Early on the last Friday morning in November, Will Falk is headed north to a yoga class in Orangeville while he fits in a call with us. Will, who describes himself as “peripatetic,” has also taken up tennis in his “downtime,” in between his involvement in a plethora of digital health initiatives, think tanks, educational institutions and private companies. “It has been nice to have a bit of time,” he says. “When I was running a professional services business, I was always running at 100 km an hour trying to meet clients’ needs – it was fun, exciting and stimulating, but I had no time.”
Now a retired partner with PwC Canada, Will is an Adjunct Professor at the Rotman School of Management at the University of Toronto where he teaches a course on innovation in healthcare with digital health futurist Zayna Khayat and, four times a year, hosts Rotman’s School of Management series of public panel discussions and presentations on health IT.
A frequent speaker and writer, he is also Executive in Residence at clinician-focused software developer Think Research; a Senior Fellow at the public policy think tank C.D. Howe Institute for which he and Dr. Sacha Bhatia co-wrote a policy paper last May on modernizing Canada’s healthcare system; a Fellow at public policy think tank the Mowat Centre; an Innovation Fellow at Women’s College Hospital; a Board Advisor at homecare software developer AlayaCare; and an advisory board member at GPS tracker device-maker LocateMotion. This is not even the complete list. All of these activities, he explains, “put me in the middle of a bunch of discussions.” We spoke to Will about his thoughts on some of those discussions and on a number of other digital health issues.
Gevity: At the November 13, 2018 Rotman lecture (What Comes Next for Digital Health), you spoke about your long involvement in digital health and the early days of Smart Systems for Health Agency. You also said that you think we’re at an inflection point. Can you expand a bit on what you meant? What do you predict will happen next?
WF: On some days I honestly feel the 15-20 year journey has been a very slow one. As you trace the history 20 years ago, policy makers recognized that health care is increasingly an information business and they have started putting money into making that happen. It’s not just an Ontario or Canada thing – the UK, the U.S., Germany, Netherlands, Australia and elsewhere have all done it. Because of the nature of Canadian federalism, we took a jurisdictional approach coordinated by Canada Health Infoway, and each of provinces, including Ontario, launched external agencies with coordinating and spending bodies to put those together. We have been through a series of initiatives but in Ontario over the past few years of the Wynne government we stalled a bit in terms of making timely decisions on what comes next. I was trying to be hopeful about the fact that there are some simple and clear decision points in Ontario that should allow a clear path forward to usable tools for clinicians and their patients.
Gevity: One of the issues that invariably comes up in discussing the path forward is the role of government and of the private sector as the digital health sector matures and evolves. Where are we now and what needs to happen at this point?
WF: As technologies have improved, there are a number of things that are currently in the “e-health portfolio” that are now commodity services provided by many vendors. There are also a number of specialty systems, such as labs, drugs and diagnostic imaging, for which there are good, robust competitive markets. An active government could slim down the number of assets they run within the system and create a vibrant, competitive environment for digital heath. That would mean that we would need to change our view of the role of government in this sphere.
Take the example of OneID (a digital identity and access management tool for clinicians) and OneMail (an encrypted email service to exchange patient health information securely): it made sense for the government to deliver those in the late 1990s and 2000s, but today, that’s just commodity identity management and secure email – and it’s much more expensive for the public sector to deliver it than it is for the private sector.
Another good example is Drug Profile Viewer, which provides prescription drug claims information. What is the cost per view and can it be more easily delivered by a private vendor? It’s just the nature of the way technology develops and changes; government procurement processes are caught in “yestertech,” but we need a nimbler approach.
This applies to areas beyond health care; in any industry created by a government, there are a series of phases. During the first part of the journey, you have to create the assets, so in the early days of Smart Systems for Health (as the current agency E-Health Ontario was called), we were in creation mode; we then started shifting into more of a consolidation role where governments chose winners and picked standards. Today, we’re in the third phase in which there is a pretty robust competitive market in a number of these systems. For example, there are dozens of portals in Canada, but there are a lot of different customer segments. The government’s job is to manage competition among those so we have a robust competitive market – but it’s also so that large vendors don’t use their market position inappropriately.
Where we used to build assets we now need to manage and regulate a market – and I’m not 100 per cent sure that governments have embraced the changing role they have; it’s different to regulate for competition than to subsidize the creation of an industry.
The question now is what is the role of government? What do we do with government agencies delivering digital services? In Ontario, there are a dozen different assets being delivered by different entities; private companies and public sector organizations are delivering the same services. The question is should government, if there is a robust private market, be using public funds to subsidize companies to deliver those service? Should government be competing with the private sector?
Gevity: So what’s the good news?
WF: The good news is we have a thriving technology community in Canada. We’ve got dozens of companies growing to scale, thousands of people entering the industry and a lot of positive stuff going on in Toronto, Montreal and Vancouver. We no longer have to rely on American software, for example; we’re developing some really innovative technology here at home.
Gevity: One of the issues that was discussed at the recent Rotman event was the need for a digital by design mindset and to integrate digital health into care and funding models, and into legislation and regulations. Is that your view as well, and if so, do you see evidence that is happening in Canada?
WF: Regulations and funding models have been the great holdup in implementing new models of care. There are two dimensions to this issue: colocation/virtual (referring to whether patients are in the same place or not), and synchronous/asynchronous (referring to whether care happens at the same or a different time). Governments have long taken the position that physical contact is necessary for care to be delivered – but that has not been true for 20 years. They have created special-purpose organizations and fee codes that limit who can be paid for virtual care. Today not only is there control over colocation of patient and provider, but often systems still insist on synchronicity; they don’t view asynchronous care as valid.
Gevity: How do we overcome this mindset?
WF: What is needed is a dedicated, thoughtful approach to opening up virtual care. It’s clear that the physical colocation of patients and providers should no longer be a barrier to care, but that means hospitals will have to be in three businesses, not two. Fifty years ago, they were inpatient facilities; then they became inpatient and ambulatory facilities. Now they have to add virtual to the mix. This is the same kind of big historical change as was the addition of ambulatory care, and for some hospitals, and for some conditions, virtual care will be a bigger percentage of their work than the first two. It’s not just about moving to home and community – this is about the fact that 25 per cent of what hospitals will do will be virtual and the entire hospital has to think about what that will mean. There are some great international examples of hospitals that have already evolved this way and now there are about a dozen hospitals around the world without beds, world including Women’s College Hospital, which is only ambulatory and virtual now.
Gevity: What does this mean for physicians?
WF: For physicians, depending on their specialty, virtual care may be an even bigger percentage of the care they deliver. The issue is the current system will not pay physicians appropriately for virtual care, and the regulatory environment is also unclear, so doctors are understandably reticent to move their full practice into an uncertain economic world. In Nova Scotia, for example, when providers moved about 20 per cent of their patient visits to virtual care, their income dropped about 10 per cent, so telling someone they should move to virtual and then not pay them appropriately is not a fair way to approach the situation. Past work has shown that all specialty practices could move 20 per cent of their volumes to virtual; in fact, many are able to move almost half to virtual, but you have to get serious about figuring out pricing. In the policy paper Dr. Sacha Bhatia and I did for C.D. Howe in May 2018, we highlighted the need for both a clinical and a pricing review of every fee code, as we recognize that current OHIP fees need to be adjusted not just for care provided virtually, but for in-person care as well since the types of cases physicians see in-person may become more complex. Virtual care should also be part of bundled pricing and providers should be free to substitute virtual for in-person care where appropriate.
Gevity: Patients/consumers are driving the demand for digital health because it’s clear it will make health care easier to access, more convenient, possibly cheaper and potentially more accurate. What does the value proposition have to be for care providers and is that being considered to the extent it should be?
WF: User experience will be a major focus in digital health in the next five years. Dr. Atul Guwande has written about why it’s important in the provider space and I agree – efficiency and usability for providers has not been focused on as we’ve created these systems. That’s partly because the big U.S. vendors who have been driven by the demands of (U.S.) Meaningful Use (an incentive program to encourage clinicians to use electronic health record technology) and the High Tech Act now need to refocus on providing a better experience for providers. Most of those systems were built using older technologies, which is not an uncommon problem in other industries. My best guess is there will be multiple solutions that will emerge, underlying systems will improve slowly and there will be wrapper software that will envelope and improve the functionality for providers of underlying systems. In some parts of banking and telecommunications, they still have green screens from the 1970s but the user experience is based on modern wrapping software. They’ll use APIs to communicate with underlying systems so they’re going to wrap the systems as we go forward. It would be great if we could get some new entrants but the switching costs are very high, and I don’t know anyone with a reasonably modern HIS thinking of switching away from that system in the next 10-20 years. So what is your path forward? If you have a modern system installed and your docs hate it, what are you going to do?
On the patient side, I think the patient user experience represents a big challenge and a big opportunity. It’s obvious to me now that integration across the whole system doesn’t work; 100 per cent integration is a myth that is used by systems integrators to create a market. It is much more practical to allow patients to access their medical records and to allow them and their families to control access to a set of providers. As a baby boomer with an elderly parent, that is what I do and what I will do with my own health care – I’m not saying we don’t need the clinical connect projects and open sharing of information but I think a much nimbler more patient-centred approach is likely to overtake that. In a way we have been victims of our own rhetoric. We made a fundamental mistake in our original conception of the challenge; the way we set the problem up is we said all providers should be able to access all data on all patients – but why? Many Canadians don’t need a health record and the ones who do often need a specialized kind of health record, so this notion of one size fits all doesn’t make any sense. If you are a cancer patient, you need a well thought-through cancer journey. I’m not saying the same person may not need to manage co-morbidities; I’m just saying 100 per cent of information 100 per cent of the time gets buried, so purpose-built, thoughtful solutions built on core systems that are invisible and wrapped is probably where we need to go. That’s a problem if I’m in the business of building big old clunky core systems – I probably built three of those – but it doesn’t mean that’s what we should be doing today. I think the next five to 10 years will see both patient- and provider-focused design drive in better directions.
Gevity: One of the audience members at the November Rotman panel discussion expressed serious concerns about the potential for disruption to our universal care model. What are your perspectives on this?
WF: I think this comes back to regulation. The slowness of policy makers to create appropriate pricing and regulatory environments threatens to undermine Canadian medicare by creating or allowing the creation of a separate, digitally enabled, more desirable tier of care. It’s incumbent upon responsible policy makers to ensure they modernize our system at an appropriate pace – by not modernizing the system, they create the opportunity for two-tier medicine. The appropriate policy response is to modernize and embrace the technologies, not to live in some Luddite world where care is only delivered if there is a laying on of hands. Caring also means not making people travel; it’s less obvious to policy makers how much it costs people emotionally and financially to travel, even in urban environment. The 82-year-old who is unnecessarily made to risk life and limb on an icy February day to spend three hours in a place full of sick people for normal follow-up visits is victimized by slow policy and it makes me angry we can’t figure this out.
Gevity: There has been lots of talk lately about voice being the next big thing that will drive major advances in digital care. Do you agree?
WF: Voice is being hyped heavily now, and there is some really interesting and great work on it in Toronto, where at least one company is looking at the diagnostic value of voice. For some consumers/patients – particularly people with visual challenges, and people with both low and high computer literacy – voice will be the perfect interface. It may also contribute to a better user experience for physicians, because so much of physician resistance is about keyboard usage in that it comes between them and the patient and they have to constantly wash their hands and then reauthenticate. Because those are barriers to use, voice may be a really workable solution and it may be a great example of a wrapper UX. It may also help solve some of the challenges in making technology more easily accessible for seniors.
Gevity: The Rotman series seems to be extremely popular. What can we expect in the future?
WF: It has become a bit of a hot ticket, which is great! On Dec. 4, we had Avi Goldfarb, Rotman’s Chair in Artificial Intelligence & Healthcare, and three companies using AI in their daily business at a session on Artificial Intelligence and Healthcare. In February, we’re introducing five to six young Canadian companies and having them do pitches at a session on How Ontario's Digital Entrepreneurs Are Creatively Destroying and Modernizing Healthcare. In March, we’re hosting a session titled How Innovative Entrants are Changing the Way We Think about Health Care.