(This article has been translated into French.)
It is impossible to imagine our world today without internet, digital transactions, video conferencing or exchanges with family and colleagues via a computer or mobile device. Yet, we still live with the idea of our health care system lacking seamless electronic information exchange between health care organizations, providers and patients. Although some progress has been made on this front, this is a reality that persists to varying degrees today.
It has been a journey of a thousand miles. Health care has been closely accompanying the journey of digital connectivity but has kept shy from fully riding the wave. The reasons may vary depending on the perspectives of different stakeholders, but one constant stands: it is difficult to fully assess and understand the state of digital connectivity in our health care system today.
If we think of the health care system as a spider web, we can find parts of this web that are well constructed and connected, whereas other sections are still missing essential threads. In Canada, there are significant variations between and within provinces and territories in digital health connectivity and the inherently complex nature of the health care system further complicates the situation. This complexity is manifested by a dual provincial/territorial and federal jurisdiction with well institutionalized policies, funding and reimbursement structures; a digital divide across more than one dimension – rural vs. urban, older vs. younger generation, diverse social conditions; and a perplexing fragmentation of health services.
Following the early national IT efforts in Canada in late 1990’s, Canada Health Infoway (CHI), an independent not-for-profit organization funded by the federal government, was established in 2001 with a mandate to lead the national IT efforts. This included the development of an interoperable electronic health record for all Canadians. Since its inception, CHI received $2.45 billion in federal funding and played an active and important role as a strategic investor in health IT projects across provinces and territories, which contributed to improved digital connectivity. These investments evolved over time and expanded in scope from infrastructure-related projects to projects focusing on digital tools used by clinicians, as well as applications allowing patients themselves to collect, retrieve, and manage their health-related data.
We have come a long way as a society on the digital connectivity front in general. According to Statistics Canada, 88 per cent of Canadians and 60 per cent of those 65 years and over have a smartphone. Most Canadians (91 per cent) use the Internet and 75 per cent also use social networking websites and apps.
A recent study showed that around 40 per cent of Canadians track one or more aspect of their health using connected care technologies. This attests to the growing demand for digital connectivity in health care. In turn, health care organizations have been increasingly implementing new systems and technologies at the point of care that support digital connectivity. Around 85 per cent of medical practices are using electronic medical records (EMRs), and hospitals have accelerated the implementation of comprehensive EMRs that replace existing non-integrated systems. For instance, The Ottawa Hospital, in partnership with five other organizations in the Ottawa region, opted for the same EMR system, which will enable timely information sharing, and better connectivity and integration of care.
According to CHI, telehealth use has also grown over time reaching 1.5 million consultations a year, yet this still represents a relatively small portion of the overall health services. Since 2019, two initiatives emerged that aim at improving connectivity in relation to e-prescribing and supporting patients’ access to their health information through patient portals. These initiatives however remain in their early stages, with considerable variation in deployment between and within provinces.
Despite the progress made, considerable challenges and gaps persist. At the patient level, access to health information is limited. Unless receiving care from the same organization, or an integrated system or network of health care providers, a patient navigating the health care system often finds the onus is on them to communicate all relevant information related to their medical history, profile, and medications at each point of care. This is particularly challenging in the case of the elderly with chronic conditions who frequently interact with and move through the health care system.
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A recent study on mobile health technology use among people 65 years and older compared to the general adult population reveals that the majority of Canadians using mobile applications and wearables, like smart watches and wristbands for health self-tracking, do not share the data with their health care providers. Enrollment in telehomecare programs for chronic conditions management also remains limited despite the wealth of research evidence demonstrating its effectiveness in reducing hospitalizations and mortality rates, and improving the clinical condition of patients. The success in the integration of pilot telehomecare programs in the standard care, similar to one at the University of Ottawa Heart Institute, is minimal.
According to the Canadian Medical Association, limited system interoperability and information integration across the spectrum of care persist. EMRs implementation progressed, but only a small proportion of Canadian medical practices support electronic communication with patients. For example, few medical practices provide electronic appointment requests or prescription refills. Communication of information between general practitioners and specialists, or hospitals and nursing homes, and the sharing of clinical summaries or test results is limited and inconsistent.
In addition, hospitals within the same city that may transfer or refer patients to one another may have EMRs systems that cannot communicate. Most importantly, digital connectivity in the context of long-term and senior care is minimal. The recent COVID-19 pandemic brought to light the dire challenges observed in these settings in relation to connecting the elderly to family, caregivers, and health care providers. It also highlighted existing issues in capturing and sharing timely relevant clinical information with other health care organizations.
The obvious question is where do we go from here? At this stage, regrouping and understanding our current state is instrumental in shaping the decisions that we make regarding the future state of digital connectivity in health care.
A wealth of experience and evidence from over 20 years of health IT projects across all provinces is available. It is our responsibility to leverage this knowledge to inform policy and practical changes, and to apply evidence-based management principles as we plan for the next steps. Federal leadership is critical to endorse a strategic planning exercise at the national level and enable the necessary policy and regulation changes to support it. The Canadian government can play an important role in advancing the digital health agenda through incentives and policies that can catalyze national changes to address the digital divide and current gaps.
In times of crises, we discover our limitations as well as our capabilities. The current pandemic demonstrated that the health care system can be agile and can adapt fast when needed. In response to COVID-19, health care delivery changed overnight in Canada. We broke the inertia and shifted to various forms of virtual care throughout the country that were considered unrealizable prior to the pandemic. Provincial health authorities implemented fee schedule codes to cover virtual health services in a timely response. It was a call for action and the health care system and health authorities responded. However, this crisis also revealed our health care system’s “Achilles heel” – long-term and senior community care, which would greatly benefit from digital connectivity.
It is time for health care to fully ride the digital connectivity wave. A pan-Canadian reform that formally integrates virtual care and connectivity in the discussion on the future of health care is merited. This is a journey of a thousand miles in health care, but we have already started it.
This article is part of the Digital Connectivity in the COVID Era and Beyond special feature.