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Softwords Newsletter
June 1997
Seamless Care, Sacred Cows… And Free Hamburgers
Burgers aside, this column and the issues raised in it may offend you. Sometimes
issues discussed are points of view that differ from our own. Such issues
may be value laden and controversial. However, different points of view
should be heard in so far as they are reasonable. Perhaps this article may
help spark discussions about sensitive and emotional issues. And it should
be noted that opinions expressed are those of the editor alone. So we begin...
Each day we hear the doom and gloom that faces the medical community around
us. Unfortunately, we don't just hear about it, we work in that community.
And it's not just Ontario or Canada. The same concerns and issues are being
heard around the world. Everywhere, Health Care Communities are facing fundamental
problems.
In Canada, the issues range from the nature and cost of Universal Coverage
and Equitable Access, to Seamless Care, Gaps in Accessing Care and issues
of public/private congruence, all connected to issues of fiscal responsibility.
The particulars vary from province to province, but the issues are basically
the same. What is the best model for providing Health Care to Canadians
and how is it to be implemented and paid for?
Of course it would be nice if the rest of the world stopped and allowed
the medical community time to figure this out. But life is on-going action
and the world moves... in these modern times, it moves at a fair clip. So,
while these issues confront the medical community, demands and expectations
of patients change and grow. One development is the emergence of what we
call Integrated Seamless Care.
More and more we expect and demand that if a service provider looks after
our concerns in a certain area, then it should look after all of our concerns
in that area. No one wants to jump through hoops or fall between the cracks
among various providers. In any marketplace customers are the final arbiters.
The medical market is no exception to this. Integrated Seamless Care is
on the rise in Canada for one reason - it is being demanded.
The health-care delivery system is being re-fashioned. The primary care
model is being reformed. Networks and Smart Systems are being set up among
health care professionals and institutions to provide an information infrastructure
that is dynamic, on-line and navigable. What this provides is the power
of a responsive system that is integrated. Integrated Seamless Care will
improve the quality of medical services, reduce inefficiencies and become
the standard tool to enable providers to manage Health Care with an emphasis
on health promotion and disease prevention. Promoting health and disease
prevention means better living and fewer costs for each individual and less
drain on the system as a whole.
Integrated Seamless Care will eliminate duplication of services, create
efficient referrals, constrain patient abuses like self-referral and double
doctoring, and promote a continuity of care based on the Primary Care Provider
model that is respected and used around the world.
The Free Hamburgers
Wouldn't it be nice if everyone could just get the medical attention they
require when they require it? Wouldn't it be nice if everyone had a dream
home? (Most of us would somehow find a country setting in the middle of
the city, close to work.) Wouldn't it be nice if we only worked 4 days of
the week?
Who could possibly disagree with any of these wishes and not want everyone
to have the same? Except there is one tiny, ever-so-small problem with this.
Who is going to pay for it? Like most human values, these things are created
by someone's effort, thought, skill and labour.
My dad used to say "If MacDonald's handed out free hamburgers, people
would at first take a burger and consider themselves fortunate. But after
a short while, many would take more than they could ever eat or use."
The Sacred Cows
In Canada, the hard truth is that because Universal Care and Equitable Access
are emotional issues they have become the sacred cows of social programs.
The not-open-for-discussion.
Around 12 million people live in Ontario. (Not that I've ever personally
counted.) Ontarians tally up somewhere in the neighbourhood of 70-80 million
doctor visits a year. (Not that I've personally counted those either.) It's
not as if everyone in Ontario goes to the doctor 6 to 7 times a year. It's
more like some go lots and lots, and lots and lots. Obviously, many visits
may be necessary for some. But I can't help but think about what my dad
said in relation to free burgers at MacDonald's.
It may be an obvious point, but someone has to pay for those burgers and
someone has to pay for those medical visits. Yet those free burgers are
in part bankrupting the business. What are we willing to consider as solutions?
Open Discussions
So far, most of the discussion has been to clamp down on how the burgers
are given out. In other words, restrict what a doctor does, how and why,
and clawback when necessary to stay on budget. So, governments decreed that
utilization must be controlled in order to comply with fiscal policies to
reduce costs, primarily by controlling physician service offerings. Of course
efficiency is imperative, but still there is a line up of those seeking
burgers that for all practical purposes seem free. Costs are at best seen
indirectly by patients. (HMOs in the U.S.A. have reported that even a minimal
user fee of $5 per visit reduces or curbs discretionary patient visits by
a whopping 20%!!!)
There have been many efforts and discussions to consider ways in which to
improve the Health Care model we have. But less discussion and no serious
consideration has been given to changing the model.
To Reform or Change
The type of system to best serve all of our needs is a hotly debated topic.
But this much is true. As with all issues that boil down to views on the
nature of organized society (including how best to deal with issues of Health
and Well-being) these issues are packages bundled together. To offer Universal
Coverage and Equitable Access is a package with consequences. Unfortunately
or fortunately, depending on your perspective, included in the Universal
Coverage/Equitable Access package is the consequence that doctors will have
to practice in a highly governed, centralized market in which they will
have only a very limited control.
Perhaps it goes without saying that Canada's Health Care System is the jewel
of our social programs. But the jewel requires a reappraisal. It has serious
problems facing it from all sectors... doctors, patients, businesses, institutions,
organizations and the citizens who are paying the bill. Given that we are
dealing with the not-open-for-discussion we may never actually confront
the causes... and all of us in Ontario will be the last to know.
Grand schemes to control markets, including medical markets and health care
systems, have failed or are failing around the world. It is true that some
of them have taken many years to fail, but fail they have nonetheless. Why
would Ontario or Canada be an exception to this?
Dynamic Solutions
At A&L, we think there are many possible solutions to what ails the
medical market. And whether those solutions come from the public or private
sector, whether solutions are reforms or drastic changes, we think that
Integrated Seamless Care will be a fundamental part of any solution. And
we are working with many groups and organizations in the medical community
to make those solutions a reality. The use of Informatics to create provider-based
patient databases with a patient chosen family doctor promoting screening,
periodic health exams and appropriate, on-going care is the future and the
present of any Reform Strategy or Change Policy. To date the medical community
has not operated as a system in any real sense. We think that technology
can make it so and that's just what A&L HERO* offers. Magically, the
message is getting through and in-roads are being created as we write. And
for good reason. The costs of health care are still escalating. It is a
trend that is continuing. To date, the MOH has tried to put on the brakes,
mostly by squeezing doctors as if doctors were the system's brake pads.
But doctors aren't brake pads and so the situation is still becoming worse.
A&L HERO* as an integrated, transactional network could go a long way
in alleviating some of the many problems facing our medical community.
Thank you for joining us… "Just the Right
Level"
This is the best seminar A&L has ever held. I've been every year."
"Having these seminars every six
months would be good." "It was a lot of fun, and great to meet
some of the other secretaries." "I really found the seminar very
informative." "I liked the Internet access stuff." "It was just at the right level. Not too technical,
yet very informative." "Excellent! Good food. Alex... you're great."
"Best lunch ever!" "Peter Berwick is such a good speaker." "Dr. Wendy
Graham was really sensitive to Primary Care Reform and was informative
about a touchy issue." "The A&L Team was great and very helpful
answering questions."
We just thought we would let a few attendees summarize A&L Teach &
Train '97. The day went as planned and we stuck to our schedule (with a
little coaxing from Blaine) and so the
morning speakers and the afternoon work shops and demonstration
sessions were lively and informative. Many of you in previous years
had suggested a buffet style lunch. It was a hit. It looked great, tasted
even better and with all you can eat, everyone seemed to want to linger
just a little longer in the lunch room. It was a good opportunity to talk
with old friends.
Congratulations to Pat Fenwick, (City Centre Family Physicians), Sandra
Glancy (Dr. Sawa), Barbara Kennedy (C.A.R.E. Health Resources), Tracey McKillop
(York Medical) and Sheryl Gofton (Dr Byrne & Dr. Gafoor). They received
beautiful A&L Notebook Bags, in the lucky draw.
Everyone seemed to have a good time. The feed back was very positive. Many
commented on the hotel being quite nice and everything being well organized.
One common complaint made we have heard too often over the years. In our
opinion, hotel air conditioning must be set by the world's warmest people.
So often it seems we hear things like, "Warm up the presentation room.
It was freezing." "Heat!!! We need more heat." We approached
the hotel staff who claimed to reset the air conditioning to a warmer temperature.
But frankly, over the years we have heard every excuse there is as to why
the temperature isn't consistent and comfortable. It seems that hotels no
longer have air conditioners, they have snow-making machines. (Perhaps next
year we may hand out parkas at the reception table.) All we can do at this
point is apologize to those of you who found it uncomfortably cold.
On a final note, we did want to thank our Guest Speakers, Peter Berwick,
Darren Polevoy and Wendy Graham for their presentations, thoughts and lively
discussion. As well, we wanted to thank all of you for helping us make A&L
Teach & Train '97 the best seminar yet.
User's Corner - The Big Easy
It is not often that the best things to do are also the easiest. But in
the computer world, it is the easiest things that make your computer life
a happy one.
We call it the Big Easy. There are three of them... ready?
- Have a backup procedure in place that you follow on a daily, weekly,
and monthly basis. An A&L System backup (The Backup Complete System
Files) is something you should do every day. Have diskettes labeled
for each day and ensure that everyone is aware of your backup procedures.
Be careful not to use or over-write your most recent backup.
- You should also have a Submission backup procedure which copies the
data you are sending to MOH. You should make of copy of your submission
each and every time you submit. Make sure you have separate diskettes
for this purpose. (Do not use your daily backup diskettes.)
- As well, it is recommended you do a Total or System Backup of ALL
your computer programs and files. This should be done once a month at
minimum. Make two copies and keep one off site in a safe place. Have
separate diskettes for this. Be sure not to use your most recent backup.
Obviously you will need at least 4 sets of backup diskettes for this.
One on site, one off, and another set so that you do not over-write
your most recent backup. (Frankly, 6 sets are better.)
- One last thing about backups. It is a good idea to occasionally check
them over to ensure your backup procedure is in order.
- Install and use Anti-virus software. So many programs, diskettes
and files are shared that it is crazy in this day and age not to. It
is protection for your computer, software, data and files. No matter
how small the likelihood of a virus infecting your machine, it's something
that is totally in your control if you act in advance.
- You only need one virus to see that it has the potential to infect
everything, including backups and data files.
- Avoid nagging, recurring printer problems. Here's what to do in brief.
- Make sure your printer is on-line and ready, as well as connected
to the computer you are using.
- Keep your printer clean and free of dust as much as possible. It
should be loaded with paper, the lid and trays properly closed and in
their proper slots.
- Paper jams occur. Keeping things clean will help. Keeping your paper
dry on muggy days will help too. When cleaning around inside or changing
toner, follow the user instructions carefully. (Handling labels with
care will go a long way in helping you avoid paper jam problems.)
- Last but not least, if you have sent a file to the printer and it
doesn't get printed, sending it again will not solve the problem. Find
out what happened first. Cancel that print job if necessary and then
start again.
The Canadian Internet and You
Electronic Mail with Patients (Part II)
In our last article, The Canadian Internet and You, Electronic Mail with
Patients, we discussed why doctors could potentially be interested in
e-mailing their patients. We also discussed the advantages of communicating
this way, as well as issues of concern. In this article we are going to
extend the issues of concern and attempt to formulate Administrative and
Medicolegal Policies or Guidelines.
Electronic mail requires specific guidelines in order to satisfy legal requirements.
The obvious issues here are data security, confidentiality and liability
regarding advice. Because of the wide-spread stories of lawsuits, many are
reluctant to even consider electronic communications. But paranoia aside,
there are guidelines to follow which allow for open electronic communication
that will provide the basis for a healthy and long-term provider-patient
relationship.
Being cautious will pay off
In our opinion, patients should sign printed guidelines that they must follow.
This acts as an informed consent procedure at the time you are establishing
electronic communication. This informed consent form should:
- Provide a user friendly explanation of the nature of the network
and the various levels (or lack thereof) of security.
- Explain the firewall systems that are in place along with an explanation
of other specific security procedures.
- Discuss whether your provider or institution is directly connected
to the Internet and whether or not there is an intermediary provider
who could potentially monitor transmissions.
- State who monitors transmissions should a message be sent with the
wrong address.
- Explain encryption software and whether or not there are alternatives
should patients not wish to encrypt their messages.
- State the liability for network infractions which are beyond your
ability to prevent.
Use e-mail communications with care
Avoid leaving e-mail on the computer screen. Have password-protected,
screen savers... (this is a good idea for any computer screen in examination
rooms. It is an issue of confidentiality.) Do not forward a patient's
e-mail or information to a third party without expressed (written) permission
from the patient. Patient name and e-mail address should be removed anytime
text is used or sent to colleagues for consultation.
Using a patient's name or e-mail address for marketing or advertising
is a bad idea, even if it is your own clinic doing the marketing or advertising.
So is making/sending a message with numerous recipients because each message
will include the names of all recipients.
Use headers or banners at the top of your messages stating this is a Confidential
patient-physician communication. And keep in mind that like any other
medical record, patient identifiable records should not be taken out of
the office/clinic/hospital. If answering e-mail is best done at home then
precautions must be taken to ensure that other household members are not
and cannot intercept messages. Passwords should be used and not shared
with friends, family or non-medical co-workers. An account for your own
use is a prerequisite.
As well policies must be considered regarding how to retain e-mail. (Is
it to be included in the patient records? All of it? Some? Your responses
as well? Or, will this form of communication be treated as a phone call?...
perhaps with only progress notes included and kept in the patient chart?)
Enough cannot be said regarding data security. Encryption methods should
be employed as soon as possible and practical. Users must have authenticated
identities (a validation or digital signature). Data must be transmitted
accurately and protected aggressively. Make it clear to all patients that
unencrypted e-mail is much like a postcard or talking over a cellular
phone.
Data integrity is an attribute of a system's robustness which indicates
whether data has been altered in transfer. Mistakes do occur and often
because of interface design, compatibility, or even the physical transport
mechanism. Constant vigilance will pay off. Attending to whom you are
sending a message is not something to take for granted. (You may be surprised
by who receives it.)
Policies will have to be set in your office or clinic regarding who will
print messages and place them in patients' charts. Will e-mailing be done
on a selective basis? Or as an option open to all patients? What happens
to the e-mail once you have read it? Does it stay on the server or on
the local provider's machine? Policies will have to be put in place for
periodic downloading to a local or home computer, as well as how to archive
and clear these potentially changing repositories.
And probably the most important consideration of all is to insist that
using e-mail is not a substitute for clinical evaluation.
We hope these considerations help you progress along this technological
road we all travel and share.
Softwords is a bimonthly newsletter published by A&L
Computer Software Ltd., (905) 886-8066. Reproduction of Softwords without written
permission is strictly prohibited. For information, questions or suggestions
concerning the publication, please contact or write the Editor, Daniel
St. Amant at the address above or at aswift@anl.com. Internet: http//www.anl.com
* HERO is a registered trademark of HTN Inc.
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