The Pan-Canadian Interoperability Roadmap: Does it get us where we need to go?

This article reflects the expertise and perspective of the Healthtech Editorial Team and represents a practitioner viewpoint based on real-world experience.

The fragmented nature of care in the Canadian health system has a direct impact on the daily experiences of both patients and physicians. While this fragmentation has its origins in long-standing structural features of the healthcare ecosystem, the COVID-19 pandemic has exacerbated its effects. Without burnout-inducing amounts of extra work, the result is a less complete and comprehensive clinical record than physicians need. I see these problems regularly in my own practice, where timely assessment and treatment of patients is often hampered by difficulties in accessing lab results. In the best-case scenario, this is merely frustrating for all concerned; in the worst cases, delayed care can have serious consequences for the patient’s health or quality of life.

Canada has made great strides in its digital health transformation in the last decade, with 91% of clinicians nationwide now using electronic records in their main practice setting, rising to 96% in hospital settings. But EHR implementation is only a stepping stone on the path to the full digitization of patient information. At present, access to certain types of patient data can be as low as 47%, with clinicians reporting that they waste more than an hour every day, on average, searching for data that should be readily available. Putting the right information in the right hands at the right time requires national data portability and interoperability standards to ensure that physicians can communicate adequately across systems and that patients can move their data effectively across provinces and territories. And here we are still in the early stages of Canada’s digitization journey.

Given the pressing need for systems that can enable more integrated care, Canada Health Infoway’s (CHI) recent release of its Shared Pan-Canadian Interoperability Roadmap is both welcome and timely. The roadmap sets out a long-term vision for digital health interoperability and then identifies the key building blocks and initiatives for achieving these goals. If recent expansions in central government funding are appropriately channeled into support for the CHI roadmap, there is real potential here for changing the health IT landscape across the country.

The roadmap has several key strengths:

• It avoids re-inventing the wheel. Instead of starting from scratch, the roadmap identifies lessons from other countries with more mature interoperability models and applies what has been learned to the Canadian landscape. For instance, the Roadmap takes the established International Patient Summary as a starting point and sets the development of a Canadian version as a deliverable. It is also well-positioned to accelerate the pace of development of the FHIR Canadian standard, a needed step for data interoperability.
• The governance model takes account of varying degrees of organizational maturity. The bottom-up and top-down framework outlined in the roadmap creates pathways for both mature organizations and those at the beginning of the digital transformation journey. It recommends a reasonable and achievable timeframe for implementation, which will be delivered through an iterative process that leaves room for incorporating the lessons learned at each stage.
• Key stakeholder perspectives are reflected, and the importance of funding and incentives is acknowledged. The roadmap is comprehensive in its integration of stakeholder views, reflecting all those that are critical to successful implementation. At the same time, there is a clear recognition that the desired outcomes cannot be achieved without adequate funding and a proper alignment of incentives. There is even a nod to the importance of change management and the provision of proper support to physicians and practices through the process, although the details of the mechanisms for delivering this support are rather vague.

The clinician and patient scenarios contrasting the current state of health IT with the target future state offer highly relatable sketches of the ground that needs to be covered. Whether a patient is receiving care at the academic center two hours away or in the emergency room in the same building as their family physician’s office, barriers to the flow of data are a frustrating waste of valuable resources. In many cases, the solution is relatively simple. A hospital-generated patient summary that could be incorporated into the EHR and a more usable provincial health information exchange would go a long way toward mitigating the current challenges.

However, before we embrace the frictionless flow of data as a silver bullet for systemic issues, a word of caution: Too much data can be almost as problematic as too little. I have seen this firsthand when practicing at an American organization with a mature health information exchange. Here, rather than struggling to get hold of information about my patients, I found myself drowning in a “deluge of dubious data” (thanks to Dr. Peter Greco at the MetroHealth System in Cleveland for introducing me to this phrase). While the CHI roadmap correctly identifies the eagerness of physicians to get their hands on more data, simply increasing the quantity risks overwhelming individuals and hindering their ability to find and process useful data. This is very much a case of "Be careful what you wish for.” What physicians really need, in my experience, is reconciled, summarized, accurate data, not an open fire hose of information. An overabundance of data, the wrong data at a given moment, or data that isn’t sufficiently accurate for the task at hand can all waste precious time just as easily as a lack of information.

Before turning on the flow of data, there are three things we need to consider if we want to avoid overwhelming already stressed systems:

1. Walk before running – Rather than exchanging as much data as possible as quickly as possible, consider a slower incremental process that leaves room for a thorough evaluation after each step. The patient summary is a good place to start. Even with the limited scope of the information included in the summary, a lot of work will be required to define many of the data elements in a way that optimizes their utility.
2. Align incentives – My office EHR uses a non-standardized vocabulary for the problem list, no standard for past medical history, and an outdated, provincially-mandated standard for billing. While a standard designed for billing will certainly not be ideal for diagnosis documentation, the provincial billing system should be structured to use the vocabulary that is most beneficial for clinical care, preventing the duplicative work that can be created by misaligned incentives.
3. Identify high-risk areas and the resources needed to address them – Medication reconciliation is a prime example. Even in the U.S., which is quite advanced, there is a lot of manual reconciliation work that frequently falls to the physician. Take a patient who is prescribed a Lopressor 50 mg twice a day by their family physician and is later admitted to the hospital where they receive an order for generic metoprolol 50 mg twice a day. The medication reconciliation lists generic metoprolol 50 mg 2x daily on discharge. When they are later seen by a specialist, she tells the specialist that she only takes half of the 50 mg tab or 25 mg 2x daily (half the prescribed dose). The specialist enters the reduced dose in her EHR, which is supported by best practices. The family physician receives a list of medications from the hospital and the specialist. Both contain a Beta-blocker, but neither is the same as originally prescribed. Should an EHR be expected to reconcile automatically? Until there are clear rules of the road that limit the amount of manual reconciliation needed, we need to think carefully about implementing exchange too broadly.

CHI’s Pan-Canadian Interoperability Roadmap does an excellent job of laying forward-looking but realistic foundations for the development of a truly integrated Canadian health system. However, as we start moving toward realizing this vision, it is essential that we remember that data fluidity is a means to an end rather than an end in itself. To truly harness the potential of the ever-increasing amounts of information that are now available to us, we need to ensure that the data delivered to end users is accurate, concise, and meets the needs of the moment.