e-Technology-FacilitatedPatientCare:
ComplementaryandContrastingViewsoftheCanadianPubicand
HealthProfessionals
AmédéGogovor,SaraAhmed,JoannaNemis-White,EmilyTorr,JohnAylen,LucasMarshall,TerrenceMontague
forHealthCareinCanadaSurveyMembers
Abstract
TheCanadianpublic,aswellasprofessional
providersandadministrators,haveretaineda
favourableimpressionofthequalityofhealth
careoverthelasttwodecades,asmeasuredin
serialHealthCareinCanada(HCIC)surveys.
Thisisdespiteagrowingperceptionthe
prevalenceofexcellent,orverygood,health
amongthepopulationhasdecreased;and,the
realitythatouragingpopulationhasa
concomitantlyincreasingprevalenceofchronic
diseases,ledbycardiovascular,arthriticand
mentaldisorders.Themostimportant
contemporarycareissuecitedbybothpublic
andprofessionalsislackoftimelypatient
access,whichisalsothepublic’smosthighly
ratedfactorindeterminingasenseofpatient
centricityinhealthcare.Toimprovecare,
enhanceduseofe-healthtechnology,especially
viatheinternetandelectronichealthrecords
(EHR),isincreasinglysupportedintheopinions
ofthemajorityofthepublicandhealth
professionals.And,e-healthimplementation
hasahighpriorityrankingamongthepublic.
However,disconcertingly,enhancingEHRuseis
nearthebottomofprofessionals'
implementationpriorities.Thus,itappears
that,whilegeneralsupportforpatient-centric,
technology-facilitatedcarestrategieshave
increasedwithinallstakeholdergroups,interstakeholderdifferencesinimplementation
prioritieshaveemerged.Whetherinterstakeholderdivergencebetweenintellectual
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supportfor,andpriorityimplementationof,ehealthtechnologieswillbecomemore
concordant,ormorediscordant,withtimeis
uncertain.Itislikely,however,theevolutionof
suchdifferencesamongstakeholderswillplaya
keyroleinshapingourhealthcarefuture.
Introduction
Thepropagationofe-healthtechnology,in
synergywithotherdevelopingtoolssuchas
evidence-drivenhealthsocialnetworks,offers
promisetoenhancepatient-centredcareand
outcomes(1-9).Nonetheless,basedonfindings
fromthe2013-2014HealthCareinCanada
(HCIC)survey(10,11),thereappearstobe
somedifferentiationamongpublicand
professionalstakeholdersbetweenthe
generallyperceivedvalueofe-health
technologyanditspriorityforimplementation.
Thepurposesofthispaperaretooutlinethese
differences,andthepotentialchallengesthey
represent,totheoptimalimpactofe-health
technology.
DataSources
Theprincipaldataunderlyingthisreviewwere
therepresentativeopinionsofthegeneral
public,aswellasthoseofhealthproviderand
administrativeprofessionals,solicitedonline
betweenNovember2013andJanuary2014
(10,11).POLLARAStrategicInitiatives
1
GogovorAetal.e-Technology-FacilitatedPatientCare
developedandadministeredthe2013-2014
HCICsurveyquestions,followingrepeated
consultationswithallHCICpartners:Canadian
CancerSociety;CanadianFoundationfor
HealthcareImprovement;CanadianHomeCare
Association;CanadianHospicePalliativeCare
Association;CanadianMedicalAssociation;
CanadianNursesAssociation;McGill
University-affiliatedConstanceLethbridge
RehabilitationCenter;HealthCharities
CoalitionofCanada;InstituteofHealth
Economics;InstituteofWorkandHealth;Merck
Canada;StriveHealthManagement;and,
CareNetHealthManagementConsulting.
Thestudypopulationswerenationally
representativesamplesoftheadultCanadian
public(n=1000)withaweightingvariable
basedon2011Canadiancensusdatatocorrect
forageandsexwithinregions;and,keyhealth
careprofessionalgroups:doctors(n=101),
nurses(n=100),pharmacists(n=100);and,
administrators(n=104).
Therewere37questionsforhealth
professionals;and,56forthegeneralpublic,
coveringmultipledomains:health/disease
status;accessto,qualityandaffordabilityof,
care;and,specificcharacteristicsandpriorities
ofpatient-centredcare(10,11).
Patient-CentredandEvidence-BasedCare
Accesstocare,particularlytimelyaccess,was
theoverwhelminglydominantcontemporary
healthcareconcernoftheadultpublic,above
allotherissues(10,11).Similarly,among
healthprofessionals,accessandwaittimes
wereratedasthetopissuesofconcern(10,11).
Notsurprisingly,whenthepublicwasasked
theirlevelofsupportforspecificelementsto
enhancepatient-centredcare,readilyobtained
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andtimelycarewasthenumberoneattribute.
Followingcloselywere:caredeliveredina
caringandrespectfulmanner,withtransparent
communicationandshareddecisionmaking;
and,research-supportedcarewithoutcomemeasurements(10,11).
Amongprofessionalstakeholders,thefindings
wereverysimilar.Timelyandcaringcaredrew
thehighestlevelsofsupportincreatingpatientcentredcare,verycloselyfollowedby
communicationtransparency,shareddecision
making;and,research-supported,outcomesmeasuredcare(10,11).
However,whenallstakeholderswereaskedto
prioritizetheirtopthreeimplementation
preferencestoimprovepatient-centredcare,
somekeyinter-stakeholderdifferencesbecame
apparent.Althoughtimelyaccesstocare
remainedthenumberoneimplementation
priorityforallstakeholders;and,thenumber
twopriorityremainedcaredeliveredina
caring,respectfulmannerforthepublic.In
contrast,thenumbertwoimplementation
priorityofphysicianswasevidence-basedcare;
and,fornurses,pharmacistsandhealth
administrators,thenumber-twoprioritywas
patient-providerpartneringindecisionmaking
(10,11).Careprovidedinacaring,respectful
contextachievedatop-threeratingonlyamong
administrators,fallingtoafourthpriorityfor
physicians,nursesandpharmacists.
Inter-stakeholderdifferencesbetweencare
improvementconceptsworthyofsupport,
versustheirprioritiesforimplementation,
suggestfuturechallengesingaining
stakeholderconsensusaroundhowto
practically,orpolitically,advancehealthcare.
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GogovorAetal.e-Technology-FacilitatedPatientCare
http://www.mcgill.ca/hcic-sssc/
Asdetailedbelow,theymaybeparticularly
relevant,regardingtheadvanceofe-health
technologytofacilitatepatient-centredcare.
Aboute-healthTechnology
Computer-assisted,ore-healthassisted,careis
notnew.Ithas,however,hadatumultuous
developmentalcurve.Initsearlyiteration,itis
fairtosaythatuseropinions,particularlyof
EHR,were,onbalance,negative.Inparticular,
therewaslittlepositiveevidencelinking
availabilityofEHRwithimportantclinical
variables,likeimprovementofproviders’
clinicalpracticesandpatientoutcomes;and,
therewerestridentmanagerialcriticisms,
includinghighcostandlittlereturnon
investment(12-14).
Stronglyagree
Inapreviousanalysis,wefeltthate-health
technologyofferedpromiseasasynergistictool
toimprovepartnership-measurementdisease
managementpractices,particularlyimproved
careandoutcomes,bothpatientandfinancial
(7).However,intheabsenceofsuchuse,ehealthtechnologywasconsideredatriskof
beingviewedasapromising,butnotoptimally
realized,opportunity(7).Datafromthe20132014HCICsurveyhaveallowedforamore
nuanced,andmorepositive,view.
Contemporarilyfavourablesupportfor
technology,especiallytheincreaseinuseofehealthtechnologyandEHR,hasbecomevery
broadandveryhighamongallstakeholder
groups(Figures1,2).
Supportfore-HealthTechnologyIni7a7ves
PublicPercep7ons
Somewhatagree
Somewhatdisagree
Stronglydisagree
Notsure
TheInternetisavaluabletooltolearnabout
andunderstandhealthissues
Technologyisimportantinhelpingmelive
independentlyinmyownhomeforaslongas
possible
Usingtechnologywillhelpmecommunicate
beDerwithmyhealthcareteam
38%
32%
28%
Apersonalelectronichealthrecordwillhelp
memanagemyhealth
31%
Iwanttobeabletobookappointmentswith
mydoctoronline
30%
46%
8% 6%
42%
39%
2013
83%
9% 9%
79%
11% 10%
76%
47%
48%
TotalAgree
10%
14%
12%
74%
11%
69%
15
Figure1.Public’sstrongsupportfore-healthtechnologicalinitiativesoptionstoimprovehealthcaredelivery,2013-2014.
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3
GogovorAetal.e-Technology-FacilitatedPatientCare
http://www.mcgill.ca/hcic-sssc/
Supportfore-HealthTechnologyIni=a=ves
ProfessionalPerfec=ons
Doctors
StronglyAgree
SomewhatAgree
Technologyisimportantin
helpingpeoplelive
independentlyintheirown
homesforaslongas
possible
29%
59%
88%
Usingtechnologywillhelp
peoplecommunicatebe9er
withtheirhealthcareteam
26% 57%
83%
TheInternetisavaluable
toolforpeopletolearn
aboutandunderstand
healthissues
32% 50%
81%
Apersonalelectronichealth
recordwillhelppeople
managetheirhealth
34% 47%
80%
Peopleshouldbeableto
bookappointmentswith
theirdoctoronline
25% 50%
75%
Nurses
StronglyAgree
SomewhatAgree
Pharmacists
StronglyAgree
SomewhatAgree
Administrators
StronglyAgree
SomewhatAgree
43%
48%
91%
31%
58%
89%
56%
38% 93%
45%
46%
91%
36%
52%
88%
49%
45%
31% 50%
81%
26% 44%
70%
40% 44%
94%
85%
46% 39% 85%
42% 41% 83%
48%
40% 88%
40% 43% 83%
40% 38% 78%
50% 35% 85%
16
Figure2.Professionalstakeholders’universallyhighsupportfore-healthtechnologicalinitiativesto
improvehealthcaredelivery,2013-2014.
Forexample,generalsupportforEHRamong
thepublichasincreasedfrom52percentinthe
2007-2008HCICsurveyto74percentin20132014(Figure1).And,Canada’sprofessional
careprovidersnowechotheviewsofthe
Canadianpublicintermsofsensingtheoverall
benefitsofEHRoutweighinganycontravening
risks;includingadesirabilityofincreasedinterprofessionalaccessibilityofEHR(Figure3).
Moreover,therewasalsoaveryhighcross-over
amongthepublic’sassociationbetweenstrong
supportofEHRuseanditsroleasakeystone
componentofpatient-centeredcare.
Specifically,70percentofthepublicwho
stronglysupportedreadilyandtimelyaccessed
care;and,69percentwhosupportedcare
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providedinacaringandrespectfulmanner,
alsostronglysupportedacceleratingtheuseof
accessibleEHR.Thiswasmuchhigherin
degreeofcross-overassociationcomparedto
othermeasuresofpatient-centeredandehealthfacilitatedcare,whichrangedfrom54to
43percent.
Somewhatdisconcertingly,despitethestrong
andbroadcurrentsupportfore-health
technologies,includingthemarkedincreasein
supportforEHRsystemsoverthelastseveral
years,whenprofessionalswereaskedfortheir
implementationprioritiestoimprovehealth
care,useofEHRplacedverylowontheirlistof
priorities(Figure4).
4
ElectronicHealthRecords-Professionals
BenefitsOutweighRisks-Accessibility
Stronglyagree
Somewhatoppose
Somewhatagree
Stronglyoppose
Neutral
Don'tknow
TotalSupport
Theexpectedbenefitsofhavingpersonalelectronichealthrecords
significantlyoutweightheriskstoprivacy
Doctors
Nurses
Pharmacists
Administrators
41%
40%
32%
2007
80%
71%
74%
69%
91%
81%
84%
89%
71%
n/a
86%
n/a
80%
n/a
78%
n/a
14%
42%
18%
45%
46%
48%
2013
6%
36%
8%
Theuseofpersonalelectronichealthrecords,evenifthismeansthatpa5ent
healthinforma5onmaybeaccessiblebyotherhealthcareproviders
Doctors
40%
Nurses
44%
Pharmacists
43%
Administrators
44%
31%
21%
42%
10%
37%
14%
34%
13%
Figure3.In2013-2014,professionalstakeholders’believethebenefitsofEHRuseoutweighrisks,includingconcernfor
9
patientprivacyandtheinter-professionalaccessibilityoftherecords.
Priori3esforCareImprovement–Professionals
ElectronicHealthRecordsNotaPriority
Doctors
Developingmorehomeandcommunity
care
Nurses
1
Self-managedcare
2
Implementa8onofdiseasemanagement
model
3
52%
48%
42%
Wellnesspromo8on/disease
preven8on/educa8on
Regularfeedbacktocareprovidersoftest
results/prescrip8ons/pa8entoutcomes
Useofelectronichealthrecords,evenif
pa8entinforma8onisaccessiblebyother
careproviders
Increasingnon-physicianhealthproviders,
meaningpa8entsmightnotseeadoctor,
whensimilarcarecanbeachievedby
otherproviders
38%
52%
3
22%
28%
21%
1
1
39%
32%
31%
54%
35%
51%
2
36%
1
41%
38%
32%
60%
Figure4.Prioritiesofhealthprofessionalsin2013-2014toimprovepatients’healthcare.
November 2016
2
3
32%
64%
42%
33%
26%
32%
30%
21%
3
21%
2
Administrators
22%
30%
39%
Regularcommunica8onbetweenpa8ents
andcareproviders-testresults/
adherence/educa8on
Pharmacists
35%
17
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GogovorAetal.e-Technology-FacilitatedPatientCare
WhatAreOthersThinking?
TheInstituteofMedicinereport(15)onhow
healthsystems’canbereinventedtofoster
innovationandimprovethedeliveryofcare,
pointedtothepotentialofinformation
technologyfortransforminghealthcare
deliveryandsafety,whileconcedingthe
challengesofapplyinginformationtechnology
shouldnotbeunder-estimated.
Otherperceptionsofveryexperienced
clinicianshavecontinuedtoreflectsignificant
reservationsabouttheexpandinguseof
computers,especiallyintheinter-personal
clinicalsettingoftheprovider/patient
covenantthathastraditionallybeenatthe
centreofphysician-directedpatientdiagnosis
andtreatmentrecommendations(16-19).
Interestingly,aninternationalsurveyreported
thatCanadianandAustralianprimarycare
physiciansweretheleastlikelytofavourehealth-facilitatedcare(17).
Inthiscontext,asdescribedbyOberand
Applegate,e-healthtechnologyispicturednot
somuchasapassive,ormissed,opportunity,
butratherasanactiveandgrowingcompetitor,
intermsoftimeandintimacy,withcaringand
respectfulcare(16).Theseauthorsarguethata
greatmanyphysicians,particularlyyoung
doctors,areroutinelytakingahand-held
computerintoexaminingroomsandspending
asmuchtimeaddressingthecomputerasthe
patient.Theyfurthersuggestthecomputerdrivenpromptsanddemandstofitthepatient’s
initialhistoryandsubsequentclinicalcourse
intoarelativelyinflexibledatamapmaydetract
fromcriticalthinkingindetermining
underlyingpathophysiologyandefficient
developmentofdifferentialdiagnosesand
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prescriptionofappropriatetherapy.In
summary,theypaintapictureofcomputercentredcarethatissomewhatdivorcedfrom
somekeyfeaturesofwhattheCanadianpublic
considerstobeattheheartofpatient-centred
healthcare(Figures1and2).
Inanotherrecentlyreleasedpolicystatement,
theCentersforMedicareandMedicaidServices
oftheUnitedStatesgovernmentpromised
moreflexibleandsimpleStage3“Meaningful
Use”rulesfortheirmulti-billiondollar,nationwideEHRIncentiveProgram(18).Thisthird
stageisenvisagedasthefinalstageofthis
federallyfundedprogramwhoseoverarching
goalisdevelopingEHRsacrosstheUnited
States,withmajorobjectivesbeing
improvementofpatientcarequality,safetyand
efficiency,whileimprovingpublicand
populationhealth.Thus,thelikelihood,atleast
intheUnitedStates,isthate-healthtechnology
willcontinuetoexpand,despiteconcernsthatit
maynotenhance,orevendetractfrom,patientcentricityasseenbypatients(16).
WhatWeNowThink–Whereise-Health
TechnologyGoinginCanada?
Briefly,thefutureisuncertain.Specifically,
predictingwhethere-healthevolutionwill
continuetopracticallyengageallstakeholders’
increasingsupport;and,produceawellfinanced,technologically-efficientand
clinically-usefulcaretechnology,whileavoiding
potentialclinicalpitfalls(16),isuncertain.The
challengesinmoney,interoperability,training
andapplicationaregreat.
Nonetheless,somepredictionsarepossible.
First,theperceivedpotential,assuggestedby
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GogovorAetal.e-Technology-FacilitatedPatientCare
thestrongsupportofallCanadianstakeholders
intheHCICsurveys,isstrong.Second,thetime
mayberightfortheaccelerationofe-health
developmentandadoptionbecausetechnology
issimultaneouslyadvancingwithstakeholder
support.
However,thereisanimportantcaveat.
Acceleratingprogresstowardlarge-scale,
practicalandmeaningfuluseofe-health
technology,particularlyenhancedEHRuse,to
improvepatientcareandoutcomes
measurementwillrequireprofessional
stakeholderstorecognizetheymaynotbe
optimizingthispotential;and,toconsiderwhy
thismaybeso.Forexample,doprofessionals
considerEHRsarealreadybeingusedtotheir
ultimateutilityinofficemanagementactivities
likeschedulingandbilling;and,theyhaveno
practicaladvantageinpatients’knowledge
acquisitionoroutcomesmeasurements?
Currently,theseremainunansweredquestions.
Lastly,itislikelythesynergisticadvanceofehealthtechnology,willnotbesmoothordevoid
ofvestedinterests.Thereisalwaysthereality
ofresistanceto,orwilfuldisbeliefin,change
messages,irrespectiveoftheirevidencebase
(18).Nonetheless,repeatedproofand
propagationofthemessages,asdefinedbythe
HCICsurveydata,offeronemeansto
potentiallyreducenegativereactancetothe
messages(18).
Inconclusion,synergisticmergerofevidencebasedandpatient-centredhealthcarewithehealthtechnologytoimprovecareand
outcomesseemspossible(8).Itsrealization,
however,mayrequiremoreattentionto
defining,provingandimplementingpriorities.
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AbouttheAuthors
AmédéGogovor,MSc,DVM,isaPhDcandidate
andResearchAssistant,FacultyofMedicine,
McGillUniversity,Montréal,QC.
SaraAhmed,PhD,isAssociateProfessor,
FacultyofMedicine,McGillUniversity,with
appointmentsintheSchoolofPhysicaland
OccupationalTherapy,theUniversityHealth
Center’sDivisionofClinicalEpidemiology,
ClinicalandHealthInformatics;and,theCentre
derechercheinterdisciplinaireenréadaptation,
Montréal,QC.
JoannaNemis-White,BSc,isaPrincipal,Strive
HealthManagementConsultingInc.,Halifax,NS.
EmilyTorr,MSc,isAssociate,CIHRInstituteof
HumanDevelopment,ChildandYouthHealth,
andknowledgetranslationconsultanttothe
HCICproject,Toronto,ON.
JohnAylen,MA,isPresident,JohnAylen
Communications,Montréal,QC.
LucasMarshall,BJourn,isaseniorresearch
consultantandVicePresident,PublicAffairs,
POLLARAStrategicInsights,Toronto,ON.
TerrenceMontague,MD,isaPrincipal,CareNet
HealthManagementConsultingLtd.,and
AdjunctProfessorofMedicine,Universityof
Alberta,Edmonton,AB.
Howtocite:GogovorA,AhmedS,Nemis-WhiteJ,TorrE,AylenJ,MarshallL,MontagueT,forHealth
CareinCanadaSurveyMembers(2014).e-Technology-FacilitatedPatientCare:Complementaryand
ContrastingViewsoftheCanadianPubicandHealthProfessionals;http://www.mcgill.ca/hcic-sssc/
accessedon<<Date>>.
November2016
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