Richard Alvarez, CEO of Canada Health Infoway, recently participated in a panel at the recent E-Health 2005 Conference in Toronto. TIG spoke with Alvarez after the conference about some of the major issues related to the development and deployment
of the electronic health record across Canada.
ITBusiness.ca: How has CHI’s strategy changed or adapted since its inception and if so, why and how?
Richard Alverez: I think the basic strategy is the same. The strategy is if you are going to have an interoperable pan-Canadian system you need consistent architectures and standards, especially messaging data security standards, so that hasn’t changed. The fact is there is no point in reinventing the wheel so investing in solutions that can be reused and replicated across the country was there from Day 1. This is a big country and lots goes on, and therefore the ability to share knowledge from different projects as to what works and what doesn’t is also key. Those are the tenets that have stayed. There are also two more programs that have been added since we got started – public health and telehealth.
Collaboration and partnering more closely with the public members has been key, and also allowing vendors to get a sense where the pocket is going to be so they can get ready for it is also a major emphasis. I think the key is getting jurisdictions to focus on what their three-year plans are going to be, because as a country if we’re going to meet those goals in 2009, are they going to be there?
ITB: I was at a breakfast panel recently and it seems that a lot of the people there – CIOs and CFOs in health care – didn’t know about the Canada Health Infoway funding. How is that possible? What are you doing on the education front?
RA: Ontario is a particularly unfortunate example, mainly because of its size and its structure. In the other parts of the country there is a tighter relationship between the ministries of health and the regions. Here it’s point to point, so you’ve got the ministry and you’ve got hospitals, community care access centres, nursing homes, etc., so until the local health integration networks come into place where you get a more formulated structure, it’s a lot more difficult to cover the waterfront. The key people we deal with are the ministries of health. You can’t have a pan-Canadian system if you don’t have a pan-jurisdictional system, so hospitals and CFOs can’t go off and do their own thing, because who knows if their systems will ever talk to each other? That’s the responsibility of the ministries to start to pull that group together. We’ve been careful not to raise expectations – not to go out to speak point to point with a certain hospital or get mistaken for grant funder, which is quite typical in this country where there is a pot of money and people are encouraged to send their proposal in. We don’t do that. From an educational point of view, my people are up and down this country constantly in meetings, conferences and educational sessions, and we publish a lot, so I’m still surprised when CIOs or CFOs don’t know about this. I wonder where they have been. They may, on the other hand, say, “We know about these guys but we haven’t been touched by them.” That’s fair criticism, but to say they don’t know about us, that blows the mind. You shouldn’t be in this business as a CIO if you don’t understand the fundamentals around where the system is going in terms of an electronic health record. You really shouldn’t be in this business because that is not just unique to Canada, it’s happening across the globe right now. I don’t care what educational session you go to as a CIO, if you don’t have that vision, you’re wasting your time.
ITB: You said IT is not a major component of the E-HR but that it’s change management. At the same time, it’s the IT people who are putting this in place and developing these systems. How do you see that evolving?
RA: This is an IT infrastructure which is incredibly important, but what is going to be important about this is not the IT systems, but how we reengineer the systems and make sure they’re appropriate. This is not rocket science, but it is brain surgery, which means the IT people have got to understand how brain surgeons work and what data is important to a GP, and to a specialist — how long they spend with patients, what they need brought up on a screen. There’s no point in developing a system where a physician has to go through 20 different screens to understand the medication you or I am on because that’s going to result in more errors than in curing people. The issue is developing systems that fit with workflow of clinicians but also getting clinicians to understand they’re going to have to work in different ways as well. And that’s the big challenge.
ITB: You said you want organizations to use commercial off-the-shelf software. At the same time a lot of people believe the technology is still immature. Is what is available today ready for prime time?
RA: I think the technology in many cases is ready for prime time. In other cases it’s ready in terms of being extended for prime time. The opportunity for this technology hasn’t been there in the past, but certainly the major vendors we talk to see the light, have deep pockets and are prepared to further their products in the light of the evolving architecture, so I don’t think there’s an excuse for folks to go out and build a viewer from scratch; there are lots they could use. So there are solutions available. There are solutions that have to be extended. If everybody starts to build custom-built solutions, they’re going to be really tough for us to replicate, whereas promoting a commercial solution and getting the private sector to invest in those, giving them a marketplace, I think is the way to go.
ITB: You mentioned you know some projects will fail. At what point does this become clear and how closely does CHI get involved with each E-HR project?
RA: The way we get involved is basically by putting gated funding in place, so if a project fails it will probably fail at a gate. For example, what if we wanted to make a hospital filmless? What if in trying to do that the facility finds their radiologists or specialists refuse to change? They’re not going to get our money until that goes filmless, so in our books that would have failed, but at least the money is not wasted. Maybe some money is wasted, like the planning study and maybe a lot of time and effort from the facility. What is more likely to happen is projects that don’t meet their deadline, because projects take longer than envisaged to do this change management.
ITB: What is your personal goal at CHI? At what point will you say your work is done there?
RA: My personal goal is to have an E-HR in place and to do it in a collaborative fashion, which at times is a bigger challenge than anything else given the fractions we have in health care and given the different needs. We’ve set our goal of 50 per cent by 2009 but we don’t want to stop there; the idea is to get 100 per cent of the population onto this system, so my personal goal is to tip this thing at least at 50 per cent so there’s no going back.
ITB: When it comes to user adoption what is most essential to the success of what CHI is trying to do — is it adoption at the facility level or at the physician level or both?
RA: Both, because the adoption comes down to our clinicians using it, and they practise in both arenas — in hospitals and facilities and in the communities as well. I think we started off with the facilities moving out, but the challenge for us is to get both sets using it.
ITB: Another issue that came up at recent E-Health 2005 Conference you spoke at was the First Nations issue. Can you elaborate a little on that?
RA: We understand there are many issues faced by the First Nations and we’ve had discussions with their leaders in the past. According to our funding agreement with the government of Canada we co-invest typically with jurisdictions — provincial and territorial — so since the First Nations are not officially a jurisdiction, our only way to do that with them is by working through the federal government. I think the key aspects are around telehealth and we’re really starting to do that. Nunavut is a good example.
ITB: You have spoken of the E-HR as a tool to reduce medical errors. There has been at least one study recently that indicated electronic health records actually contribute to more errors. What’s your view of that?
RA: A badly designed E-HR could in fact do the opposite of actually saving lives and time and access, but that’s no different to a badly designed automobile that blows up in your face. The articles were based on what we would call first-generation systems in a lot of cases that we’ve moved well away from, and on situations in my previous example where physicians have to go through 20 screens to find out the medication a patient is on. So the issue is that’s why it’s so essential for the IT folks to understand how clinicians work and for the clinicians to adopt it as well and re-engineer their practices and to integrate their workflow. Otherwise, if these systems are badly designed they could do the opposite of what we’re trying to do.
ITB: If $1.1 billion is not enough to give 100 per cent of Canadians an E-HR, what do you see as the solution in the future?
RA: The obvious answer is additional public funding, especially from the federal government. There is no doubt in my mind this is very analogous to the TransCanada highway or railway systems being put across this country and the federal government played a major role in that. This is the bedrock across the country; it’s one area in health care that no one is going to argue with, not the provinces or the federal government, so I see it as a big place for the federal government to play in. And while one is not suggesting they come up with the remaining $10 million, there is certainly an opportunity to further contribute in this area.
ITB: Are you concerned about the possibility of an upcoming election and what could happen?
RA: Health care transcends political parties. I don’t see any political parties arguing about a quality and a universal health care system. I don’t see them arguing about a modern health care system, one that is going to be supported by an IT infrastructure, so I think this is an apolitical issue, because we’re talking about the best quality health care system that can be provided to Canadians, and I think all politicians agree on that.