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health care system that maintains the five principles of the Canada Health Act, is integrated, is supportive of community action, and is driven by information. (National Forum on Health 1997: 4, emphasis added)

A recent international IBM Special Report on health care suggested that: ‘Healthcare is in crisis…while this is not news for many countries, we believe what is now different is that the current paths of many healthcare systems around the world will become unsustainable by 2015’(Adams et al. 2007: 1 ). A more upbeat view of the Canadian system is presented in the Rock Report where it states that ‘while Medicare is sustainable as Canadians want it to be, we now need to take the next bold step of transforming it into a truly national, more comprehensive, responsive and accountable system’ (Rock 1999). In other words, this suggests that the question of whether the system is sustainable is not the right question to be asking, as we have little choice but to sustain it. More importantly, we have produced the health care system and therefore we have the power to make it as sustainable as we want it to be. Perhaps, the better question is how do we create a system that will be more sustainable than it is now?

In 1997, there were a series of reports that, in my view, for the first time brought attention to the idea that information technology had acquired the capability (through ongoing technological advancements) to help materialize a new vision of healthcare. This meant that a more coordinated approach to health information systems development would be needed in order to better support the sharing of data across the healthcare system (National Forum on Health 1997: 40). As a result of this line of thinking, developing a

collective vision or overall pan-Canadian strategy to guide the future development of healthcare was to become a high priority (Rock 1999: 6). I will now briefly describe the main line of argumentation that appears in two such reports in order to give the reader a better sense of what role information technology was expected to play in the renewal of the Canadian healthcare system.

Towards a Canadian Health Iway: Vision, Opportunities and Future Steps

One of the first published documents to make a strong connection between the challenges faced by the healthcare system and the possibility of IT enabling a solution was the CANARIE (Canadian Network for the Advancement of Research) report. In this report, it was stated that ‘Driven by fiscal realities, the recognition that there is room for improvement in the efficiency and effectiveness of our health services, and enabled by new technologies and new knowledge about the provision of quality care, our health system is being fundamentally transformed’ (CANARIE 1997: 3). The aim of this report was plainly stated as ‘to accelerate discussions among potential stakeholders and other public and private organizations in Canada leading to the development of the Canada Health Iway’ (CANARIE 1997: 1). CANARIE felt that now was an opportune time to begin a discussion on how Canada could leverage recent advances in information and communication technologies, commonly known as the Information Highway, to develop a national health information network. Importantly, they realized that getting various stakeholders involved in this dialogue was critical.

This report introduced the idea of a pan-Canadian network called the ‘Canadian Health Iway’, describing it as a virtual information centre that could be created and used by communities and individuals across Canada. More specifically, the Canada Health Iway would be ‘a network of networks, applications and people that collectively support a wide range of health-related systems, activities and services in support of Canadians in all part(s) of the country’ (CANARIE 1997: 1). Importantly, there was a strong acknowledgment that this network, formed by the interaction of both human and non- human elements, could enable a fundamental transformation of the healthcare system and

forge the way for a new vision of healthcare. The transformation was described in the following way:

We are moving from a focus on acute care and cure to a broader vision that includes health promotion and disease prevention; from a focus on central control of institutions to regional support of home and self- managed care; and from a reliance on medical specialists to a recognition by all citizens of the need to assume greater responsibility for their own health (CANARIE 1997: 3).

The CANARIE report also highlighted the need for a national strategy and framework in order to enhance the value of existing reform initiatives. This was one of the first times that healthcare information systems that ‘transcend traditional organizational, program and geographic boundaries’ (CANARIE 1997: 5) were being actively discussed. Importantly, the report also laid out a pan-Canadian vision of healthcare for the first time, along with specific acknowledgement of the many stakeholders that would need to be involved in the discussion. The vision of the kinds of things that the new system could afford was described as follows:

The Canadian Health Iway will be ‘a virtual “information centre” that is created and used by communities and individuals across Canada. It will be open and accessible, yet assure sufficient confidentiality and privacy to assist decision-making by health professionals and patients; support research and training; facilitate management of the health system; and respond to the health information needs of the public. The Network will be an agent of change for the health system and contribute to improving health of Canadians. It will foster the development of globally competitive technologies and services. (CANARIE 1997: 5)

In order to create the Canada Health Iway, three types of strategic partnerships were proposed: federal/provincial partnerships; private sector alliances with public sector organizations; and a partnership between Health Canada and Industry Canada to leverage

support from the private sector. Provincial/territorial governments would be held responsible for coordination, collaboration and the sharing of initiatives. Their aim would be to facilitate a team approach and minimize fragmentation. Health Canada and Industry Canada were to provide national leadership by stimulating and coordinating the development of the Health Iway and by promoting the development of the Telehealth and IT&T sector. More specifically, they would also be responsible for supporting Health Iway meetings, workshops and training opportunities and collaborative ventures. Telecommunications carriers were expected to work with the health sector to identify pricing options that would permit the integration of networked health systems into day- to-day operations. Even NGOs had a role to play by providing independent, non- governmental and non-industry viewpoints, as well as by taking on specific roles in specific initiatives. The Iway was envisioned as a truly collaborative venture.

The conclusion to the report was reflective of its more holistic view of technology: ‘Developing the Canadian Health Iway is not simply a matter of building technological connections and defining a means of promoting economic growth. While such an undertaking focuses in part on technology and is an element in the development of Canada’s information economy, developing the Health Iway will also deal with some of the fundamental values of concern to Canadians: health standards, public health promotion, training standards and the protection of personal privacy (CANARIE 1997: 15). This was a clear recognition that the building of a system of this magnitude would involve socio-technical factors that superseded technical concerns.

The Canadian Health Info-Structure: A Conceptual Overview

In the same year, the Canadian Health Info-Structure report was prepared as a background document for an upcoming National Conference on Health Infostructure. This conference, that was to be co-hosted by Health Canada and Alberta Health, was to take place in Edmonton in February of 1998. A major focus of the report was to look at what specific barriers existed that prevented the establishment of a health information system that would enable wider and better use of health information to support evidence- based decision-making. The desire to put an evidence-based system in place seemed to be

one of the major factors triggering the need for a pan-Canadian healthcare information system.

Notably, the report introduced a term that was to become a fundamental part of the future discourse in this area. Health Canada and Alberta Health, co-sponsors of the conference, coined the comprehensive term ‘info-structure’ to include four key components: a supporting technological framework; information and the application software needed to access, manipulate and organize it; the governance and management of information, including the standards to ensure interoperability, interconnectivity and reliability; people and organizations involved in creating the information, developing the applications and systems, constructing the facilities, and those using this infrastructure to deliver, maintain and improve health-related services for the benefit of all Canadians. Importantly, there was a realization that ‘in order for the health system in Canada to be organized and managed better to deliver health services, technology is a critical underpinning and an underlying enabler…. However, it is the use and management of information that will change the system’ (5). The overall implication was that simply focusing on implementing technology in healthcare would not be enough to bring about healthcare renewal. Social factors were important to consider too.

In identifying the key challenges moving forward, there was specific recognition of possible stakeholder issues originating in those aspects of the health info-structure that would ‘fundamentally change the way that stakeholders carry out their functions within the health system’ (23). A fundamental change in culture would ‘likely change the relationships between providers and consumers in a very basic way, shifting the current locales of information based “power” in the health system’ (24). There was also a realization that ‘a comprehensive health info-structure is beyond the capabilities of even the largest single jurisdiction’ (6) as ‘a wide variety of stakeholders are involved in the development process’ (7). Both of these observations implied that the lack of a collaborative approach to healthcare renewal could eventually impede change.

A couple of years later, building on the notion that such a system could enable a new vision for healthcare, the Rock report (1999) made a convincing argument that new

information and communication technologies should be strategically deployed as part of a pan-Canadian health information highway (what was now being called Canada Health Infoway, for short) to help ‘empower Canadians with better health information and new opportunities’ (Rock 1999: exec summary). Accountability appeared prominently in the logic: ‘if we are to build a better health system, we need a better information sharing system so that all governments and all providers can be held accountable to all Canadians’. By this time, there was an acknowledged realization that, due to current fiscal realities, the current ways of working in the healthcare system were no longer tenable. The focus of discussion, from this point on, was more on trying to find ways of capturing, analyzing and sharing information that would enable better healthcare outcomes. Overall, there was recognition that because the fragmentation in the healthcare system was mainly informational by nature, an IT solution was justified.

Fact 3: The EHR will integrate healthcare information, We will get reformed!