FEATURE ARTICLE COMMENTARY

eHealth: A provincial and regional perspectiveRoger Girard, BA (L.Ph.), MBA

In recent months, I have run across several articles thatseem to say: “let’s stop investing in (traditional) eHealthand, instead, do �insert favourite silver bullet�. In the

case of our lead article, the authors are advocating for aneHealth focus on chronic illness, at the expense of theimplementation of Electronic Patient Records (EPRs) in hos-pitals, perhaps among other things. Although I may agreewith the need for focus, in the real world this focus cannotand must not occur at the expense of another part of thesystem.In the first place, we read that “there is little debate

that the overall lack of routine successful [informationtechnology] IT adoption is indeed a roadblock that weall share.” I do not share this view and wish to . . . debateit. Francis Lau and his group have found much evidenceof success and he pleads that we should “continue withthis [electronic health record] EHR journey.”1 In fact, it isquite easily demonstrated that EHRs are routinely usedin today’s healthcare system and, although adoptionmay be a challenge in some instances, to generalize thatthis is a common problem is unfair to those clinicianswho use IT systems successfully every day. A seeminglysimilar comment was recently made in the pages of theCanadian Medical Association Journal.2 In this latter case,however, it seems to me that the comment is more areflection on “Canada’s (ie, Infoway’s) strategy” and doesnot apply to eHealth in general in the context of regionsand provinces.Second, adoption of IT is generally not a major problem

in most businesses, and healthcare is no exception. Alllarge laboratories and pharmacies are automated todayand a rapidly increasing number of providers in hospitalsand clinics all over Canada are adopting EHRs. In fact, pooradoption is more a function of project design; when aproject properly deals with the process of change, andfunds the technology adoption curve (ie, temporary loss ofproductivity), adoption happens. In some cases, it is true

From Manitoba eHealth, Winnipeg, Manitoba, Canada.Correspondence: Roger Girard, BA (L.Ph.), MBA, Manitoba eHealth, 300-

355 Portage Avenue, Winnipeg, Manitoba, Canada R3B0J6(e-mail: RGirard@Manitoba-eHealth.ca).

Healthcare Management Forum 2011 24:141–1430840-4704/$ - see front matter© 2011 Canadian College of Health Leaders. Published by Elsevier Inc. Allrights reserved.

doi:10.1016/j.hcmf.2011.07.002

that the “business process” itself needs to be changed, notthe eHealth system. It is when we try to cut corners thatthese projects fail. Also, for every heralded failure, there aresuccesses that go unrecognized; good news does not sellnewspapers.Third, the comment that “[eHealth] investment has

not focused on meeting the needs of the public” seemsa bit misplaced. Perhaps there is confusion between the“consumer’s self-interest” from the “public interest,” butit is improper to conclude based on such an argumentthat we should move from investments in institutionallybased “EHRs and order-entry systems” to consumer-based chronic disease systems. In the real world, weneed to invest in both. Rosenblum et al2 advocate for anumber of measures that include self-managementtools, on a much broader and balanced program thatwould include incentives and quality indicators, a focuson outcomes, the creation of policy coordination func-tions, and the “construction of a business plan for thecomputerization of primary care practices and commu-nity-based care” (Figure 1).Finally, I wish to advance a perhaps new argument that

our healthcare system needs to foster an environment thatleads to disruptive change. The system that exists todaysimply cannot meet the needs of tomorrow. Rememberbanks of 30 years ago? IT has enabled them to be a verydifferent business today and so should go the business ofhealthcare. “Information Technology (i.e. eHealth) will playtwo crucial roles in facilitating the emergence of disruptivebusiness models . . . the enabling mechanism that shifts thelocus of care from solution shops to facilitated networks[and] it will be the primary mechanism of coordinationamong the providers in the disruptive value network. Thiswill make it easier to avoid costly mistakes and will en-hance the involvement of patients in their own care.”3

eHealth needs to be the enabler to a “new business ofhealthcare,” and I agree that starting with 3C patientsmakes perfect sense.

eHEALTH IN THE REAL WORLD

An effective eHealth strategy is not a simple challenge,and is much more than what we see at the national (ie,Infoway) level. In fact, Infoway’s mandate deals with�20% of the cost of a comprehensive strategy. Rosen-blum et al2 rightly state that “efforts must be devoted to

achieving effective regional interoperability.” Our own

strate

Girard

strategy recognizes four distinct strategic dimensions, asfollows (Figure 1):

1. Point of Service (POS): As banking cannot functionwithout ATMs and airlines without reservation sys-tems, in our world pharmacies have their Drug Infor-mation Systems (DISs), hospitals have EPRs, clinicshave Electronic Medical Records (EMRs), and so on.Hospitals with EPRs are more efficient and much saferthan those that have not.4 A useful by-product of POSsystems is that they permit easy movement of infor-mation between points of service in ways that man-ual systems cannot. Our strategy addresses 6 health-care pillars, one of which we call the “self-care”domain, the POS for consumers, and we are eagerlyawaiting the lessons that the early adopter provincessuch as Alberta will teach us.

2. Coordination of Care (CoC): This strategy addresseshow we enable care across the POS pillars, so that a

Figure 1. Components of the provincial e-health

client or a provider can navigate the maze more

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effectively. There are several parts to an effective CoCstrategy:a. Shared information: Key client information needs to

be available where and when it is needed. In Mani-toba, we recently launched eChart Manitoba,5 andhave developed systems supporting referrals and ap-pointments.6 This is roughly as described in the In-foway blueprint and is an essential component ofany eHealth strategy.

b. Knowledge management: This is about the systems,standards, and processes that ensure that informa-tion about high-quality clinical care is made availableto all that need it. In Manitoba, we have developedHealthlinks, a consumer help line, and are imple-menting other such tools.

c. Collaboration: Providers and clients also need tointeract in various ways. One key asset in thisregard is our Manitoba TeleHealth (Telemedicine)

gy. (Colour version of figure is available on-line).

program.

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eHEALTH: A PROVINCIAL AND REGIONAL PERSPECTIVE

3. Health systems management: Oversimplifying this greatly, weplan to take pertinent data from the POS dimension,where it is originally created and used, and make itavailable for management purposes through data ware-housing, dashboarding, and analytical tools. It is a sadfact that we do not do this well in Canada, the mainreason being that it is impossible to do this properlyuntil the POS and CoC dimensions reach a greater stateof maturity.

4. Infrastructure: This is what most people think aboutwhen they hear about eHealth. This is information andcommunications technology: desktop computers, per-sonal productivity tools, e-mail systems, networks, serv-ers, data centres, networks, and so on.

When you do all of these things correctly and in theright balance, you begin to get a positive return on invest-ment. Having all hospitals with sophisticated EPRs withfully functional CPOE systems might be a really good thingfor their clients and providers, but this is not very usefulonce either try to go anywhere else. Similarly, a self-caresystem that exists when providers lack such tools in hos-pitals and clinics is also not very useful. We must investeverywhere, and in the right balance.

ABOUT INNOVATION

I believe that no one in the traditional healthcare systemhas made it their business to “coordinate the care” betweenthe various points of service. We have navigators andgatekeepers and primary care homes, but who is respon-sible for enabling the client’s journey, end-to-end? Chris-tensen et al3 advocate for “value-add networks” that needto be developed, and then enabled by eHealth. Building anelectronic system based on the premise that thousands ofproviders and millions of consumers will figure out how tonavigate the system as it is today, by themselves, is a recipe

for failure. To expect an eHealth strategy that builds the

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tools but ignores the “business of navigation” is also astrategy destined to fail.Investments in POS and infrastructure alone, although

necessary, will only drive sustainable innovation. What weneed is to promote disruptive innovations, enabled byeHealth, in the CoC and health systems management do-mains, with some disruptive technologies like mobility andcloud-based computing. Christensen et al3 make the argu-ment that disruptive innovation usually focuses on non-traditional consumers, those that do not value the oldproduct, but allow the new products to take root becausethey are simpler and more affordable. The old product isthe current healthcare system. The non-traditional con-sumers are likely a subset of the 3C patients.The new product needs to emerge, but it will be resisted

by the players in the traditional business model. An inter-esting notion; because we are building the eHealth en-ablers for this brave new world, who can we count on todisrupt the traditional business model?

REFERENCES

1. Lau F. Making sense of electronic health record success: apersonal viewpoint. Healthcare Information Management andCommunications. 2011;25:6.

2. Rosenblum R, Jang Y, Zimlichman E, et al. A qualitative studyof Canada’s experience with the implementation of electronichealth information technology. CMAJ. 2011;183:E281–E288.

3. Christensen CM, Grossman JH, Hwang J. The Innovator’s Pre-scription – a Disruptive Solution for Health Care. New York, NY:McGraw-Hill; 2009 p. xxxix.

4. Amarasingham R, Plantinga L, Diener-West M, et al. Clinicalinformation technologies and inpatient outcomes. Arch InternMed. 2009;169:108–114.

5. Connected Care. eChart Manitoba. Available at: http://www.connectedcare.ca/echartmanitoba/index.html. Accessed July6, 2011.

6. Canadian Research Policy Networks. Improving family physi-cian and specialist communication. Available at: http://www.

cprn.org/doc.cfm?doc�2021&l�en. Accessed July 6, 2011.

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