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Digital Health Care Consultation: What We Heard from Industry Stakeholders

February 24, 2021

Table of contents

Message from the Commissioner

The COVID-19 pandemic has changed our world dramatically and altered the way all Canadians carry out their daily lives. The pandemic has also underscored the importance that technology and innovation can play in helping Canadians access vital health care products and services.

The Competition Bureau is committed to tackling issues that matter to Canadians and health care has always been an area of critical importance to Canadians. As an advocate for policies that promote competition, the Bureau has a role to play in ensuring our health care sector remains innovative, accessible, and able to meet the needs of Canadians.

Last year, we sought public feedback on factors that may be restricting access to digital health care in Canada, or inhibiting innovation and choice in the delivery of products and services through digital means. Thirty-five stakeholders contributed to this important dialogue. This What We Heard report will summarize the input received through our public consultation, and will help us identify areas of focus for the Bureau's ongoing health care market study.

I want to thank everyone who provided feedback as part of this public consultation. Your contributions have provided insight into some of the key issues that Canadian patients, health care providers and businesses are facing, and highlighted possible opportunities for greater innovation and choice. This information will be invaluable as we work with policymakers to promote digital health care in Canada.

Matthew Boswell
Commissioner of Competition

Our public consultation at a glance

Our public consultation at a glance.

35 stakeholder submissions

Introduction

Competition drives growth, innovation and productivity. It empowers consumers, leads to lower prices, greater choice, and better products and services. Government policy is central to driving competition. That is why the Competition Bureau (Bureau) is committed to advocating for pro-competitive policies in markets that matter to Canadians.

Health care has been—and continues to be—one of the most important issues for Canadians. The need for innovation and choice, and the ability to access digital health care solutions, has never been more pronounced than it is right now.

In July 2020, the Bureau announced that it would be conducting a market study of Canada's health care sector. By examining policies in the health care sector through a competition lens, the Bureau hopes to encourage the adoption of pro-competitive policies that will support greater innovation, choice and access to digital health care across Canada.

As a first step, the Bureau held a public consultation inviting stakeholders to share their views on factors that may be impeding access to digital health care, or limiting innovation and choice in Canada's health care sector. The Bureau received submissions from 35 stakeholders, including a range of public and private sector organizations and individuals across the country.

Upon reviewing the information provided by stakeholders, the Bureau identified issues related to six common themes that can impact the availability and adoption of digital health care in Canada. These will be elaborated on in the What we heard section of this report:Footnote 1

  1. Interoperability: common standards for health information that allow patients and health care providers to access and share vital data while protecting the privacy of sensitive information.
  2. Compensation: health care coverage, conditions of payment, remuneration rates, and payment models that incentivize the adoption of digital health solutions.
  3. Procurement and commercialization: procurement and commercialization processes that promote innovation and allow small and medium sized enterprises the opportunity to compete.
  4. Digital products and services: standardized policies and expanded scopes of practice for health care professionals to promote the delivery of digital care, as well as policies to increase the range of products and services that can be provided digitally.
  5. Digital divide: accessible and affordable digital infrastructure, and education and training to support the use of digital technology and enhance digital literacy among different populations segments.
  6. Patient protection: a patient-centric focus to digital health care, with an emphasis on continuity of care, choice, and the safety and security of patients and their personal health information.

This image represents a word cloud and is made up of keywords from submissions the Bureau received during its public consultation. The keywords are listed below:

Frequency of keywords appearing in stakeholder submissions.

What we heard

I. Common themes

1) Interoperability

Over half the submissions received in response to the Bureau's public consultation spoke to a lack of interoperability as a barrier to digital health care in Canada. Stakeholders commented on differences in systems across provinces, territories and health care providers. We heard that common standards are essential for full, frictionless communication across information systems, devices, and applications. Stakeholders believe that this is necessary for the development and adoption of digital health care, and for effective patient care. We also heard that that unified federal, provincial and territorial privacy and data protection regimes could strengthen safeguards for the protection of personal health information.

Challenges and opportunities

Health information: Many stakeholders believe that the ability to access and share health information is a basic requirement for the development and adoption of digital health care across the country. We heard that interoperability of health information can, among other things, facilitate the creation of national patient identifiers and electronic health records. This can enable greater coordination and integration among health care providers, and promote more patient-centric approaches to care. With better transparency into and control of their health information, patients may be empowered to manage their health more effectively.

"Digital interoperability across the health care system is essential to support comprehensive virtual care. More specifically, the interfaces must be fully known and have the ability to work with other existing products or systems, without access restrictions and in compliance with the laws on the protection of privacy and confidentiality." [translation]

Submission of the Montreal Economic Institute

Numerous stakeholders suggested that the development of a pan-Canadian framework for health information may help achieve these outcomes. This could include establishing national standards for health information access and exchange, as well as technical and interoperability requirements. However, stakeholders noted that a key challenge to achieving a pan-Canadian framework for health information is the nature of Canada's health care system, which varies across our provinces and territories. This increases the complexity of developing national standards, as each province and territory has its own technical and policy considerations to take into account.

Some stakeholders identified other jurisdictions that have made inroads to addressing barriers to interoperability. For example, one stakeholder told us that in 2019, the National Health Service (NHS) in the United Kingdom launched a long-term plan to become digital first. Some of the features of this plan include the introduction of open standards, as well as a standardized, easy way for citizens to access digital health services and consultations offered by general practitioners. Other stakeholders highlighted countries like Australia, which have implemented unified health record systems, while in Denmark, the Danish Health Data Network (Medcom) acts as a data integrator to ensure interoperability.

Privacy: With appropriate privacy and data protections in place to safeguard sensitive information,Footnote 2 several stakeholders suggested that interoperability requirements can also reduce barriers to entry and expansion for new and innovative digital health solutions, and enable important health care research. These stakeholders believe that the development of a pan-Canadian framework for the protection of personal health information could facilitate this by establishing clear and consistent rules related to privacy, data protection and consent. They also told us that national standards could improve access to and sharing of health information, and support open data efforts by making anonymized health information available to a wide range of stakeholders, including researchers and the public. This could offer further protection for patients, and help foster the development of new and innovative tools and approaches to the delivery of digital health care in Canada.

2) Compensation

Numerous stakeholders raised the issue of compensation, with over half of those providing feedback commenting on some aspect of the issue. Stakeholders spoke about health care coverage, conditions of payment, remuneration rates for health care providers, and payment models. Stakeholders believe that compensation can act as an incentive for health care providers to deliver care, as well as motivate Canadians to seek care. As such, they said that proper and adequate compensation may help encourage the provision of more effective and efficient health care for Canadians, be that through virtual or other means.

Challenges and opportunities

Coverage: When it comes to digital health care coverage, some stakeholders view the line separating insured and uninsured services as blurry. Discrepancies between what health care coverage is permitted by regulations and polices, and what is actually covered through insurance plans, can cause confusion and limit the adoption of digital health care. Who provides coverage (e.g. government, employers, private insurers, etc.) can also impact the accessibility of digital health care. Some stakeholders believe that adequate insurance coverage can help incentivize more routine use of digital health care, but to keep pace with digitization in the health care sector, terms of coverage need to be continually updated to accommodate services moving online.

Stakeholders also told us that restrictions on billing codes for physicians and other health care professionals can limit the delivery of digital health care. In response to the pandemic, and in an effort to help facilitate the provision of care, billing codes (some of which are temporary) were implemented across Canada to allow certain health care providers to seek compensation for specific services provided through digital means. Looking forward, a number of stakeholders believe that additional, and more permanent billing codes, are needed to improve accessibility for Canadians and make digital health care worthy of business investment.

Conditions of payment: Stakeholders said that the terms upon which health care providers are compensated for providing care, or those upon which patients are reimbursed for receiving care, can vary based on a variety of factors. For example, conditions of payment for health care providers can depend on the number of services provided or patients seen daily. Provider compensation and patient reimbursement can also be contingent upon where care is received and the patient's home province or territory, should those differ. Several stakeholders believe that increased flexibility around factors such as these can encourage the provision and adoption of digital health care.

"For digital health, the challenge is that compensation policy was generally developed when care was delivered entirely in a physical setting, and this has created disincentives for providers to adopt and deliver virtual care solutions."

Submission of Shoppers Drug Mart

Remuneration rates: Stakeholders told us that the rates that health care providers are paid for the provision of their services can impact the type, quality and frequency of care provided. When it comes to providing care virtually or in-person, some stakeholders suggested that removing financial incentives to offer health care through one mode of delivery over others, could potentially encourage the use of the most appropriate method to address patient needs. With regards to digital health care specifically, having the same remuneration rate for certain services (e.g. phone and video consultations), may incentivize health care providers to default to less costly, and potentially less effective, solutions. We also heard that different remuneration rates for the type of software used to provide care can influence health care providers to use lower quality tools. This can decrease incentives for innovation, particularly as it pertains to the uptake and use of video-based care.

Payment models: A variety of different payment models are used in Canada to compensate health care providers for their services. Some stakeholders believe that certain payment models, including the fee-for-service model, can discourage health care providers to innovate or introduce digital solutions into their practice. They said that these models may also encourage repeated patient testing, which may be unnecessary. Some stakeholders also believe that a move away from payment models like the fee-for-service model that uses billing codes, and towards payment models that enable flexibility, encourage innovation and consider both quality and costs (e.g. value-based models, bundled payments, capitation models), can help improve patient outcomes.

3) Procurement and commercialization

Nearly half of the submissions received through the Bureau's public consultation raised issues regarding procurement and commercialization processes for health technologies in Canada. Stakeholders told us about the importance of updating the technology used in health care facilities, as well as ensuring Canadians have access to digital health tools, especially those developed in Canada. We heard that current processes for the approval and public procurement of health technologies are long, complex, and lack transparency. Stakeholders spoke about how certain processes decrease incentives to innovate, and limit the ability for small and medium sized enterprises (SMEs) to compete in Canada and abroad. We heard that procurement and commercialization processes need to be reformed to increase efficiency and promote innovation and choice in the health care sector.

Challenges and opportunities

"We need standardized Canada-wide practices around soliciting, procuring and evaluating new digital care solutions. This will ensure innovation targets are a key part of regular operations and advance Canada's innovation profile to match that of our international counterparts."

Submission of AGE-WELL

Streamlined processes: Stakeholders believe that opportunities exist to improve processes for the procurement and commercialization of health technologies in Canada. Due to the multi-jurisdictional nature of our health care system, regulatory approvals and purchasing decisions typically require input and review at the federal, provincial and territorial level. Some stakeholders feel that a more centralized and coordinated processes for soliciting, procuring and evaluating health technologies could help improve upon the current methods used. For example, we heard that steps could be taken to make the pathway for the approval and purchase of health technologies similar to that used for pharmaceuticals. It was also suggested that Canada could learn from the experience of other countries such as the United Kingdom, where the government has adopted a centralized approval process for health applications.

Approach to procurement: We heard that procurement processes that use requests for proposals can be prescriptive, and may reward the lowest bidder. We also heard that certain processes tend to focus on short-term investment and cost-containment rather than innovation. Furthermore, procurement of digital health technologies often requires entrepreneurs to demonstrate that their business solutions can be effectively deployed on a large-scale, which can limit the ability for disruptive technologies to compete domestically and expand abroad. It was suggested that by implementing processes that value longer-term investments and have elements of co-design and collaboration between the public and private sectors, some of the shortfalls of current processes could be addressed. We also heard that new approaches to procurement can help stimulate a culture where patient safety and innovation are regarded as dual, rather than competing objectives, which can help improve innovation and choice.

Funding: Some stakeholders said that current procurement processes also tend to reward large corporations with access to funding and other key resources. New technologies may be regarded as risky, and requirements to demonstrate return on investment, among other things, can act as a barrier to entry, particularly for SMEs. We heard that government funding for health care innovation needs to incorporate measures to allow SMEs to have an equal opportunity to compete in the market, and to help ensure that new and disruptive technologies are not overlooked. We also heard that government programs that fund innovation should support the commercialization of products and services. One stakeholder raised that in Germany, for example, the government has established a clear set of rules to enable innovators to bring digital health technologies to market in the country's publicly funded health care system.

4) Digital products and services

Many stakeholders told us about policies that may limit the expansion and delivery of health care through digital means. We heard how differences in standards across the country can restrict health professionals from providing care nationwide, and discourage the entry and expansion of businesses and innovative health care solutions. Stakeholders told us that limitations on the scope of practice for health care professionals, such as nurses and pharmacists, limit their ability to perform certain tasks and ultimately restrict digital health care. Stakeholders also spoke about policies that limit the range of products and services that can be provided digitally, which can create barriers to entry and expansion for businesses, restrict innovation, reduce choice and increase costs.

Challenges and opportunities

Standard-setting: Several stakeholders believe that the lack of national standards, in particular those pertaining to licensure, drug scheduling and digital health care, have restricted the availability and accessibility of digital products and services in Canada. They said that harmonizing certain federal, provincial and territorial standards could help facilitate the adoption of digital health solutions.

With regards to licensure, a number of stakeholders said that efforts to standardize and simplify registration and licencing processes for physicians could facilitate the provision of care across provincial and territorial boundaries. Collaboration among regulatory colleges and memorandums of understanding between provinces and territories could allow physicians to care for patients in different jurisdictions. Portable medical licences would go one-step further, permitting physicians to provide care across Canada. For instance, Australia has moved away from state-based regulation to a single licence for health care professionals, including physicians.

"One way to expand access to care is to increase the scope of practice of health professionals other than physicians. For example, Nurse Practitioners [sic] have the education and expertise to support many of the health needs currently provided by virtual care. Supported by a uniform regulatory framework, the expansion of the role of nurse practitioners will be critical to expanding access to care."

Submission of TELUS Health

We heard that different rules and requirements across provinces and territories make it difficult for health professionals to offer digital solutions to their patients, and for businesses to develop and scale digital solutions across Canada. Several stakeholders said that national standards related to the products and services health professionals can provide digitally could enable greater access to digital health care and permit businesses to develop and scale digital solutions nationwide. As previously mentioned, the NHS in the United Kingdom launched a long-term plan to build and scale digital transformations across the health care system. A key feature of this plan included introducing open standards to support the implementation of digital solutions.

Scope of practice: Health care professionals, such as nurses and pharmacists, can play an integral role in facilitating digital health care across the country. However, some stakeholders believe that these professionals are limited in the types of services they can provide to patients, and may be underutilized. Increasing the scope of practice for these, and other, health care professionals to better match their professional capacity, could improve access to care—both through virtual and in-person means.

Range of products and services that can be provided digitally: Some stakeholders identified certain policies, such as technical requirements that vary across jurisdictions, as limiting the range of products and services that can be provided digitally. Such policies can create barriers to the entry and expansion of new and innovative businesses, restrict innovation, reduce choice, and increase costs for Canadians. Some solutions put forward by stakeholders include reviewing the powers of self-governing health professional organizations to ensure they do not unduly restrict competition, and modernizing and standardizing conditions of sale for over the counter drugs, by, for example, leveraging electronic labelling and other digital tools.

5) Digital divide

In addition to policy barriers, stakeholders told us about non-policy barriers that are impeding access to digital health care and limiting innovation and choice in the sector. We heard about the need for accessible and affordable digital infrastructure and technology. We heard about the importance of education and training to support the use of digital technology, and to enhance digital literacy more broadly. Stakeholders also told us about the impact that various social, economic and environmental factors are having on access—and equity of access—to digital health care across the country.

Challenges and opportunities

Digital infrastructure and technology: In order to decrease the digital divide across Canada and make digital health care accessible for all Canadians, some stakeholders identified the need for better infrastructure and access to modern, affordable technology. Despite trends towards digitization in many sectors of the Canadian economy, they said that our health care sector continues to rely on antiquated technology and methods of communication, such as fax machines and paper documentation. Expanding e-Prescribe and e-Referral solutions could help modernize our health care system. Several stakeholders also said that Canadians—particularly those living in rural and remote regions of our country—need better cellular reception and more reliable internet with adequate bandwidth to effectively receive digital health care.

"46% of Canadians report not having the digital literacy skills to take full advantage of digital health. They may lack awareness of the digital tools and resources that are available to them, they may not have the technical skills to operate in a virtual environment and/or they may lack the ability to understand the health information that is being shared. These issues are more pronounced for vulnerable and marginalized populations and must be addressed."

Submission of Canada Health Infoway

Education and training: For the deployment of digital health care to be successful, several stakeholders said that both patients and health care providers need to be able to use digital technology effectively, and embrace its adoption as an alternate means of providing and receiving care. Improving Canadians' digital literacy through education and training can expand Canadians' understanding of digital health care, and what this method of health care delivery entails. Certain groups, including vulnerable and marginalized populations, may face more challenges in accessing and using digital health care. It was suggested that the development of education programs, training materials and other tools could help these groups overcome these challenges and successfully access digital health care.

Education and training can also support the health care workforce in becoming digital-ready, and aid in the efficient delivery of digital health care. Some stakeholders believe that specialized programs are needed for those entering the health care workforce, and continuing education programs should be put in place for current members of the workforce. This could help raise awareness of digital technology and its use, and reduce barriers to the adoption and delivery of health care through digital means.

Determinants of health: We heard that our age, language of communication, place of residence, and income—as well as a host of other factors—can all have an impact on our health, and our ability to obtain health care through digital means. A number of stakeholders suggested that improvements in the delivery of digital health care are needed so that patients belonging to different population segments can seek and receive health care. This could include the elderly, those living in poverty or without permanent housing, those who reside in rural and remote communities, and those who have specific language needs. For example, patients with specific language needs can benefit from being able to access technology and the services of health care providers in their preferred language. These, and other measures to address various social, economic and environmental barriers to the delivery of digital health care can help facilitate equity of access for all Canadians.

6) Patient protection

Stakeholders told us that it is imperative for digital health care to have a patient-centric focus. Stakeholders spoke about the importance of continuity of care, and how digital solutions should be designed and deployed in ways that can support existing patient-provider relationships. We heard about the importance of self-care and the need for choice, including the ability to determine how and where to access health care through virtual and in-person options. As discussed in the section on Interoperability, above, the safety and security of patients and their personal information was also a concern raised by stakeholders. Stakeholders stressed that the benefits stemming from digital health care should not come at the cost of Canadians' privacy, or the protection of their personal health information.

Challenges and opportunities

"While companies have some limited growth of e-commerce sales of Canadian OTCs [over the counter], it has been limited to certain products and certain retailers, falling short of its full potential. In contrast, the US OTC market experienced a 35% growth [in] total e-commerce within the health department. In the US, 41% of consumers are buying more health products online than they used to, compared with only 14% of Canadians."

Submission of Food Health and Consumer Products of Canada

Choice: We heard that Canadians need to be able to play an active role in managing their own health as well as their interactions with the health care system. To do this, patients must have choice in determining how to access health care to meet their individual needs. For example, the ability to purchase certain over the counter drugs online could improve accessibility, and assist Canadians in taking steps to maintain and promote their own health.

Continuity of care: Although choice is important, we heard that the need for choice must be balanced with continuity of care considerations. Some stakeholders told us that digital health care needs to be incorporated into the clinical workflow and integrated with patients' health records and regular health care providers. Rather than a substitute for in-person care, it was suggested that digital health care should be viewed as a complement to more traditional patient-provider interactions, and policies should promote their integration within existing health systems in a patient-centric way.

Patient engagement: We heard that patients should be included in discussions regarding the implementation of digital health care, as their perspectives and experiences will help address and overcome challenges inherent in the delivery of their health care. However, to achieve this, regular and open dialogue between patients, health care providers and other industry participants is needed. It was suggested that international experience may provide helpful insights as to how patients can be better engaged going forward. In Australia, for example, patients and health care providers regularly come together to discuss issues regarding digital health care in an effort to advance telehealth.

Mental health: We heard that digital health care solutions are also needed to address issues pertaining to mental health, particularly for the youth and the elderly. Some stakeholders told us that there are many opportunities to innovate in this field, and to use better, and domestically sourced solutions, to further support Canadians' mental health needs.

II. The impact of COVID-19

In addition to seeking stakeholder input on barriers to innovation and choice, and opportunities to improve digital health care in Canada, the Bureau asked about the impact of COVID-19 on the health care sector and Canadians' ability to access health care through digital means.

Stakeholders told us that governments moved quickly to remove barriers to digital health care in response to the pandemic, and that digital health care swiftly became integrated in settings where it may not have previously been considered or offered. Stakeholders said that virtual visits with health care providers have increased, and that Canadians generally appear to be satisfied with the care they are receiving virtually. However, stakeholders noted that the pandemic has highlighted additional measures that can be taken to improve patient outcomes. For example, Canadians want access to information and support so that they can take steps to manage their own health, which is particularly important at a time when we are limiting interactions outside of the household, and when in-person access to health care professionals may be constrained.

Despite the many strides that have been made to date, stakeholders noted that significant barriers continue to impede advancements to digital health care in Canada. We heard that we need to continue our work to break down these barriers in order to build upon progress made, and move forward. COVID-19 has been a catalyst for change, but options for digital health care will be needed beyond the pandemic.

Next steps

This What We Heard report summarizes feedback received from stakeholders who contributed to the Bureau's 2020 public consultation. The Bureau hopes that this report can shed light on some of the key issues that Canadian patients, health care providers and businesses are facing when it comes to digital health care, and provide policymakers with information that may help inform the many efforts currently underway.

This information will be used to identify areas of focus for the Bureau's health care market study. In determining areas of focus for its market study, the Bureau will also consider the following factors:Footnote 3

  1. Does a forum to present the Bureau's findings exist, and is there a high level of public interest?
  2. Will the Bureau bring forward unique arguments, unlikely to be presented by others?
  3. Will the Bureau be able to gauge the impact of its advocacy efforts?
  4. Will the Bureau's efforts have clear, tangible benefits for Canadians? How widely and how deeply will the impact be felt?

The willingness of market participants to work collaboratively with the Bureau to advance its study, as well as the availability and accessibility of data and information to inform our work, will also be taken into account.

Once areas of focus for the Bureau's study have been established, a Market Study Notice will be posted on the Bureau's market study portal. The Market Study Notice will set out the scope of the Bureau's study in more detail, and include information on key milestones and anticipated timelines.Footnote 4

For questions or comments pertaining to this report, or the Bureau's health care market study more broadly, please contact the market study team.

Annex A: Stakeholder index

For a list of individuals and organizations, along with their written submissions, please refer to Responses to the consultation on Share your views on how to support innovation and choice in Canada's health care sector.Footnote 5

The following organizationsFootnote 6 also provided comments to the Bureau on a confidential basis:

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