To say that Richard Alvarez is a man on a mission is an understatement in the extreme. With a goal to have Canadians and their healthcare providers using a pan-Canadian health record by 2015, the meter is running. Providing national leadership to provincial mandates, the president and chief executive officer of Canada Health Infoway has been at the forefront of change management in healthcare. It is no secret that e-health initiatives vary from province to province and, while national leadership is important, success is linked to significant investments by a host of sponsors, with convergence across the entire system, coast to coast, north to south. Recently, progress from federal and provincial investments in e-health has fallen from grace and Canada Health Infoway itself was the focus of a review by the Office of the Auditor General of Canada. HQ's Ken Tremblay spoke with Richard last fall.

 
HQ: Your website lists a host of current projects and accomplishments. What have been the highlights for your tenure at Infoway to date?

RA: This job is a non-starter if you don't have the co-operation of the federal government, provinces and territories. The level of co-operation and collaboration I have enjoyed across the country has made this job a lot easier. When you consider jobs in a federation [model], it's not always easy to attain co-operation, especially when money's involved. In my book, this level of co-operation is unprecedented.

While I have always been blessed with good management teams, the management team at Infoway is probably one of the highest-calibre teams I have ever worked with. As well, we have a board that is not only wise and experienced but incredibly supportive of the Infoway agenda.

After 18 months of a fairly gruelling audit, the auditor general announced that Canada Health Infoway has made significant progress on its mandate, including progress made by our partners. It's good to know we are getting recognition on the world stage for aspects of the electronic health record. We were studied by an independent technology group who commented about the Infoway model in any federated model like Canada. They said, in essence, "If you're going to go about building an electronic health record, you should look to the Infoway model and the investment approaches that they are taking."

At the political level, this [mandate] has been tough, especially in these times; but politicians have supported us in absolute spades. That has allowed us to get on with our job to deliver on benefits such as picture archiving and communications systems (PACSs) in diagnostic imaging and what that has meant for the country's healthcare system.

HQ: The literature is starting to report on the progress of other jurisdictions with e-health initiatives, especially access to primary care. How would you rank Canada's track record and successes on the international scene?

RA: I really want to talk about primary care and the Commonwealth Fund Study that looked at primary care physicians in some 11 countries such as Australia, Canada, France, Germany, Italy, the Netherlands and New Zealand. With respect to primary care and information technology, Canada's track record is, in one word, abysmal. In that study, Canada ranked last in terms of community physicians using electronic patient medical records. But that's only one indicator. When you look at e-prescribing, the Netherlands had 98% of their clinicians enrolled versus our 27%. When you look at the use of electronic alerts and prompts for potential drug problems, Canada is at 20% while Australia is at 92%. In the area of prevention of missed routine tests, New Zealand scored 96% while Canadian patients received reminders only 22% of the time. Not being able to equip our clinicians in community settings with the right tools is having a severe impact on the quality of primary care.

HQ: What were the lessons learned from recent developments at Ontario's E-health Secretariat? For example, how has Infoway changed its procurement or project management practices in the wake of controversies in Ontario?

RA: In terms of management practices, we had an independent outsider study our management practices and we came through with flying colours. There has been absolutely no need to change any of our management practices because, in many cases, I suppose they are best of breed.

In terms of procurement, we never experienced any of the issues that have dogged eHealth Ontario. There were examples where the auditor general made some recommendations of how we can be more transparent, and we've adopted those.

HQ: What are the challenges of working on a national agenda through the provinces? For example, how do variations from province to province affect Infoway's progress?

RA: The level of collaboration has been significant, and provinces have learned from each other. They have replicated projects, implemented similar standards, used the same tool kits. There are variances, and where it becomes tricky is where one province moves at a faster rate than another. If a province's priorities fall within Infoway's strategic direction and plans, we fund the initiatives. Thus, we have some variances across the country because some provinces are making greater progress than others since they have embraced these priorities and been able to get on with it. I will add one rider here: the larger the province and the more unstructured it is, the tougher it is to gain stakeholder consensus and get on with the e-health agenda.

HQ: Which province or projects are the best examples of "doing it right" vis-à-vis your mandate?

RA: Provinces that come to mind are Alberta and Prince Edward Island. They have made terrific progress, and patients in both provinces are moving into 21st century healthcare. We have some great successes with the Telehealth Network in Ontario, diagnostic imaging projects in the Maritimes and drug systems in British Columbia.

HQ: Given the scale of investments required to build Canada's information technology infrastructure, what are your thoughts on how public confidence can be maintained as these investments come on line?

RA: Members of the public, certainly in the polls that we have taken, want to see this happen, and want it sooner than later. They need to see evidence of projects delivering results, and they need to see it in a fairly transparent way. Patients are tired of repeating their histories over and over as they move from one provider to the next. For example, they cannot understand in this Internet world why their test results take so long to get to their clinicians when they have waited weeks for an appointment. They can't understand why, if one hospital takes a radiograph, it is not available in another hospital. They need to see evidence and benefits of these investments. As members of the public start to see progress, not only will their confidence grow but they will clamour, "Why isn't my province moving as fast [as others]?"

HQ: Describe the end game for Canada Health Infoway. How will Canadians experience their healthcare system differently?

RA: The end game is simply that they won't have to repeat their histories over and over again. They will be able to get access from afar: using telehealth services, using PACS where images are beamed in from repositories. They may not notice, but many adverse drug reactions will be averted. They should experience a decrease in dangerous drug-to-drug reactions, which could have previously ended in injury or death. They will have access to their own records. We will improve the public's ability to navigate the health system as we give them the tools to do so. We certainly intend to give them the tools as part of our end game.

In short, I would say [Canadians' experience will be different in] three ways: a safer and a higher-quality healthcare system, a more productive and more efficient healthcare system and better access to health services.

HQ: E-health is vulnerable to the availability of working capital on two fronts – the initial funds to tool up for information technology adoption and then ongoing maintenance, replacement and upgrades. What capital solutions do we require to accelerate the deployment of a pan-Canadian e-health strategy?

RA: The first thing is belief. If you believe that this technology could be transformational, then you need to find the money to sustain the system. It is as simple as that. We have about $3 billion in play; $1.6 billion from the federal government, which is matched by the provinces. This level of investment is unprecedented in Canada. That being said, there are still challenges to get the job finished, especially in these recessionary times.

We've seen examples of private sector funding, for example, in diagnostic imaging where capital costs were repaid from operational revenues spread over a number of years. We're seeing that in provinces such as Saskatchewan, which helps secure capital funds. As we start to see the benefits [of the investments], my sense is that more capital will become available. As far as I'm concerned, the electronic health record should become a standard of care – no different from a stethoscope.

HQ: How have you found the national political landscape associated with e-health? Are the federal ministers of health and finance ready for these directions?

RA: The federal government demonstrated enormous leadership and a leap of faith when it came together with the provincial premiers to form Infoway and launch this program. Ever since, there has been strong support from all governments. In my career, this level of co-operation is unprecedented. We have letters of support from every single province and territory across this country, be they at the health or finance minister level. Many premiers are incredibly supportive of what needs to be done in this area. It goes back to your first question: in terms of my tenure here and reflecting on our achievements, I would say the politicians have been enormously supportive.

HQ: How has the vendor marketplace responded to Infoway's mandate and agenda?

RA: The vendor community has been extraordinarily positive about the health sector's intent to design and implement this interconnected, pan-Canadian electronic health record. Vendors have adopted the blueprint and are well aware of our requirements for privacy, security and interoperability. The system integrators and larger vendors have benefited first; the point-of-service providers, that is, hospital systems and the electronic medical records systems, at this stage are to follow. Vendors have been supportive and are perhaps more confident now as the US market improves.

HQ: And the professions and providers?

RA: The name of this game is not technology. The name of this game is change management. When you see, as I did last week, ads from the Canadian Medical Association, the Canadian Nurses Association, the Canadian Pharmacists Association and the Canadian Healthcare Association that say, "Look, we've got to get on with the funding of Infoway because we've got to get on with this journey; our members are ready for it," their message speaks very loudly to me.

HQ: Your career has taken a few twists and turns over the years. What do you hope will be your legacy at Canada Health Infoway?

RA: It's really not about me and not even about Infoway. The legacy I think that we should all leave is a successful partnership that delivers on this national project. The real legacy will be the partnership that transforms and modernizes Canada's healthcare system. If we could do that, get it to a tipping point of take-ups and adoption, I, for one, would sleep like a baby every night.

HQ: What else would you like the readers of HQ to know about Richard Alvarez?

RA: That I'm a man with a mission. We must do something about sustaining and modernizing our healthcare system, and certainly one can count on me to do whatever I can to work with others to make it happen.

HQ: Thank you.

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