e-Health, are we there yet?

e-Health is a rapidly growing area. 73% of Canadian primary care physicians are now using electronic medical record systems (EMRS), though Canada was among the lowest of the 19 countries studied, and that number is expected to continue to rise. e-Health Ontario has been working to allow health providers across Ontario to have access to a patient’s record, regardless of where the file was created thanks to the programs ClinicalConnect and ConnectOntario (Weber, 2017). We see many hospitals embarking on new hospital EMRS, which allow for access to charts from any computer with appropriate approved access.

Patient centred care is a big part of heading forward with e-health. e-Health allows for remote access to specialists and other services that might otherwise be difficult to reach as well as the ability to deliver care with lower costs. For example, many vulnerable Indigenous communities are located in remote areas of Canada and have been able to get advice from health providers such as general practice physicians and specialists via Ontario Telehealth network through telemedicine (“Aboriginal telemedicine” 2015).

There are also e-Health tools that also allow for the patient to book their own appointments, check on the status of their appointments, see their imaging reports, all from their computers through programs such as Mychart, created at Sunnybrook Health Sciences Centre (“Mychart” 2019). Another program called Pockethealth allows a patient to gain access from any computer to all their images done at an institution that subscribes to PocketHealth’s service for a low fee, from a computer that can then be used for personal use or shared electronically with others in the patient’s care circle, all while the person is sitting at home! (“Pockethealth. Our mission”, 2019). e-Health tools can certainly provide access to services that might not otherwise be possible. These tools also allow for health information to be more easily shared with other healthcare team members and reduces the risk of medical errors due to increased ability to interpret orders written in the EMRS (Hecht, 2019).

An example of an e-health program that is on the right track is the telemedicine program Telehomecare. This program helps support individuals with COPD or congestive heart failure for 6 months from home. The participants are given a tablet connected to the internet to track daily values for heart rate, blood pressure, oxygen saturation and weight which is reviewed daily during the week by a nurse. A resource is sent to the home to help the patient get set-up with the process. The nurse resource connects with the patient via phone to provide help by coaching, encouraging a healthy lifestyle, monitoring medication use and teaching self-management. Providing the technology, set up support and regular phone check-ins, the program is able to equally service patients. This program has resulted in decreased acute care hospital use. At William Osler Health System, emergency visits declined in this group after entry into the program by 46%, a decrease of 53% for hospital admissions and a reduction of average length-of-stay by 25% (Mierdel & Owen, 2015). Clearly this type of program is exactly what e-health is all about, better patient outcomes while reducing costs.

e-Health in Canada is not without issues and is not uniform across the country. The Canadian healthcare system is inconsistent across Canada, due to the fact provinces are responsible for health care delivery but are also dependant on federal government for funding as defined by the Canada Health Act (“Canada’s health care” 2019). Because each province determines how they will deliver health services, within the boundaries determined by the Canada Health Act of course, there are differences in what services provinces cover and promote. There is also a rather nearsighted approach to funding of pilot projects, with emphasis on the cheapest option possible versus more upfront spending to get more fruitful outcomes later, and challenges with healthcare policy are also identified as areas of deficiencies by MacNeil et al. creating barriers to implementing new technology in Canada (MacNeil et al., 2017). Other issues with e-health include a forced feeling amongst patients and their families to take-on a more active role in providing care for themselves or a loved one then they are comfortable with providing, as well, a disconnect between what a patient shares versus what a doctor needs to provide care has also been identified as a flaw (Anderson et al. 2018). And of course, there is always the concern of technology privacy breaches.

When considering e-health, you must also be mindful of all members of society and their access to such tools. Social determinants of health reduce an individual’s ability to equally achieve health and include features such as race, education, income and gender to name a few (Canada public health, 2019). Individuals with a lower socioeconomic status are at a deficit when it comes to using new technology to help with their health issues. These individuals have lower reported use of on-line health tools such as tracking health information on apps or communicating with health providers on-line (Kontos et al., 2014). Those with a lower education are also identified as a group with lower adoption of on-line health tools. It is important to reduce the barriers created by the social determinants of health to enable all individuals equal access to health. Health should be something that is equally achievable by all. Care must be taken to ensure all are given the opportunity to benefit from e-health which could include subsidies to electronic tools such as a computer or help to create access support on accessible stations such as computers in libraries.

e-Health tools can certainly be an aid for vulnerable populations of people such as those with diabetes. Electronic tools can help the diabetic group track lifestyle factors such as weight control and diet. There are now wearables and sensors that store data which can later be shared. Apps in development include ones that will personalize nutrition plans based on the patients’ current glycaemic numbers. Current and future technology will certainly change how diabetics and their healthcare team receive information allowing for more accurate and timely decisions related to treatment and maintenance to be made (Fagherazzi & Ravaud, 2018). Figure 1 shows some examples of diabetic tools available now to aid in the treatment of this chronic disease.

Figure 1. Recent and future medical innovations to help people living with diabetes. Adapted from “Digital diabetes: Perspective for diabetes prevention, management and research.” By Fagherazzi, G. & Ravaud, P., 2018, Diabetes & Metabolism, Vol. 45, Issue 4, September 2019.

Switching to an e-health model will require constant change. Collaborative approaches in creating new programs will be important to ensure future programs are well received and therefore more likely to be adopted by all users (Anderson et al., 2018). If patients aren’t happy with the information a tool can provide, they will not be inclined to use it. Another item to be mindful of is compatibility amongst the many competing vendors. When imaging first began to be stored and shared digitally, it was impossible to display images on other vendors software which resulted in the creation of a standard system, digital imaging and communications in medicine (DICOM), which would allow images to be viewed anywhere. The same issue is now being identified across the many EMRS. The US government is set to propose the mandatory implementation of Fast Healthcare Interoperability Resources (FHIR) to Medicare to allow for easy of sharing of information (Hecht, 2019). In Ontario, “incompatible systems are still being purchased with public funds due to overly permissive procurement policies” (Webster, 2017). This is certainly an area for concern where policy needs to be in place to ensure the scarce tax dollars are being spent on EMR programs that will be able to work together to accomplish the ease of health information transfer amongst organizations within our province.

The currently accepted definition of health is defined by WHO as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (WHO). We have a long way to go in e-health to be able to use the tools created to help all individuals achieve health, but we have made good first steps. As more people become comfortable with technology and the advanced access to resources it can provide, we have an opportunity to reduce costs to healthcare, reducing medical errors and duplicate tests which can also result in reduced radiation all while keeping patients more informed and active participants in their own care. Being mindful of creating solutions to help vulnerable people must also be considered as well as creating change at multiple levels of care, from policy at the top to support at home to the individual on the bottom. Solutions to help ensure our health information remains secure while at the same time shareable will have to be created in conjunction with new advancements in order to enable trust in this new world of e-health.

Resources

Aboriginal Telemedicine (2015). Retrieved November 30 2019 from https://support.otn.ca/en/programs/aboriginal-telemedicine

Anderson, T., Bansler, J., Kensign, F., Moll, J., Monsted, T., Nielsen, K., Nielson, O., Peterson, H., & Svendsen, J. (2019). Aligning Concerns in Telecare: Three Concepts to Guide the Design of Patient-Centred E-Health. Computer Supported Cooperative Work (CSCW) (2019) 28:1039-1072. DOI 10.1007/s10606-018-9309-1

Canada’s Health Care System (2019). Retrieved November 30 2019 from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html

Canada Public Health Association. What are the Social Determinants of Health? Retrieved October 14, 2019 from http://www.cpha.ca/what-are-social-determinants-health

Fagherazzi, G. & Ravaud, P. (2018). Digital diabetes: Perspectives for diabetes prevention, management and research. Diabetes & Metabolism Vol. 45, Issue 4, September 2019, pg 322-329. Retrieved November 30 2019 from https://www.sciencedirect.com/science/article/pii/S126236361830171X

Government of Canada. (2019). Canada’s Health Care System. Retrieved November 24 2019 from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html

Hecht, J. (2019). The future of electronic health records. Nature, outlook 25 September 2019. Retrieved November 24 2019 from https://www.nature.com/articles/d41586-019-02876-y

Kontos, E., Blake, K. D., Chou, W. Y., & Prestin, A. (2014). Predictors of eHealth usage: insights on the digital divide from the Health Information National Trends Survey 2012. Journal of medical Internet research, 16(7), e172. doi:10.2196/jmir.3117

MacNeil, M., Koch, M., Kuspinar, A., Juzwishin, D., Lehoux, P. & Stolee, P. (2019). Enabling health technology innovation in Canada: Barriers and facilitators in policy and regulatory processes. Health Policy 123(2019) 203-214. DOI.org/10.1016/j.healthpol.2018.09.018

Mierdel, S. & Owen, K. (2015). Telehomecare Reduces ER use and Hospitalization at William Osler Health System. Global Telehealth 2015: Integrating Technology and Information for Better Healthcare. DOI:10.3233/978-1-61499-505-0-102

Mychart (2019). Retrieved November 30 2019 from https://sunnybrook.ca/content/?page=mychartlogin-learnmore

Pockethealth. Our Mission is Simple (2019). Retrieved November 30 from https://pocket.health/ourmission

Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June-22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p.100) and entered into force on 7 April 1948. Accessed October 5, 2019.

Webster, P. (2017). Growing use of integrated e-health systems. CMAJ 2017 August 21;189:E1075-6. DOI: 10.1503/cmaj.1095455