Canada Health Infoway is leading the charge to bring Canada's healthcare system into the twenty-first century. Canada Health Infoway is an independent, federally funded, non-profit organization tasked with accelerating adoption of pan-Canadian digital health solutions. Since 2001, the organization has functioned as a strategic investor, policy advisor and principle architect as Canada and its provinces and territories struggle with the implementation hurdles of digitizing Canada's healthcare system. The rationale for an eMR for Canadians is as simple as it is complex: improved access, improved efficiency of providers, better care and outcomes, better communication and coordination of care, and, ultimately, a system better positioned to deal with the issues of today – chronic disease management, empowered patients, interoperability among providers and population health and surveillance.

In 2014, Michael Green was appointed President and CEO, Canada Health Infoway. With an international track record of transforming healthcare through the use of innovative digital health strategies, Michael's mandate was to leverage expertise and experiences gained through his transformation of diagnostic imaging at Agfa to the Canada Health Infoway mandate. With a diploma in Medical Laboratory Sciences from the London Metropolitan University and early days at King's College Hospital in London, his career took him to the C-suite of Agfa Healthcare, Americas Region, where he led that organization's transformation of the imaging industry. Michael received the Queen's Jubilee Medal in 2012 for his contributions to Canada's IT industry, including a three-year term as Board Chair, Information Technology of Canada. Ken Tremblay spoke with Michael this summer.

HQ: After two years at the helm, how have you found the transition to Canada Health Infoway and the public domain?

MG: I've enjoyed it and it's been a good new challenge for me. I spent the majority of my career working in the private sector with a company based in Europe looking after the Americas. There was a tremendous amount of travel. I enjoyed the position and its challenges, many the same as in this role. In contrast, what I enjoy about this role at Infoway is that there is more time to spend on strategy, building relationships with the government and other stakeholders and, new for me, trying to see where we can make a difference and how we can help them achieve their goals.

HQ: When you speak to political or non-healthcare audiences, how do you describe your role?

MG: It's a bit about Infoway, the organization, that we're a not-for-profit organization funded by and arms length from the federal government, where all the provinces are members. Our role is to bring digital health innovation across the country and [all] the provinces. My role is to work with those various stakeholders and, given the environment here and internationally, to focus on the priorities and efforts we need going forward. In a health system like Canada, which is a mix of 13 different systems, where can we make a difference and migrate gains across the country?

HQ: Whenever we say pan-Canadian and healthcare in the same sentence, there is often a shudder and the imagery of "herding cats." How have you found that dialogue as Infoway goes about its mandate?

MG: The interesting thing is that there are a lot of common issues that people and governments face time and time again: governance, privacy, standards and areas like that. The trick for us is to find the areas that are pain points in every province and territory, so that a good idea somewhere can be identified and replicated. People are interested in ideas that help them locally; but they obviously want the flexibility to run their own systems.

HQ: Assuming that seamless integration of provider and patient information is, in part, a solution to the challenges we face, what's working well with our journey with digital healthcare?

MG: What's worked well is the rollout of electronic medical records in primary care – a large percentage of primary care doctors have electronic systems. That's a foundation for more advanced applications. Within the hospital system, nearly all the lab results, diagnostic imaging, public health and discharge reports, etc., have been entered into these systems. Telehealth is a great success in Canada. Virtually every hospital uses Telemedicine in some way or other and it contributes significantly to care in remote communities. There are many areas that have worked well and it is a big enterprise to put it all together. We're now in a position where we are about to see more impacts for the public than ever before.

HQ: What issues and challenges keep you up at night?

MG: One is determining the key priorities that will unite both the provincial and the federal governments. As you've mentioned before, these are elusive solutions and we need to ensure that we focus on areas that will give a return on investment and be supported by our stakeholders going forward.

HQ: Most readers have seen your ad campaigns and message about how patients would benefit from Canada Health Infoway's mission. What have been your metrics about the public's perception of investing in digital infrastructure for healthcare providers and the system?

MG: The Better Health Together campaign has measured the number of views that each of the particular programs has had, fairly standard metrics that the advertising world uses to assess their [market] penetration and online uptake. We also measure responses and any increase in the coverage of those materials in events such as Digital Health Week. We measure the participation of supporting organizations, and the awareness that that type of program creates. Those are fairly soft measures. Does every citizen have full awareness of digital health? Probably not, so we have a long way to go.

HQ: Investments in healthcare IT must compete for working capital – medical technology, bricks and mortar and the impact of lower margins and restricted funding. How should policy makers view these large investments and tradeoffs?

MG: That's a very good question. What we haven't done quite right is that we've looked at these projects purely as IT projects. What we need to look at is the real return on investment or the improvement in care that a project can bring. That may be more difficult to measure in some areas than others, but in areas such as diagnostic imaging, you can measure the reduction in film use, the ease of transferring images among providers to get a quicker diagnosis.

In the US, technology is often used to support specific strategies, rather than a means to its own. So, for example, if we want to improve the quality of outcomes, reduce bed stays, improve efficiency, you certainly need to have IT systems in place. When we go forward with projects, we have to pick where there will be gains in efficiency or care. One example is home care, where we are supporting initiatives [dealing with] chronic heart failure, chronic obstructive pulmonary disease, renal dialysis at home and high-risk pregnancies, to mention a few. There will be a big focus on chronic diseases to determine we can improve outcomes, reduce visits to the ER, reduction in hospital stays, etc. Future programs and projects will need these measures in place, so that we can assess the return on investment.

HQ: The triple aim: better access, better quality and lower costs. How essential are investments in IT for this agenda?

MG: There is a business case. Last year, I toured Israel by invitation. Their government (and public system) is looking at providing effective care at the lowest cost. I went to a call centre, where they make outbound calls to groups of patients with multiple chronic illnesses. They can certainly demonstrate how much they're improving care and reducing costs. We need better mechanisms, better objectives to assess programs, but I have no doubt that, used correctly, digital technology and IT will definitely improve care and reduce costs. But it has to be part of an overall program objective.

HQ: The quintessential dilemma for large infrastructure investments: build or buy? What's your take on how to approach this issue?

MG: We probably need a bit of both. In the end, it depends on the field. If you are looking at hospital information systems, that [provider] segment tends to be dominated by large American companies, where Canadian users customize American solutions to the Canadian market. Is the Canadian market big enough to build these platforms from scratch? I'm not sure. We certainly need to have systems that can be configured, so that they satisfy our requirements. In some cases, we do need to build things; but, in my view, buy and customize is a better solution.

HQ: When you survey the international scene, how is Canada doing? Are there some best practices or lessons learned from jurisdictions we should adopt?

MG: If you compare benchmarks between Canada and other countries in terms of health system performance, we don't do too well. Measured on many parameters, we rank tenth out of eleven, with only the US being behind us. Where can we act to improve that? There are a number of solutions we could apply and many countries have clear national leadership even though they may work in decentralized models.

The Affordable Care Act in the US focused on more cost-effective care, defining certain parameters for providers, changing rules of reimbursement and so on. There are many lessons learned from leading systems in Europe. The UK has focused on specific principles, like primary care being the focus of healthcare, different diseases and systems that support specific objectives like a national booking system. However, even those countries have had their challenges in finding the right type of approach, getting physician adoption and so on.

HQ: Big public investments mean long projects and big politics. How do we navigate a multi-year vision when (shorter) political and economic cycles have the capacity to divert our attention?

MG: That's a very difficult issue. With four- or five-year election cycles, policies can definitely change. The federal government, the provinces, and territories are discussing a health accord noting, for example, how home care is becoming a theme, along with areas like chronic care, long-term care, an aging population and so on. If they can reach consensus with long-term objectives, such as population health, strategies over a longer term are the way to go. It's often attractive to go for short-term goals, say wait times for certain conditions, knee replacement, cardio-thoracic surgery and so on. While these initiatives definitely improve performance in those areas, they take our eye off others. A longer-term approach is probably better, but it is not so much the technology, rather the policy. If we can create savings in one part of the system, how can we invest in another?

HQ: When you engage the public, what do they want from your mandate and efforts? Are they right?

MG: In surveys and sessions with the public – patients and non-patients – people certainly want to have more tools to make care more accessible. And one of the top things that we get back is that people want to be able to book appointments online. They want to be able to get referrals, to send a message to their doctor and get a response and to obtain prescription renewals online. There are a number of core services Canadians want to have and we've certainly tried to address some of these in our programs.

HQ: Interoperability, privacy, standardization and compliance … How do we reconcile the many interests inherently seeking attention in your agenda?

MG: We have several steering groups looking into these areas; there are conflicts. Infoway has a role to play in the area of privacy, where we bring together the various privacy commissioners to look at best practices here and internationally. But we also have to consider new approaches: who owns the information, how do we give patients the ability to share their information and what are the methods of providing access to patient data. In the areas of interoperability and standards, it is very important that [IT] systems talk to each other.

What we've tried to do as much as possible is promote industry-wide, as well as international, standards rather than customize standards for each province; we need a broad debate that will facilitate interoperable systems in the future. There's more work that can be done. We're looking at the Blue Button initiative in the US, where patients can press a blue button on an application to allow a provider to get their healthcare information. Another initiative, Commonwell, is an alliance of large hospital information systems that have embraced a common standards approach, allowing hospitals with different systems to transfer patient files, with the patient's permission, to different locations. We're working with industry groups to see how we could possibly bring some of these systems to the Canadian market.

One of the most important things that will help patients share their records with their local care team or to support a pan-Canadian perspective will be the emerging technology [devices and applications]. In several provinces, we are seeing the evolution of patient and clinical portals. For example, southwest Ontario and the GTA have clinical portals that allow clinicians to share patient information across their [provider] continuum. Ultimately, that example should spread across the whole province as they have in other provinces, like Alberta. That's professional healthcare providers sharing information, e.g., lab information through integration tools enabled by these portals.

Patient portals, as in the case of Nova Scotia, where they are implementing Relay Health, the model is one patient, one record. So all patients – the primary care provider enables portal access to patients – are able to view all their results, tests, manage appointments, etc. There's a similar approach with a different technology in Saskatchewan and Alberta. We're beginning to see this information coming together in various strategies and formats.

HQ: When you talk to vendors, what is their take on your efforts and strategies?

MG: One of the concerns among vendors is the area of procurement. They certainly see that as a big barrier to rolling out system solutions effectively. It's a big cost to the vendors and very time consuming for both the vendors and the jurisdictions. And they have to answer the same questions over and over again, nuanced to each different jurisdiction.

If we could find a way to help on the procurement side (this is something we're looking at), we could potentially help with national procurement in certain areas and, in conjunction with the provinces, ease that burden. Companies are looking for more investments and are willing to take a certain amount of risk if they could play a greater role as a service provider, rather than just a provider of products and software. I think industry looks to Infoway to drive more programs that would benefit healthcare IT infrastructure across the country. The current government sees innovation as a big component of this new health accord, and digital innovation is part of that. Canada Health Infoway has a role to play there, and we would definitely look at public–private partnerships and other ways to work with industry and the jurisdictions across the country to make that happen.

HQ: Thank you.

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