Tag Archives: healthcare

Public Policy: The Big Opportunity For Health Record Data

A few weeks ago Colin Hansen – a politician in the governing party in British Columbia (BC) – penned an op-ed in the Vancouver Sun entitled Unlocking our data to save lives. It’s a paper both the current government and opposition should read, as it is filled with some very promising ideas.

In it, he notes that BC has one of the best collections of health data anywhere in the world and that, data mining these records could yield patterns – like longitudinal adverse affects when drugs are combined or the correlations between diseases – that could save billions as well as improve health care outcomes.

He recommends that the province find ways to share this data with researchers and academics in ways that ensure the privacy of individuals are preserved. While I agree with the idea, one thing we’ve learned in the last 5 years is that, as good as academics are, the wider public is often much better in identifying patterns in large data sets. So I think we should think bolder. Much, much bolder.

Two years ago California based Heritage Provider Network, a company that runs hospitals, launched a $3 Million predictive health contest that will reward the team who, in three years, creates the algorithm that best predicts how many days a patient will spend in a hospital in the next year. Heritage believes that armed with such an algorithm, they can create strategies to reach patients before emergencies occur and thus reduce the number of hospital stays. As they put it: “This will result in increasing the health of patients while decreasing the cost of care.”

Of course, the algorithm that Heritage acquires through this contest will be proprietary. They will own it and I can choose who to share it with. But a similar contest run by BC (or say, the VA in the United States) could create a public asset. Why would we care if others made their healthcare system more efficient, as long as we got to as well. We could create a public good, as opposed to Heritage’s private asset. More importantly, we need not offer a prize of $3 million dollars. Several contests with prizes of $10,000 would likely yield a number of exciting results. Thus for very little money with might help revolutionize BC, and possibly Canada’s and even the world’s healthcare systems. It is an exciting opportunity.

Of course, the big concern in all of this is privacy. The Globe and Mail featured an article in response to Hansen’s oped (shockingly but unsurprisingly, it failed to link back to – why do newspaper behave that way?) that focused heavily on the privacy concerns but was pretty vague about the details. At no point was a specific concern by the privacy commissioner raised or cited. For example, the article could have talked about the real concern in this space, what is called de-anonymization. This is when an analyst can take records – like health records – that have been anonymized to protect individual’s identity and use alternative sources to figure out who’s records belong to who. In the cases where this occurs it is usually only only a handful of people whose records are identified, but even such limited de-anonymization is unacceptable. You can read more on this here.

As far as I can tell, no one has de-anonymized the Heritage Health Prize data. But we can take even more precautions. I recently connected with Rob James – a local epidemiologist who is excited about how opening up anonymized health care records could save lives and money. He shared with me an approach taking by the US census bureau which is even more radical than de-anonymization. As outlined in this (highly technical) research paper by Jennifer C. Huckett and Michael D. Larsen, the approach involves creating a parallel data set that has none of the features of the original but maintains all the relationships between the data points. Since it is the relationships, not the data, that is often important a great deal of research can take place with much lower risks. As Rob points out, there is a reasonably mature academic literature on these types of privacy protecting strategies.

The simple fact is, healthcare spending in Canada is on the rise. In many provinces it will eclipse 50% of all spending in the next few years. This path is unsustainable. Spending in the US is even worse. We need to get smarter and more efficient. Data mining is perhaps the most straightforward and accessible strategy at our disposal.

So the question is this: does BC want to be a leader in healthcare research and outcomes in an area the whole world is going to be interested in? The foundation – creating a high value data set – is already in place. The unknown is if can we foster a policy infrastructure and public mandate that allows us to think and act in big ways. It would be great if government officials, the privacy commissioner and some civil liberties representatives started to dialogue to find some common ground.  The benefits to British Columbians – and potentially to a much wider population – could be enormous, both in money and, more importantly, lives, saved.

If the Prime Minister Wants Accountable Healthcare, let's make it Transparent too

Over at the Beyond the Commons blog Aaron Wherry has a series of quotes from recent speeches on healthcare by Canadian Prime Minister Stephen Harper in which the one constant keyword is… accountability.

Who can blame him?

Take everyone promising to limit growth to a still unsustainable 6% (gulp) and throw in some dubiously costly projects ($1 billion spent on e-health records in Ontario when an open source solution – VistA – could likely have been implemented at a fraction of the cost) and the obvious question is… what is the country going to do about healthcare costs?

I don’t want to claim that open data can solve the problem. It can’t. There isn’t going to be a single solution. But I think it could help spread best practices, improve customer choice and service as well as possibly yield other potential benefits.

Anyone who’s been around me for the last month knows about my restaurant inspection open data example (which could also yield healthcare savings) but I think we can go bigger. A Federal Government that is serious about accountability in Healthcare needs to build a system where that accountability isn’t just between the provinces and the feds, it needs to be between the Healthcare system and its users; us.

Since the feds usually attach several provisions to their healthcare dollars, the one I’d like to see is an open data provision. One where provinces, and hospitals are required to track and make open a whole set of performance data, in machine readable formats, in a common national standard, that anyone in Canada (or around the world) can download and access.

Some of the data I’d love to see mandated to be tracked and shared, includes:

  • Emergency Room wait times – in real time.
  • Wait times, by hospital, for a variety of operations
  • All budget data, down to the hospital or even unit level, let’s allow the public to do a cost/patient analysis for every unit in the country
  • Survival rates for various surgeries (obviously controversial since some hospitals that have the lowest rates are actually the best since they get the hardest cases – but let’s trust the public with the data)
  • Inspection data – especially if we launched something akin to the Institute for Health Management’s Protecting 5 Millions Lives Campaign
  • I’m confident there is much, much more…

I can imagine a slew of services and analysis that emerge from these, if nothing than a citizenry that is better informed about the true state of its healthcare system. Even something as simple as being able to check ER wait times at all the hospitals near you, so you can drive to the one where the wait times are shortest. That would be nice.

Of course, if the Prime Minister wants to go beyond accountability and think about how data could directly reduce costs, he might take a look at one initiative launched south of the border.

If he did, he might be persuaded to demand that the provinces share a set of anonymized patient records to see if academics or others in the country might be able to build better models for how we should manage healthcare costs. In January of this year I witnessed the launch of the $3 million dollar Heritage Health Prize at the O’Reilly Strata Conference in San Diego. It is a stunningly ambitious, but realistic effort. As the press release notes:

Contestants in the challenge will be provided with a data set consisting of the de-identified medical records of 100,000 patients from the 2008 calendar year. Contestants will then be required to create a predictive algorithm to predict who was hospitalized during the 2009 calendar year. HPN will award the $3 million prize(more than twice what is paid for the Nobel Prize in medicine) to the first participant or team that passes the required level of predictive accuracy. In addition, there will be milestone prizes along the way, which will be awarded to teams leading the competition at various points in time.

In essence Heritage Health is doing to patient management what Netflix (through the $1M Netflix prize) did to movie selections. It’s crowdsourcing the problem to get better results.

The problem is, any algorithm developed by the winners of the Heritage Health Prize will belong to… Heritage Health. This means the benefits of this innovation cannot benefit Canadians (nor anyone else). So why not launch a prize of our own. We have more data, I suspect our data is better (not limited to a single state) and we could place the winning algorithm in the public domain so that it can benefit all of humanity. If Canadian data helped find efficiencies that lowered healthcare costs and improved healthcare outcomes for everyone in the world… it could be the biggest contribution to global healthcare by Canada since Federick Banting discovered insulin and rescued diabetics everywhere.

Of course, open data, and sharing (even anonymized) patient data would be a radical experiment for government, something new, bold and different. But 6% growth is itself unsustainable and Canadians need to see that their government can do something bold, new and innovative. These initiatives would fit the bill.

Fatness Index 2 years on: the good, the bad, the ugly

Two years ago I saw that Richard Florida and Andrew Sullivan had re-posted a map created by calorielab that color-coded US states by weight.

As I found it interesting I created a North America wide map the included Canadian data (knowing that it probably would be a perfect apple to apple comparisons). The map and subsequent blog post turned into one of my best viewed pages with well over 20,000 pageviews.

The very cool people over at Calorie Labs informed me that they have released an updated version of the American map (posted below, you can see the original at their site here). Not too much has changed, but after looking at the map I’ve a few comments.

Calorie lab’s release of an updated version of the map has triggered a few thoughts and some lessons that I think should matter to policy makers, health-care professionals and citizens in general. Here they are:

The Good

The amazing people at Calorie Lab. When I created the map 2 years ago I didn’t even check to see if their work was copyrighted. Although the data was public domain, I copied Calorielab’s colour palette as I was trying to create a “mash-up” of their work with Canadian data. I wanted the maps to look similar. My map was a derivative work.

Did the people at Calorielab freak out? No. Quite the opposite. They reached out, said thank you and asked if I needed help.

It seems this year they’ve gotten even cooler. I don’t remember if the original map’s license but with the publishing of their 2010 update they wrote:

CalorieLab’s United States of Obesity 2010 map is licensed for use by anyone in any media and can be downloaded in various formats (small GIF, large GIF, SVG, EPS).

There’s a line directed specifically at people like me. It says, please, use this map! Not only is the license open but they’ve provided it in lots of formats (Which is great cause two years I had to recreate the thing from scratch and it took hours).

So naturally you are wondering, where is David’s 2010 mashup-Northern American Fatness Index.

The Bad

The bad is that trying to find the Canadian data is a pain. A couple of times a year I get a cool idea for a visual or graph that Statistics Canada data might help me create. In minutes I’m on their webpage and, within 5 minutes, I’m walking away from my computer fearing I might throw it out the window.

StatCans website may be the worst, most inaccessible government website in the western world. Whatever data you are looking for always seems to be at least one more click away.

It spent an hour trying to find data that StatsCan allegedly wants me to find. (This in an era of google where I generally find data people don’t want me to find, in minutes). Ultimately, I think I found the relevant data on overwieight/obesity figures by province (but who knows! Should I be choosing peer group A, or B, or C, D, E, F, G? None of which have labels explaining what they mean!).

The Ugly

Sadly, it gets worse. Even if you a) locate the data on Statscan’s website and b) it is free, it will probably still be inaccessible.  The only way the data can be viewed is with a Beyond 20/20 Professional Browser. You need to learn a new software package, one 99.9% of Canadians have never heard of, and that only works on a PC (I’m on a mac). The data I want is pretty simple, a CSV file, or even an Excel spreadsheet would be sufficient, something the average Canadian could access. But I guess it is not to be.

So I give up.

You win StatsCan. There are 10s of thousands of Canadians like me who would love to do interesting things with the data our tax dollars paid to collect, but even when your data is free and “open,” it isn’t. You’ve enjoyed tremendous support in the last month from those Canadians who understand why you are important (including me) but many Canadians have had to go up a steeper learning curve around why they should care. I might suggest they’d have gotten up that curve faster if they too could have used your data.

Myself, healthcare professionals, students and countless others could paint innumerable stories explaining Canadians and Canada to one another – helping us grasp our history, our social and health challenges, as well simply who we are. But we can’t.

In the end I’m still one of your biggest supporters, but frankly even I feel alienated.

Note: If someone wants to help me get this data, I’ll take a cut at recreating the map again, otherwise, as I said before. I give up.

How Science Is Rediscovering "Open" And What It Means For Government

Pretty much everybody in government should read this fantastic New York Times article Sharing of Data Leads to Progress on Alzheimer’s. On one hand the article is a window into what has gone wrong with science – about how all to frequently a process that used to be competitive but open, and problem focused has become a competitive but closed and intellectual property driven (one need only look at scientific journals to see how slow and challenging the process has become).

But strip away the talk about the challenges and opportunities for science. At its core, this is an article is about something more basic and universal. This is an article about open data.

Viewed through this lens it is a powerful case study for all of us. It is a story of how one scientific community’s (re)discovery of open principles can yield powerful lessons and analogies for the private sector and, more importantly the public sector.

Consider first, the similarities in problems. From the article:

Dr. Potter had recently left the National Institutes of Health and he had been thinking about how to speed the glacial progress of Alzheimer’s drug research.

“We wanted to get out of what I called 19th-century drug development — give a drug and hope it does something,” Dr. Potter recalled in an interview on Thursday. “What was needed was to find some way of seeing what was happening in the brain as Alzheimer’s progressed and asking if experimental drugs could alter that progression.”

Our government’s are struggling too. They are caught with a 20th-century organizational, decision-making and accountability structures. More to the point, they move at a glacial speed. On the one hand we should be worried about a government that moves too quickly, but a government that is too slow to be responsive to crises or to address structural problems is one that will lose the confidence of the public. Moreover, like in healthcare, many of the simpler problems have been addressed. citizens are looking for solutions to more complex problems. As with the scientists and Alzheimer’s we may need new models to speed the process up for understanding and testing solutions for these issues.

To overcome this 19th century approach – and achieve the success they currently enjoy – the scientists decided to do some radical.

The key to the Alzheimer’s project was an agreement as ambitious as its goal: not just to raise money, not just to do research on a vast scale, but also to share all the data, making every single finding public immediately, available to anyone with a computer anywhere in the world.

No one would own the data. No one could submit patent applications, though private companies would ultimately profit from any drugs or imaging tests developed as a result of the effort.

Consider this. Here a group of private sector companies recognize the intellectual property slows down innovation. The solution – dilute the intellectual property, focus on sharing data and knowledge, and understand that those who contribute most will be best positioned to capitalize on the gains at the end.

Sadly this is the same problem faced within governments. Sometimes it has to do with actual intellectual property (something I’ve recently argued our governments should abandon). However, the real challenge isn’t about about formal rules, it is more subtle. In complex siloed organizations where knowledge is power the incentives to maximize influence are to not share knowledge and data. Better to use the information you have strategically, in a limited fashion, to maximize influence. The result, data is kept as a scarce, but strategic asset. This is a theme I tackled both in my chapter in Open Government and in blog posts like this one.

In short, the real challenge is structural and cultural. Scientists had previously existed in a system where reputation (and career advancement) was built by hoarding data and publishing papers. While the individual incentives were okay, collectively this behavior was a disaster. The problem was not getting solved.

Today, it would appear that publishing is still important, but there are reputational effects from being the person or group to share data. Open data is itself a currency. This is hardly surprising. If you are sharing data it means you are doing lots of work, which means you are likely knowledgeable. As a result, those with a great deal of experience are respected but there remains the opportunity for those with radical ideas and new perspectives to test hypothesis and gain credibility by using the open data.

Unsurprisingly, this shift wasn’t easy:

At first, the collaboration struck many scientists as worrisome — they would be giving up ownership of data, and anyone could use it, publish papers, maybe even misinterpret it and publish information that was wrong.

Wow, does that sound familiar. This is invariably the first question government officials ask when you begin talking about open data. The answer, both in the scientific community and for government, is that you either believe in the peer-review process and public debate, or you don’t. Yes, people might misrepresent the data, or publish something that is wrong, but the bigger and more vibrant the community, the more likely people will find and point out the errors quickly. This is what innovation looks like… people try out ideas, sometimes they are right, sometimes they are wrong. But the more data you make available to people the more ideas can be tested and so the faster the cycle of innovation can proceed.

Whether it is behind the firewall or open to the public, open data is the core to accelerating the spread of ideas and the speed of innovation. These scientists are rediscovering that fact as our some governments. We’ve much to learn and do, but the case is becoming stronger and stronger that this is the right thing to do.

What the Liberals needed to Learn in Montreal

There’s been a lot of ink shed about the Liberals and Montreal. Some seizes on the corporate tax freeze, others on Robert Fowler’s blistering critique of the party, still others on the age of the participants in the room. My sense is that, in the short term, the issues discussed at Montreal – on the surface – won’t matter. It is the deeper changes, to thinking, to culture and to processes that take time to manifest, that will determine if Montreal was a success.

Are these deeper shifts happening? Hard to say, but here are three lessons the party will need to take away from Montreal if it is to succeed in the long term:

Lighten up. The scariest thing about the images from Montreal is the uniformity. The participants were older. And white. And male. That is a problem easily (and repeatedly) identified. It also needs to be fixed. But there was another interesting challenge – one more subtle and less commented on.

Ignore the uniform demographics and count how many people are in suits. And a tie. On a Saturday.

Most Canadians I know don’t wear suits. Ever. Even when working with in Fortune 500 companies, or at the banks, people look professional, but suits? Increasingly less and less. So does the Liberal Party need a new dress code? No. But it speaks to the culture of the party elite. When people look at a party they want to see themselves – people they trust and believe in. Even if Canada were populated only by white, older men, most people would probably still look at the conference and not see themselves there. Moreover, many would imagine the event as unapproachable, or unwelcoming – teeming with operatives. If the Liberals are going to win again, they’ll need to be approachable, a group many people feel like they can belong to. Keep the suits if you must, but think about the culture.

Learn the right lesson about the internet. Many participants were amazed by how many people were participating and asking questions online through skype or twitter. This belies a lack of understanding of how the internet is reshaping the way people live, work and organize. Over the past few decades, before campaign finance reform, the party had become accustomed to relying on big donations and it so its capacity to reach out to party members diminished. The Reform/Conservatives were the opposite. Early on they were too scary for traditional big companies and cultivated a vast network of small donors. For them, the internet was a blessing – it enhanced their strategy – and campaign finance was a godsend – it meant their strategy was the only effective one. Today, the Conservative donor network keeps them well financed and effective.

The danger from all this is that the Liberals will walk away understanding the power of the network, but believing they can can control it, rather than simply harness it. You can’t. All those people online, they aren’t there to do the bidding of some communications director. They are there to share their story and engage with peers. Working with such a network requires a radically different skill set then dealing with the media or cultivating a big donor. It also means getting comfortable with the fact that you aren’t in control of the message (your just seeding it) or the medium (your just a platform for others to play on). If Montreal did anything it let the younger leaders show the old timers what social networks and a connective network can do. Will be interesting if the right lessons get drawn. But the Party had better figure it out soon – the Conservatives have a serious head start.

Be honest and clear. The weekends highlight moments occurred when speakers bluntly and firmly pushed back on basic ideas or assumptions. Janice Stein responding to a questions about women’s issues in Foreign Policy by saying she was much more concerned about the destabilizing effect of large groups of unemployed young men. Roger Martin talking about how Canada’s healthcare system is one of the most expensive and inefficient in the G7. Pierre Fortin (who gave a model speech) spoke bluntly about how little money there will be, for anything. Parties need to give people hope, but they also have to be honest.

Most Canadians still struggle to understand what the Liberal Party stands for.  The public knows what both the NDP stands and Conservatives stand for. Both parties have been happy to eschew certain voters in order to stay focused on what makes them who they are. It is sometimes hard to know who the Liberals will eschew. Injecting a little dose of honesty and clarity a la Janice Stein into the party’s communications might help. Sometimes you have to tell the public that their priority isn’t the number one and that there are bigger fish to fry. It isn’t easy. Especially for politicians. But being honest and clear about where the party stands and where it doesn’t may produce better results than the status quo. The Conservatives may have had a scandal rife year, but they aren’t going anywhere so long as people know who they are and don’t have a clue about their rivals.

Jane Taber noted that at the last “thinkers conference” in Aylmer the Liberal Party shed its protectionist past in favour of globalization. But that took some time to become clear. The impact – if any – of this conference will likewise take a few years to be fully realized. But maybe a similar transition will take place, with the famously centralist party favouring a more networked, open and engaging approach to both the party, and governing. It will be interesting to see what unfolds.

Open Source Strategy: OpenMRS case study

Last week I had the pleasure of being invited to Indianapolis to give a talk at the Regenstrief Institute – an informatics and healthcare research organization – which also happens to host the founders of OpenMRS.

For those not familiar with OpenMRS (which I assume to be most of you) it is open-source, enterprise electronic medical record system platform specifically designed to respond to those actively building and managing health systems in the developing world. It’s a project I’m endlessly excited about not only because of its potential to improve healthcare in developing and emerging markets, but also because of its longer-term potential to serve as a disruptive innovator in developed markets.

Having spent a few days at Regenstrief hanging out with the OpenMRS team, here are some take aways I have regarding where they are, and where – in my mind – they should consider heading and what are some of the key places they could focus on to get there.

Current State: Exiting Stealth Mode

Paul Biondich and Andrew Arenson point me to this article about Community Source vs. Open Source which has an interesting piece on open source projects that operate in “Stealth Mode”

It is possible to find models similar to community source within the open source environment. For example, some projects opt to launch in a so called ‘stealth mode’, that is, they operate as a truly open source development from inception, but restrict marketing information about the project during the early stages. This has the effect of permitting access to anyone who cares enough to discover the project, whilst at the same time allowing the initiating members to maintain a focus on early strategic objectives, rather than community development.

OpenMRS has grown in leaps and bounds and – I would argue – has managed to stay in stealth mode (even with the help of their friends at Google summer of code). But for OpenMRS to succeed it must exit stealth mode (a transition that has already been steadily gathering steam). By being more public it can attract more resources, access a broader development community and role out more implementations for patients around the world. But to succeed I suspect that a few things need to be in place.

Core Opportunities/Challenges:

1. Develop OpenMRS as a platform to push people towards cooperating (as opposed requiring collaboration) whenever possible.

One of the smartest things Firefox did was create add-ons. The innovation of add-ons accomplished two benefits. First, it allowed those working on the trunk of the Firefox code to continue to do their work without being distracted by as many feature requests from developers who had an idea they wanted to try out. Second, it increased the number of people who could take interest in Firefox, since now you could code up your own add-on cooperatively but independently, of the rest of the project.

With OpenMRS my sense is that then entire UI is a platform that others should be able to develop or build add-on’s for. Indeed, the longer term business model that makes significant sense to me is to treat OpenMRS like WordPress or Drupal. The underlying code is managed by a core open source community but installation, customization, skinning, widgets, etc… is done by a mix of actors from amateurs, to independent hackers and freelancers to larger design/dev organizations. The local business opportunities to support OpenMRS and, in short, create an IT industry in the developing world, are enormous.

2. Structural Change(s)

One consequence of treating OpenMRS as a platform is that the project needs to be very clear about what is “core” versus what is platform. My sense is that members of the Mozilla team does not spend a lot of time hacking on add-ons (unless they have proven so instrumental they are brought into the trunk). Looking at WordPress the standard install theme is about as basic as one could expect. It would seem no one at WordPress is wasting cycles developing nice themes to roll out with the software. There is a separate (thriving) community that can do that.

As a result, my sense is that OpenMRS should ensure that its front-end developers slowly begin to operate as a separate entity. One reason for this is that if they are too close to the trunk developers they may inadvertently prevent prevent the emergence of a community that would specialize in the installing and customizing of OpenMRS. More importantly, those working on the platform and those working on the trunk may have different interests, and so allowing that tension to emerge and learning how to manage it in the open will be healthy for the long term viability of the project as more and more people do front end work and share their concerns with trunk developers.

3. Stay Flexible by Engaging in Community Management/Engagement

One of the challenges that quickly emerges when one turns a software product into an innovation platform is that the interests of those working on the product and those developing on the platform can quickly divide. One often here’s rumblings from the Drupal community about how drupal core developers often appear more interested in writing interesting/beautiful code than in making Drupal easier to use for businesses (core vs. platform!). Likewise, Firefox and Thunderbird also hear similar rumblings from add-on developers who worry about how new platforms (jetpack) might make old platforms (add-ons) obsolete. In a sense, people who build on platforms are inherently conservative. Change, even (or sometimes especially!) change that lowers barriers to entry means more work for them. They have to ensure that whatever they’ve built on top of the platform doesn’t break when the platform changes. Conversely trunk developers can become enamored with change for change’s sake – including features that offer marginal benefits but that disrupt huge ecosystems.

In my mind, managing these types of tension is essential for an open source project – particularly one involving medical records. Trunk developers will need to have A-level facilitation and engagement skills, capable of listening to platform developers and others, not be reactive or defensive, understand interests and work hard to mediate disputes – even disputes they are involved in. These inter-personal skills will be the grease that ensure the OpenMRS machine can keep innovating while understanding and serving the developer community that is building on top of it. The OpenMRS leadership will also have to take a strong lead in this area – setting expectations around how, and how quickly OpenMRS will evolve so that the developer ecosystem can plan accordingly. Clear expectations will do wonders for reducing tensions between disparate stakeholders.

4) Set the Culture in Place now

Given that OpenMRS is still emerging from Stealth mode, now is the time to imprint the culture with the DNA it will need to survive the coming growth. A clear social contract for participation, a code of community conduct and clearer mission statement that can be referenced during decisions will all be essential. I’m of course also interested in the tools we can role out that will help manage the community. Porting over to Trac the next generation of Diederik’s bug-fix predicter, along with his flame monitor, are ways to give community the influence to have a check on poor behaviour and nudge people towards making better choices in resolving disputes.

5) Create and Share Data to Foster Markets

Finally, I think there is enormous opportunity for a IT industry – primarily located in the developing world – to emerge and support OpenMRS. My sense is that OpenMRS should do everything it can to encourage and foster such an industry.

Some ideas for doing this have been inspired by my work around open data. I think it is critical that OpenMRS start asking implementations to ping them once complete – and again whenever an upgrade is complete. This type of market data – anatomized – could help the demonstrate demand for services that already exists, as well as its rate of growth. Developers in underserved counties might realize there are market niches to be filled. In addition, I suspect that all of the OpenMRS implementations that have been completed that we don’t know about represent a huge wealth of information. These are people who managed to install OpenMRS with no support and possibly – on the cheap. Understanding how they did and who was involved could yield important best practices as well as introduce us to prospective community members with a “can do” spirit and serious skills. I won’t dive into too much detail here, but needless to say, I think anonymized but aggregated data provided for free by OpenMRS could spur further innovation and market growth.

Postscript

I’m sure there is lots to debate in the above text – I may have made some faulty assumptions along the way – so this should not be read as final or authoritative, mostly a contribution to what is an ongoing discussion at OpenMRS. Mostly I’m excited about where things are and where they are going, and the tremendous potential of OpenMRS.

Canada’s Three Tiered Healthcare System

Thanks to Premier Danny Williams’ comments, we are in another short bout of collective denial and misunderstanding of Canada’s healthcare system and the public perception thereof.

1. Denial.

For those not in the know, Premier Williams recently jaunted down to Miami for heart surgery. In his interview with NTV reporter Fred Hutton, he stated, “This is my heart. It’s my health and it’s my choice.” True. It is a choice. If you can afford it.

It’s also a wonderful reflection of the fact that despite all the mythology awe, in Canada, actually have a three-tiered healthcare system. Williams enjoys the benefit of tier three – travel to the US. It’s a choice that many, many wealthy Canadians make. Indeed, it’s a choice other wealthy politicians have made, including former Quebec premier Robert Bourassa and former MP Belinda Stronach. I’m willing to bet that the Mayo Clinic has made a lot of money off wealthy Canadians.

Of course, this effect is largely ignored since most Canadians can’t afford to go to the US. So we pretend it doesn’t happen. Indeed, the 1998 Katz paper, a frequently cited paper that claims Canadians don’t travel to the US for healthcare, strikes me as deeply misleading. As the study states:

An important limitation of this study is that only public out-of-country expenditures are included in the analysis; private sources of funding, including “travel” health insurance plans and out-of-pocket payments, are omitted.

This of course doesn’t prevent them from drawing some very strong conclusions, namely that Canadians don’t go to the US for healthcare. In some ways they are right, average Canadians don’t, but what did you expect if the  study only looks at people who used Ontario public insurance – in short, those who couldn’t afford to travel to the US and pay privately…

Then of course, there is the more familiar second tier. This is private healthcare available here in Canada. Don’t be fooled, there is plenty of private healthcare in Canada. Indeed, at least 30% of healthcare spending in Canada is from private funds. This includes simple things like your glasses and dental costs, as well as the more complex, such as clinics that conduct surgery in Quebec (which the Feds don’t dare close) to those in British Columbia (which most people pretend don’t exist). These service upper middle class Canadians and, ironically, provincial Workers Compensation Boards which are not bound by the Canada Health Act and so can pay to have their patients serviced by private clinics in Canada. Irony!

Finally, there is familiar tier one — the public system that most of us avail ourselves of. (Which still has a huge private component – all those doctor offices are private businesses…) The system generally works, but often has too few doctors (try finding a GP – 4.5 Million of us haven’t!), long wait lines in Emergency Rooms (often hours long) and waiting lists for some procedures (don’t break your hip).

This is the reality of healthcare in Canada. Yes, we have universal healthcare. But it is within a three-tiered system and the wealthy – like Danny Williams – opted out a long, long time ago.

2. (Mis)perceptions of Canadian (Mis)perceptions

Of course, many Canadians know that the wealthy go elsewhere. They even know that their healthcare system is either groaning or breaking (try being on a waiting list) or financially unsustainable (try living in a province where healthcare eats up 45% of the budget and rising). Moreover, they know more money isn’t going to magically solve it (or at least not the amount of money we can afford). Did anyone really believe that $41 billion over 10 years would “save healthcare for a generation?”

(As an aside, I suspect this is why Canadians reject the Liberals’ National Daycare Program – many people agree daycare is good and important but they remain suspicious of a system that is likely to become as top-down, hard to contain and even more difficult to reform/evolve as Healthcare. In short, they don’t wanted it modeled after I system they already think is borked.)

But the story isn’t that Canadians want either the status quo or the American option. Although Canadians recognize our system has huge challenges, most of us agree the American system is far, far worse, particularly for the vast majority of us who can’t afford to fly down there to begin with. Far better to stick with the devil we know, than the bogey man to the south. The fact is… better the system you know and hate, then the one you don’t know and hate even more.

Ultimately, both the Canadian and the American models are likely done. Neither country can afford to manage double digit (or even high single digit) increases in healthcare costs. Somewhere, something has to give. But we’ll have to experience a lot more pain (and denial about how great our system is) before we get there. What I suspect is true is that the wealthy and privileged stopped caring a long time ago. They aren’t invested in the system because – residing in the third tier – they are outside of it.