Essays April 2011

The Grassroots eHealth Revolution

Will Falk and Dr. Sacha Bhatia

EHealth is seen by health care professionals and government policy makers as a cornerstone for the modern health system, yet the building of electronic health record systems around the world has been fraught with technical challenges, skyrocketing costs and even political scandal. Away from the formal construction site, a grassroots eHealth revolution has grow-up in hospitals and physician practices across the world, and it has come at little cost to government. You can see eHealth in action in any hospital or clinic where you see doctors, nurses and other providers typing away on their Blackberries or iPhones.

Smartphones are now a common tool for physicians in their practice.  A California Healthcare Foundation study in 2009 said that 70% of doctors now own such a device.  If you walk into any teaching hospital that has medical students or residents, you will see that the penetration of these devices is even higher now. While most physicians get a free pager from their hospital, in 2011 you hear the buzz of a pager far less, instead you hear the ping of a text or email.

Smartphones (and now tablets like the iPad) are being used in a variety of ways.  Health professionals easily communicate with one and other about mutual patients, can send patient care orders to other members of the team and get results in real time.  Improved screen quality allows medical images such as ECGs, X-rays, and simple photos to be transmitted to specialists remotely to allow quick diagnoses to be made or confirmed.  For example, a paramedic called to see a person with a suspected heart attack can do an ECG and transmit it to the smartphone of a cardiologist who can make the diagnosis of a heart attack and activate the appropriate care pathway. The cameras on smartphones can be used to take pictures of rashes or other skin problems, and emailed to a dermatologist who can also make the diagnosis and start treatment.  While these devices don’t yet support formal diagnostic quality, they are incredibly useful in practice and save time and lives. Medical applications are being created at the rate of 100’s per month to provide health professionals with up to date medical information at their fingertips. In short, smartphones are revolutionizing the way that health practitioners are delivering care. What is even more amazing is the speed at which this change is happening.  It is truly a grassroots revolution which is being driven by the providers themselves not by policy changes from above. 

The benefits are very clear to doctors, nurses, and patients.  Information is available at the point of care.  The treating provider has the right medical colleague available to them remotely. Results can be communicated back to the patient quickly and the right care can be started.  Knowing is better. 

Balancing the advantages of these new technologies are real questions about maintaining patient privacy and the accuracy of health information. Should a patient be concerned about a surgery resident communicating with her chief resident or a staff physician using her Gmail account?  What about facebook discussion groups in which former medical student colleagues share a case of the day? How do we handle lost devices and are they password protected if they have patient information on them?  How do we know that apps that carry medical information like medication dosages are accurate? How do we store and maintain the information flowing among multiple devices? Most importantly, how do we answers these questions without ending the very innovation which is so rapidly improving patient care?

Currently, a minority of healthcare professionals have devices that are supported or sanctioned by the hospitals they work with.  This is particularly relevant for clinicians who work at multiple facilities and resident physicians.  Many use a personal email account, like gmail or hotmail to transmit personal health information.  If they asked permission to do this they would likely be turned down.  So they don’t ask.  In Ontario and Canada, Infoway and eHealth Ontario have very few programs for smartphones and most of their established funding programs don’t recognize these devices except maybe to provide rudimentary web access. 

In some ways, there is little that the agencies responsible for building electronic records could have done to predict this.  And this is true across the developed world (although interestingly not the less developed world).  The technology evolved so quickly and the physician uptake has been so rapid that government-led planning missed it. eHealth programs take 5-10+ years to deliver properly-procured IT systems against a set of requirements that include tough privacy standards.  When the western world started most of the current eHealth the programs the iphone didn’t exist so how could you plan for it?

Rather than a “don’t ask, don’t tell policy”, governments should embrace the grassroots ehealth revolution and its near 100% user base potential by incorporating smartphone technology, the ipad, and future form factors into eHealth plans. We worry even raising this issue in public for fear that the reaction will be to stop the innovation.  This would hurt patients and hinder physicians and nurses from delivering the best possible quality care to Canadians. Instead we need to allow the status quo for an interim period and give time to ensure that providers can have secure email accounts to transmit patient information, medical apps are quality controlled and/or labelled when they are in start-up mode.  We need to find a way to allow a thousand flowers to bloom while continuing with our centrally planned revolution.

At a more fundamental level, policy makers need to move beyond our centrally funded projects to enable the modernization of our health system.  Physician payment systems must pay for patient care virtually delivered and regulations need to be modernized.  There are huge potential productivity gains to be made, with better access and higher quality care, from physicians being able to manage patients concerns virtually as opposed to bringing them in to hospital or their office. There are great examples of smartphone devices improving patient care. There are green shoots in eHealth and the investments of the last decade have provided the nourishment for the innovation that will now be led by physicians, nurses, pharmacists, allied health professionals and ultimately patients and their families.

About the Author

Will Falk, BSc., MPPM Executive Fellow in Residence, Mowat Centre for Policy Innovation, School of Public Policy & Governance; Adjunct Professor, Rotman School of Management, University of Toronto Dr. Sacha Bhatia, MD, MBA Cardiology Resident, University of Toronto Former Health and Research Innovation Advisor to the Premier of Ontario

 


Comments

Robert Fraser wrote:

Posted 2012/11/04 at 09:25 AM EST

I could not agree more.

Healthcare organizations that facilitate and encourage employee utilization of technology. I regularly use technology not provided by my employer, both hardware (laptop, secondary monitor, tablets) and software (photoshop, pages, iShowUHD, etc.) because it allow me to be more effective at my work. This applies to clinical and non-clinical jobs. If a individual sees the value of the tools why don't organizations? Many providers and staff are purchasing their own smartphones, so why not enable them to have access to digital libraries and journals at the very least.

To be fair there is some risk and it is not simple, but the changing landscape of leadership means there needs to be transparency and discussion. The traditional command and control model will not work. Why not focus on creating a culture the fosters dialogue about privacy issues, and shares innovative practical uses of technology so others can learn and increase their own effectiveness?

 

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