President-Elect Address 2007 / Allocution du président élu 2007

Marc J. Moreau, M.D., FRCSC

The honoured position of President of the Canadian Orthopaedic Association comes to few. I am honoured and very thankful for the opportunity that this organization has given me to represent it both here in Canada and abroad over the next year. C'est aussi un grand honneur pour moi de terminer mon année spéciale dans la ville ou j'ai reçu mon baccalauréat ès arts, près de la ville ou j'ai complété mon éducation en orthopédie, dans ma province natale.

I would like to give thanks to the organizers of this wonderful meeting here in Halifax, to Doug Thomson and to the staff in the COA office. I would like to thank my wife, Barb, who has helped me grow over the past 32 years of our marriage. I would also like to recognize and thank our five children Michael, Kathleen, Geoffrey, Colette and Matthew, our new daughter-in-law, Laurie and son-in-law Tom, and our new grandchild Ethan, all of whom have made our family life so rewarding. I would like to make special mention of my orthopaedic family that is my brother Paul, who is here today, and my father, Dr. Joseph Moreau, who inspired both my brother and I to pursue this wonderful, exciting field of orthopaedic surgery. It is appropriate at this time to mention my mother Marie Moreau who provided a loving and encouraging home life for our family of eight children. Mon père a complété son entraînement avec le D^r J. Édouard Samson, un des fondateurs de notre illustre organisation, et je l'ai suivi une génération plus tard, sous les ailes des D^rs Carroll Laurin, John Fowles, Pierre Labelle, Roger Simoneau, Morris Duhaime et de plusieurs autres. From this chronicle of the past, we move into the next age that we, as providers of orthopaedic care, face in an ever changing world. In the words of Yogi Berra: "The future isn't what it used to be."

Wikipedia, the ever so popular "Encyclopedia" of the computer literate generation, describes a Luddite as an individual who consciously resisted the changes that were being thrust upon society in England at the time of the industrial revolution. Ladies & gentleman and honoured guests, we are in the throws of yet another revolution, that of the electronic age in medicine. We cannot remain Luddites of the 21^st century as we witness the continuous transformations occurring in our midst. The data we record, the way we teach, the tools of the future, all will be affected by the sweeping changes we will witness. My address today is titled: "The Orthopaedic Surgeon and the Electronic Revolution". It will touch on the latter's effect on the community orthopaedic surgeon in the urban and lesser populated centres as well as on the orthopaedic surgeon in our academic centres.

Marshall McLuhan was quoted as saying: "Our Age of Anxiety is, in great part, the result of trying to do today's jobs with yesterday's tools."

Our time honoured practice of throwing up an X-ray onto a view box has evolved into feeding a CD into a computer terminal or accessing a PACS network and when necessary, drawing lines or measuring angles with the click of a mouse. On that same screen, we can bring up three-dimensional reconstructions of a CT-scan of a fracture or of other bony pathology and then rotate that scan in front of our eyes to better understand the pathomechanics of what we used to study by lining up images across a field of view boxes. Our residents no longer haul a large stack of X-rays into rounds, but simply project onto a large screen the view of the fracture they have retrieved by simply typing in a name on the ubiquitous laptop. With a VPN connection we can see, from the comfort of our own home, the X-ray described so poignantly by a medical student or a casualty officer back in the hospital. We can share by cross-country video conferencing our most challenging cases. In my home province, I simply access a protected web site, enter the patient's name and have access to a patient's lab results, X-rays and soon his or her EMR & EHR. From the straps hanging around our necks decorated with security access cards and memory sticks, we dangle FOB's which change six-number codes every minute allowing us to access the technological monolith that is shaping our future.

Although some orthopaedic surgeons still feel more comfortable handling that silver black parchment called an X-ray as they analyze a fracture and have their office assistant hand them the lab report sent out a week ago by snail mail, we know that these traditional practices are disappearing over the horizon. The Luddites in our midst have nowhere to hide as that Trojan horse full of the latest technology opens its portals and pours over into our everyday work life.

So what is this digital cornucopia spewing forth and what will it do for us as orthopaedic surgeons?

First, some definitions. The electronic medical record or EMR is a patient's medical record in digital format that replaces the traditional paper file maintained in our offices. It provides us with one stop shopping for a record accessible to our staff and ourselves at any time and from any given location. Electronic clinical information systems are created to facilitate patient care. We, as health practitioners, see our role and primary interest in providing patient care, not in documenting provision of the latter, thus eager acceptance of this new manner of patient follow-up is relatively uncommon. The advent of EMR's in the long-run should increase efficiencies and hopefully improve health outcomes as we improve our abilities to mine data.

The electronic health record or EHR is a composite of electronic patient records compiled from different organizations, provinces or the like. It gives us instant access to the pertinent information that many disciplines, (other orthopaedic colleagues, internists, family doctors, ER physicians and pharmacists) may require as they treat their patients.

Another entity which is now entering our stream of medical consciousness is called Clinical Diagnostic Decision Support Systems - these will provide us, the practicing orthopaedic surgeons, with patient-specific assessments or recommendations to aid us in our clinical decision-making process. Artificial neural networks, where the axons and dendrites of our nervous system are reconstructed as nodes and links of a computer system, will be capable of "learning" over time as more data are inputted, patterns of disease are identified and recommendations for care are provided. The last bits of terminology that are invading our medical "psyches" are very familiar to all of us, but have perhaps not spilled over into our practices. Evidence-based medicine systematically applies what is now known, rather than having us depend on our practice experience alone. Evidence-based medicine and medical informatics go together hand in hand.

The digital revolution is finally reaching the area of health. Computers have been omnipresent in commercial, industrial and scientific arenas for a number of years and have improved efficiency, safety and productivity in those areas. Our regional health authorities have caught up to this preoccupation; large dollar amounts are being consumed by health care infostructure projects in the Western world. What are the issues surrounding this shift?

Firstly, there is the issue of the record itself: an EMR is either "born digital" or is a scanned or imaged record. Converting old records into digital format is straightforward for radiographs, but a handwritten chart may have illegible components when transferred to digital. "Born digital" will possess set formats, sizes and fonts not to be found in the scanned version. The conversion process is expensive and time consuming. Those managing the record must assure us that hardware, software and media used to manage the collected information remains viable and is not subject to degradation secondary to use.

Secondly, stewardship of the records must be made clear. Once we convert to this EMR/EHR new information technology, the scope of our records will change as well as their portability, their new uses or purposes and the way we share them between practitioners. We cannot abandon our roles as stewards of the patient record - it is our professional responsibility. These changes that we are presently experiencing can provoke uncertainty about rules regarding health information administration and information sharing. As custodians of the patient record, we must be mindful of who is receiving the information, their need to know and their expertise in interpreting said information. A record of those using the information and the subsequent disclosures will need to be kept. The rules set out in regards to our paper records of patient information concerning security and confidentiality will not change. The implementation of the latter precautions, however, is more complex than simply having a key for a filing cabinet. The orthopaedic surgeon will ultimately be responsible for his EMR, but once that information is passed on to an EHR, subsequent disclosures from the latter will then no longer be the responsibility of the surgeon. The information manager of the EHR, however, will be acting on behalf of the custodian of this information, i.e. the surgeon, and will be governed by a strict set of guidelines.

The above issues will apply to orthopaedic surgeons in small urban centres as well as to the large urban academic region. How does this revolution in thinking and action change the academic world? Are there issues here?

All of us as orthopaedic surgeons have a duty to keep up on the literature. In this era of evidence-based medicine, our patients expect no less; between clinical encounters, they are using information technology to supplement or even substitute for traditional medical information. But what about these volumes of information? Medline adds 33,000 articles per month to the literature. Our patients expect that this new medical information will be applied effectively and efficiently to improve results.

In our academic centres, we are made aware of this growing amount of information and the technological acceleration which we have to come to grips with for our students. If you have your assistant print out all of your e-mails and have the librarian do your Medline searches, our students will conclude that these skills are not important, or worse still, that you are anachronistic! Dr. Robert Hayward, the Director of the Centre for Health Evidence at the University of Alberta, is teaching the concept of the rule of fives to our students as a goal for the use of informatics. He teaches us that one should be able to access good evidence within five seconds or five clicks of the mouse; that we should be able to learn about what we are looking for within five minutes, that we should be able to be offered five information leads with five rewards to use, five times per week. All this is to drive home that technology should give us quick access to good information that is useful to us everyday of our working week.

Most medical schools have implemented some form of PBL or Problem Based Learning into their curricula. PBL is costly in manpower. Our new PBL teaching programme starting at the University of Alberta Medical School this Fall will require a time commitment on the part of our orthopaedic teaching staff of two hours a day, Mondays, Wednesdays and Fridays for six weeks. Alternatively, the Clinical Diagnostic Decision Support Systems or CDDSS offers student-centered learning. This is accomplished by using the large knowledge bases, that is, expert medical literature with statistics and disease-finding relationships, as well as, inference engines with computer algorithms to process patient findings in relation to the knowledge base.

A CDDSS provides prompt feedback to the student and helps them to come up with appropriate differential diagnostic hypotheses. The systems are interactive and correct the student as they formulate appropriate inquiries and perform key diagnostic steps using relevant patient data. Faculty, that is we, the teachers of the musculoskeletal system, must become appropriately computer literate.

In conclusion, health care informatics is coming to the fore on the agendas of health care administrators. The funding necessary to advance this shift is now being set in place and orthopaedic surgeons from all practice venues, be they from small or large urban centres or academic institutions cannot escape this wave of change, nor should they wish to. This anonymous quote states: "you cannot discover new oceans unless you have the courage to lose sight of the shore". We must become more and more literate and facile in this new language as our patients and students will demand this in the end. High quality, to the point, directed evidence from high quality technical resources can be integrated into the workflow of our daily lives.

I leave though with a quote from a CDDSS text: "as long as the healing professions are practical in a matrix of scientific uncertainty and patient values, we err if we appoint computational decision support as a surrogate for compassionate communication, shared decisions and quality care by competent humans." We must not lose our humanity while we struggle to catch up to technology.

I would like to thank the COA for proffering this great honour upon me. To Barb, my wife and closest friend, I thank you for your constant, loving support. Together we will do our best to represent the COA here in Canada and abroad for the next year.

C'est notre désir cette année de bien représenter notre belle organisation, l'Association Canadienne d'Orthopédie. Barb et moi nous mettons à la tâche dès maintenant et terminerons ce mandat avec fierté dans la belle ville de Québec, en 2008. Merci.