Mobile innovation – gathering the evidence
As the country that invented the BlackBerry it comes as no surprise that Canada is leading the world in testing the clinical benefits of mHealth applications.
First, the University of British Columbia Centre for Disease Control (UBC CDC) is running a research project from 2012 to 2014 examining the influence of mobile phones and SMS text messaging on patients with latent tuberculosis infections. Specifically, it will gauge the effects of regular SMS messages on how closely patients follow their prescribed treatment plans.
To test this, half of the study participants will receive weekly text messages asking how they are doing with their prescribed treatment. Adherence to the treatments by all participants will be assessed by monthly visits to a clinic where blood tests and patient interviews will take place.
The researchers are predicting that communication with a healthcare provider through a structured cell phone SMS text messaging based program will result in an improvement in the proportion of patients completing their treatment plans of around 15%.
The work builds on research carried out by the team on the effect of SMS text messages on HIV-infected patients taking antiretroviral medication. After the first year of treatment, patients receiving the messages were 27% more likely to be following their medication regime closely, and 19% more likely to have fully suppressed viral levels compared with those who received standard care.
A second project is taking place in Toronto, provincial capital of Ontario.
The Centre for Global eHealth Innovation at Toronto’s University Health Network has developed “Bant”, a range of mobile applications that help patients to manage diabetes (named for Frederick Banting, co-discoverer of insulin).
Users can record their glucose readings, upload data to health records and share information. A recent innovation is an iPhone application that connects to a glucometer using Bluetooth. It has been designed to appeal to young patients, helping them to overcome reluctance to using blood glucose monitors at school or college several times a day, pricking their fingers and taking readings. The Bant app includes gaming elements that reward teens with iTunes credits every time they use their glucometer.
Young people are also the focus of work by Dr Jennifer Stinson, a researcher working with the Chronic Pain Program at the Hospital for Sick Children in Toronto. Stinson and her colleagues are developing mHealth applications that help young people manage painful chronic and life-threatening conditions.
Currently, she is developing online tools such as a self-management care program for youth cancer, as well as smartphone tools and web-based applications that help young people provide regular feedback to doctors about painful conditions such as arthritis and sickle cell disease.
Healthcare for all within a Federal Framework
Toronto has also been the centre of work on more general mHealth applications. For example, Sunnybrook, the largest single-site hospital in Canada, offers the MyChart service to all patients, enabling them to access their health records, appointment and medication reminders via smartphones.
However technology advances are often perceived as isolated examples, leading to discontent among groups representing the interests of all Canada’s patients. Reflecting on the Sunnybrook service, the Patients’ Association of Canada said: “There are some places where one can get appointments online but these remain few and far between. And the archaic fax machine remains a necessity almost everywhere for renewing prescriptions. As patients, we can take the lead in expecting to access our medical records electronically.”
Responsibility for ensuring that healthcare services are available to all Canadian citizens falls to the federal government, exercising powers set down in the Canada Health Act of 1984.
The federal government is responsible for health protection, regulation of pharmaceuticals, food and medical devices, and disease surveillance and prevention. It also provides support for health promotion and health research.
Provincial and territorial governments have most of the responsibility for delivering health and social services within guidelines set by the federal government. The Act sets out the criteria for health insurance plans that must be met by provinces and territories in order for them to receive federal cash transfers in support of health.
Publicly funded healthcare is financed through a mix of federal, provincial and territorial taxation. Provinces may also levy a health premium on residents to help pay for publicly funded health care services, but non-payment of a premium cannot limit access to medically necessary health services. With a few exceptions, all citizens qualify for health coverage regardless of medical history, personal income, or standard of living.
Modernising the system, including healthcare ICT innovations such as electronic health records, requires all levels of government to work together. The first steps were taken in 2000 when federal, provincial and territorial government leaders agreed key reforms in healthcare ICT, supported by increased cash transfers from the federal government.
This was followed by the Accord on Health Care Renewal in 2003, which committed Canada to specific implementations of healthcare ICT such as electronic health records, and telehealth, and in 2004 by the 10-Year Plan to Strengthen Health Care, which set out further commitments to the use of new technologies.
But Canada is fast approaching a crossroads in 2014, when the Canada Health Accord comes to the end of its 10-year commitment. New policies for strengthening the use of new technologies in healthcare are needed, and must take the whole range of new mHealth projects and trials into account.
The federal agency with perhaps the greatest influence on take-up of mHealth across the country is Canada Health Infoway, an independent, not-for-profit organisation given the task of accelerating development of electronic health records (EHR) across Canada.
Established in 2001, its members are Canada's 14 federal, provincial and territorial Deputy Ministers of Health. Infoway aims to work closely with the country’s ten provinces and three territories, enabling best practices and successful projects in one region to be shared or replicated in other regions.
In particular, Infoway is responsible for drafting the “EHR Blueprint”, a high level technology specification aimed at a broad audience. This includes IT professionals in government agencies and healthcare providers at all levels. It is also intended for private sector technology vendors intending to develop products and services that are compatible with Canada's plan for an interoperable electronic health record.
Infoway could be well-placed to maximise the gains made by the clinical researchers in British Columbia and Toronto: an important part of its remit is fostering and supporting clinical adoption of EHRs, including point-of-care systems used by health care professionals such as electronic medical records.
It aims to achieve this by supporting clinical health IT support networks, promoting demonstration sites and case studies, and developing knowledge-sharing toolkits and evaluation guidance for EHR projects. In June 2011, Infoway set up an Emerging Technology Group with a remit that includes providing guidance on the privacy and security aspects of smartphones and tablets.
Infoway also shapes the development of healthcare ICT by funding projects. In 2011 it opened two new funding streams: Accelerate and Imagine. The Accelerate project stream is intended to develop new initiatives with proven value for clinicians and patients, while the Imagine project stream is focused more on identifying and exploring innovations in healthcare delivery.
Future Challenges: A Regional Framework
In 2011, Canada’s total spending on healthcare reached $200 billion, amounting to roughly 12% of GDP. The country had the 7th most expensive system of 34 countries examined, according to an OECD survey in 2010.
Many Canadians do not see the results as meeting expectations, according to a report by Gartner and Praxis in 2011. “Access, productivity and quality continue to be challenges facing Canadian health systems. It is becoming more difficult to deliver healthcare, in line with expectations of quality and cost, whilst achieving expectations for improvements in effectiveness and efficiency and equitable access to care,” Gartner said.
Some influential observers agree. Canadian healthcare needs to broaden its scope, including prevention and socio-economic factors. It needs to be centered more on the patient, and place greater emphasis on managing chronic conditions if it is to satisfy public expectations, suggests economist Don Drummond, a Fellow at Queen’s University who has also served as Chair of the Commission on the Reform of Ontario Public Services.
The Gartner research proposes that greater use of telehealth services could make an important contribution to such efforts, not least from the cost perspective: estimated future benefits of telehealth could lead to annual savings of approximately $730 million for the health system, and an additional $440 million in cost avoidance for patients, it says.
However, there are a number of barriers to greater adoption of online consultations with patients, including lack of financial incentive and lack of clarity about the regulatory issues for physicians, says Gartner. More work on issues facing clinicians is needed, but this cannot be at the expense of greater progress with electronic health records, “a critical success factor to telehealth adoption and benefits realization.”
Despite this need, there is a perception in Canada that progress with electronic health records has been leisurely. An OECD statistic published in 2009 reinforced this view: just 37% of Canadian primary care physicians reported using electronic medical records, compared with more than 90% in countries on a similar path.
This is in spite of Infoway’s investment of more than $1.6bn in more than 280 projects over a period of ten years. There are two main reasons for this lack of progress, according to research based on interviews with key stakeholder groups, and published in 2011 by the journal of the Canadian Medical Association.
A typical view was that there has been an absence of policies that could produce a strategy for engaging clinicians: the direction and priorities of work on electronic health records have not been informed by their needs. To accelerate adoption, study participants identified four key requirements:
- Meaningful engagement of clinicians
- Coordination between provincial, professional and regulatory authorities
- A revised model of financial incentives for use of electronic health records
- Focus on technology that would improve the value of health care
The second concern related to the aim of a national infrastructure for electronic health records. Although many study participants believed that national and even international standards are highly desirable, national interoperability was not seen as a key priority.
Instead, it was suggested that efforts should be focused on regional interoperability to support clinical adoption, and to increase the speed of implementation. There were concerns that Canada Health Infoway was unreasonably ambitious in its attempts to attain national interoperability when regional interoperability seemed more important, less expensive and easier to implement.
Political systems across the world are currently facing similar challenges – when it comes to mHealth adoption, a strong regional strategy within a national framework often seem the most powerful.