Canada’s COVID-19 pitfalls highlight need for integrated health information system
In the globalized world of today where outbreaks can spread far and wide within a matter of days, a global-level integrated health information system is ideal but Canada’s provincial barriers show that the country lags much behind in deploying even a national-level system for real-time information flow.COE-EDP | Updated: 11-08-2020 10:09 IST | Created: 10-08-2020 15:58 IST
On January 27, Canada recorded its first confirmed case of COVID-19 of a man who had recently returned from Wuhan – the original epicenter of the outbreak. At the time, Canadian health officials in different provinces were quite confident about the country's ability to deal with the outbreak, and the World Health Organization was holding off on declaring it a health emergency of international concern.
Much has happened since then and the opinions of policymakers and the public have changed drastically as the outbreak has grown to become the most severe pandemic in decades having infected over 2 million people across the world and at least 115,000 people in Canada alone. Although Canada's COVID-19 response is largely viewed as a success because a significant portion of Canadians are inclined to compare their situation with that of their southern neighbor – the United States of America, which is also the worst-hit country by the pandemic. But keeping the US apart, Canada's tally of over 115,000 cases is staggering especially when compared to some other countries like Australia and South Korea. Some disadvantaged groups have also been disproportionately affected by the pandemic. In this research-based analysis, we try to find out key shortcomings that led to a worsening situation in the country.
Long-term care homes crisis
Probably the most talked-about "failure" of Canada's COVID-19 response has been the shocking outbreaks in long-term care homes for the elderly. Spiraling outbreaks in care homes of Ontario and Quebec were so severe that the federal government had to deploy the Canadian military to help. Disturbing revelations were made in a few reports by the Royal Society of Canada and the troops who found cockroach infestations, force-feeding, and "significant gross fecal contamination" in patients' rooms. Long-term care homes account for more than 80 percent of COVID-19 deaths in Canada – a statistic that sent shockwaves across the country.
Reports have concluded that the pandemic only exaggerated the deficiencies in these care homes and the situation wasn't much better before the pandemic. Allegations have been leveled that these homes have been allowed to drop staff-to-patient ratios and have increasingly shifted to an unregulated workforce in recent year seven though life expectancy has risen and people are living longer with complex diseases.
It's important to note that nursing homes and long-term care homes aren't covered under Canada's universal health care system, which means that these institutions are not insured by the federal system. But exclusion from that system also means that these homes aren't subjected to as strict regulations as other healthcare facilities and this results in inadequate data collection from these facilities which deter critical policymaking decisions. The report by the Royal Society of Canada has suggested that the federal government should also ensure data is regularly collected on resident quality of life, care standards, and worker satisfaction among other things.
Health information flow mishaps
Deep-rooted problems with the health information system of Canada are also one of the major pitfalls of the country's response to COVID-19. Data problems started causing problems early on as health officials and families struggled to determine the actual impact on elders in long-term care homes. Different authorities, possibly using different information systems, posted conflicting statistics on deaths and cases in long-term care homes causing confusion in the public. Instead of using an integrated system that engages all stakeholders, the usage of different systems, some of which are operated manually, caused dire problems in assessing the situation.
In another instance, the lack of integrated, real-time health information systems led to hundreds of confirmed COVID-19 cases not being reported to public health officials in Toronto because of a mix-up between two hospitals. This mixup meant that contacts of infected individuals identified in those tests were not traced and went on to spread COVID-19 in the community.
Canada's hardest-hit province Quebec even decided to stop publishing daily updates on COVID-19 in late-June to provide "more stable numbers" in weekly updates. The decision, however, was reversed within a day as it drew sharp criticism from stakeholders who raised concerns over transparency in COVID-19 statistics and response.
Several instances of delays in releasing data have been reported over the months as Canada continues its fight against COVID-19. One such instance was in mid-July when Montreal's public health department delayed the release of data on new COVID-19 cases linked to bars. This delay stood out because it came after authorities urged people who have visited a bar in Montreal since July 1 to undergo a COVID-19 test. The announcement triggered massive lineups for tests in the city.
Discrepancies in COVID-19 data continue to date as some reports found differences in hospitalization data released by different sources in late-July. Quebec authorities have acknowledged discrepancies in the figures on infections and deaths but linked it to the upgradation of its information systems. Authorities have also acknowledged that there is a one-two day delay in the transmission of data to the ministry. Such time lag could have been avoided with an automated and integrated health information system that builds on Canada's advanced digital health infrastructure.
Toronto's hardest-hit poor regions
Toronto's northwest corner has been relatively harder hit than neighboring areas and experts are attributing it to the demographics of the region. Toronto Public Health's publically available data on hardest-hit areas within the city shows that the northwestern neighborhoods are most affected by COVID-19. Coincidently, these regions also have the highest concentrations of chronic diseases like diabetes.
These are also the same regions that are among the most social and economic disadvantaged in the city with high concentrations of poor people and low post-secondary education. The region has also witnessed two massive outbreaks at long-term-care facilities where the military was called in for help.
Problems in ramping up testing
Canada responded relatively quickly to the outbreak and its political leadership was quick to acknowledge the risk, unlike some other developed countries that continued to undermine the outbreak until the situation got out of control. From mid-January when Canada had no cases of COVID-19 and the risk of the disease spreading to Canada was considered low, the Public Health Agency of Canada started analyzing the potential COVID-19 related risks to Canadians.
But the country still struggled to ramp up testing capacity when the pandemic started spreading far and wide in the weeks to come. The second worst-hit province Ontario repeatedly failed to hit its testing target throughout May even though province health officials agreed that broader testing is critical.
Several provinces including not only Ontario but also British Columbia, Alberta, Quebec, and Manitoba reported backlogs on testing in March. As the outbreak continued to spread, provinces limited testing to front-line health-care workers, people with severe symptoms, and those who work with vulnerable groups. Even people with clear symptoms were being turned away due to a lack of testing capacity. The governments have since managed to clear backlogs and ramped up testing but low testing in the critical initial weeks likely had a major impact on Canada's COVID-19 response.
'Exposure notification' app problems
Released after weeks of delay, the federal government's COVID-19 'exposure notification' app topped the charts of both Apple's App Store and Google Play Store and quickly became the most downloaded free app in Canada. But concerns have been raised over its usability and accessibility because the app requires users to have Apple or Android phones made in the last five years that equips a relatively new operating system. That drawback could make the app inaccessible for older Canadians and those from lower socio-economic brackets - who are likely the most affected by the pandemic.
Furthermore, the app is built on Apple and Google's framework that doesn't collect location data of users nor does it forward the ID codes to a central authority. Both the companies have also stressed that the apps using their framework should be called "exposure notification" apps instead of contact tracing apps because no data goes to a central authority.
Canada's health information system
Canada follows a complex mechanism to collect and disseminate health information critical for policymaking which can be attributed to the fact that there is no single health system in Canada. The country has distinct health systems for each of the provinces and territories. Those systems are regulated by the Canada Health Act which asks provinces to ensure that healthcare is universal and accessible but the details of how each system operates are determined at provincial levels.
Canada has a total of 15 unique health care systems distributed across the country. While such a system has its advantages like provinces having the ability to tailor health services according to the needs of residents of different provinces, negative sides include increasingly complex coordination for nationwide health reforms and collection as well as interoperability of data.
Substantial challenges remain in the timely collection of health data that is critical for policy decisions while the real-time flow of health data remains a distant dream for Canada as it lacks a comprehensive national health record despite repeated calls.
Each Canadian province and territory has the foundational infrastructure required for connecting health information. Most doctors in Canada already use digital systems to manage their practices which means that many patients also have an electronic medical record (EMR). But EMR is not the same as an Electronic Health Record. EHR is meant to be accessible across the country by any clinician who might require the medical history of their patients and can also support data collection efforts at the national level. EMR, on the other hand, is most commonly available only to your family doctor or primary care clinic and is not interoperable across hospitals. It's relatively easier for Canada to deploy national-level EHR because it already has the required infrastructure but political challenges could be a deterrent.
In the absence of a comprehensive health information system, currently four contributors namely - Canadian Institutes of Health Research, Health Canada, Public Health Agency of Canada, Statistics Canada, provide statistics, facts, reports, and data on healthcare to policymakers and the general public. Their efforts are supported by the Canadian Institute for Health Information (CIHI), which is an independent, not-for-profit organization that provides essential information on Canada's health system and the health of Canadians.
But given the complex structure of Canada's health system that varies in different provinces, substantial challenges remain in ensuring timely access to critical health data. As evident during COVID, time lags due to manual reporting could prove to be a major concern for policymaking decisions.
Conclusion and agenda for discussion
The provincial model of healthcare delivery has its advantages and might work for Canada but experts have repeatedly pointed out that the federal government should have more oversight for coordination and implementation of national health reforms. The availability of real-time healthcare data through an integrated health information system at the national level is critical to achieving such oversight of the federal government. In the globalized world of today where outbreaks can spread far and wide within a matter of days, a global-level integrated health information system is ideal but Canada's provincial barriers to health information and inadequate federal oversight show that it lags much behind and highlight the immediate need for reforms to improve the availability of healthcare data.
VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.
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