Wasting $1 B.. good enough incentive to revamp eHealth programs in Canada?
After misusing $ 1 B of taxpayers money trying to develop an effective eHealth infrastructure, Ontario decided to revamp its digital health program. After spending another $ 1.1 B, the initiative is still far from being implemented. What should they have done differently? What to do now?
The future of healthcare is shaped by eHealth initiatives. It’s universal for developed and developing countries. In 2008, Ontario (Canada) attempted to develop a program to implement electronic health records (EHR), a drug information system, an immunization tracking system and a diabetes registry.
Some of the benefits of digitalization of healthcare services across various players are [1]:
- Continuous flow of information preventing information loss and transforming healthcare delivery services
- Access to files from remote locations by providers and patients
- Enhanced decision support, clinical alerts, reminders, and medical information
- Accurate, complete documentation that facilitates accurate coding and billing
- Interfaces with labs, registries, and other EHRs
- Reduced need to fill out the same forms at each office visit
- Transfer of e-prescriptions electronically to pharmacies, minimizing lead time
- Patient portals with online interaction for providers
- Electronic referrals allowing easier access to follow-up care with specialists [1]
- Increasing the productivity of health workers who will minimize the time wasted on redundant processes (such as filling charts, travelling to pick up test results, calling other doctor offices to obtain records etc).
In addition to these benefits, the government of Canada could have saved $6 B if eHealth platforms were implemented in each province and regions. [2]
What went wrong?
The main issue that has led to the failed initiative was the mis-allocation of resources, specifically:
- The program had only 30 dedicated full time employees and more than 300 consultants who were grossly overpaid
- The Ministry of Health showed favoritism towards certain consulting firms, without organizing a proper tender system (value of untendered contracts reaching $16MM)
- The hired consultants claimed personal and unreasonable expenses as part of the program which were ultimately paid from taxpayer money [2]
However, if we move past the fact that Ontario residents had to accept that $1 B out of their tax money was misused [3], eHealth systems in Canada (a country with a population of 35MM) should be an achievable goal. If South Africa managed to digitalize the records of HIV positive women (to follow up with them, minimizing the chances of HIV transmission from mothers to infants), then why couldn’t Canada, a country with an average tax rate of 42%, with yearly healthcare spending of $200B (12% of GDP) manage to integrate eHealth as an integral part of the health system.
Ok, that sounds swell, but how should the government fix this?
The Ministry of Health assigned responsibility to Canada Health Infoway, a non-profit Crown corporation to complete the eHealth project. By 2011, the government invested $2.1 B in the initiative with no clear deliverable. The culprit: “lack of a clear e-health policy, inadequate involvement of clinicians, failure to establish a business case for using electronic health records, a focus on national rather than regional interoperability, and inflexibility in approach.”[4]
Avenues to consider to solve the eHealth gap:
- Focus on target population: aging population (setting up EHR for youth will be more expensive than the savings that eHealth implementation promises) [4]
- Clarify the strategy of the program: who are the main parties to be integrated, what is the information flow, how do various systems interface
- Outsource to private agencies: it’s hard to innovate in a bureaucratical environment, thus outsourcing will be more economically efficient and would provide access to the work of the industry pioneers
- Tying fees to deliverables: providing payment for services only upon completion of various stages of the project
- Acknowledging the active role that the patient plays in this initiative and design incentive systems to get patients on board
Dr. David Chan is dedicated to prove that eHealth platforms can be implemented at reasonable costs. He used physician and patient feedback to develop a system performing a multitude of tasks such as: disease surveillance, medication management, clinician reminders, scheduling and billing. OSCAR (Open Source Clinical Applications and Resource), was designed without incurring exorbitant costs, as he “quietly succeeded in turning a modest little clinic into one of the most innovative e-health laboratories in the world–without so much as a sign on the lawn.” [5]
“The system–which has not had the benefit of a single promotional dollar–has proven popular with Canadian doctors: It’s now the fastest-growing electronic health record system among scores of products competing for contracts with Canada’s 72,000 physicians.” [5]
OSCAR is “open source”–the code is non-proprietary–and thus almost free. In Vancouver, 14 doctors use OSCAR to treat 20,000 patients at a cost of $12,000. With these metrics, Chan questions the need for expensive computer systems such as the $47-million diabetes registry system spearheaded by the government of Ontario. The future focus should be on low-cost, user-friendly health information solutions that reach the patient and provides true value as they explore the health systems. [5]
Image source: ehealthcareers.ca
References:
[1] The Benefits of Electronic Health Records (EHRs) | Providers & Professionals | HealthIT.gov. 2016. The Benefits of Electronic Health Records (EHRs) | Providers & Professionals | HealthIT.gov. [ONLINE] Available at: https://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs. [Accessed 17 November 2016].
[2] www.cbc.ca. 2016. EHealth scandal a $1B waste: auditor – Toronto – CBC News. [ONLINE] Available at: http://www.cbc.ca/news/canada/toronto/ehealth-scandal-a-1b-waste-auditor-1.808640. [Accessed 17 November 2016].
[3] National Post. 2016. Canadians pay 42% of income in tax — more than they spend on food, shelter, clothing combined | National Post. [ONLINE] Available at: http://news.nationalpost.com/news/canada/canadians-pay-42-of-income-in-tax-more-than-they-spend-on-food-shelter-clothing-combined. [Accessed 17 November 2016].
[4] The Globe and Mail. 2016. After all the time and money invested, will e-health ever deliver on its promise? – The Globe and Mail. [ONLINE] Available at: http://www.theglobeandmail.com/report-on-business/rob-magazine/after-all-the-time-and-money-invested-will-e-health-ever-deliver-on-its-promise/article5796658/. [Accessed 17 November 2016].
[5] The Globe and Mail. 2016. After all the time and money invested, will e-health ever deliver on its promise? – The Globe and Mail. [ONLINE] Available at: http://www.theglobeandmail.com/report-on-business/rob-magazine/after-all-the-time-and-money-invested-will-e-health-ever-deliver-on-its-promise/article5796658/. [Accessed 17 November 2016].
Thanks for this mysterious author, and well done for your excellent name! As a total outsider, not only from healthcare but also from the world of IT, it does seem peculiar how difficult governments around the world are finding it to digitalise patient records and processes. The fact that Ontario chose to hire in consultants rather than build the expertise in house highlights th problem in my mind – public officials are regarding this as a one-off piece of work rather than recognizing that the digitization of their bureaucracies will be a permanent, ongoing and central part of their work for ever more. They need to develop the management expertise and technical functions in house and total cement this outlook – I fear that a continuing reliance on outsourced help will not only waste tax payer money going forward but also allow generation after generation of public servants to just not fully ‘get’ IT projects. Cheers!
Very insightful read, thank you for sharing. The colossal impact on taxpayer trust and the government’s credibility is difficult to quantify from the failed initiative. I appreciate some of the suggestions you have made to revamp the eHealth program. The recommendation to outsource to private agencies is a better alternative to hiring consultants. That said, I wonder if the government should consider entering into public private partnerships with healthcare and technology companies who are already ahead of the curve when it comes to digitizing healthcare. This way, the government can transition from an opex model to a revenue sharing model where the private sector has skin in the game post implementation. There is no reason to start from ground zero especially given some entrepreneurial initiatives such as OSCAR that have proven to be successful.