Should RHIOs Extend to Canada?

There is certainly a business case for establishing interconnectivity between the U.S. and Canada, though neither government would particularly like to acknowledge it.

There are populations on both sides of the border who would benefit from the ability to exchange medical information between countries. Providers in the U.S. would have access to medication information similar to that available from pharmacy billing managers (PBM) in this country, and Canadian providers would have electronic data about the diagnostic and other procedures taking place south of the border. As projected, access to complete health records would foster higher quality, lower cost, safer care and improved outcomes.

In the case of the U.S., there has been an "official" illegal trade in prescription drugs for years, with American citizens crossing the border (virtually or actually) to purchase lower-cost Canadian medications. While the introduction of the Medicare Part D benefit in 2006 certainly has had an impact on this cross-border trade in medications, there are no studies published yet that can quantify the impact.

In fact, immediately prior to the introduction of the Part D benefit, Canadian mail-order pharmacies were putting forward the case that, because of the complexity of Part D, with a variety of plans covering different medications with varying deductibles and copays, many U.S. citizens would still be better off purchasing their meds from Canada.

The pitch from these mail-order pharmacies suggested that, while Part D worked well to reduce the total cost of medications for those at the lower end of the income scale, and for those with very high annual medication costs (more than $10,000), those in the middle-income ranges would not enjoy overall savings.

For Canadians, coming south to receive medical care that they cannot obtain (or cannot wait to receive) from their single healthcare payer system has always been an option if they could afford to pay for it out of their own pocket. While hard numbers have always been difficult to come by, even proponents of a single-payer system in the U.S. acknowledge the existence of waiting lists for medical services in Canada.

Unfortunately, even with these benefits in mind, interoperability between the U.S. and Canada seems to be a vision relegated to the distant future.

While there has been progress both in the U.S. and Canada on establishing interoperability within their respective countries, there appears to be no organized effort to define or establish linkages between the countries. Each country continues to be focused within its own border. The U.S. continues to lag behind Canada in achieving interoperability goals.

President Bush issued an Executive Order on April 27, 2004, that included the objective of having medical records for the majority of Americans available in electronic format by 2014. To that end, the Office of the National Coordinator of Health Information Technology (ONCHIT) was formed, and since then, several hundred million dollars have been spent toward meeting that goal. While there have been several useful activities undertaken by ONCHIT related to standards and certification of EHR systems, actual progress towards creating a national interoperable network has been limited to a handful of pilots, some completed and more just beginning. At the community level, there have been hundreds of interoperability projects initiated, however, the failures outnumber the successes.

Canada’s Approach

Contrast this with Canada. In 2001, the Canadian government formed Canada Health Infoway (Inforoute Santé du Canada) with very similar goals of providing, by 2010, electronic information systems for every province and territory, covering 50 percent of the population with electronic health records. Infoway is made up of the federal, provincial, and territorial Ministries of Health, and serves as a mechanism to coordinate, incubate, arbitrate and fund the development of standards, tools and systems that will interoperate as they are deployed across the country by the individual health delivery organizations.

Since 2001, Infoway has invested $1.6 billion (Canadian) in this effort. More than 200 projects have been sponsored in partnership between Infoway and individual health delivery organizations in areas that include patient registries, diagnostic imaging, laboratory information systems, telehealth, public health surveillance, drug information systems, innovation and adoption, infrastructure, interoperable electronic health records, and standards definition and development.

This progress is impressive, particularly in comparison with the results achieved thus far in the United States. Keep in mind, though, that Canada has significant advantages that simplify some of the major challenges faced in America. For example:

Funding— Infoway has served as a central source of funding projects that fit with the overall objective of advancing cooperation and interoperability. In addition, they provide coordination, project management and a quality control check to maintain the level of standardization, reusability and interoperability of deliverables that come out of these projects. While ONCHIT plays a somewhat similar role, the lack of ability to fund projects (and to not fund projects that don’t advance the goals of interoperability and reusability) prevent it from being as effective as it could be.

Competition— For the most part, all non-primary care in Canada is delivered by regional health authorities, which are essentially government-run monopolies. As a result, the issue of losing competitive advantage to another participant in an information-sharing organization such as a RHIO
(a huge barrier in the U.S.) doesn’t exist in Canada.

Benefits Realization— While involving all parts of the community in an integration project is a major challenge in the U.S. (and often a problem), this is less true in Canada. The uneven distribution of the financial benefit is a problem in gaining support for the costs and the effort in the U.S., where most of the benefit is seen as accruing to employers and payers, rather than to the parties who have to do the most to accomplish integration, such as hospitals and physicians. In Canada, they are focused on the good for all.

Adoption— In Canada, technology adoption among physicians and providers is still a major part of designing and implementing electronic systems and interoperability. However, there are very few choices available to providers who do not wish to participate. Given that payments ultimately come from the government, there is a very strong incentive for providers to jump on the bandwagon, unlike provider incentives in the U.S.

Access to health related information coming through integration and interoperability are necessary for improving quality, safety, and ultimately, driving down health costs. With the task of creating an interoperable healthcare environment in the U.S. far from being a repeatable, clear solution, it’s not likely that organizations will look to become interoperable outside the U.S. anytime soon. However, both countries should begin a conversation around interoperability across the borders before too much time passes.

As medical tourism grows, and cross-border care scenarios become more common, there will be greater incentives (and pressure) to extend the concept of patient-centric recordkeeping to encompass the entire globe.

Barbara Cox is a senior principal and senior researcher with the Noblis Center for Health Innovation. Contact her at Barbara.cox@noblis.org.