Watchdog issues urgent call for electronic health records

Family physicians routinely prescribe drugs under the wrong circumstances and overuse diagnostic imaging tests, serious problems the Health Council of Canada says must be repaired by introducing electronic health records across the country.

The council, an independent body created by federal and provincial governments to monitor the health system, released a report Monday that warns family doctors are facing increasingly complex demands but often lack the proper guidance to make the best decisions for patients.

It's one of the strongest calls to action by the council, a prominent health organization that regularly helps inform policy makers. It predicts that if Canada continues to delay implementation of electronic health records and doesn't do more to support family doctors, the problems of inappropriate prescribing and excessive medical testing will dramatically worsen as the population ages.

Drug spending is one of the biggest costs for Canada's health care system and diagnostic imaging tests are becoming an increasing financial burden. The council pointed out the trends can also harm patients: many of them are getting prescriptions for expensive drugs that may not help them and could put them at risk of serious side effects, while others are exposed to potentially harmful levels of radiation during CT scans or other diagnostic tests that aren't actually needed.

"If there is no change in how family physicians are supported ... we can expect a surge in health service use as the population ages, chronic diseases become more prevalent, new drugs and technologies are introduced, and patient and provider expectations expand," the report said.

Overworked family doctors are increasingly taking on the care of patients with multiple or chronic health problems, the report added, and becoming more responsible for ordering diagnostic tests, tasks once largely handled by hospitals or specialist physicians.

Those trends aren't necessarily negative. Doctors are taking on more responsibilities in part because a growing number of patients are able to get the care they need outside of hospitals or without seeing a specialist, saving time and money.

But as their roles become more complex, family doctors across Canada aren't being given the proper guidance or support needed to determine the best course of action for patients, the report says. Doctors were also said to have chaotic, overwhelming schedules, making it difficult to spend time with patients to discuss potential options or alternate therapies.

As a result, family physicians end up prescribing drugs, sometimes at the request of patients, even though it's unclear whether the medication will help or if other therapies would be more effective, according to the health council. In addition, doctors order expensive computer tomography (CT) scans or magnetic resonance imaging (MRI) tests to err on the side of caution or because patients demand them, even though they may be unnecessary.

Danielle Martin, a family physician at Toronto's Women's College Hospital, said the problems identified in the report affect her life daily and are "frequent" topics of discussion among her colleagues. She said doctors must juggle demands from patients, emerging information about new drugs or treatments and overwhelming schedules, creating an environment where it's often easier to order tests or write a prescription.

"It becomes a negotiation when you're trying to ascertain whether there's really a requirement for that expensive test. Those pressures are real and I think we all feel them and we need to do better."

It's difficult to know the exact scope of the problem because of the lack of data that's collected in this area, according to the health council, which culled information from medical surveys and studies for its report. It can also be difficult to ascertain which drugs or tests are unnecessary. For instance, a child who suffers a head injury may undergo a CT scan that doesn't find any evidence of serious trauma, but many parents and doctors would still prefer doing the test to rule out the possibility.

But the real problem is family doctors aren't being given the information they need to make the best decisions and Canada does little to track the health outcomes of patients who are put on various medications or given diagnostic tests, the report said.

"We take doctors to task if they overbill, but do we take them to task if they overprescribe?" asked John Abbott, CEO of the Health Council of Canada.

There is no sound mechanism in place to monitor how many patients who are taking blood-pressure drugs, for instance, actually improve while on the medication, how many of them see no change, or how many suffer serious side effects.

Although the number of CT scans and MRIs performed in Canada jumped 58 per cent and 100 per cent, respectively, from 2003 to 2009, family doctors may lack the training to determine when certain tests are necessary, the report said. The Canadian Association of Radiologists estimates that up to 30 per cent of CT scans and other diagnostic tests are unnecessary or contribute no useful information.

The report calls for major improvements to the scope and use of electronic health records in Canada. In addition to allowing health care professionals to easily access important information about patients and work more efficiently, electronic health records could link medications and diagnostic tests to the health outcomes of patients in order to determine what works and what is wasteful. Canada has been widely criticized by health experts and medical organizations across the country for its slow approach to adopting electronic health records in comparison with other developed nations.

Although governments across Canada have pledged support for electronic health records, the implementation process has been difficult and slow because of the complex nature of information involved. But there have also been major money problems, with the federal government delaying a 2009 promise to release $500-million in further funding to get electronic health records up and running. A major scandal at eHealth Ontario, the organization charged with bringing electronic records to the province, saw $1-billion wasted on out-of-control consultant costs and untendered contracts.

The report also calls for major improvements in medical guidelines, which family doctors can use to determine when medications or tests are necessary.

While the Canadian Medical Association has more than 1,000 guidelines on its website, the health council says Canada must develop a system to ensure they are being used and followed. The report says provinces should hold physicians accountable and develop mechanisms, likely through the promised electronic health record system, to ensure they have access to the best medical guidelines and actually follow them.

It also says electronic health records need to be quickly rolled out across the Canada to give physicians help they need to manage patients, and allow for better monitoring of the effect drugs and tests have on patient health outcomes.

Jeff Turnbull, president of the Canadian Medical Association, said the report outlines many of the serious challenges facing family doctors and how they are harming the country's health system.

"We certainly can do better. There's no question about it," he said in an interview.

But the College of Family Physicians of Canada argues the report is flawed because it assumes the rising number of prescriptions dispensed and diagnostic tests ordered is excessive. The problem is there is no data that definitively spells out whether these trends are a serious problem, said Cal Gutkin, executive director and CEO of the college.

"Some of their conclusions really are lacking in the evidence that's needed to be able to come to the conclusion that they can, with certainty, identify who it is that is linked most closely with the ordering of these tests and the prescribing of these medications," he said.

Dr. Gutkin added that in many cases, medications and tests are recommended by specialists but are prescribed by family doctors, which makes it appear they are responsible for the rise in prescriptions and diagnostic imaging tests.

However, Mr. Abbott at the health council said even though no one knows exactly how much over-prescribing or overusing of tests is occurring, it's clear that it's happening, and that something must be done to stop it.

"Let's call a spade a spade and let's get at the problem and help doctors improve their ability to care and prescribe more appropriately, order tests more appropriately," he said.