[This article was originally published in Essays May 2011] 

Digitising health records has been a policy priority for provinces, the federal government, and governments around the world since the late 90’s.  It is a given in policy circles that investing in the electronic health record (EHR) is worthwhile and all political parties support this. In Canada “eHealth” has been led by provincial Health IT agencies and Canada Health Infoway.  However, it is experiencing the trial and tribulations typical of a maturing industry/sector. These are its teen years and face some difficult choices and angst as it moves on to the next stage. It is likely torn between leading, following or getting out of the way. The reality it needs to do all three.

Against international and domestic standards, Infoway has been successful.  Internationally we have achieved more value for money spent than the UK which began at about the same point.  We lag leaders in Scandinavia, Australia and elsewhere on the primary care side where we have an admitted weakness due to the organization of our PCP system.  The jurisdictional repositories and infrastructure have progressed reasonably well and are largely tracking according to plan. Domestically, Infoway avoided the common pitfall among national health investment programs. The money did not disappear into general revenues and/or of being too nice to the provinces. 

Few people have ever accused Myrna Francis, Dick Alvarez and their executive teams of being too nice.  This is to their credit.  They made good plans and stuck with several tough decisions. 

1. The first half a billion dollars was not simply put against hospital system costs — A great temptation in the early days.
2. Infoway insisted on interoperability standards and denied funding (when possible) to those who did not meet those standards.
3. They insisted on “gated funding” and “reproducibility” from the beginning   — vendors couldn’t simply build it once and get funding and they had to show adoption of the technology
4. Infoway moved early to COTS (customizable off the shelf) solutions and away from a design-build-run system integration approach. They stuck with that approach over opposition from vendors and some jurisdictions
5. The investments made created a talent pool in Health IT in Canada and created an industry.  From a start of a few hundred professionals a decade ago, we have grown at least ten fold.  COACH is a vibrant and strong organization and its membership is ready for the next set of challenges.

Infoway is a high tech venture and also a government venture and that presents some unique challenges, which are growing. Firstly, high tech ventures, regardless of the industry they are in, traditionally get their assumptions spectacularly wrong.  In the private sector, we adjust and move forward (or go bankrupt).  High tech start-ups constantly adjust and course correct to respond to fast-changing technology trends.  Rightly or wrongly, government agencies don’t get to do that.  Instead, they get audited.  Organizations like Infoway have to run through endless loops of procurement, fairness, reporting, and other processes.  These important process constraints mean that Infoway will be slow-footed as the industry, which is by its very nature “fast-footed”, matures.  The challenge of being both a government agency and a high tech venture has manifested itself in several ways:

1. Platforms -Smartphone: Infoway missed the smartphone entirely; there are only a couple of homecare mobile projects that have received Infoway funding to date.  This in the country that invented the Blackberry.  Smartphones usage among Docs is now 90%+ and largely unmanaged.  Doctors aren’t waiting for Infoway; they are using “mHealth” in practice now.

2. Platforms – Tablet: The last year has seen an explosion of iPad usage amongst MD’s and other providers. Infoway has yet to adapt EMR adoption money to that platform.  Most commentators believe that MD iPad ownership is at about 30% after one year.  Infoway is still paying to install PC’s and claims 37% EMR penetration.  The Ottawa Hospital alone has handed out 2300 iPads. With the fast-pace of technology change, Infoway is really in a difficult position here; caught between the need to take a position around standardization and missing emerging technologies which are clearly game-changing.  The best they can do is focus on paying for outcomes and not specifying hardware and software choices.

3. COTS vs. System Integration: While the move to COTS has led the industry, Infoway and the provinces have still poured hundreds of millions in to one-off system integration projects.  We just need to stop this now.  The SI model doesn’t work unless it sits on top of a supported commercial software system. The market for these systems is international. Provinces and even countries are subscale.  

4. Public System Integrators: Funding federally province-by-province has spawned and supported what I will call “public systems integrators” in each of the provinces and sometimes regionally (sub-province).  These organizations are subscale, commercially unviable and compete with software, telecom and SI vendors using their own public dollars or Infoway dollars funded at 75%.  They distort the industry and slow adoption.  They were appropriate in the early days when the industry was immature.  All provinces/jurisdictions will need exit strategies in the next five years.  Sale to the private sector looks viable except from a political perspective where the write-downs will be in the hundreds of millions (although several of the hospital based operations may turn a profit when sold).  Provinces need to stop one-off custom development projects that will not be commercially supported unless there is a very compelling business case.  These projects are simply unviable in the long term without huge expense to taxpayers.
5. Core hospital systems are still underinvested in.  Arguably, this is not Infoway’s job.  But the Boards of many hospitals don’t believe that.  They await Infoway and provincial funding and fear spending 100 cent dollars if they could spend 25 cent dollars tomorrow.  In this way, the presence of the government program actually hurts innovation.  We need to declare firmly and credibly that we will never fund core operating systems.  Infoway should take responsibility for clearly identifying this problem and declare it is not a future funder.

6. Social Networks and Patients.  It is admittedly hard for government to wrap its minds around the applicability of Facebook and Patients Like Me to chronic disease management. However, patients will demand this and Infoway needs to advocate for patients.  As a starter government needs to stop the ridiculous ban on networking in the office.
7. Letting Go of the Banking Analogy.  The EHR Blueprint is idealism and central planning at its best and worse.  It provides vision, direction and standards.  But it also kills anything that is outside the paradigm.  Thomas Kuhn made this argument a century ago and was recently quoted by Christensen et al as follows: “…when a new paradigm is emerging from the work of scientists in other fields, the experts in the old paradigm remain convinced, even to their dying day, that the new paradigm cannot possibly be true.  The reason is that the old paradigm has so powerfully shaped their beliefs about how the world works and what is and is not possible, that their minds literally cannot see the phenomena that led to the articulation of the new paradigm.”  We need humility in front of the awesome technology changes we are seeing.

On balance, the first decade has been successful and Infoway should feel proud of what it has accomplished.  In fact, Dick and Co. should probably consider seriously whether or not to simply declare victory and close up shop.  The business case for Infoway in the second decade is radically different than the business plan in the first decade.  Infoway has creatively destroyed its original reason for existence.  Indeed some of the literature about government support for a new industry suggests that we should expect an institution like Infoway to have an expiry date.

According to work coming out of Harvard Business School, there is a clear role for government agencies in the early days of an industry.  Government responds to an identified market failure by investing and raising the basic level of sophistication.  Christensen et al. describe the stages that industries go through in The Innovator’s Prescription, as follows:

1. Subsidizing the foundation of the industry
2. Stabilizing and strengthening the companies involved, ensuring fair and equal access to their products and services and assuring that their products are safe and effective.
3. Encouraging competition to reduce prices

Infoway and the Health IT industry have moved through Stage 1 and in the stabilizing and strengthening stage.  What is happening now is that the fast pace of new technology development is making it possible for us to move very quickly into stage 3.   We will examine how Infoway is progressing through these stages in Part 2 of this essay which will appear in the Longwoods eLetter on June 7th, 2011.

For Part Two click here.

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