A digital checklist for the homeless to help doctors plan medical treatments.


Everything is going electronic these days.  Most hospitals and community clinics are switching over to electronic medical record (EMR) systems for patient charts as well as other administrative management in the health system. Ritika Goel, a family physician working at the Inner City Health Team in Toronto, Canada, has been pouring efforts into developing a streamlined preventive health checklist tool to be integrated in an EMR. The checklist will be geared specifically toward the homeless community in Toronto, which also comprises refugees and asylum seekers.

The premise of the tool is to develop a preventive health care framework that addresses and prioritizes needs of this unique population. Often health practitioners see these patients in a one-off fashion due to the episodic nature of their health issues, and consequently the most important health needs don’t get attended to.

It doesn’t make sense to prioritize pap smears in a patient who has inadequate housing much in the way it doesn’t make sense to give large sums of money to developing countries without the infrastructure to manage it.

Having a checklist system enables physicians to easily view what needs to be addressed in a straightforward, user-friendly format.

Additionally, there is a growing pressure for physicians to fit everything in to a limited number of encounters, and collate fragmented health information to capture a picture of patients’ health status. There is also an intractable emphasis on physicians to rely on their memory for what needs to be done with a patient, inevitably causing crucial health maneuvers and investigations to be inadvertently left out. The checklist tool would circumvent this and also ensure thorough, comprehensive care.

Ensuring that vulnerable populations such as these are receiving prioritized and comprehensive health care is an issue that physicians, and the general public, ought to care about.

Why should we care? Well, for starters, each year, approximately 160,000 individuals in Canada experience homelessness. Other countries have similar, if not higher rates of homelessness. Homelessness can be experienced across genders, age groups, marital status or family composition, as well as among immigrants and life-long citizens of a country. Evidence suggests that people experiencing homelessness face higher morbidity and mortality than the general population owing to a combination of social determinants, certain maladaptive behaviors, and poorer access to social supports and health care services.

Similarly, migrants are an ever-growing group in the Canadian population that face barriers to health services. Immigrants and refugees, while healthier than the Canadian-born population upon arrival, face a rapid decline in health thereafter.  The health needs of the newly arrived immigrants and refugees and the homeless differ from the Canadian-born population. It has become increasingly evident that guidelines in health care, such as the Canadian Task force on Preventive Health Care, which produces high-quality, clinical preventive recommendations, must better account for the unique needs of such populations.

Having evidence-based recommendations can improve uptake of key screening practices as well as improve health outcomes, especially when tailored to specific populations.

So how does it work? Vital information on patient’s immunization status, preventive health maneuvers, and extended health care such as vision and dental is captured in the system as well as the social determinants of health including that include social benefits and housing.  Physicians will be taken through a checklist, which is intended to guide their care and clinical decision-making rather than act as an alternative. They will gain access to information such as dates when the last investigations were ordered, which vaccinations are not yet up to date, and their housing status; items that are particularly helpful when these patients have been been around the health system to various providers.

Identifying and providing a framework for marginalized populations is a cornerstone to good health care. Such a tool in an EMR would be generalizable both to other marginalized populations, as well as other health systems and countries. Adopting an electronic, comprehensive and tailored framework not only makes good sense, but is also a necessary step in bridging the gap in care between the rich and the poor. After all, a nation does better with a narrower gap, and that includes equitable access to health care. Once again, Canada takes a lead on innovative models to address inequities in health!


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Originally from Canada, Manisha Sachdeva is a registered physiotherapist and Irish-based medical student. She works with marginalized populations, particularly refugees and the homeless community. Her latest research includes counseling on end-of-life wishes and integration of advance directives into medical record systems, as well as co-developing a preventive health care tool for an inner city electronic medical record system. She’s the founder of a student think tank and she's interested in the dimensions of social innovation in health care.


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