop it on the floor, for example?
We probably won't be able to support everything ever, but we'll be able to provide support to a lot more than we do today. So yes, I think that's absolutely coming.
9. What about the health care landscape for patients?
I think similarly, it's certainly within our IT strategy, that we will be giving patients access to their health information. It's just a question of "What's the best mode of that access right now?" And just as staff have varied level of comfort and experience with technology, the same is true for patients and their families. So we have to look at that and make it as easy as possible.
But I also expect that patients will come in expecting that. And it won't be acceptable for us, five years from now, not to be able to meet that need. Because they're going to be even more informed and more inquisitive, and they're going to have already read everything on Google before they come in. There's so much information out there. So I think that people will be way more informed and they'll have a lot more questions when they come into the organization. That's going to force us to be ready for that. It's already happening.
I think the exciting thing here at UHN is that people want to push information out. They want to push quality content out to patients. So that if you, for instance, want credible information about whatever your clinical circumstance is, come to the UHN website as opposed to going on Google and not knowing whether something's good, bad or otherwise. People here want to be able to say that if you read an article or you get information from UHN, you know it's good stuff.
So I think there's going to be an expectation of that, and that's built into what we're planning on doing.
10. Any final thoughts or comments about the tech future of health care?
I'll make a little plug here—I'm the president of COACH (Canada's Health Informatics Association) and the one thing that we spend a lot of time on is professionalism of health informatics. What makes health informatics professional?
And what makes health informatics professional is not only IT people who happen to work in health care. Health informatics is when you put a clinician skill set together with an IT skill set with a project management, or change management, skill set. You have that whole package, right? I fully expect that we're going to see lots more of those kinds of people within five years. Not to say everybody's going to be super health information technology savvy, but I think we're going to see a lot more of those people. Because this is a neat area that's expanding in health care, and the resources are getting better and better for training and project opportunities.
And I would also put telehealth in that too, because I think there's no question that the more sophistication that we get with telehealth technologies, the more telehealth is going to be part of the regular care process. So for those people who are supporting telehealth—that group is growing. The program is going to hit ten years next year, which is pretty cool, and I see that growing exponentially. And those are the people who are going to not only be growing the video-conferencing, but they're also going to want electronic access to the information from wherever it is that they're sending and receiving. So I think that'll change health care delivery in the future.