We are a woeful, laggard nation when it comes to the use of e-health records. There are 67,000 licensed doctors in Canada; approximately 45,000 have clinics outside of acute-care settings—that’s 30,000 GPs and 15,000 specialists, a huge group who could benefit from office-based electronic medical records (EMRs).

According to Bill Pascal, the Canadian Medical Association’s chief technology officer, about 10% of those 45,000 doctors have EMRs and fully use them. Another 15% have them but limit their use to scheduling and billing, not to the full clinical capacity EMRs offer.

How does EMR use by Canadian doctors compare with other countries with similar health systems?

In a seven-nation survey, the Commonwealth Fund in 2006 found that Canadian physicians came dead last, far behind those in Germany, Britain, the Netherlands, Australia and New Zealand, and even behind another e-health laggard: the U.S.

Here in Canada, the recent federal budget included new health money for only two areas: aboriginal health and Canada Health Infoway, the agency tasked with getting doctors wired. So, the importance of getting medicine through the same paper-to-electronic record conversion that industries such as banking have already gone through is crystal clear. Medicine needs to catch up.

E-health data can offer us the “right information at the right place at the right time,” says Pascal. Yet, because an electronic record can do much more than just sit on the shelf like a paper chart, there are ethical questions the health community’s deep thinkers are having to work through.

Alberta and P.E.I. are the provinces closest to the goal of having comprehensive e-health data systems, so their leaders are having to sort through these issues first. “We’re the guinea pigs,” joked Alberta Medical Association (AMA) president Dr. Noel Grisdale during an interview.

Ethical questions
Thankfully, clarity is building around some of the key issues:

1. Do patients have the right to opt out of their data appearing on the (still developing) provincial electronic health record (EHR) networks?

In British Columbia, a little-known website (bcoptout.ca) provides residents with forms to give to their doctor and others expressing their desire to opt out of the province’s in-development EHR. However, whether patients will be able to opt out of EHRs is very much under debate.

The growing consensus is that patients should have the right to “mask” parts of their health information. This is countered by those who argue there should be some way of indicating to health-care providers who view a patient’s file the existence of masked data, especially if it may be diagnostically valuable.

2. Do doctors have the right to veto their patients’ EMR data from being included in an EHR?

Currently, almost no EMR data are uploaded to provincial systems, according to the CMA’s Pascal. But this past winter, the Alberta government introduced a bill to allow Netcare, the province’s EHR, to extract data from doctors’ clinic-based EMRs.

The early version of the bill gave the health minister sweeping powers to decide what data could be seen and by whom—and it featured non-compliance fines of up to $500,000 for doctors who refuse to share their data with Netcare.

The AMA attacked this ham-handed info grab and a number of sensible changes were made to the bill that assuaged both the association and the province’s privacy Tzar. The fines have been dropped and the College of Physicians and Surgeons of Alberta will be developing guidelines about what EMR data Netcare can use.

However, it seems unlikely that individual doctors will win the right to not share data.

Dr. Grisdale said individual clinics opting out “is not in the spirit of what we’re trying to achieve.” Indeed, one can quickly see problems arising. Consider this example: The Alberta college has set the standards for uploading office-based EMRs to the provinces’ EHR. But a doctor doesn’t want her patients’ data going to Netcare; however, some of her patients want their records easily available at their local hospitals. Does the physician have the right to say, “I have opted out of data sharing so you’ll have to switch to a doctor who does data share if you want that”?

That seems an untenable position.

Canadian courts have made it clear that physicians have duties as guardians of their patients’ data but also that the information in the chart belongs to the patients. The patients have the right to see what is in the chart and make copies, and then to distribute it to other health professionals if they see fit.

The non-compliance fines are gone in Alberta and the province has sensibly recognized the profession has a role in deciding just what kinds of electronic patient data can leave clinics, who may access them and under what circumstances. But once the appropriate steps have been taken to guard how EMR data are used by provincial health networks, will EMR-using physicians have the right to opt out? Seems unlikely.—Colin Leslie, editor