There’s been a lot of talk in Ontario recently about what the province can do to jumpstart “innovation” in healthcare. The Ministry of Health and Long-Term Care is touting a “Patients First” initiative that includes a plan to modernize digital health by giving patients better access to their personal information, allowing them to become more active participants in the management of their own health. To achieve these goals, Ontario intends to build an innovation-friendly marketplace that will help leading-edge firms get their apps into the hands of patients and providers.
The “Patients First” action plan recommends services that patients have long been asking for, such as online appointment booking and access to their health records. The “Patients First” plan also assumes that all the providers in a patient’s circle of care will have access to this shared electronic health record.
Unfortunately, many health IT firms who wanted to bring their products to the Ontario market have more or less given up, instead focusing their efforts south of the border. Ontario has achieved great innovation in other industries such as financial services, supply chain and retail, but there’s something special about healthcare that continues to hold innovation back. What is it?
As co-chair of ITAC Health’s Interoperability and Standards Committee, I regularly meet with Canadian healthcare system vendors, large and small, and have come to appreciate some of the key barriers to innovation in the province.
Having draconian, vendor-hostile procurement policies is one major barrier. All too often, purchasers ask vendors to take on liability and insurance terms that don’t make sense for smaller firms.
It’s common to see requests for multiple production reference implementations dating back several years, something that no new firm could reasonably produce. Probably the greatest burden for leading-edge firms is the resources required to create a winning response to unwieldly and unnecessarily complex RFPs. But although this harsh procurement environment is a critical barrier, in my experience it isn’t the most significant.
To my mind, the biggest barrier to healthcare innovation in Ontario is the fact that patient data is locked away in proprietary legacy systems.
All the features that patients are asking for (online appointment booking, shared access to patient health records, etc.) require direct access to doctor office EMR and hospital systems. There are simply no APIs available today that support these functions.
Patient Data is locked away in proprietary legacy systems
There was a time when we hoped to achieve shared patient data by building centralized repositories such as OLIS and ConnectingOntario, and then giving patients access to these provincial assets. But these central repositories do not provide data at the right level of detail or in the structured format required by innovative health apps. Patients want access to specific details about their health, such as prescribed medications, diagnostic codes, etc., but because of patient data lock-in, all we have are PDF documents, essentially glorified faxes that are of no use to data-hungry apps.
As long as patient data is trapped inside proprietary systems, building a vibrant marketplace for innovative “Patients First” solutions will not be possible. Our options will be limited to asking legacy EMR / HIS system vendors to build expensive add-ons for their existing systems. That is not a formula for disruptive innovation.
How can Ontario achieve the innovation in healthcare we need?
Mandate Open Interoperability Standards
Innovation blossoms in the fertile soil of open standards. The explosion of Internet innovation that we saw earlier this century was a direct result of the wide adoption of open interoperable HTTP and HTML standards. If you look at any innovative industry transformation, you will see an open interoperable standard behind it, such as barcodes and packaging for supply chain management, Interac and EFTPOS for retail, SWIFT for financial services, etc. Innovation happens when an open standard establishes a level playing field, allowing new entrants to challenge legacy incumbents. In the healthcare space, this means open, uniform APIs for moving data into and out of hospital and doctor office systems. But until this specific interoperability problem is solved, innovation will be limited to a handful of legacy players and one-off expensive isolated pilots.
Can we get there?
Some European jurisdictions (notably Denmark and the Netherlands) have demonstrated that it is possible to mandate interoperability standards in procured healthcare systems. However, those countries have citizenry that support “strong state” models of governance. Could such an approach work in Ontario?
My current answer is yes for ambulatory care but not by ourselves for acute care. All our hospital system vendors are American and, sadly, the U.S. has stumbled badly on the interoperability front. CCD-oriented Meaningful Use 3 Certification has demonstrated that it cannot achieve the interoperability required to support modern digital health. With Ontario being such a comparatively tiny market, we will have little sway over the interoperability capabilities of the large American hospital systems. Our best hope will be to state that any new hospital systems we purchase must support FHIR STU 3 interfaces, but even if we do, it’s unclear whether current or new vendors would play along.
There is more hope for doctor office systems as they are almost exclusively Canadian, giving us some leverage to force those firms to provide APIs for getting patient data in and out.
From Pilot to Scale
In summary, a prerequisite for healthcare innovation is the wide adoption of open interoperability standards. To scale innovative solutions across the entire province, we will need a base level of interoperability in all our healthcare systems. FHIR has shown great promise as an inexpensive option, and I am greatly encouraged by the extent to which the Ministry of Health and Long-Term Care has embraced FHIR. We now need to take the next bold step and mandate that all hospital and doctor office systems support FHIR, allowing us to usher in the next wave of innovative healthcare products in Ontario.