I submitted my draft Findings and Discussions chapter this weekend! I’m now on a rare break from my research project as I await some supervisory feedback.
In the meantime, I have LOTS to do. I’ve been working as part of a CIFAR funded research team looking at the impact of COVID-19 in Alberta. That’s a glamourous way of putting it. The reality is I’m gathering secondary data sources that will be used for analysis, monitoring the weekly events surrounding COVID-19 from an Alberta perspective, preparing potential questions for a proposed study on virtual care, writing ethics applications and handling other administrative tasks that support the quest for further grant funding (the business model of academia).
As I was delving into the world of virtual care this week, I watched a great panel discussion featuring Dr. Ewan Affleck*. Among his many accomplishments, Dr. Affleck led the charge for a shared digital health record across the North West Territories. It sounds like a simple and logical idea – literally getting all clinicians on the same page in order to enable better, patient-centric care in the north. Yet, within Canada’s fragmented healthcare system, it’s a revolutionary idea that was 17 years in the making.
A quick overview of the Canadian healthcare system provides a bit of context…
Provinces are responsible for governing healthcare within Canada. Each has a corresponding ministry that governs provincial legislation. The actual work of providing healthcare happens thorough provincial healthcare authorities. Here in Alberta, we have one provincial healthcare authority – Alberta Health Services (AHS) – who are responsible for delivering care across the province. Yet, one province over in BC, there are five regional healthcare authorities plus a province wide First Nations healthcare authority. Many provinces follow a template of multiple regional healthcare authorities and a few, like Saskatchewan, Yukon and PEI, have a single health authority (Wikipedia). As you might imagine, many benefits of having a centralized single provider relate to scale.
Digital favours scale at a platform level.
Everyone can contribute at a content level, but at a platform level, we see digital monopolies emerge like Amazon, Facebook, Apple, Google (Alibaba and Tencent in China). There is an efficiency that comes with scale. AI likes scale. As I’ve been writing about, AI needs a lot of data to work well. It’s especially useful if that data is readily available in consistently organized digital formats.
One of the benefits of digital healthcare information is the ease in which information can be aggregated and shared, as Dr. Affleck noted when it came to medical charts. In Alberta, we are already moving towards one digital EMR (electronic medical record) as part of the ConnectCare implementation. Other countries, such as the UK, have done this work at a national level and it’s one reason why they can move fast to provide research like this – a study on 17 million patients that analyzes risk factors for COVID-19. That would not be possible without having a national digital health care record in place.
Virtual care - Zooming with our doctor – will challenge the provincial governance model. Why do we need to limit ourselves provincially when we can connect to a doctor anywhere? Industry infrastructure providers may find a business model in serving a single large health authority, like an AHS, but is there a business case to implement these technologies in smaller regional health authorities? Does that even make sense? What about interoperability – both within provinces and between provinces? I am left wondering...
Should healthcare be run at a national level?
The just released CIFAR report, Building a Learning Health System for Canadians, seems to point in this direction. It’s calling for a national framework on AI for Health (AI4H) in order to be scalable. While the language (I'm guessing for political reasons) speaks to “alignment” between the levels of health governance the report also says “without this alignment, Canadians will not reap the full health benefits of the opportunities available from responsible use of AI and machine learning more generally”. In other words – we need scale to make this work well.
It's not too much of a stretch to think that if we “aligned” by removing healthcare from provincial oversight and the quagmire of provincial policies coupled with regional level delivery systems, it would solve a whole lot of problems in moving towards a digital future. Dr. Affleck said as much (I’m paraphrasing)…
“Healthcare is an information industry. Illness doesn’t end at the border of a province. When the information is attenuated (stops at the border) then there is greater likelihood of mistakes. Borders are not always geographic –they can be between family doctor vs specialist; they can be cultural and political. We need all parts of the system to work together to fix it.”
This to me, also sounds like making a case for scale.
Health City Panel on Virtual Care (May 5, 2020) - it's Alberta focused but the issues are relevant at a national level
Williamson, E. J., Walker, A. J., Bhaskaran, K., Bacon, S., Bates, C., Morton, C. E., Curtis, H. J., Mehrkar, A., Evans, D., Inglesby, P., Cockburn, J., McDonald, H. I., MacKenna, B., Tomlinson, L., Douglas, I. J., Rentsch, C. T., Mathur, R., Wong, A. Y. S., Grieve, R., … Goldacre, B. (2020). OpenSAFELY: factors associated with COVID-19 death in 17 million patients. Nature. https://doi.org/10.1038/s41586-020-2521-4
Yarr, K. (2020, January 8). N.W.T. doctors hares his vision for better healthcare with P.E.I. CBC News. Retrieved from - https://www.cbc.ca/news/canada/prince-edward-island/pei-electronic-health-records-ewan-affleck-1.5419251
*It should be noted for transparency that Dr. Affleck is on the board of BrightSquid, which is a healthcare software and privacy consulting service. A BrightSquid representative was also featured on the Health City panel.