New contract a shining example of health care failure

We are constantly told there is a doctor shortage in Nova Scotia. Yet, statistically we are about where we should be in terms of patient-doctor ratios. The problem with statistics is they get skewered by geography, since most of our doctors are concentrated in HRM, which leaves the rest of the province under-serviced.

Provincially, the hottest information in any community is not a scandal, but about a new doctor accepting patients.

On the surface the province’s just-announced $200,000 contract with Emergency Medical Care to reduce ER closures by tapping a floating supply of provincial doctors seems a good idea. Anything that reduces closures and wait times is a good, right? In reality this contract is a shining example of the failure of Nova Scotia Health Care as it is currently organized.

How is it that Nova Scotia’s ten health authorities, using their existing army of over 400 administrators, can’t schedule staff?

And does the Province actually know the problem? Will this contract address all the issues?

On Wednesday, September 19th, a friend travelled to Halifax to meet with a surgeon about potential treatment. The surgeon was mad as hell over two surgeries which had to be cancelled that day because there were no operating room nurses. He was there, the patients were there, the nurses weren’t. Now, nurses, like anyone else get sick or have family emergencies arise. So how is it that in all of Halifax, which lists 222 health care administrators in the six-figure club, no one was capable of scheduling back up OR support?

This isn’t a unique situation. I’ve spoken with a psoriasis sufferer who had their treatments set back by four months because a support person in Halifax was out sick. In June, Middleton Mayor Calvin Eddy complained that Annapolis Valley Health (AVH) scheduled ER closures at Soldiers’ Memorial Hospital on weekends when the town was hosting large events, like the ironically-named Relay for Life which drew an additional 1,000 people to the community and again for the following weekend’s Antique Show and Shine. AVH said these closures were due to a doctor shortage.

Doctor shortages have been the quick and easy answer. But as we later learned, there appears to be a resistance by doctors to fill in at the Middleton ER because they’re paid $55 an hour less than their colleagues working in the Kentville ER, which are both under Annapolis Valley Health. It seems there are doctors, but the issue may come down to administrators who are trying to cut front-line costs.

Additionally, the Annapolis Spectator, reported that two ER closures in Middleton and Digby in the week between events were due to a nurse shortage.

In a November 26, 2011 letter to the Herald, Wayne Boucher, Chairman of Friends of the Annapolis Community Health Centre, referencing what he described as “a feel-good” announcement of a Collaborative Emergency Centre at the Annapolis Community Health Centre said the 1,512 hours in ER closures in 2010-11 credited to doctor shortages was “emphatically not the case. Those hours had more to do with AVH decision-making than a doctor shortage. It is unclear why there were 104 hours of ER closure from July to October 2011. It was not due to a doctor shortage.”

There are enough examples coming out to suggest that ER closures and other treatment delays are more of a scheduling problem that a lack of available medical professionals. Otherwise where is this private company finding a pool of available doctors? How come they can do it, but publicly paid administrators can’t? Is this some sort of subtle movement towards a private health system?

If we had better scheduling then maybe we wouldn’t lag behind the rest of the Canada in terms of treatment and delivery of services. Maybe then the 58 percent of Nova Scotians not getting knee replacement surgery and 46 percent not getting hip replacements within recommended treatment times, would. Maybe children on eight-month-long, pain-treatment waiting lists wouldn’t have to suffer so long.

We are always being told that productivity is a problem in Canada. The implication is that the “workers” have to do better. But what happens when the productivity failures are at the top?

Clearly having our health care organized into 10 separate, competing, non-communicative silos is not productive, efficient, coordinated or in the best interest of patients. This contract illustrates the on-going failure of our organizational structure. One provincial authority would ensure everyone working in health care was treated fairly and paid equally, and would result in better coordination of facilities and scheduling of doctors, nurses and support staff so that patients are treated in a more timely manner.

Nova Scotia is looking at all manner of ways to save money by reducing the numbers of council seats, re-aligning school boards, and discussing cutting the number of municipalities and merging driver’s licenses and health cards. Yet health care, which consumes 40 percent of the provincial budget, is allowed to flounder with an inefficient, non-responsive, top-heavy organizational structure. It’s clearly not working, why stick with it?

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22 Responses to New contract a shining example of health care failure

  1. Heather Davidson says:

    Saw your article in the Chronicle Herald this morning. It relates to the current situation here in Hantsport. Our most recent full-time (?) doctor left at the end of August 2011. Now we have a new definitely full-time doctor, Dr. Yuri Canete. He started Sept. 10, 2012. The practice has 2500 patients. He does have a nurse practitioner. He is not taking any new patients. Before Dr. Wile arrived we had two doctors – a married couple. Former patients agree that this was the best situation. Now some people in town don’t have a doctor. I go to Mud Creek Clinic but then I have a car. Lots don’t. Keep up the good work, Allan. -Heather Davidson, Hants Border.

    • Thanks Heather.

      It’s good that Hantsport again has a doctor. Now, the community will have to ensure he is happy there. His happiness could act as a type of subliminal recruiting message for more doctors to come in later.

      Here’s to everyone’s good health.

  2. ausca says:

    “It’s clearly not working, why stick with it?”
    I had such high hopes that the incoming Dexter government would tackle this. They arrived with enormous goodwill, a huge majority, a fresh perspective after decades of same old same old Liberal or Tory government, and public health care was a signature Tommy Douglas achievement.

    What a disappointment.

    It seems no NS government can do more with public health care than nibble around the edges. I see no better alternative from MacNeil’s Liberals or Baillie’s Tories. If they have plans to deliver the radical reforms that are needed for public health care to survive in any meaningful way, they’re keeping mum.

    I wonder why no government seems able or willing to tackle this? Health care is the single largest program provided by the NS government – even larger than education. The Harper government tying Federal health care contributions to GDP instead of regularly increasing it by 6% after 2017, should trigger serious reviews, public discussion of new ideas and a clear resolve to manage cost increases, but so far all I see is the usual whining about the Feds.

    Is there something wrong with the Deputy Minister and their staff that makes them unable to assist ministers to initiate genuine reforms?

    Are governments so intimidated by the opaque, byzantine NS health care bureaucracy that they dare not intervene?

    I don’t know what it is, but we are clearly headed for financial disaster if nobody takes the helm. That doesn’t even consider the human costs of rescheduled surgeries, unfair wait times, inability to find family doctors and determination to control costs by minimizing patent bed times.

    Increasing geriatric demands, clear notice of reduced Federal support, continual patient grievances – why does the Dexter government not act?

    • In the spring at their annual meeting the Liberal Party of Nova Scotia did make amalgamation of health authorities a formal part of their party platform for the next provincial election. The Conservatives haven’t had their meeting yet, however, their leader, Jamie Ballie, has taken a strong position opposing the status quo. I expect that should the government change with the next election we will see a massive re-organization of health care in this province. The only people defending this legion of highly-paid health care executives is the NDP.

      I never thought I would defend the federal Conservative Party, but having looked at our health care system I understand their reticence in committing to funding beyond 2014. The 2004 Health Accord set out a clear set of goals and laid out a stabilized funding schedule so that health care authorities across Canada would know what it had to work with. At the time, health executives said the uncertainty surrounding their funding hampered their planning.

      We are eight years into the Health Accord and those in charge of health care haven’t come close to hitting the targets they help set! This summer the Premiers met in Halifax and decided to cooperate on drug purchases as a way to contain rising costs. That’s such a great idea they’ve been announcing it since February 2003. Bulk purchasing of drugs was a key element of the 2004 Health Accord. Every year someone drags this out as a solution for cost containment. And eight years later, the only jurisdiction to do anything about drug costs has been the province of Ontario. Any fool knows the value of block buying in reducing per unit costs. These people talk about it, but don’t it. There are drug shortages in the world right now – if we had used/if do use the power of our combined drug purchasing budgets, we would not only save money, we would avoid shortages by guaranteeing drug companies sufficient volumes to ensure supply. Look at the recent talk of merged services in Nova Scotia: the took nine months and $100,000 to study six areas where they might save money. Bulk drug purchases was not one of the studied areas. As a result, the district health authorities decided to save money by merging their laundries. HR and IT are not being merged. Not, at least for several years. And even to merge laundry services, the DHAs gave themselves 18 months to do. In essence, the lowest-paid people in the health care system are losing their jobs for window-dressing. We are in an era of rising energy costs, yet our health care system has opted to truck laundry from Yarmouth to Amherst to Sydney and every hospital and clinic in between to Dartmouth to be washed and dispersed across the province!

      I’ve written about this elsewhere on this blog: I believe the merged services have been set up to fail, so that a year or two into them the health care authorities will be able to say, ‘it didn’t work’, ‘it’s not saving any money’ and return to the status quo.

      We could have change, we could have a system that works a hell of a lot better than it does, but it starts at the top, not in the laundry. They were already doing their jobs.

      • ausca says:

        “I never thought I would defend the federal Conservative Party, but having looked at our health care system I understand their reticence in committing to funding beyond 2014.”

        I believe Stephen Harper is ideologically opposed to public health care and would prefer to see a two tier private / public system. That goes some way to explain his ‘take the money with no strings’ position. The other is that the money will be cut unless Canada starts generating remarkable GDP.

        However I do agree with tying Federal investment to GDP because…

        – Ottawa cannot continue to increase the rate they pay into Medicare at a faster rate than it increases revenue,

        – The Provinces will never take public health care reform seriously until they are forced to do so. 2017 is not so far away and bashing the Feds will only carry them so far.

        “…the Liberal Party of Nova Scotia did make amalgamation of health authorities a formal part of their party platform for the next provincial election.”

        It will take much more than that to reform public health care in NS, but that is a start and considerably more than we have seen under the Dexter government.

        Bulk drug purchase in concert with the other Provinces is another.

        Moving everyone’s medical record to a live EPR located not in hundreds of clinic archives but hosted on secure central servers and accessible to licensed health providers is another. This could eventually eliminate the non emergency caseloads in ERs, overcome the ‘shortage’ of family doctors while becomeing an important tool in preventative publi health care. NS started work on this early, so why is it taking so long to become universal?

        Advocates to force the system to be more responsive to patient needs might be another.

        I see no sign of broad lateral thinking backed up by determination from any NS party on this. It’s complicated, risky (in terms of human lives and public money) and hugely expensive but I see no alternative. We can no longer afford the luxury of muddling along with guaranteed 6% more each year from Ottawa while costs and demand both increase. It will take a long time to turn this ship around, and we’ve already wasted years.

        “The only people defending this legion of highly-paid health care executives is the NDP.”
        Why do you think that might be? Do you think they are more concerned with the welfare of highly paid union staff than their constituents at large? The NDP and big bucks executives are not a natural fit. Do you believe they have made a worse job of overseeing health care than previous governments?

      • I don’t know why the NDP are so firm in maintaining the status quo in health care. They have shown a distinct lack of innovation and are completely deaf to change or investigation of problems. I asked the former health minister to at least investigate how one health authority operates – she told me she was “disinclined to spend the money.”

        I spoke to a former senior civil servant from another province recently and was told that while the electorate votes in a new government for their new ideas, everything is strangled by the same old advice from the same old departmental advisors. That’s the first problem.

        The NDP have had no guts for change. They want health authorities to first live with a freeze on funds, then a modest cut back, and as soon as they say that they start digging in to reserve funds to buy their way out of negative public relations caused by health authorities complaining about the cuts. It’s an old game that health authorities across Canada have successfully played. So the government finds $500,000 to pay for new uniforms for nurses. I know nurses who are offended by this. They didn’t ask for the money and are insulted by the notion that they can’t pay for their own uniforms. Most would have preferred to have this go to patient care. Now the province comes up with $200,000 to pay for staff scheduling. They’re like a permissive parent. No one believes what they say because they only listen and give in to health care executives. Never has any government in this province listened to the people – whether they’re patients or patient families – about the quality of health care, the delivery of care, the failings of the system. Ministers are insulated from bad news so they can have deniability. So for the sake of their careers, people have to suffer.

        Everyone I know in health care wants electronic health files. That was another aspect of the 2004 Health Accord. One knowledgeable insider suggested the reason we haven’t instituted this in Nova Scotia is because with 10 authorities they’re all collecting different information, using different forms. Additionally, several nurses have told me that not only would electronic files be better for patients and staff, they would be more truthful. Electronic files are date stamped and it’s been suggested to me that the resistance to electronic files is that charts can’t be changed without leaving a trail. Having written that, an insider told me if I were to ever get photocopies of a patient file to insist on colour copies so one would know when files were written and altered.

        Over and over again, those who study the system say that giving it more money just makes the problems more expensive. And as long as we continue to find new money for the system there is no incentive to problem solve.

        Doctor after doctor, consultant after consultant have told me that health care administrators are only responsible for managing their budgets. They are not responsible for improving patient outcomes or meeting treatment targets. If we want a better health care system, we need to change their focus.

  3. woof says:

    If Mr. Harper were to keep giving the provinces boatloads of money for healthcare nothing would ever change. The administrators are too concerned about their own backsides to ever try and change the existing disfunctioning system. Their thinking is “it’s never worked before and we’re not about to change that”. Cut the cook’s helper, cut the cleaning lady, cut the maintanance man. They’re almost like little Jack Horner ‘what good little administrators we are’.

    Pay one person $50,000,000 a year to run the system efficiently and we’ll at least have a system that works.

  4. ausca says:

    “Everyone I know in health care wants electronic health files. ”

    Who owns the data on the health files? Surely that would be the patients, even if the paper and manilla folders that hold existing data may well be owned by family doctors or their clinics.

    Who paid for the services that lead to the compilation of that data? That would be MSI, so they too may be able to claim some degree of ownership.

    Family practices are usually privately owned, so I imagine that makes the doctors contractors to MSI. The Province could offer free secure client gateways to their EPR system, to be operational by a certain date. Thereafter the medical records of all consultations would be appended to a client’s NS EPR, visible to any doctor, or through appropriate filters to any nurse, nurse practitioner, pharmacist, dentist etc.within NS.

    Those without a family doctor could consult any available doctor (such as those in grocery store drop-in clinics) who could request diagnostic tests, the results of which would be appended to the same EPR – not the exclusive domain of any specific family doctor. If fact any available doctor could be consulted on this result, although there is nothing here to preclude consultation with a preferred doctor. This could end the problems with finding family doctors, and consequent non-emergency pressure on ERs.

    This would have to be developed in consultation with representatives of the medical and nursing professions, but if the government made it clear that this would be required of doctors contracting to MSI, and that the Province would install and maintain these EPR clients, it would be hard to resist on purely professional or business grounds – especially if the public found out.

    This is the kind of radical reform I’m talking about. It involves a certain amount of cost, a degree of risk, the possibility of a brawl with doctors groups, but it could ultimately help the system become more patient-centric while eventually reducing costs. It requires lateral thinking and a degree of determination I’ve never seen from any NS government, no matter what party. My guess is that NS public health and provincial finances have to deteriorate to the verge of catastrophe before any NS government feels they have no choice but to act.

    Of course, by then it may already be too late.

    • This is an interesting position. Most of us think of digital records in terms of hospital and clinic records, not necessarily reaching into the private practice of family physicians. I think that is a discussion for doctors and patients to have – I do not want health care administrators involved. They’ve had decades of say, but patients have had no say in anything, so since the records are about them and since they’re the ones who pay for the system, let’s hear what they think.

      We do have to have a discussion about who owns patient records, both from a private practice and hospital. In theory, they belong to the patient, but ask for them and you’re going to be shocked by the fees charged to receive them and the resistance you’ll get from hospital administrators who seem to automatically take the position that anyone seeking any information is planning to sue. Thus, they system digs in, resists and does everything not to make it fast and efficient.

      • ausca says:

        Since my hospital and medical and diagnostic records were compiled as part of the public health system to which I contribute by law, I would imagine that I must surely have legal rights to them.

        Since the Province paid for them on my behalf, I would imagine they too have some sort of rights to access them.

        If the Province requested my consent to collect my future medical, hospital and diagnostic records in the form of an EPR, I don’t understand how they could be stopped.

        If I optionally wished to retrieve my previous records to complete my EPR, that might involve archiving and transcription costs which I might be expected to cover, at least in part. The hospitals and family practice clinics can keep the original paper records for which they paid for pen, paper and storage, but the data contained within them is mine.

      • You might want to inform those of us who don’t know, what an EPR is.

      • ausca says:

        Sorry, EPR is short for Electronic Patient Record, medical data stored electronically rather than on paper.

    • Josh says:

      There already exist EPRs in various forms, and Capital Health in particular uses the “Horizon Patient Folder” (HPF). It’s not the best system, but contains complete patient hospital charts, and can be viewed either by patient encounter or by chart type. So you could either view all the records for Mr Smith’s March 11, 2008 visit to Emerg or you could choose to look at the anesthesia records for all of his operations (well, those since mid-2005). The trick is that HPF consists mainly of scanned paper records and dictated notes (consult, OR, clinic, discharge) and isn’t searchable or generally accessible by family doctors. It really should be, though.

      In the community, though, many family practices use one or another EPR – “Nightingale” is the one I’m familiar with. It’s designed for outpatient clinic visits, and while I don’t really like it for aesthetic and some functional reasons, it does replace paper charts and is far superior for management of medications.

      Again, the problem is that neither system talks to the other, and while hospitals have HPF, they have no access to Nightingale or any other records from the family doctor, and the reverse is true for family docs.

      To add yet another problem, districts outside Capital don’t use HPF and use a system not in use in Capital. If that sounds convoluted, it’s far worse in provinces where nearly every hospital has its own system, especially Ontario. At least now if you show up at Hants, Cobequid, Dartmouth General. or the QEII there won’t be any problem seeing all your records… assuming you’re not a woman who recently had a baby or surgery at the IWK, that is. (If there’s one simple that should be done, it’s to merge the IWK’s IT services with CDHA.)

      • If electronic patient files aren’t searchable and have to be read in whole like a paper chart then that’s not efficient or effective. The other problem at Capital Health, according to doctors, is that when Capital Health purchased high speed computers they connected them to 40-year-old land lines. A doctor can wait for eight-to-ten minutes, depending on how busy the system is, for a patient file or recent lab report to load. If a doctor is scheduled to see ten patients in a day then an hour and a half of their time is lost waiting for files to load.

        Another problem with this system is that because the bulk of medical specialists are in Halifax and patients are sent there to see them, which means that almost 60 percent of Nova Scotians aren’t covered with electronic medical files. So the specialist has to rely on paper charts and letters. The medical professional or team looking after the patient on their return home or to their home health authority have to wait for medical reports – many of which are mailed. How often are patients told the report will take two weeks? Meanwhile their condition continues.

        Plus, many hospitalized patients are cared for doctors who are not their personal physician. At the Valley Regional Hospital, 86% of patients are attended by doctors on rotation. So, even if they have their own physician, he/she is left out of the loop. I’ve had doctors tell me they get no information about patient care while that patient is in hospital. Doctors have told me they get a letter after the patient is released that ‘so-and-so has been in care’. They are not – in most cases – consulted on the patient’s care and treatment while that person is hospitalized. Had we province-wide electronic patient file personal physicians could check in on their patients and guard against bad decisions by doctors who don’t know the patient as intimately as the personal physician does.

        We had an example in Kentville where a doctor walked into the patient’s room early one morning, glanced at her chart and removed one of her drips. He said there was no need for it. The patient objected. She had been ill for a long time and knew this drip was necessary. She told the doctor what happened when another hospital removed this drip and pleaded with the doctor to check with her doctor in Annapolis before doing this. Nonetheless, this doctor was there and the nurses had to follow his instructions. Two hours later this woman was in Intensive Care and her family was called to come say their goodbyes. She managed to live another two months.

      • ausca says:

        Are we saying that after all the investment and bickering to date, NS EPR’s represent out of date paradigms and should be written off and eventually replaced by something better? Hell, I hope not!

        Ideally all electronic patient records would have text stored as text rather than as an image (i.e. a scan of a paper document). That would enable fast searches across many records. However I would imagine that a more important imperative might be that all patient records (in whatever form) be viewable from a secure terminal by any caregiver entitled to use it.

        I’m not sure how to deal with different proprietary EPR clients that may be held by various doctors, clinics and hospitals. Would it be possible to construct a gateway that could present data from different sources (e.g. HPF and Nightingale plus imaging network) as one patient record, or would that be too impractical or unreliable? Could that work as a stopgap measure until the Province cold devise or acquire something more universal that could be supplied to all labs, hospitals and care givers who contract to MSI? Perhaps after establishing such a system older records could gradually be transcribed into it (perhaps at patient cost)?

        If the provinces together formed an inter-provincial body that could agree upon server and client applications to be used in every province, the shared development cost might be considerably defrayed and pressure applied to hospitals, clincs, labs etc. to adopt them?

      • A couple of things: not everyone who reads this blog works in health care, so we need to avoid too much use of insider abbreviations. Typically, we would write: Electronic Patient Record (EPR) and use EPR for all secondary references so that the reader can follow.

        Does HPF stand for: hospital patient file? And I don’t know what the Nightingale software does.

        Now, to your points about collecting, storing and accessing electronic patient files. You talk about costs, but how costly is it to have outdated and inaccessible files? That cost is not just to the system, but to the individual patient. The greater the cost to the patient – in terms of suffering and progress of illness or misdiagnosis – the greater the cost to the system, whether directly to medical care in a facility or on-going after care and possibly future financial support.

        Let’s not assume we have to reinvent the wheel. Other jurisdictions and countries have already dealt with this and developed electronic patient record systems. Why can’t we go out and buy the world’s best? There’s no reason we have to start from scratch. And don’t forget having electronic patient records were one of the goals of the 2004 Health Accord. So politicians and health care executives have no excuse other than laziness or an inability to do their jobs for failing to implement a workable system. They have had eight years to do this and they haven’t.

        As for who has access to an electronic patient file, how would that differ than the rules governing who has access to a paper chart? We’re talking convenience and speed. And in a mobile society, where we travel for work and pleasure or are sent to other communities for specialized care, this is a major benefit to the patient. One set of regulations/laws across the country regarding access should be sufficient.

      • ausca says:

        I appreciate your aversion for acronyms – I don’t work in health care either: Josh mentioned 2 posts back that “There…exist EPRs in various forms,… Capital Health… uses the “Horizon Patient Folder” (HPF)….In the community, though, many family practices use one or another EPR [including] “Nightingale”…”

        Yes we don’t have to create our own electronic patient record (EPR) client, but I had thought NS had already spent money on building networks for these (am I wrong?).

        Irrespective of what EPR client a clinic or healthcare giver uses, I hope this investment will not be wasted. Ideally all patient records should be searchable, which means notes should be in text form, as much as possible in database categories located in standard places along with images. This actually reduces storage and transfer times compared with scanned images of paper notes, although I can understand that jotting scrawl on paper is fast and can be passed to an office secretary to add to an electronic record. There may be fast EPR data input clients available on hand held devices which doctors could use during consultations then quickly sync up with the main data base later.

        I see 2 concerns with standardizing EPRs.

        – Who pays for them? Purchase and support for them can be costly and asking clinics to dump their present but incompatible EPR client for the new provincial standard one will be resisted. If possible NS should negotiate a province wide deal for seat licenses and supply them free or discounted to clinics.

        – A certain amount of pressure will need to be applied for them to become universally adopted. There may need to be a time by which data from them will be required from each clinic on an ongoing basis as part of eligibility for MSI payments. One needs to be firm but careful here. Nobody needs a public brawl between the government and the medical profession, but if the public are educated about the benefits of province-wide standard EPRs, and the caregivers are mostly shielded from the changeover cost then their resistance will be harder to justify.

        Just a few thoughts.

      • Thanks.

        I am unsure if there is an organized resistance to Electronic Patient Records (EPR) or just apathy and the all-too-typical lackadaisical attitude to instituting change. In the eight years since EPRs were made a national goal there has been no public uproar about it, but then there has been no movement on it either. One insider suggested to me that the resistance provincially is because each district health authority collects different information, so the challenge is more than inputting written data and charts into a digital format, it’s the gaps in the information collected which will become more apparent. Those gaps can explain some of the uneven level of care and service across the province.

        You mention a doctor handing notes to an office secretary to input. I have had complaints about the quality of the clerical help provided by health authorities. Doctors complain that some of these staffers – and it doesn’t take more than one to create a problem – are poorly educated. They can’t spell, can’t write sentences, aren’t attentive to detail. The doctor complaint is that since you’re handed this support staff with no say into using them they (the doctors) are still liable for this person’s errors. I was told by a doctor that two colleagues in one hospital quit because of the potential liability which arose because of the sloppy clerical work!

        As for who pays for this: guess? The taxpayer pays for everything now. Health care is not a gift from the politicians or administrative elite. So for a change it would be nice to have a system that was more efficient and effective and actually worked for patients.

      • ausca says:

        I’m not sure how well our government much less its citizens understand the potential of electronic health and patient records. At the risk of boring you, let me append an extract from a 20+ page list of ideas I sent the Dept of Health and Wellness, which was summarily ignored for 9 months then answered with a standard ‘thank you for your interest’ boilerplate reply…

        – An Unrestricted Health Record.

        Every citizen has a “medical profile”. This currently resides with your Family Doctor. Yet today many people cannot find a family doctor. They flood outreach clinics like those in the Superstore, or in Emergency Rooms never intended to treat the likes of chronic arthritis. Results of prescribed tests must be passed back to your medical home (i.e. the family doctor). What if you don’t have one? The system makes no allowance for that as far as I know.

        Consider what would happen if we uncoupled your medical health record from the custodianship of one particular family doctor.

        Imagine it were possible to see any available general practitioner when you needed them, wherever you happened to be.

        Suppose any health practitioner could immediately access your entire electronic health record (EHR), their observations and treatments were immediately appended to all those previous, so any practitioner could subsequently access them.

        Since 2005 Nova Scotia has been building electronic medical databases as part of its Primary Health Care Information Management (PHIM) program, using a privately developed web-based electronic patient record application to maintain electronic medical records (EMR) for clinics with access to high-speed Internet services.

        By September 2007 there were 88 clinics and 801 users registered, representing 32% of the province’s primary health care physicians. For each citizen, their EMR from each of the doctors they consulted could be compiled into their electronic health record (EHR) – a complete description of their known health history.

        Nova Scotia is the first province to develop province wide electronic delivery of lab and diagnostic imaging results for its provincially approved electronic medical records. The province has been nominated as a finalist for a Government Technology Exhibition and Conference Distinction Award for this achievement. The groundwork has already been laid!
        (See http://www.gov.ns.ca/health/eResults/default.asp)

        Ideally we may construct controlled gateways to all medical, pharmacological, dental, physiotherapy data etc. within a province wide, secure database that could be accessed by registered health professionals on a logged, need to know basis. A paramedic might have a more limited access than an emergency doctor, while a pharmacist or a physiotherapist or a dentist might have a different view.

        However, it would be illegal for employers, insurers, police (without a properly issued court order) or anyone else to access it or to require information to be furnished to them from it. Security and privacy would be comparable to those of tax records.

        Now consider this…

        An elderly woman from Yarmouth collapses while visiting her grandchildren in Glace Bay…

        * Using a common PDA, and data on her driver’s license, the first responder already may have a functional idea of her medical history while on route to attend, and…

        * The nearest ER knows she’s coming, her profile is already open and the attending emergency physicians know her essential history, what the paramedics found, and may have a head start on how best to manage her condition and what allergies she has when she arrives, then…

        * Her family physician is automatically notified, receives all details, and becomes a direct part of the post-emergency care when she returns home.
        How quickly could we compile that data now?

        Could this ever become the difference between life and death?

        The important thing here is that wherever she was in NS, her Health Record went with her. It was not limited to the availability of her family doctor in Yarmouth, but they are fully and rapidly briefed on these events.

        Uncoupling my patient record from my family doctor means that I could see any doctor I please. In fact, I might not even need to have a specific family doctor (although I would be free to choose one if I wished).

        Such a database might also include continually updated utilities to assist physicians to accomplish such things as …

        * To rapidly and accurately narrow diagnosis of medical conditions,

        * To prescribe medications (reducing the chance of medication errors and ensuring side effects are fully understood),

        * To locate the most expeditious referral for specialist services via a central booking scheme (See item 5, below).

        * To personally view the latest CT scan, and to compare it with earlier ones,

        * To automatically see a plot of last week’s PSA result against others taken over many years – and to project a likely future trend.
        This might assist in control of over-prescription and illegal trafficking of drugs, and over the longer term provide a detailed pharmacological history that could be considered when evaluating a patient’s current condition – which may in part be due to longer term adverse effects of medications.

        In return, the overall usage and perhaps even some idea of efficacy and side effects of new medications can be assessed by the NS Department of Health over a broad sample space. This might be used to…

        * advance the substitution of brand name drugs by cheaper but equivalent generic ones,

        * identify adverse trends related to the outcomes associated with specific medications.

        * identify unusual regional variations in the usage of certain medications or medical services relative to the national or provincial norm (for example it might be that the rate of caesarians in one hospital is considerably higher than the provincial average).

        * identify patients who appear to require more frequent medical consultations than expected.

        Remember this data is as current as the latest entries, which arrive daily.
        Further, MSI may also be able to be able to use these EHRs to quantify the insurance risk represented by individual clients. Surely those who smoke or are overweight or have high blood cholesterol levels represent a higher risk than those who do not. How could we use that?

        Well, what if we were able to either impose health insurance taxes to those who choose despite repeated warnings to remain seriously overweight (since they may represent a higher risk of heart disease, cancer, diabetes, back and joint damage etc.)?

        Instead, we might reward those deemed to be a lower risk (or who have demonstrably lowered their risk) with tax or other discounts? (See 4. An Ounce of Prevention, below).

        Ultimately, if ours proved workable, I would hope to eventually see patient record gateways of all provinces and territories integrated into a secure, national Medicare database, where every access is logged and where the Medical Profile of any Canadian follows them anywhere in Canada.
        We have a shortage of doctors and we have an excess of good IT people (many leave NS to find work). Why not leverage our strength to cover our weakness?
        (http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Future_Practice/English/emr-faqs.pdf)

        – An Ounce of Prevention

        Once we have our hypothetical, unified, province-wide EHR system let’s put it to good use… Why wait until people acquire painful, scary medical conditions that will cost a great deal of public money to remedy, when it might often be to minimize or avoid them before they require expensive treatment?

        We in the Maritimes have a reputation for an unhealthy diet, and little exercise. Some see it as part of our culture, almost as a right. I suspect that a substantial amount of personal grief and public money caused by cancers, cardiac conditions and worn out joints, for example, can be traced to these.

        Poor diet and sedentary lifestyle begins early in life. Overweight, unfit kids are the seminal illustration. Could we not foster better exercise by building more sporting facilities, awards and otherwise offering more opportunities for kids to desire an active lifestyle they may continue into adulthood?

        (I wonder how many foregone knee replacements at an average $13,000 each it would take to construct a skateboard park or a swimming pool)?

        What if it were possible to identify subscribers from our proposed NS health care database, who might be at elevated risk of specific classes of disease? Here’s what I mean…

        Each year, every Nova Scotian would receive a birthday card from MSI that might request they take a comprehensive physical examination. Issues specific to an individual are included on their EHR for their doctor (who would also get a reminder). This is preventative medicine. The EHR would then be updated with the results.
        Every day the EHRs of subscribers in the NS health care database would be passed through epidemiological software filters that employ algorithms aiming to correlate the overall medical profile of every subscriber with a set of disorders of public health interest.

        For example, it might be possible given enough data in the patient record to estimate the likelihood of someone eventually suffering from Type 2 diabetes. Automated correlation with family EHRs may also help. When someone is identified at an elevated risk…

        * They are contacted directly by the Department of Health, a consultation proposed and noted on their EHR,
        * Details of the reasoning behind their selection would be included for any attending physician, diagnostic tests requested to update or extend the EHR,

        * The patient would be added to a “watch list” to monitor progress.
        At this point, why not invest money early on to hopefully save much more later, while also helping reduce medical and hospital demand?

        We might, for example, offer to sponsor someone at risk for a period of an approved exercise program at a registered gym. Others might receive part-sponsorship to a diet program. You can bet the private sector would compete to offer these, while costs could be held down by economy of scale.
        To encourage people to maintain a good standard of health, it might be possible to reward those who have taken requested steps that have demonstrably reduced their health insurance risk with discounted MSI contributions at income tax time.

        Has anyone ever estimated the public cost health cost caused by obesity alone?

      • Thanks for your thoughtful, detailed, constructive contribution to the discussion.

  5. WOOF says:

    ausca – are you hinting at ACCOUNTABILITY from out health authorities?

    Their thinking is and will always be: “this system has never worked before and we’re not about to change that”.

    Change will have to come from the premier and/or the health minister…don’t hold your breath.

    We need commitments from Baillie or MacNeil – in writing – that change will happen under their leadership, and I don’t mean more studies and consultants. Get rid of the present health authorities and their useless bureaucracies and hire one person who will be accountable.

    The janitor or cleaning lady(person) or any bystander could run a more efficient system at less cost…guaranteed.

    • In the Spring at their annual general meeting, the leader of the provincial Liberal Party, Stephen MacNeill, did make reducing the health care bureaucracy part of the party’s official platform for the next provincial election.

      The Conservative Party leader, Jamie Baillie, while not yet making it a formal part of the party platform, is strongly leaning that way.

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