Electronic health records: Why Spain is getting it right

SEVILLE, SPAIN — There are many reasons Canadians visit Spain's olive and grape bedecked Andalusia province. To frolic and burn on the beaches of Costa del Sol. To discover the meat of the bull killed in the bull ring surprisingly tastes like venison and not beef. To be dazzled and dumbfounded by the Alhambra and the abstraction of beauty that was Moorish Spain. However, as part of a series I am writing on electronic health records I recently visited Andalusia to see an entirely 21st century amazement — an electronic health record system that doctors loved, that pharmacists loved, that hospitals loved, that patients loved, and that seemingly saved everyone time and money.

That is, to see an EHR system which absolutely exists nowhere in this country.

Why would such a marvel come to be in southern Spain? Thinking small and thinking big simultaneously would be my initial verdict.

'Once they [the doctors] started to use it, they completely accepted it.' —Eulelio Moreno Hernandez

Let me share an anecdote. In the small town of Pozoblanco, about two hours northeast of Seville, the local health authority has taken the first two steps of the province's EHR program. These steps required family practice doctors to allow appointments to be booked electronically and for prescriptions to be entered and filled electronically. It also encouraged doctors to write year-long prescriptions for people with chronic conditions. However, three Pozoblancon doctors who were used to writing these things on paper balked. "We're not going to change from paper," they said. "We're muy feliz with the way things are."

In Spain of 1939 to 1975 — that is, the Spain of fascist dictator Francisco Franco — the recalcitrant doctors might well have been told that if the state ordered them to digitalize their records they would do it or face jail, if not worse. But in a post-Franco Spain that in many ways is still trying to tell itself and the world that it is a modern, progressive, non-fascist country, a literally democratic tack was taken. The local radio station put on a public service announcement. It told Pozoblanco's 80,000 citizens that the new electronic health record system was being put in place and that instead of having to line up early to book an appointment, instead of travelling for an hour to a doctor's office to see him or her for prescription renewal, this could be done electronically.

The patients then started going into their doctors' offices and asking if the system had been put in place yet and could they use it. After enough of what in the business world would be called "client push," the muy feliz doctors relented and installed the system their patients wanted.

"Once they [the doctors] started to use it, they completely accepted it," Eulelio Moreno Hernandez, director of Information Systems and Technological Development for the North Cordoba Health Area, tells me.

But don't think you have to strictly believe in the power of an apt anecdote. When the systems were put in place throughout Andalusia to serve its roughly eight million inhabitants, a remarkable thing happened. According to a study by the European Commission's Information Society and Media group, the number of visits to doctors' offices fell by 15 per cent. Hernandez says the number is more like 30 per cent in Pozoblanco. Why, you ask? It seems that this was the number of people who were simply coming to renew prescriptions in person.

But that is not the only benefit the system brought about in terms of drugs. In Seville, primary health care doctor Juan Suarez showed me what a doctor goes through in the prescribing process. The doctor enters the drug he wants, and then the system starts to talk back to him. It shows all the pharmaceuticals that contain the "active ingredient" of the drug being prescribed. Active ingredients are the body and soul of generic drugs. But Suarez points to the screen and announces something more. "It shows price at the same time," he says.

Doctors keeping drug costs down

I have to stifle a gulp. All the doctors in Andalusia see as they are prescribing the cost implications of their actions. The system doesn't require them to only prescribe generics; there can be legitimate reasons a brand name drug is better. But if they do prescribe one, they have to explain the reason why they are doing it in the electronic record.

Effectively it is a doctor's implicit role in Andalusia to keep drug costs down.

The prescription information then goes to a central information bank, which every one of Andalusia's 3,524 for-profit pharmacies can access. Then the patient's electronic health record card is entered into a reader at the pharmacy, whereupon two other, in the Canadian context, astounding things happen. The first is that if a pharmacist sees that an active ingredient has been prescribed, he or she is only allowed to fill the order with the cheapest or the next most expensive of the drugs. Anyone who has been following Ontario's efforts to cut down on what amounts to $750 million in yearly bribes by drug companies to have pharmacists fill prescriptions with their products may feel their mouth dropping open.

Andalusia's pharmacists, like its doctors, have effectively been recruited into a program where it is their job — that word should be underscored — it is their job to keep costs down. And it works. The estimates are the EHR drug system alone has saved 253 million euros since it was put in place.

Moreover, Andalusia's doctors now prescribe active-ingredient drugs about 80 per cent of the time. In Canada, the figure is — again the mouth drops — a bit more than 50 per cent.

"And one more thing has changed for pharmacists. The change is that the pharmacists became more active participants. Before they [were] just a vendor," says Rocha.

This happens because electronic prescription systems give them both the right and the responsibility to challenge a doctor's order. Pharmacists can see the other drugs a person is taking. They can check for drug interactions and drug effects on other conditions.

We go into a small pharmacy to fill the order I described above and I ask the pharmacist if she ever answers back to a doctor. Twice she says in three years. One was for an allergy; the other was for a drug interaction.

What happened?

"One doctor changed the medication; the other cancelled it," she tells me.

Again, this is not merely an anecdote. A study has shown that pharmacists refuse to fill about one in 200 prescriptions. A recent survey of doctors found that roughly 97 per cent of the time they sided with the druggists' second opinion.

I say all of this and then come to what seemed the transcendent truth I learned in my trip to southern Spain. Even more important than the money and time saved has been the psychology and sociology of implementation. What Andalusia did is put in place a system in which all of the players in the health-care system could immediately see personal benefit. Immediately.

That system wasn't an expression of the capacity of what electronic health record systems are technologically capable of doing. Indeed, unlike many places in Canada Andalusia's doctors still aren't yet hooked up to the internet as they sit with patients.

'It goes in easy; it goes down easy'

But what the system known as Diraya — the Arabic word for knowledge — did was create a medical psychology and a sociology that said: These electronic records are good. They make our lives easier. Adaptation happened because people could see almost immediately that the new system was of benefit. They continue to adapt to the system because they have come to believe it is good for them.

And I think the reason Canada continues to have trouble implementing EHRs, the reason doctors still are resistant and patients are indifferent, the reason hospitals are skittish and governments are nervous about spending is that we didn't do the psychologically smart thing. We didn't give Canadians a system, which Dominic Covvey, director of Ontario's Waterloo Institute for Health Informatics Research, describes to me as "it goes in easy; it goes down easy."

Instead we have given them a technologically advanced system that is hard to learn, and confusing, and completely not habit forming. We gave them a system where they could and do ask all the time: So what's in this for me?

And that leads to my final image. As I sit in Hernandez's office I can't but notice on the wall behind him is a print of the famous drawing Picasso did of Don Quixote and Sancho Panza. One feels in Quixote's stick-figure body lines the manic lure of a quest which led him to attack windmills. And then there is another start. That's us and EHRs, I think. Andalusia has been saying what do we need and why do we need it, while Canada has been tilting at technological illusions.

The Spanish are acting like cautious, pragmatic Canadians, while in Canada we've been behaving like Don Quixote — or maybe more accurately — like Don Quixote's horse.