Imagine having the results of your bloodwork, X-rays, prescriptions, and medical history available on one computerized health record that travels with you to appointments — whether in person or online — to see a family doctor or a specialist, and which will remain accessible if your doctor retires and you’re lucky enough to find another one. Science fiction?
In Nova Scotia and most other provinces, yes.
This idea has been percolating for at least a generation in health and digital circles. But after a tortuous and protracted process spanning seven years and three political parties, the Halifax Examiner has learned the Houston government is poised to announce it will award a lucrative contract to a company that will establish electronic health records for every Nova Scotian.
Dubbed “One Patient, One Record” (OPOR) the initiative goes all the way back to December 2014, when the policy was first approved by the NDP Dexter government.
In an email response to a request to interview a senior official accountable for OPOR, Health Department spokesperson Khalehla Perreault said, “We are in the final phases of the procurement and cannot comment at this time.”
Now before we wade into the weeds for why it has taken more than five years to award this tender (two companies, Cerner and Allscripts, were short-listed back in June 2017), it’s more important to note that the current patchwork of online systems for sharing patient information inside and outside hospital walls, doctors’ offices, or diagnostic centres appears unsustainable and even fragile.
Readers may not realize there are more than 100 computer applications (some as much as 15 years old and no longer even supported by developers) operating inside Nova Scotia hospitals. Some deliver results from diagnostic tests (for example, ultrasounds and CAT scans), which doctors and patients rely on every day. But many are on finicky, outdated platforms that require significant maintenance or workarounds from IT professionals. Most of the applications used inside the IWK Health Centre and the QEII Health Sciences Centre can’t talk to each other and can only share information in a limited way with family physicians and nurse practitioners outside hospitals.
Dr. Leisha Hawker is a family physician and the current president of Doctors Nova Scotia. The group supports the move to one electronic or digital health record that follows the patient.
“Doctors Nova Scotia is really looking forward to the announcement of the OPOR vendor. And the sooner that OPOR is up and running, I think it will be beneficial for health care providers and for patients,” Hawker told the Examiner in an interview.
Is the current health information sharing system unsustainable?
“Where we are now, it causes a lot of physician and administrator burden,” replied Hawker. “It takes a lot more time for doctors to do their assessments and then as well, we run the risk of error and not treating the patient properly because we don’t have all the information at the time when we need it. And then we are seeing higher costs because of the duplication of tests. OPOR will be a lot more efficient and cost-effective.”
Hawker has plenty of hands-on experience. Here is the process she follows when she is trying to access test results or follow-up on a patient seen at a hospital emergency department.
“Depending on the program I am trying to access, sometimes I have to use an old internet browser, like Internet Explorer and an older version of that, because it won’t run on newer browsers such as Chrome,” said Hawker. “As a family doctor, I have my own electronic record keeping system. If the patient had a test at the hospital or a trip to the emergency [room] and I haven’t received anything yet, then I would log in through a VPN (virtual private network, which offers a secure internet connection) that would then let me log into a hospital computer, and then I could login to one of the programs such as One Content. It’s a three-step process that is often cumbersome and hit-or-miss as to whether it works — all while the patient is just sitting there waiting.”
Hawker is based at the North End Community Health Clinic in Halifax but she also works at an addictions clinic at Regency Park across town. She said she recently had a patient who was at the emergency department two days earlier. “I did the whole VPN thing but the information wasn’t there yet. That’s probably because in the emergency department, the doctors do their chart notes on paper and then the notes go somewhere to be scanned, so the patient information is in limbo.”
She said she often receives bloodwork results for patients she sees at one location at her other clinic and the mix-up means added work and delay in re-directing those results to the patients.
Hawker said she is in the minority of family doctors or nurse practitioners who even have access to hospital records. A few years ago, she recalls taking a course or seminar so she could be permitted to access patient information held by hospitals (possibly due to privacy concerns). The family doctor said she believes there is still “paperwork” involved to obtain VPN access and that could be a barrier keeping some physicians and nurse practitioners from using the existing system.
The view from inside the system
On April 29, 2021, Nova Scotia Health, which was leading the “One Person One Record” initiative, held an online session to report the results of a survey about physician engagement with online health records.
A survey of 12 hospitals and 71 physicians working inside them found more than half (56%) were logging on to five or more computer applications each time they worked a shift. Half of the physicians said they found it difficult to find information on systems ,which often timed out before they could find the health data they and their patients needed.
The survey also included family physicians and other doctors who work outside hospitals. Here are highlights from the physician engagement survey shown on a slide during the April 2021 session.
Core health care IM/IT systems are at the end of their life cycles
• Incomplete patient information poses safety risks and provider frustration
• Siloed, highly customized health IM/IT systems means information cannot seamlessly flow from one provider to another
• End-of-Life health IM/IT systems routinely break down and are very expensive to maintain
Workarounds and duplication
So what do family doctors, nurse practitioners, and specialists who work in hospitals do when they find it difficult to obtain patient information online?
According to Dr. Michael Wadden, a rural physician who is also a big OPOR supporter, experienced doctors like himself prefer to text requests to people they know inside various hospital departments, “bypassing” time-consuming and often fruitless computer searches. But that’s unlikely to be a route available to medical school graduates or to internationally trained doctors who are new to the province.
Hawker said in her experience it’s not unusual for a specialist who can’t access a patient record to simply order another round of tests; she’s seen patients who had their bloodwork or X-ray or ultrasound “repeated” within two months of the last test.
That type of duplication is a waste of time and money, said Hawker, and something the implementation of One Person One Record should eliminate. Yes, OPOR will cost big bucks — perhaps in the hundreds of millions of dollars over a 10-year period to implement and service — but current computerized processes for sharing patient information are not sustainable in the long term.
We had a chilling foreshadowing of what could happen in the health system last summer, when the provincial Property Online platform crashed. The crash paralyzed real estate transactions for four days. It was a tremendous inconvenience, but no real estate agents, buyers, or sellers died.
However, what would the consequences be if vital patient information or the scheduling for appointments, cancer treatments, and operations crashed for that period? With hospital platforms that exist in a digital Tower of Babel, only risk managers would dare to imagine the effects on Nova Scotian lives.
Doctors Nova Scotia says the goal of OPOR must be either to (a) create one user-friendly platform for hospitals that can be integrated so that other health care professions can also use it, or (b) find a pathway where info from the new system can be easily shared with the hodge-podge of electronic systems used by family doctors, paramedics, pharmacists, and nursing homes.
Hawker estimates “well over half” of family physicians in the province now use one of two Electronic Medical Record software programs to chart their patients, a big change from 10 years ago, but still with a long way to go.
And the winner is…
Speaking of long, what about the more than five-year gap between the Department of Health’s announcement of two final bidders in the competition to provide electronic health records and September 2022, when the Department of Health and Wellness indicated a winner is on the verge of being announced?
The final Request For Proposals for the One Person One Record (OPOR) project went out in June 2017. Two of the biggest companies in the industry at that time, Cerner and Allscripts, were the only firms invited to bid based on results of a qualification round that knocked out four other companies.
Hawker suggests COVID may have delayed things. But we know that prior to the pandemic, a smaller electronic health records company that failed to make the cut accused the Health Department of playing favourites and it launched a lawsuit.
There are also significant privacy considerations and as Hawker points out, given the huge size of the expenditure, it’s critical this once-in-a-generation investment be done right.
To that end, Hawker makes one final plea to the government: once the OPOR process does begin to roll, make sure to consult the various health care professionals who will use the information system to fix glitches early and design the software to be both flexible and customized enough to work as envisioned.
The change won’t be easy and it will require extraordinarily good management. But it looks as if there is no other choice, considering that IT professionals are continually working long hours to try to keep a crazy quilt of obsolete patient information software from crashing — an event which would compromise the health care of Nova Scotians.