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Mike recently chaired an event for UK companies to explore the opportunities for health information technology companies in Canada. Sponsored by UK Trade and Investment, GLE London, and the Canadian High Commission, the event attracted a group of firms with expertise in this sector, to hear presentations from EMIS and RIM and also learn about R&D tax credits, FP7 opportunities and partnering opportunities that are often not exploited.

Opportunities abound in Canada as it seeks to enhance the uptake of information technology in healthcare. Canadian physicians have a low adoption rate of office-based clinical systems, while connectivity between hospitals and primary care is not well developed. The focus in Canada has seen public investment, mainly linked to InfoWay, being poured into hospitals systems, with very little actually where the bulk of clinical encounters occur, namely in primary care. Slow adoption of electronic prescribing systems, coupled with often weak and poorly defined provincial electronic health record implementation strategies suggest that market entry opportunities lie in bringing order out of chaos and demonstrating clear benefits for clinician adoption.  The companies attending this event had that experience and could bring this level of structure to the market.

The partitioning of health markets into provincial systems means market entry strategies must pay particular attention to provincial characteristics and objectives, and incentives, such as tax credits, but also links to provincial infrastructure and innovation opportunities. There are pros and cons to each provincial system from a market entry strategy where the Alberta system has clearly centralised to Ontario with a purchaser/provider split and major reform underway in Quebec. There are also opportunities in specific market segments such as military health, prison health, workplace health and aboriginal health, which are frequently ignored as firms tend to focus on the publicly funded system as a whole and ignore these specific areas of opportunity and which offer market entry. Working with smaller Maritime provinces for instance offers scalable opportunities.

In addition, Canada’s position next to the US offers firms access through NAFTA, to take advantage of the huge stimulus in healthcare technology that is linked to health reform in the US; providers are early adopters and invest in technologies, including clinical systems so there are market-based opportunities around, for instance, clinical decision-support systems.

My own presentation focused on the opportunities working with Canadian academic health science centres [AHSC], which anchor provincial specialist service delivery, research and professional training. Since they combine research, teaching and service delivery, they offer partnering opportunities across a wide range of areas, and have sufficient commercial freedom to engage in alpha or beta partnering as well co-investment with start-ups. While many are still tied to the traditional technology transfer or licensing model, other ways of structuring deals are available.  They are valuable sources of new technologies for early stage investment, and with a relatively small early stage health investment community, the AHSCs are always looking for new people to have commercial discussions with. There is considerable interest by the federal government to ensure that early stage firms do stay in Canada so jobs and opportunities stay domestic, rather than being exported mainly to the US. But risk aversion and apparent shortage of second round financing sees many firms find their future with US investors. The removal, though, of disincentives in the income tax act which made life overly complicated for investors (similar to disincentives used in Australia) by the current government may encourage investors to feel more relaxed about the income tax regime.

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Beware digital errors as they can bite

We all know accidents (unusual occurances in healthcare) can happen. Where systems are involved, errors can arise from how a system works, the way the various bits mesh, the knowledge and training of everyone involved working together.  It is no real surprise that some errors arise from the technologies that we use. In particular, health information technology systems can cause new types of errors and mistakes, beyond just not working properly.

In the US, the Health IT Policy Committee has proposed establishing a database to track potential safety risks related to IT systems.  These risks include:

  • hardware and software failure and bugs
  • workflow interactions between staff and users
  • interoperability problems
  • implementation and training deficits.

Since healthcare work is complex, the workflow risks are particularly complex and can arise from, for instance, inaccurately understanding how a manual system achieves its results, and thereby designing a software-based system that fails to do just that. There is a funny little thing that happens when a patient sees a doctor; the doctor often will use writing a prescription to terminate the patient encounter — tearing the piece of paper off the tab, a swirl of signature and handing the slip to the patient leads to the patient leaving, a neat way to end the consultation.

In an automated system (electronic prescribing, for instance), the consultation is not terminated in this behavioural manner, but involves essentially hitting the return key on the keyboard to enter the required prescription data in the system, and perhaps handing (or not) the patient a copy — but the Rx is off on electronic wings to the pharmacy for dispensing. There is an error that can occur if the doctor does not hit the return key between patients — the Rx list builds up, from patient to patient, until the return key gets hit (unless some sort of failsafe has been built in); this error actually happened and it was an alert pharmacist commenting to the patient that the doctor had added a lot of new drugs that the alarm was raised. Perhaps the patient should have been more distrustful, too.

We must be mindful of risk and error in any kind of technology, but particularly in systems where it is very hard to look inside the black box of software code.

I wrote a paper on digital risk some years ago, which can be found here: Patient Safety and Digital Risk. I have also raised the issue of risk in the even blacker box of predictive algorithms used to data mine record systems and profile risk of patients and this can be found here: Predictive Health. This second paper suggested that software may need to be subjected to comparable regulatory review like a medical device.

Just because you can’t drop it on your foot, doesn’t mean something can’t be dangerous.