The relationship between our technology use and patient communication policies, and our ability to care for patients who have limited access to technology is a thorny issue. Providing accessible health care is one of our priorities, so our use of technology is something that we grappled with at length prior to proceeding as we have.
One principal consideration was what barriers to health care currently exist, apart from technology:
- Language barriers are an extremely common problem, particularly as many disadvantaged groups are not well represented in the healthcare profession. Even services in French are only rarely available in Ontario. As a system, the onus is typically on the patient to supply their own translator if they cannot speak English.
- In-person appointments are another significant barrier to obtaining health care. For many patients, such as single parents with limited child-care options, those who are mobility challenged, or individuals precariously employed, an inability to access health care except in person is a major impediment. Organizations such as the Ontario Telemedicine Network are attempting to address this barrier to care, but it remains unattainable for most.
- Business hours are another common problem as most health care facilities only accept incoming communication, whether in person or by phone, during limited business hours. Even then, long wait or hold times are common. This is a problem particularly for low-income working individuals who are not in a position to make or take phone calls during working hours. Health care facilities do attempt to provide some extended hour coverage (e.g. evenings, weekends), but this is limited at best.
- Wait times to obtain appointments, and then in-person wait times once a patient arrives at the clinic, are a challenge throughout the healthcare system. As a result, issues are not addressed in a timely manner, or simply not addressed at all, or patients are required to miss large portions of school or work days while waiting for a comparatively short medical appointment.
- Human error or oversight by both health care facilities and patients is a significant issue. This is particularly the case when facilities complete tasks manually, or if patients are provided information verbally instead of in writing. Consequences include missed appointments and tests, privacy and security breaches, confusion and misunderstanding, and morbidity and mortality in extreme situations.
Turning to our view of computer technology, a critically important conclusion that we came to was that robust and comprehensive use of computer technology can help us address many of the existing barriers in health care. While use of technology can be itself inherently a problem, it also has the potential to solve or mitigate certain intractable and systemic problems.
- Individuals who speak English as a second language oftentimes have an easier time communicating in writing than verbally. Written communication mediated by technology (e.g. email) provides an opportunity to use online translation services, ask friends and family members to assist with the translation, or simply to review the communication multiple times in detail.
- Many medical issues, while perhaps best addressed in-person with real-time discussion, can be adequately addressed remotely, through a time-delayed method of communication such as email. Patients are able to obtain necessary medical information and advice at home, at a time convenient for themselves, without needing to incur the time, effort, and cost of travelling.
- Technology can play a significant role in reducing wait times by significantly increasing the utilization rate and capacity of physicians and their support staff. For example, for many physicians, a surprisingly large number of appointment times are wasted because patients cancel at the last minute. Online scheduling means cancelled appointments are immediately available to other patients – if a patient cancels an early morning appointment the night before, a different patient can book that timeslot overnight when an urgent issue arises.
- Computers have the advantage of being able to complete repetitive tasks far faster and more accurately than humans. One example of this is the use of computerized tracking systems to minimize the risk of test results falling through the cracks. Another is the use of automated systems to advise patients of specialist appointments and preparation instructions in writing. When it comes to matters of health – accuracy is critical and verbal communication is anything but, in practice.
Returning to the conclusion mentioned above, these examples helped shape our view that the use of computer technology is critical towards helping us address some of the most difficult and pressing problems in health care and to make material strides towards better health outcomes for our patients. It’s not a panacea, but it’s one way to address numerous pre-existing barriers to health care while balancing a myriad of competing factors and interests.
A final consideration that warrants discussion is why we elected to make use of computer technology, and in particular, the use of online electronic communication, mandatory instead of optional for the most part. Indeed, we’re sometimes challenged on this decision given the existence of individuals who might not be familiar with computer technology.
- Most importantly, we think it’s critical to recognize that we are located in Toronto Central, which has the highest density of health care providers in Ontario. Indeed, within a short distance of us there are numerous alternative clinics (1, 2, 3) and physicians who have not elected to use computer technology to the extent to we have. In no way do our policies prevent any individual from having reasonable access to health care services, even if they prefer a clinic that employs more traditional methods than ours.
- Adopting a mandatory policy is what enables us to innovate, experiment, and improve. By making our policies clear upfront and providing prospective patients with a list of alternative health care options in the neighbourhood, we’re able to push forward on the assumption that our patient population is comfortable with computer technology and able to adapt to new systems and processes. If this assumption is not made, the practical reality is that many innovations become unaffordable and unattainable. In our view, this is a major cause of the shortage of innovation of the Canadian health care system, and a common pitfall that we seek to avoid.
- Treating tech literacy as a non-negotiable characteristic belies the seriousness of other barriers to access that exist, particularly where such barriers can be ameliorated through the use of technology. From a health care system point of view, not all health care facilities are designed to provide care to all individuals; to us, trying to be all things to all people is the path to mediocrity. Whereas some clinics focus on certain demographics (e.g. adolescents, students, seniors, recent immigrants & refugees, the LGBTQ population, etc.), other clinics focus on certain geographies, and still other clinics focus on certain types of medical issues (e.g. sexual health clinics), our clinic assumes tech literacy and in so doing, we’re able to address certain barriers to access that may otherwise go overlooked.
It is in view of all of the above that we've elected to specialize in the use of technology, and to make certain policies mandatory for the most part (although we do work to make reasonable accommodations in exceptional circumstances). Our sincere hope and intent is that this approach will help us design and develop innovative solutions to long-standing problems, and ultimately, to share with the healthcare community at large improvements that leverage the startling improvements in information technology of the last 50 years.