One small, silver-lining from Covid-19 has been a heightened impetus for digital innovation in health care. Unfortunately, much of the technological underpinnings of Canadian health governance are evermore antiquated, heightening risks and costs accordingly. Such is the stark message from many quarters, notably provincial and federal Privacy and Information Commissioners.
As first reported in IT World Canada last September, the Commissioners passed a resolution urging governments at all levels to collectively: i) ‘develop a strategic plan and provide appropriate supports, funding, or other incentives to phase out the use of traditional fax and unencrypted email and replace them with more modern, secure and interoperable digital alternatives in a coordinated fashion; and ii) ensure that all digital health information sharing infrastructure…are equitably available and accessible to all Canadians’.
While this need has been longstanding, the pandemic further exposed major challenges with data collection and sharing across jurisdictions, which inhibited a truly national response. The federal government’s own Expert Advisory Group, established in fall 2020 to explore the makings of a ‘pan-Canadian Data Health Strategy’ exhaustively exposed these shortcomings, calling for urgent action. The Panel recommended that governments establish ‘federated data governance, clear standards for interoperability, an effective policy environment and meaningful engagement with the public to facilitate this change.’
Despite such sound advice, this federal body lacked formal ties to the Provinces and the Panel’s’ sharply one-sided critique of Provincial data efforts during the pandemic did little to establish mutual trust. Nevertheless, the views of both the Privacy Commissioners and the Expert Advisory Group have helped to contextualize recent federal-provincial discussions around health care data (a theme returned to further below).
Political federalism versus federated architectures:
The current reality is that a truly national approach to digital health requires shared governance mechanisms enjoining federal and provincial governments in ways that are antithetical to the political structures of federalism. Rather than working jointly to lay the groundwork for a truly national architecture for collaborative innovation, Canadians have witnessed the engrained posturing of Provincial calls for more funding – without conditions, while federal Ministers seek to temper such demands and embellish their own spending and support.
Tensions between traditional federalism and innovation are hardly a novel theme. As just one example, a prior Advisory Panel from 2015, which featured stronger buy-in from Provincial stakeholders, sought a National Health Care Innovation Agency to spearhead systemic change. Indeed, such an agency exists down-under, where the Australian Digital Health Agency leads and oversees the ‘National Digital Health Strategy and Framework for Action.’ Within such a framework, state governments work with one another – and with their federal counterparts, on a national framework for electronic health records and interoperable and secure data management capacities.
The 2015 Panel articulates a renewed federal role in Canada that could spur national action of a similar sort: “The federal government must play a leadership role in collaborating with jurisdictional counterparts in the formation of a pan-Canadian health mechanism to identify, promote and advance needed healthcare innovation.” Writing in Policy Options during the pandemic, the University of Ottawa’s Mirou Jaana concurs: ‘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 contrast to Australia’s holistic efforts, Canada’s health ‘system’ remains a disjointed set of thirteen fiefdoms – all facing similarly escalating challenges in terms of costs and performance. Digitization is occurring, albeit in a ragtag manner detrimental to providers and patients alike. A recent study by the Commonwealth Fund ranked Canada tenth in a group of eleven countries (just ahead of the United States).
A pivotal moment in health care governance?
What about the billions in increased federal funding to Provinces, as well as additional bilateral agreements centered on ‘shared priorities’? Can this be a watershed moment in forging at least some of the groundwork for digital transformation for the country as a whole?
While any potential basis for shared action cannot be dismissed as a positive, the major shortcoming with the current approach is the absence of any formalization of governance across provincial, territorial and federal levels. Most Provinces are intent on minimal commitments to secure additional funds, while otherwise seeking to preserve as much operational autonomy as possible.
Digital transformation on a national scale, by comparison, means devising federated governance with both shared political will and integrative capacities for investments and actions. As the Privacy Commissioners have urged, developing a pan-Canadian, Health Data Charter offers a reasonable and overdue starting point. Such a charter could facilitate data-driven innovation and more modular and shared digital solutions – leveraging the foundational work of the Canada Health Infoway which presently lacks an operational mandate and implementation capacities.
While data has been a central theme of recent funding discussions, the emphasis has mainly been on gathering and reporting otherwise separate data sources from Provinces to better compare and track varying jurisdictional indicators and performance outcomes. By contrast, a National Health Data Charter – and the underlying infrastructure to enable its value, necessitates an interoperable infrastructure and integrative action plans underpinned by collective political will and shared accountability.
With such an overarching national governance framework in place, there are at least four priority areas calling for urgent and concerted attention: i) integrative workforce planning and skills development tied to digital health capacities; ii) shared solutions for digitizing health records and data management systems; iii) combatting health misinformation online and building cyber-resilience; and iv) emerging technological capacities for wider health innovation, notably Artificial Intelligence.
In terms of workforce and skills, beyond the intense competition for frontline healthcare professionals, there is a dire need for nurturing digital skills on a national scale, and for a common understanding of public sector skills requirements now and going forward. As governments compete with industry, and as Canada competes with the world, a holistic lens is essential. Not surprisingly, workforce planning is a key component of Australia’s national strategy for digital health.
With respect to shared solutions for digital health records and data management, here is where the role of the Canada Health Infoway can be expanded and better utilized. Rather than each Province and Territory creating separate data systems and vendor agreements to maintain such systems, a shared governance architecture – featuring the aforementioned Digital Health Charter, could strengthen readiness, improve efficiency, and better engage the public in addressing societal trade-offs between privacy protection and data-sharing.
Indeed, the Infoway has already provided a detailed ‘path forward for data sharing in Canada’ which provides a basis for such a coordinated approach. Similarly, Ontario’s own Health Data Council has devised a complementary vision for an emergent health data eco-system. Embracing a national approach, in turn, is not about constitutional change but merely a willingness on the part of Provinces to shift their mindset from control to meaningful collaboration, and for the federal government to become a strategic and supportive partner.
With regards to online misinformation – a challenge obviously transcending any set of domestic political boundaries, a recent panel formed by the Council of Canadian Academies ‘estimates that misinformation cost the Canadian healthcare system at least $300 million during nine months of the COVID-19 pandemic in 2021.’ At the same time, the growing risks of cyber-breaches and nefarious ransomware attacks on hospitals and clinics are a national security concern – one that also reinforces the importance of workforce and skills development in order to ensure collective resilience across all facets of health care governance.
Lastly, with growing Artificial Intelligence experimentation, governments must be agile and intelligent in balancing innovation, privacy, and trust. Openness and public engagement are essential in doing so. With roots in Canada, organizations such as the Responsible A.I. Institute are leading the way. Yet as smaller Provinces and Territories struggle to finance current priorities – let alone invest in emerging ones, the risks of deepening cleavages between jurisdictions escalate. With a national prism, the Australian Alliance for Artificial Intelligence in Health Care provides a detailed roadmap to ‘implement AI seamlessly and successfully across the healthcare system at a local, state and federal level to help create a resilient healthcare system’. A Canadian equivalent is a crucial element of next generation reforms.
The bottom line is that as with everything else, health care is going digital. In a world of some eight billion people, thirteen separate frameworks for digital health for less than forty million citizens is simply an absurd and harmful notion. It’s long past time for political leaders to step up, catch up, and work together.