How Infoway is Changing Canada: A Conversation with Richard Alvarez
Richard Alvarez, a leader in Canadian healthcare, is known for taking on challenging mandates and building successful organizations. As President and Chief Executive 
Officer of Canada Health Infoway, he has been a catalyst for accelerating the development of electronic health records in Canada. We talked to Richard about his plans for advancing Canada’s health care system and the enigmatic “meaningful use.”
ZocDoc: What was the state of Canadian healthcare before Infoway was developed?
Alvarez: Prior to 2001, we were doing relatively well as far as hospitals having clinical information systems. From a community doctor’s perspective, things were pretty abysmal. Everyone operated individually; it was a bit like the U.S. system, from a competitive point of view. Two hospitals across the street would be competing, so they wouldn’t even share patient records. And in a lot of cases, doctors couldn’t share patient records if they had different systems. Prior to 2001, information systems were built around a specialty or a provider’s care, as opposed to being built around the patient.
There was no sense of standards, and clearly there was no economy of scale. It really helped that some of the studies coming out from the Institute of Medicine pointed to limited sharing of information and practices, and system error. We were actually injuring and killing thousands of people because we didn’t have the right information at the right time. A lot of these injuries and a lot of these deaths were preventable if the right information had been there. That was one of the factors leading to the formation of a national organization that could create the thinking and bring all the players together to focus on a patient’s record.
ZocDoc: What was the uniting idea that ended up bringing all the players together?
Alvarez: I think the number one issue around the world is the issue of sustainability and trying to smooth out the growth curve in terms of cost escalation. If one can be convinced that information technology does bring about improved quality of care, improved safety, productivity gain, efficiency gain, and better access, I think you can find win/win solutions for this. And it really helps if the federal government steps up to the plate and incents the states/provinces to move in the right direction by providing some funding. This requires them to have skin in the game, as we do, and that way we can find incentives. Obviously the key incentive is convincing the clinicians that all of this makes sense – that it is going to make them more productive. If you can sell all of that, I think you can sell a model which people will jump onto.
ZocDoc: How did you approach working with the government?
Alvarez: In Canada one of the things we did is quite unique for a national organization: we refused to fund the provincial jurisdiction on a per capita basis. We acted as strategic investors, which meant that the jurisdiction had to also see the need. They had to buy in, ready their resources, and have a project that was worth investing in. If they didn’t have any of those things, and if they didn’t show commitment, we wouldn’t invest in them because it would have been a total waste of money. Given the fact that there will never be enough money to go around at any point in time, it’s really important that you move with the earlier doctors. They can show the rest of the country the gains they are making and hopefully inspire the laggers to get on the bandwagon – that is so important.
ZocDoc: How much funding have you received from the Canadian government and can you talk a little bit about how you allocated it?
Alvarez: Right now I would say there’s in excess of 5 billion dollars in play, of which the federal government has put up 2.1 billion. Those funds are typically being matched by the jurisdictions as they build out their systems, and in some of the larger jurisdictions it’s even more than 50%. We’re looking to spend about 10 billion dollars over fifteen years, but the benefits are anywhere between 6 and 7 billion dollars on an annual basis. Where we spend a lot of money is the interconnectivity of the systems that are already in hospitals and the emerging EMR systems, which are already in doctors’ offices. We call that the Health Information Access Layer, which connects those systems and pulls that data.
ZocDoc: What successes have you seen so far, and what are your hopes for the future?
Alvarez: One of the things we’ve done already is funded demonstration projects. The name of the game here is not to have too many pilot projects where if the money runs out, the project stops and dies – we want to have systems built and sustained over a period of time. But it’s also important to show the possibilities of information technology and what it can do, so we’ve funded some of those demonstration projects. Politicians can stand up and point to certain areas and show real benefits for the population in their areas. Some of this really does require clinical transformation – clinicians have to practice in different ways to be able to utilize the technologies. Our new wave of money now is being spent to build out the EMRs in community settings. I really hope to be able to take the level of doctors using EMRs within the next two years from 17% (where we are today) to about 50%, with 35% making meaningful use of the EMR system. And we hope that with meaningful use, we can start to move onto maybe chronic disease management, and to develop consumer health solutions.
ZocDoc: How would you define meaningful use?
Alvarez: For us meaningful use would be, for an example, better prescribing, whether that’s anything from reducing call backs between the primary care prescribers and the pharmacists, or whether that’s actually moving to a reduction of adverse drug events. We would like to see meaningful use clearly extend to increase patient participation, where there’s a dialogue between clinicians who are now automated and an informed and engaged client or patient. We would like to see well-managed chronic diseases, especially diabetes, starting to happen in the community, with screenings and follow-ups. We would like to see meaningful use reduce duplicate and unnecessary tasks, and make it a lot more convenient for patients. We would like to see a real improvement in terms of wait times – if a doctor doesn’t have to see everyone in his office, if he can communicate with them in other ways, then he should probably do so, and only see those that he actually needs to see.
ZocDoc: Do you find that doctors are open to all of these changes?
Alvarez: Clearly the physician leaders are very open to this. Now, is the majority of doctors open to this? At this point in time I would say no. There is a lot of fear out there in terms of who is going to monitor them. There’s a lot of fear in terms of learning something new. And there’s a lot of fear in terms of who’s going to pay for it. I think that particular one is being taken away, because I think money is now becoming available for clinicians to get engaged. But my own sense is that the electronic health record, the electronic medical record, they have got to become a standard of care. And by 2016 we would like to see this as a standard of care and I think we’re going to get there.
ZocDoc: How would you convince a doctor that does not see the immediate benefits?
Alvarez: Well, it’s not a one-size-fits-all. Clearly there are some examples we have in terms of our diagnostic imaging systems where radiologists have improved their productivity anywhere between 25-30%. That means their earnings have gone up substantially, and it certainly improved their clinical decision-making by 30-90 minutes every week. So for some parts of the system it’s very, very clear-cut. For other parts of the system it’s less clear-cut, and we’ve scanned the world looking for case studies where there has been a bit of a bump to get over while changing systems. We’re making productivity improvements available to physicians, we’re creating demonstration sites across Canada, and what we’re finding is that in some cases physicians are having to work a lot less because now they’re communicating electronically with their patients. They don’t have to bring their patients in to tell them what their labs test results are, etc. So this automation is giving clinicians a different way of working.
ZocDoc: Which aspect of healthcare needs stimulus money the most?
Alvarez: I think the first for us would be aspects of interoperability. You’ve got to be able to pull down a complete history of an individual, certainly in terms of the medications, their lab tests, etc. So following some of those standards, and embedding them in your system is absolutely key. If you look at the rhetoric, if you look at the reasons within the stimulus package, it is around patient safety, it is around quality of care. And the IOM have been on to this for a long, long while, so if you read their documents, patient safety is a key element.
ZocDoc: Tell us about how you plan on setting standards.
Alvarez: I’ll tell you what we’re doing, and why we deviate slightly from what ONCHIT is doing. We’re going to be funding vendors to upgrade their systems for aspects of interoperability, aspects of privacy and security, and aspects of just a couple of issues of functionality. One would be immunization management, and the other would be e-prescribing. We are not going to be prescriptive in terms of functionality. We want the market to play and compete around aspects of functionality. We have what we call Standards Collaborative, which we run out of Infoway. It consists of all the jurisdictions across Canada, and their key people – clinicians, nurses, pharmacists, and the private sector. So, yes we do have a process that’s been around for quite awhile. Infoway is now moving into certification of some of these systems based on the standards we’re putting forward.
ZocDoc: This is a question we ask often: what are your recommendations on revamping the healthcare system in the United States?
Alvarez: I think what’s really important is trying to get buy in for what is needed. And that’s the tough part for knowing what you’re going to invest in, and how you’re going to invest. I haven’t seen that yet, it takes awhile to develop. And in terms of meaningful use, I think it’s brilliant. We do not want to fund clinicians who use their computers as doorstoppers. So meaningful use should be absolutely clear – I think there should be a definition of what is mandatory, and what is nice to have. The market will play at developing the solutions if they can follow some core set of standards, especially around aspects of interoperability, and trying to get on with the job. I think there’s a lot of excitement, and now’s the time to capitalize. It’s absolutely important to get some of the clinician leaders on site, because there’s going to be a lot of opposition from the status quo not wanting to change things, and that’s not good. It’s also important to get a strong consumer voice in this discussion, because what all these systems are about is our patients and our consumers. Their voices really need to be heard.
