An ICU doctor at Michael Garron Hospital has been spending time on hold with 311 lately, waiting to report patients with COVID-19 to Toronto Public Health.
The hotline that citizens call to complain about potholes and faulty green bins isn't usually part of the process of alerting the public health unit to coronavirus cases, but Dr. Michael Warner believes the usual process is broken — and it's just one example of how Ontario's failure to effectively collect, share, analyze and act on data is stopping the province from beating back COVID-19.
One stop shop to report potholes, dead raccoons, and a potentially life-threatening respiratory illness that spreads easily among close contacts.
— Michael Warner (@drmwarner) May 29, 2020
Warner calls 311 to get public health workers to begin contact tracing — the work that is key to containing the spread of the coronavirus.
Ontario's 34 local public health units usually start the process after the patient's sample has been tested by one of the labs in Public Health Ontario's network, confirmed positive, and the result sent from the lab to the local public health unit. But the lab turnaround time is up to four days, according to Public Health Ontario, precious time in which the patient and any of their close contacts who have also been infected can further spread the disease, even while asymptomatic.
The province has set a pair of contact tracing benchmarks. The first is that contact tracers should reach at least 90 per cent COVID-19 cases within 24 hours — but the clock only starts when the local public health unit has been notified. Then, the COVID-positive person is interviewed and asked who they have been in close enough contact with to spread COVID-19. The second benchmark is that 90 per cent of those contacts should be reached within 24 hours and warned they may have been exposed, and told they should self-isolate and get tested.
After treating more than 50 patients with COVID-19, Warner is confident in his ability to recognize it and has been trying to notify public health quickly, before the lab results are ready, saving time.
"The time to contact tracing is really important because as you wait longer that chain of transmission can lengthen," said Warner.
He offered an example of one recent patient who presented with classic COVID-19 symptoms — that patient is at "high risk" of spreading the coronavirus, living in an apartment complex and working a job that involves contact with many people. That's why Warner will spend the time on hold — and speaking to the operator, and speaking to public health when they call back to collect the patient's information. His other options are sending a fax and calling the health unit's main line, but only during business hours.
"This is not a public health problem, this is a system problem," he said.
Warner said he only recently figured out how he could alert Toronto Public Health of his cases directly. A Toronto Star columnist had written about Warner's concerns over how long it takes for contact tracing to begin and Toronto's medical officer of health wrote an op-ed response. She said process of notifying public health units of positive lab tests is "not always smooth" and noted that doctors can also inform public health of suspected or confirmed positive cases — and they even have a responsibility to do so under the Health Protection and Promotion Act.
With a little research, Warner found that in Toronto, he must call 311 if the case comes in after hours. But as far as Warner knows, no other doctors are doing what he's doing — there has been no messaging from any provincial official saying that they should.
"We will never get ahead of this unless this part is fixed," he said. "And the other question is, is it the best use of the ICU doctor's time — who's resuscitating said patient — to be on hold with 311 and then wait for a phone call from public health?"
Warner said it should be possible for him to simply "press a button" to transmit the information to public health using the province's electronic health record infrastructure. "This is 2020 — that, I think, is not a significant ask."
"There must be some way to fix this because we are going be in this not for a week or a month, but at least a year," he said.
But according to Dr. Sohail Gandhi, the immediate past-president of the Ontario Medical Association and a doctor with a background in eHealth, the province isn't close being able to do that, "at all." Not all public health units use electronic record systems — they rely on paper — and those that do aren't linked to the broader health-care system — including Warner's hospital.
"That's why I'd like to see some wise investments made in public health," Gandhi said, adding those should include having all of the province's 34 public health units use the same electronic record-keeping system.
That technology gap among local public health units is another system problem that is hampering the ability of some public health units to do contact-tracing efficiently and share that information with the provincial government.
Some public health units are struggling to keep up with the number of positive cases — contact tracing is labour-intensive and public health units, especially in the Greater Toronto Area, have been overwhelmed. For example, more than a day after Warner called 311 and alerted Toronto Public Health about that high-risk case, the test came back positive, but the contact tracing process had yet to begin, he said.
"We've lost time, and that's inexcusable," Warner said.
Dr. Vinita Dubey, Toronto's associate medical officer of health, said the city is "striving to meet" the province's benchmarks and successfully reaching the close contacts of a case quickly, but is still having trouble with the initial step of reaching the person who has COVID-19 within a day.
"We're working to increase our staff complement to reach that metric," she said.
Contact tracing has two main functions — ensuring each case is managed in a way to reduce the spread of the virus and collecting the information from positive cases that the province's leadership requires to make decisions. To set effective policy, the Doug Ford government and the command table it has established need to understand why, when, how and where the virus is circulating in the province.
That insight comes mostly from the Integrated Public Health Information System (iPHIS), a database system for disease surveillance to which each of the province's 34 public health units sends information concerning reportable diseases, including COVID-19. However, the province's medical and political leaders have admitted problems with the system — there are data entry backlogs at local public health units, depriving the province of real-time information.
That system was fully implemented in Ontario 2005, in the wake of the SARS crisis — after the independent inquiry found the province's inability to manage data about the outbreak using Excel spreadsheets and overflowing boxes of paper records was a disaster and hampered the province's ability to handle the crisis. By that time, iPHIS was already 15 years old, according to a report from the province's auditor general. That report, in 2007, also flagged data entry delays from local public health units as a problem when the province is dealing with routine disease surveillance — and warned there could be consequences in another pandemic situation.
That has come to pass, and reporting delays have meant the officials leading Ontario's COVID-19 response have at times struggled to understand the basic facts on the ground. When case numbers began to rise again in mid-May, the Chief Medical Officer was unable to say why, or give an accurate breakdown of how many cases where part of institutional outbreaks and how many represented spread in the broader community.
One of the steps Toronto and some other public health units have taken to speed up and simplify the process of gathering information and sending it to the province is to create new tools that allow contact tracers to enter data gleaned from their interviews directly into a secure web-based platform that is directly fed into iPHIS. Toronto created the Coronavirus Rapid Entry System (CORES), Ottawa created the COVID-19 Ottawa Database, and London-Middlesex created the Case Contact Management Tool, which is now being used by several other public health units.
But some busy public health units, including Peel and York regions, are still manually uploading to iPHIS. Halton is "actively adopting a new electronic tool" to replace its paper records, but it's not currently interfacing with iPHIS.
Dubey said Toronto's tool is saving their public health unit valuable time that would have otherwise been spent inputting data from paper notes into iPHIS. Before it was online, the health unit had data-entry backlogs that prevented real-time data from being available.
"It requires a lot of training, you need special access, it's not the kind of thing you can get people up to speed with quickly," she said. "First of all, our cases were going up quite quickly, and it was really important to have on-the-spot data entry to increase the efficiency and to have good data entry."
IPHIS also can't be accessed remotely, so the new systems allow for the work to be done while respecting social distancing, she added.
Local public health units also need accurate, accessible real-time data from contact tracing to do their investigative work, looking for the possible exposure points cases have in common to find what venue — such as a supermarket, workplace or backyard barbecue — might be responsible for the viruses' spread and begin an intervention, said Dubey.
Toronto and London-Middlesex also began tracking race-based and socioeconomic data with their new tools — something the province still has not begun to do through iPHIS, despite saying three weeks ago it was planning to do so.
Data could bear out what Warner says he's seeing in the hospitals — the virus is disproportionately affecting people in low-wage jobs, living in apartment buildings, many of whom are New Canadians. And those anecdotal observations, if confirmed by data, might prompt specific public-policy responses, such as providing housing support for people who need to self-isolate. "How do you tell someone to self-isolate when they're in an apartment building with eight people and one bathroom — I don't even know what that looks like," he said.
"The data is what's going to save us here and jurisdictions that have been successful, whether it comes to testing or contact tracing or whatever the case may be, they've used data to inform their decisions," said Warner. "That means the data has be to quality data, it has to be timely, it has to be actionable and it has to be organized, and it has to be public, for accountability. Without those things in place, I don't see how we're going to move forward."
Warner, who has an MBA along with his MD, compared some of the province's problems — like the one that leaves him on hold for 311 — to inefficiencies and pain points in an assembly line process that should be identified and fixed.
The kind of problem is something the premier has set out to solve. Ford was elected on a message of running the province like a business and creating efficiencies, promising to bring a method borrowed from the manufacturing sector called "Lean Six Sigma" to the business of government.
In a statement to QP Briefing, a spokesperson for Health Minister Christine Elliott touted some of the government's accomplishments in health technology, including updating the Personal Health Information Protection Act to enable the sharing of information, such as lab results, between public health units and hospitals.
"At the beginning of May, the province announced the creation of a user-friendly online portal for patients to quickly review their test results," said spokeswoman Hayley Chazan. "The portal was developed to help ease the pressure on frontline workers, allowing them to focus their efforts on combatting COVID-19."
The government is planning to release a renewed strategy to support Ontario’s public health units in case and contact management, which will include an app that will alert Ontarians when they may have been exposed to COVID-19 and recommend what actions to take, she said. "Further COVID-19 testing and expanded capacity for contact tracing and case management will provide the province with fast and comprehensive analytical data to understand trends and reduce the spread."
Chazan also said the average processing time for a COVID-19 test is now less than a day, and then the lab results are uploaded to the Ontario Laboratories Information System (OLIS) for physicians and public health units to review. However, as of June 3, Toronto Public Health reports it takes an average of 2.5 days for the public health unit to receive positive test results from labs, and they come by fax, mail and phone, as well as the electronic system.
(This story was updated on June 3 to reflect the information from Toronto Public Health concerning the average time it takes to receive positive tests results from labs.)
(Photos by Rick Madonik and Richard Lautens / Toronto Star)