Literature Review: EMR Adoption in Canada

Outline[edit | edit source]

1. What is open-source?
   1. General description
   2. History
   3. Popular open source projects
2. What is an EMR?
   1. General description
   2. EMR history in Canada
3. Review of open-source EMR literature
4. Should we use open-source EMRs and why?
5. What steps need to be taken (if any)?

NGOs Involved in Digital Health in Canada[edit | edit source]

• Medtech Canada
• Digital Health Canada
• Canada Health Infoway
• Healthcare Information and Management Systems Society (HIMSS)

Summary of Provincial and National Digital Initiatives[edit | edit source]

Key Statistics[edit | edit source]

• • Supply: In 2020, there were 92,173 physicians in Canada, representing a 0.9% increase over 2019. There were 242 physicians per 100,000 population; 8% of physicians were located in rural areas and 92% were concentrated in urban areas. Overall, the average age of physicians was 49. 56% of practising physicians in Canada were male and 44% were female. 26% of physicians were trained internationally.
  • Payments: In 2019–2020, total gross clinical payments to physicians increased 4.3% over the previous year to $29.4 billion. Fee-for-service payments accounted for 72% of gross clinical payments, and alternative payments accounted for 28%. In 2019–2020, the average gross clinical payment per physician was $354,000. The average payment to family medicine physicians was $287,000; the average payment to medical specialists was $370,000; and the average payment to surgical specialists was $497,000.
  • Family medicine profile: In 2020, 52% of family medicine physicians were male and 48% were female. The average age of male family medicine physicians was 52, while the average age of female family medicine physicians was 46. 30% of family medicine physicians were trained internationally.
  • Medical specialists profile: In 2020, 59% of medical specialists were male and 41% were female. The average age of male medical specialists was 51, while the average age of female medical specialists was 46. 24% of medical specialists were trained internationally.
  • Surgical specialists profile: In 2020, 68% of surgical specialists were male and 32% were female. The average age of male surgical specialists was 53, while the average age of female surgical specialists was 45. 16% of surgical specialists were trained internationally.
  • https://www.cihi.ca/en/a-profile-of-physicians-in-canada-2020
• Most billing codes created during covid 19 were for virtual care
  • https://www.cihi.ca/en/physician-billing-codes-in-response-to-covid-19

Literature[edit | edit source]

√ Open-Source Electronic Health Record Systems for Low-Resource Settings: Systematic Review[edit | edit source]

• Reviewed GNU Health, OpenEMR, FreeMED, OpenMRS, Bahmni across 20 factors

√ Functionalities of free and open electronic health record systems[edit | edit source]

• According to the U.S. Institute of Medicine, EHR systems (i) improve accessibility to health records, (ii) facilitate communication between staff, (iii) are repositories for information collected during the treatment of the patient, (iv) support continuing treatment of the patient, (v) are a repository of information for further treatment of the same patient, and also a knowledge base for advanced research and medical education
• ISO/TC 18308 and ISO/TR 20514 clinical and technical requirements for a standardized Electronic Health Record Architecture (EHRA)
• A Boolean scale (0,1) was used to evaluate 120 of the 124 requirements
  1. MirrorMed
  2. A02  PatientOS
  3. A03  Cottege Med
  4. A04  OpenEMR
  5. A05  OpenMRS
  6. A06  FreeMED
  7. A07  Tolven
  8. A08  MedClipse
  9. A09  GNUmed
  10. A10  OSCAR
  11. A11  Elexis
  12. A12  CHITS
• In summary, the study revealed that most analyzed FOSS EHRs currently have several functional limitations including general but not universal lack of support for identification services; representation for health concepts; privacy and con- fidentiality of EHR; access consent management; integrity of EHRs; auditability of access to EHRs; knowledge manage- ment; decision support capabilities; and support for com- munication services.
• The results show that FOSS EHR projects have fo- cused their development efforts in the core requirements of an EHR system

x Open Source software in medical informatics why, how and what[edit | edit source]

• Massachusetts General's COSTAR and the Veterans Administration's VISTA software have been distributed as source code at no cost for decades
• all federally-funded bioinformatics software development should be licensed under the Open Source model
• HL71 messages [14] provide an almost universally available 'plumbing' for delivering information between independent software modules or products

√ Open-source point-of-care electronic medical records for use in resource limited settings: systematic review and questionnaire surveys[edit | edit source]

• From 20 only six open-source EMRs suitable for use in resource-limited settings
• Unfortunately, the long-term goal of having primary care data available for local, national and global use in making public health and quality care comparisons is nowhere in sight.
• a new Millennium Development Goal should include the creation of a universal open-source health informatics platform
• Funding agencies have supported the development of open-source EMRs for HIV care, which contain most of the functionalities needed by clinicians to ensure efficient workflow but have not supported systems applicable to primary care.
• OSCAR is a fully developed system and appears to be the best choice for primary care

√ SURVEY OF OPEN SOURCE HEALTH INFORMATION SYSTEMS[edit | edit source]

• In 2009, President Obama signed into law, the American Recovery and Reinvestment Act (ARRA). This was a $787 billion stimulus package
  • Within the stimulus package was the HITECH (Health Information Technology for Economic and Clinical Health) Act.
  • Intended to computerize all of America's medical records by 2014.
    • hope to improve the quality and lower costs of health care
• benefits of EHR systems that have been identified include reducing medical errors, improving quality of care, conserving physician time, sharing patient information among healthcare practitioners, and workflow efficiency
• Including: clearhealth, openmrs, vistA, worldvistA, OSCAR, OpenEMR, Toven, Indivo

√ Free/Libre Open Source Software in Health Care: A Review[edit | edit source]

• Open Source Initiative promote their definition of Open Source software.
• Several scientific papers have been published in the last de- cade about FLOSS-HC [19-42]. An overview of these articles is given in Table 1.
• Table 2. Resources for Free/Libre Open Source Software (FLOSS) on the Web
• potential value of the VA's health IT investments is estimated at $3.09 billion in cumulative benefits net of in- vestment costs
• The Hakeem Program was launched 2009 and aims to computerize all of the public hospitals and clin- ics in Jordan
• In the UK there exists an initiative to adopt VistA for the UK National Health Service (NHS) called NHS VistA
• OpenMRS is probably the best known and widest deployed system in low-resource settings

√ Adoption of Open Source Software in Healthcare[edit | edit source]

• OSS is experiencing an exponential growth in several industries such as finance, sales and marketing, pharmaceuticals, and manufacturing but not in healthcare
• "The Cathedral and the Bazaar" = i) software users are treated as co-developers; ii) the software is released early with frequent inte- gration of new codes characterized with high level of modularity; and iii) the devel- opment team is capable of making strategic decisions based on user requirements that evolve and change over time
• see table 1 for list of open-source software in healthcare
• OSS is also considered more secure than proprietary software because source code can be in- spected and reviewed for potential breaches by a large number of code developers
• OSS products have also fewer bugs and less fre- quent system failures
• problem of technology fragmenta- tion and lack of process integration
• open standards and higher degree of interoperability
• improved system stability, reduced vendor lock-ins, and lower cost

√ Comparison of Open-Source Electronic Health Record Systems Based on Functional and User Performance Criteria[edit | edit source]

• Alexa web ranking and Google Trends found OSHERA VistA, GNU Health, the Open Medical Record System (OpenMRS), Open Electronic Medical Record (OpenEMR), and OpenEHR are most popular
• OpenEMR met all the 32 functional criteria, OSHERA VistA met 28, OpenMRS met 12 fully and 11 partially, OpenEHR-based EHR met 10 fully and 3 partially, and GNU Health met the least with only 10 criteria fully and 2 partially.  
• OpenEMR is the most promising EHR system, closely followed by VistA
• user-facing system performance, OpenMRS has superior performance in comparison to OpenEMR.
• OSS has several technical benefits, such as reliability, security, quality, good performance, flexibility of use, tester and user base, compatibility, and harmonization.
• FOSS in healthcare is different because of the inherent need for do- main-specific experts in the community.
• These EMRs vary greatly regarding their audience and the type of health facility that they target (e.g., primary care clin- ic, community hospital, or a tertiary hospital)
  • OpenEHR is a standard, a set of archetypes that are implemented in EHR system products.
  • OSEHRA VistA and GNU Health are hospital information systems.
  • Open- EMR and OpenMRS are EHR systems or platforms, respec- tively, but those are details that are common across propri- etary EHR systems, which market their products to different audiences
• not exhaustive, especially on security and interoperability

x Conformance Checking: Workflow of Hospitals and Workflow of Open-Source EMRs[edit | edit source]

• free acquisition of OSS EMRs/EHRs does not entirely make their use easy.
• check con- formance of workflow in Open-Source EMRs (workflow discovered from OpenEMR event logs) with the actual the workflow of hospitals
• 3000 physicians 65% reported EHR disrupting their workflow
• there is conformance in the workflow of open source EMRs/EHRs and workflows of hospitals.
• The Open Source Initiative's (OSI) set of standards states that for a software to be classified as open-source, it must have the following qualities: I. Unrestricteddistribution II. Sourcecodedistribution III. Modifications IV. Author'ssourcecodeintegrity V. Nopersonaldiscrimination VI. Norestrictiononapplication VII. Thelicensemustnotbeproduct-specific VIII. Norestrictiononothersoftware IX. Technologyneutrality[19]
• Application of machine learning methods in EMRs helps streamline administrative processes in hospitals, map and treat infectious diseases, and personalize medi- cal treatments

√ Family doctors call for guaranteed access to EMR data for research and quality improvement[edit | edit source]

• decrying demands imposed by EMR vendors, such as prohibitive fees, restrictions on third-party extraction and analyses, and limitations on the type and frequency of data extractions.
• Who owns the data in an EMR? Pereira said the general consensus among medical ethicists is that the data belong to patients, and clinicians are the custodians to ensure privacy.  

√ Functionalities of free and open electronic health record systems[edit | edit source]

• examine open-source electronic health record (EHR) software to determine their level of functionalities according to the International Organization for Standardization
• According to the U.S. Institute of Medicine, EHR systems
  • (i) improve accessibility to health records
  • (ii) facilitate communication between staff
  • (iii) are repositories for information collected during the treatment of the patient
  • (iv) support continuing treatment of the patient
  • (v) are a repository of information for further treatment of the same patient, and also a knowledge base for advanced research and medical education  
• CHITS, Cottage Med, Elexi, FreeMED, GNUmed, Med-Clipse, MirrorMed, OpenEMR, OpenMRS, OSCAR, Patien- tOS, and Tolven
• lack of support for identification services; representation for health concepts; privacy and con- fidentiality of EHR; access consent management; integrity of EHRs; auditability of access to EHRs; knowledge manage- ment; decision support capabilities; and support for com- munication services.  

√ How American EMRs came to dominate Canadian health care[edit | edit source]

• The company's share in Canada is about half that proportion, but together with Meditech and Cerner their products control more than 90% of EMRs in this country.
• $459-million deal with Alberta Health Services, as well as becoming the EMR provider for Toronto's Hospital for Sick Children, Ottawa's Children's Hospital of Eastern Ontario, the Ottawa Hospital system, and other sites across the coun- try.
• Canadian vendors lack the financial resources to carry out ongoing research and development for their products on the same scale.

√ Implementing e-Health through CHI: A Very Canadian Solution to a Very Canadian Problem[edit | edit source]

• Eventually a consensus was reached that a 'National Information Highway' should be built (Advisory Council on Health Infostructure (ACHI) 1999)
• The Canadian Constitution of 1867 gave provinces the majority of responsibility for health care provision and left the federal government with minimal in- fluence over health care decisions.
• states that provinces must ensure 'medically necessary' health care is available to all citizens: e-health was obviously not included.
• CHI's funding was, however, entirely federal
• An initial aim of CHI was to ensure that 50% of Canadians had an interoperable Elec- tronic Health Record (EHR) in place by 2009; by 2010 only 22% was achieved, with the target eventually delivered by 2011  
• John Kingdon (1995) suggests that there are three means by which an issue can move on to, and up, a government's agenda: the problem stream, the proposal stream and the political stream.

x Infoway is shifting, not shuttering: Alvarez[edit | edit source]

• In 2011, an exter- nal performance audit commissioned by Infoway showed that the organiza- tion had missed its program targets by a wide margin, and the Auditor General of Canada criticized its implementation of the national e-health strategy as being haphazard.
• eHealth Ontario scandal

√ Interoperability of electronic medical records requires more than just technical understanding[edit | edit source]

• advocating for single emr
• However, handing over administration of all health information to 1 vendor, unmo- lested by competition, confers great power upon the vendor

√ Open-source Software and the Primary Care EMR[edit | edit source]

• excessive cost, the transience of vendors, and the lack of common data standards.
• OSS fits naturally our scientific model of shared, peer-reviewed knowledge in medicine
• EMR vendors can become professional service pro- viders competing on service quality rather than on the basis of software secrets.
• Lack of so-called vendor lock-in
• authors of open-source applica- tions are known for embracing standards

√ Multi-criteria analysis for OS-EMR software selection problem: A comparative study[edit | edit source]

• Similarily to Open source EMR software: Profiling, insights and hands-on analysis by similar authors except deals with selection instead of analysis
• GNUmed, OpenEMR, and OpenMRS software are the most promising candidates for providing a good basis on ranking scores/orders
• ZEPRS is not recommended because it records the worst ranking score/order in comparison with other OS-EMR
• further investigation is required, particularly on security, interop- erability, and developer support.  

√ Primary care electronic medical records: a new data source for research in Canada[edit | edit source]

• As the use of EMR expands, there is an opportunity to use the patient data from EMRs for other purposes
• view of primary care that has never been avail- able in Canada

√ National electronic health information strategy needs to be refocused, critics say[edit | edit source]

• the primary focus should be on local, often inexpensive, health information solutions not national infostructure

x Digital advantage in the COVID-19 response: perspective from Canada's largest integrated digitalized healthcare system[edit | edit source]

• Alberta Electronic Health Record Information System (started in 1997) is one of the largest population based comprehensive electronic medical record (EMR) installations
• Alberta Health Services is the largest employer in Alberta and fifth largest in Canada.
• Advantages included:
  • Self-assessment online tool for healthcare & shelter workers, enforcement personnel and first responders
  • Fit for work online assessment for healthcare workers
  • Linking online screening with testing, online result sharing and tracing
  • Standardized management with best practice advisories, pandemic data collection and decision support
  • Alberta trace together mobile device software application
  • Telemedicine and digital healthcare
  • Virtual clinical hospital meetings and multidisciplinary conferences
  • Virtual hospital and other care in the community programs
  • Additional billing codes for telehealth released
  • Not all economies are equally prepared for digitalization in healthcare

√ Understanding challenges of using routinely collected health data to address clinical care gaps: a case study in Alberta, Canada[edit | edit source]

• High-quality data are fundamental to healthcare research, future applications of artificial intelligence and advancing healthcare delivery  
• Alberta, Canada is a globally recognised jurisdiction for its health data infrastructure and capture. However, health service researchers have identified important limitations to its use.
• capture, categorise, and label overarching and recurring problematic data patterns in electronic health records
• A trained analyst employed by Alberta Health Services extracted the data.
• Rapid access to clinically important information is crucial to building a powerful learning health system
• he strengths and limita- tions of administrative and electronic medical record health databases have been described extensively, for instance in the work of Burles et al, Clement et al and Edmondson and Reimer.
• inability to analyse data in real time is not a problem unique to the Canadian context
• overarching issues relating to data capture, completeness, accuracy, and harmonisation, exist across healthcare systems
• Federation of Medical Regulatory Authorities in Canada's goal that all Canadian physicians participate in data-driven practice quality improvement.
• Believes the long-term benefits of improved data capture would signifi- cantly offset upfront investments.  
• Recommendations
  • To have more clinically important data available in readily extractable formats, we suggest expanding and harmonising mandatory data submission requirements
  • To increase the quality and validity of the data available to assess patient care, we suggest the use of more specif- ic codes and consistent taxonomies across the health- care system to capture encounter diagnoses; standard- isation of data
  • To enhance efficiency and speed of data capture so that upgrading data quality, quantity, and structure is not at the cost of the clinical user, we suggest the incorporation of technologies like natural language processing, cross-platform interoperability, and appli- cation of human-centred design for workflow process improvement.
  • To promote real-time usability of data, we propose inte- grating technologies such as natural language process- ing and artificial intelligence

√ Ontario's Electronic Health Records Initiative[edit | edit source]

• Allegations were made that contracts were sole-sourced to a number of consulting firms or individual consultants by the CEO of the eHealth Ontario agency or her appointees. Our work indicated that this was undoubtedly the case.

√ The future of electronic medical records in Canada[edit | edit source]

• We need a mandate, from the federal government, that forces the provinces and the EMR providers to adhere to a common standard, not a single electronic health record

x Implementation of a nationwide electronic health record (EHR): The international experience in 13 countries[edit | edit source]

• implementation of nationwide electronic health record (NEHR) system has progressed much more slowly worldwide than it was initially anticipated
• best practices, in respect to organizational and operational issues
• Breakdown of roles within the NEHR bodies:
  • Four participants where the project managers
  • three where the directors  
  • Three were principal advisors
  • One was chairman
• eight participants come from Europe (Denmark, Austria, Sweden, Norway, the UK, Germany, the Netherlands and Switzerland)  
• five from the rest of the world (Canada, the USA, Israel, New Zealand and South Korea).
• 19 out of 33 countries are still at the planning stage of the development and implementation process of a patient summary and EHR-like system
• Canada and Australia are the countries with the most advanced stage of NEHR implementation
• Denmark and Sweden is considered as a leading country as far as eHealth integration and healthcare delivery services are concerned
• outcome of the implementation process is affected by the quality of the design of the systems graphical user interface, the functionality of the features incorporated, project management, procurement and users' previous experience.
• strategic, organizational and human challenges are usually more difficult to master than technical aspects
• design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction and lack of time and workload
• "top-down," "bottom-up" and "middle-out" = England, the USA and Australia.
• Segmented systems by
  • National healthcare systems
  • EHR implementation approach – method used
  • Reasons of the chosen EHR implementation approach – method
• top-down approach was used in the UK, it was abandoned in 2010, replaced by a more locally middle-out approach
• in the USA, although the bottom-up approach was initially adopted, nowadays it is moving toward a middle-out approach
• "commitment and involvement of all stakeholders" is critical
• "Clear long-term perspectives, endurance, and patience" is also critical
• Critical failures is lack of support and the negative reaction to any change from the medical, nursing and administrative community
• Another critical failure is low budget or poor resources are not considered as very important factors for EHR system

√ Toward a healthcare strategy for Canadians[edit | edit source]

• Outlines a strategy for a coordinated EHR in Canda
• Evaluated current literature on EHR specifically about Healthinfo way
  • 12 studies on 13 systems funded by infoway
  • 25 canadian studies on HIT
  • Auditor General of Canada report and the reports of 6 provincial auditors
• Detailed the value of EHRs

√ Open Source, Open Standards, and Health Care Information Systems[edit | edit source]

• In the United Kingdom, contracts were negotiated in 2004 for a National Health Service (NHS) National Programme for Information Technology (NPfIT) with a budget of £12.4 billion over 10 years. This makes it an information technology (IT) project unprecedented in terms of cost and scale
• US $19 billion to develop and encourage the implementation of HIS as part of the American Recovery and Reinvestment Act of 2009
• Open Standards Need Open Source Software Implementations
• In the United Kingdom, the government chose to procure HIS centrally and implement them locally via five separate local service providers, who in turn were able to choose and change subcontractors
• output-based specification
• compared with OSS, this development model is often more expensive, less responsive to users, less secure, and more vulnerable to lock-in.
• in the us, outside of the VA network of hospitals, uptake of HIS has been poor
• The major reported barrier to the adoption of HIS is cost  
• Lack of awareness and understanding of, and familiarity with, OSS is a major barrier to the adoption of OSS HIS
• lack of clear governmental support
• lobby groups
• more expensive, less secure, or riskier in terms of liability, which are debunked here and elsewhere
• In 2004 the UK government announced that it will consider OSS solutions alongside proprietary ones, only use open standards
• 2003 the official US Department of Defense policy is that OSS solutions should be given equal consideration  
• US Navy has gone further and in 2007 recognized OSS as key to operational effectiveness

√ What Do Electronic Health Record Vendors Reveal About Their Products: An Analysis of Vendor Websites[edit | edit source]

• A list of EHR systems available in Ontario was created. The contents of vendor websites were analyzed.  
• Vendors provided little specific product information on their websites.  
• trial EHR versions were not available.
• EHR vendor websites employ various persuasive means, but lack product-specific information
• OSCAR (the open-source option) had all 8 core functionalities display compared to the Primary EHR cateogry average of 6.083.

√ Towards the Adoption of Open Source and Open Access Electronic Health Record Systems[edit | edit source]

• Reviewed openEMR, openMRS and patientOS

√ Evaluation and selection of open-source EMR software packages based on integrated AHP and TOPSIS[edit | edit source]

• Similarily to Open source EMR software: Profiling, insights and hands-on analysis by similar authors except deals with selection instead of analysis
• Recommends GNUmed and OpenEMR

√ Cooking Up An Open Source EMR For Developing Countries: OpenMRS – A Recipe For Successful Collaboration[edit | edit source]

• described the OpenMRS system, an open source, collaborative effort that can serve as a foundation for EMR development in developing countries.
• Eldoret, Kenya and is planned for use in Tanzania and Uganda.

√ Barriers to Open Source Software Adoption in Quebec's Health Care Organization[edit | edit source]

• At the end of the 1970s, before the term entered the vernacular, Octo Barnett freely distributed the source code for the "OSCAR Ambulatory Medical Record" application
• A recent survey of all health and social services centers in Quebec revealed that the IT budget represented 1.8% of the total annual budget in these organizations in 2007, a very small increase since 2000
• 14 of the 15 respondents mentioned that that their IT budgets represented between 1.5% and 2%
• 15 interviews, 45 and 90 min, 195 pages of verbatim text
• Association of Quebec Health Network Information Technology Managers
• see screenshot
• The Ministry is more and more involved in certain projects with this vendor.
• of the 14 establishments only four have development teams.
• Ministry of health doesn't want any software development
• Little has been written in the scientific press of the role that political pressure plays in the open source adoption decision.
• For many open source products there is no salesperson  
• lack of presence at trade shows.
• McDonald et al. [1], CIOs in the health care sector are more conservative than their counterparts in other industries.
• lack of support for providers
• whether the company will be there in 10 years
• OSS 2.0 landscape is characterized by commercial, for-profit companies offering support and maintenance contracts for OSS licensed products whose development is controlled by a well identified, often for profit, organization.

√ Open-source health information technology: A case study of electronic medical records[edit | edit source]

• It is estimated that, by improving health care efficiency and safety, the widespread adoption of electronic medical record (EMR) in the United States can save more than $77-$81 billion annually.
• In ambulatory care, EMR systems are found to reduce the number of unnecessary or marginally productive visits by 9%
• integrated physician order entry (CPOE) and ICU physician staffing (IPS) could save over 65,000 lives, prevent over 907,000 serious medication errors, and save approximately $9.7 billion annually
• A recent estimate of the cost of purchasing an EMR in the US is $15,000 to $50,000 per physician
• Operating costs may reach $20,000 per year  
• Costs soar when the system is implemented in a larger organization.
• For example of, the Quebec Health Record had an initial budget of $562 million  
• patients need to interact with multiple health workers and insurers in multiple health units, patients' data should be portable
• UK and Taiwan chose to implement an EMR system to be used nationwide
• In North America, however, the trend is toward allowing different competing systems while insuring interoperability of the data.
• the Quebec Health Record stores records of patients in Quebec centrally
• Successful OSS HIT projects seem to have commercial and government sponsors
• Commercial vendor lock already limits the possibility of future OSS adoption in many health institutions.
• OSS favors open standards and protocols to insure that efforts of multiple parties can integrate.
• Internal advantage of OSS more flexibility in changing the system and customizing it
• External advantage of OSS open- source systems tend to comply with standard programming interfaces and open architectures such as the Health Level 7 (HL7) protocol in the medical context.
• However, network effects may favor existing proprietary HIT.
• Large-scale systems are typically developed by big vendors and are designed to integrate well with complementary products from the same vendor.  
• some argue that by being open, OSS are less secure because an attacker can access the source code and learn about the inner working of the system in order to exploit vulnerabil- ities.
  • this argument is controversial because vulnerabilities can be quickly fixed
• open-source HIT may lack the availability of coded data that may be proprietary or strictly licensed including databases of diseases, drugs, procedures, and billing codes
• Interviews with government officials and health managers indicate that barriers to adopting OSS HIT are more organizational than technical
• The open-source development model is not properly understood by many stakeholders including medical practitioners.
• miscon- ception that because open-source HIT is cheaper than commercial software, it must be of lower quality.
• power of lobby groups that represent commercial vendors
• OSCAR gained substantial market share in major Canadian provinces reaching third place in Ontario in 2012.
• The OSCAR project receives funding from multiple sources. Government is the main grantor
• Currently there are over fifteen OSCAR service providers (OSPs) in Canada and their number is growing rapidly
  • There is now only one!
  • Because OSCAR is open-source, OSPs do not have the right to sell licenses to use the software. However, they can sell related services such as installation, training and support.
• e-form generator quickly build new medical e-forms by scanning paper one (implemented by user)
  • commercial EMRs that charge an hourly rate for developing e-forms.
• OSCAR manual (http://oscarmanual.org/) utilizes wiki technology also developed by users
• OSCAR has passed provincial EMR certification in Ontario and Quebec

x Northwest Territories leads Canada in electronic medical record coverage[edit | edit source]

• NWT has over 90% coverage
• Infoway unable to tell the stats for other provinces
• That almost all physicians are salaried employees in the territory has made EMR implementation simpler, said Li manager of technical services for the Yellowknife Health and Social Services Authority

√ Open source EMR software: Profiling, insights and hands-on analysis[edit | edit source]

• EHR is defined by ISO/DTR 20514 as "A repository of infor- mation regarding the health of a subject of care in computer processable form, stored and transmitted securely, and acces- sible by multiple authorized users"
• FreeMED, GNUmed, GNU Health, Hospital OS, HOSxP, OpenEMR, OpenMRS, OSCAR, THIRRA, WorldVista, ZEPRS, ClearHealth, and MedinTux
• software quality models International Organization for Standardization and International Electro- technical Commission 9126-1
• Three users were selected for this test. Two are from the medical field with low and high IT literacy. The third user is a professional programmer.  
• Three very common tasks in an electronic medical records system are to:
  • (1) create a patient, filling at least the basic demographic data
  • (2) enter a visit at the counter
  • (3) gener- ate a report.
• Reviewed 32 articles from 2003 to 2013
• 25 sub features
  • 1. OpenEMR (19/25)
    2. GNUHealth (16/25)
    3. GNUmed (14/25)
    4. WorldVista (14/25)
    5. OSCAR (14/25)
    6. FreeMED (13/25)
    7. HOSxP (10/25)
    8. Hospital OS (9/25)
    9. MedinTux (9/25)
    10. OpenMRS (8/25)
    11. ClearHealth (7/25)
    12. THIRRA (7/25)
    13. ZEPRS (5/25)
• Out of the 13 systems under consideration, only four report their compli- ance to HIPAA and none to the 95/46/EC European Directive.
• committed technical support is necessary even through paid options
• always possible, in theory at least, to modify the software to one's own needs
• mostly fulfil structural and procedural requirements at the minimal and sometimes full functional- ity levels.
• OpenMRS is the most popular and widely employed open source EHR system.
  • It could be the case, however, that it is the most extensively covered sys- tem, rather than the most deployed.  
• OSS based on voluntary communities might not be able to meet demands of Healthcare systems operate large, complex and all-day non-stop operations, face heavy and changing regu- latory burdens, and have heavy implementation and support requirements.
• no evidence yet that OSS applications are more reliable than commercial products in this area, and this is despite the acknowledgment that availability of source code makes immediate fixes for identified problems possible.
• Still no widespread deployment of OSS health- care applications was reported in the literature, nor does compelling evidence exist of their superiority compared to more matured commercial systems in this field.
• See table screenshots in Zotero

√ E-health progress still poor $2 billion and 14 years later[edit | edit source]

• Canada's $500-million electronic medical records market.
• vendors are required to submit their products for testing in each province to prove their conformance with provincial technical standards
• "Infoway funds things but doesn't manage them. There's a big leadership gap."

√ Administrative health data in Canada: lessons from history[edit | edit source]

• Canada has some of the most comprehensive and high-quality administrative health data in the world, in part due to its universal health insurance registries, com- prehensive coverage of inpatient and outpatient services, and linkage of databases via unique personal identifiers within provinces and territories [2].
• largest adminis- trative health database in Canada is the Discharge Abstract Database = all separations from acute care institutions in Canada, 75 % of all inpatient discharges in Canada
• Canadian Institute for Health Information (CIHI)
• We then compiled our findings to construct an historical narrative, spanning from 1847 to the present day (2015).
• Statistics Act to give the federal government authority to "collect, compile, analy[z]e, abstract and publish statistics" to include "hospi- tals, mental institutions, tuberculosis institutions, and char- itable and benevolent institutions."
• in the 1961–1964 Royal Commission on Health Services (RCHS), the lack of communication between the Dominion Bureau of Statis- tics and other departments throughout the first half of the 20th Century resulted in the timely and often dupli- cated collection of statistics
• Recommendation 1: Federal financial support in consolidating existing registers (also provincial support)
• Recommendation 2: Standardize classification of diseases and social and demographic characteristics to facilitate comparability between regions
• Recommendation 3: Establish a national clearinghouse and coordinating agency for health statistics

√ A Qualitative Study of Open Source Software Development: the OpenEMR Project[edit | edit source]

• increasing interest in applying the Open Source approach in domains that are not traditional Open Source territory.
  • the U.S. Department of Defense has established an Open Source "forge" in an effort to promote sharing of software among DOD contractors
  • European Space Agency has requested tenders for a feasibility demonstration of an Open Source repository of source code to support space missions  
• it has been hypothesized that a successful Open Source project requires an active community of developers and testers that is much larger (two orders of magnitude) than the "core" developer group  
  • If this is the case, there may not be sufficient participants in specialized domains
  • Internet infrastructure and programming tools [5], where one would expect the majority of developers to also be users of the product they are developing.
• Can the Open Source approach work in specialized do- mains?
• employed content analysis to classify a total of 1218 OpenEMR discussion forum messages
  • core developers contributed nearly half of all messages, almost three-quarters of implementation announcements, and over half of bug fixes and proposals for enhancements.
• Found open source projects can be successful with a relatively small community in contrast to earlier suggestions
• MP Pro was released in 2001. In 2002, the name was changed to "OpenEMR" GNU General Public License
• examines data from 2005 to 2010.
• Tested hypothesis from Mockus and colleagues
  • • Successful projects will have a core of no more than 15 developers. • A large group of developers surrounding the core will repair defects. • Projects without a large group of developers repairing defects will fail due to poor code quality. • Developers of successful Open Source products will also be users of the product.
• RQ1: Is the OpenEMR project successful? RQ2: What is the size of the core developer group? RQ3: Who fixes bugs in OpenEMR? RQ4: How many of the OpenEMR Core Developers are also users of the product? RQ5: How long does it take OpenEMR project members to respond to issues?
• 16 core developers with 3 being physicians
• median response time to issues of 2.3 and avergae of 11.74 hr

√ A national electronic health record for primary care[edit | edit source]

• Canada Health Act states health care should be portable but it isn't.
• Still mailing or faxing records
• Some clinicians have even created their own electronic health record.
• should rebuild it [the EMR system] from the ground up
• Switching will be painful
• US Department of Veterans Affairs implemented a national electronic health record in 1999
• Plans were announced last year to drop this tailor-made system and switch to the proprietary system used by the US Department of Defence, as the several hundred million dollars poured into improving interoperability between the 2 sys- tems had failed
• SingHealth, 1 of 2 health clusters in Singapore, uses a single electronic health record for nearly 4 million annual patient
• open-source software may avoid dependence on the owners of a proprietary product,  
• Canada Health Infoway should be given the specific mandate to select and improve one electronic health record

√ A tactical framework for EMR adoption[edit | edit source]

• Buntin et al.2 illustrated that 62% of Health Information Tech- nology (HIT) research showed positive results, with another 30% of research studies showing mixed-positive conclusions overall.
• Electronic medical records can provide a number of benefits including reducing medical errors and facilitating appropriate treatment or screening strategies.
• EMRs can provide organizational and societal benefits such as increasing research ability, averting costs, and improving compliance at both legal and regulatory levels.
• Canada Health Infoway12 found benefits such as decreased adverse drug events, enhanced preventive and chronic care management, and fewer duplicated tests.
• Some of the main [adoption] bar- riers are high upfront investment costs, interruptions in work- flow, physician buy in/autonomy, security concerns, and other unintended adverse outcomes.
• Kruse et al.4 grouped over 60 different barriers into 39 distinct categories. These different barriers appeared 125 times in the 27 articles that they reviewed for the study.
• One common work- around is continued use of paper to duplicate EMR charting or in some instances a full ghost chart, where a full paper chart is maintained outside the EMR.
• Technology adoption models of such models include Actor Network Theory,2 Holistic eHealth Framework,17 Sociotechnical Frame- work,18 adoption models such as Technology Adoption Model,19
• the Delone and McLean model20 was used by the Canada Health Infoway12 to develop a benefits framework for EMRs. The model states that key contextual factors including strategy, culture, and business processes are out of scope; however, it is these contextual factors that differentiate implementation from adoption.
• need to focus on technical and non-technical implementation factors
• Variet of questions for Tactical framework for EMR adoption.
• A number of theoretical models exist that look at various aspects of EMR implementation, often from a high level. While these models provide meaningful insight, they do not provide a tactical approach
• Further, there is no one size fits all EMR adoption solution but rather they need to be tailored to the individual context of where the EMR will be used.

√ Canada's future health care system[edit | edit source]

• There are at least 300 primary care interactions for every inpatient admission to an academic health sciences centre, representing an important longitudinal source of information about the health of Canadians in our commun- ities.
• Univer- sity of Toronto Practice-Based Research Network (containing the primary care records of more than 500 000 people), which contributes to the Canadian Primary Care Sentinel Surveillance Network (con- taining records of more than 1.5 million Canadians).

√ A qualitative study of Canada's experience with the implementation of electronic health information technology[edit | edit source]

• Unlike other countries that lever- aged local initiatives toward a national system to achieve high rates of adoption of electronic health records, Canada Health Infoway set out to establish a national infrastructure
• used by Hendy and colleagues to assess the imple- mentation of a national program for health infor- mation technology in the United Kingdom
• Interviewed stake holders from national and provincial agencies responsible for health information technology; quality/safety and public health agencies; health professional associations; and vendors of health information technology.
• e-Health varies from province to province Alberta, the most advanced; Ontario, the least advanced; and British Columbia, in the middle
• "health information technology" was used to represent both electronic health records19 and electronic medical records.
• CHI used
  • gated funding (the release of funds in accordance with performance benchmarks)
  • Linked project funding to the use of standards to support interoperability.
• Analyzed interviews with ATLAS.ti software
• 29 of the 32 selected representatives agreed to participate. Nine of the participants rep- resented national or regional agencies responsible for health information technology, seven were from health professional groups, eight repre- sented safety/quality and public health agencies, and five were from the vendor community.
• blue- print needed to be less top-down, and more flexi- ble and adaptive
• national and even international standards were highly desirable, there was consensus that na- tional interoperability was not a priority. Focus on regional interoperability instead
• Moreover, there were con- cerns that Canada Health Infoway was unreason- ably ambitious
• Interviees thought CHI was successful in
  • A comprehensive strategy that defined a national approach to the infrastructure and standards of health information technology (HIT)
  • A framework that coordinated and brought provincial HIT planning together,... strengthening provincial purchasing power
  • Successful lobbying for HIT, and acquisition of political and financial support
  • Digital imaging technology and provincial patient registries are the most successful HIT applications (e.g., PACS and Enterprise Master Patient Index)
• In most Western countries, health care systems face common challenges: improving patient safety, establishing better models for the management of chronic diseases, and engineering sustainability of the health care system in the face of escalating costs.
• vision of creating a national system... has no immediate impact on any of these challenges... most health care is rarely delivered outside provincial jurisdictions
• key components such as problem lists, clinical notes and computerized decision-support were not in the e-health investment plan
• Interviees future direction related to Canada's e-health policy and adoption of electronic health records:
  • Canada's e-health plan needs to be driven more by policy related to expected benefits for patients and providers than by technological solutions
    • set up to implement, it was not a policy body), our federal health ministry at that time decided to downtool on the policy stuff. So, we have basically had a policy vacuum
  • More meaningful engagement of clinicians is needed to ensure clinical utility to increase adoption
  • Investment in the promotion and implementation of electronic health records in collaboration with the regulatory and professional organizations is needed
  • To increase patient benefits, payment models and incentives to promote adoption of electronic health records should be based on patient outcomes that can be achieved with electronic health records
• Although a "top-down, technical, architecture-first" approach may eventually lead to the same outcome as a "bottom-up, clinical- needs-first" approach would, the top-down approach was considered to be too slow, expen- sive and inefficient by some of the participants.
  • Stakeholders involved in implementing the National Programme for IT (NPfIT), the national electronic health record system in the United Kingdom, expressed similar sentiments
• the US Office of the National Coordinator for Health Information Technology has specified a list of requirements for clinically meaningful use, func- tions and features of electronic health records
• Canada Health Infoway's approach was to build the infrastructure and then let the provinces and territories implement applications that use this infrastructure.
• Future directions proposed by participants that were related to the national infrastructure for electronic health records
  • Strong leadership and structure is needed to engage stakeholders, build consensus, implement the e-health plan and get clinicians to adopt electronic health records
  • Strong leadership and structure is needed to engage stakeholders, build consensus, implement the e-health plan and get clinicians to adopt electronic health records
  • National interoperability is not a priority; interoperability needs to focus on the implementation of more rapid methods of supporting the continuum of care locally
• Canada Health Infoway's approach was to build the infrastructure and then let the provinces and territories implement applications that use this infrastructure.
• consensus among the par- ticipants that a process is needed to update the architecture and standards of the e-health plan on a continual, timely basis,
• In addi- tion, effective strategies for closing the gap be- tween national standards and existing legacy systems were identified as a challenge
• unable to assess whether the participants' views varied across provinces or between stakeholder groups
• To achieve these objectives, policies are needed (a) to facilitate timely sharing of clinical informa- tion between health care providers in all settings, including community, hospital, long-term care facilities and home care; (b) to make personal health records and self-management tools accessi- ble; (c) to support electronic communication between providers and members of interdiscipli- nary teams; (d) to establish incentives for the use of reminders for preventive care and for the use of comparative quality indicator assessment and reporting; (e) to facilitate the development of point-of-care, evidence-based clinical decision- support methods for personalized health care; (f) to enable reimbursement for e-visits; and (g) to re- form the payment model to include financial reim- bursement based on patient outcomes that can be achieved with the use of electronic health records. To foster innovation, policies are needed to sup- port research and translation of successful regional initiatives (i.e., a "bottom-up" approach).
• cadre of clini- cians trained in medical informatics
• The creation of a chief provincial clinical information office  

√ Advancing Primary Care Use of Electronic Medical Records in Canada[edit | edit source]

• 1990s, the Advisory Council on Health Infostructure recommended setting up a nation-wide 'information highway'
• 2003 First Ministers' Accord on Health Care Renewal (Health Canada 2006) supported the EMR
• Electronic Health Record Solution Blueprint in 2006
• Alberta began enrolling physicians in provincial EMR support programs in 2003, followed by Ontario and Nova Scotia in 2005 and British Columbia in 2008.
• studies conducted by the Commonwealth Fund and by academics (e.g., Protti 2007) showed that Canada was falling behind global leaders in the adoption of EMRs in primary care.
• For example, the Standing Senate Committee on Social Affairs, Science, and Technology (2002) noted that six different provincial reports on primary health care between 1999 and 2002 stressed the need for electronic records.
• Commission on the Future of Health Care in Canada said that "primary health care should be a major focus for actions designed to implement electronic health records" in 2002
• Canadian Medical Association noted that EMRs would lead to "significant improvements in 2008
• Use of EMRs in primary care rose from 23% in 2006 to 64% in 2013

√ Evaluating EHRs and EMRs in Canada's e-Health System[edit | edit source]

• Establishment of CHI in 2001
  • $2.1B funding over 13 years in 2001
  • $500M funding in 2008
• EHR and EMR are records under the custodianship of the healthcare provider(s)
• Differences between EHR and EMR
  • 1. an EHR is a complete health record while an EMR is a partial health record;
    2. an EHR is described as a 'person-centric' health record while an EMR is described as a 'provider-centric' or 'health organization-centric' health record;
    3. an EHR can be accessed online from many separate, compatible systems within a net- work (i.e., used by many approved health care providers or health care organizations) while an EMR can be accessed from a single system in a doctor's office and it may, or may not, be shared with other health care professionals.
• Evaluating EMR/EHR programs is challenging due to a lack of available data and context-specific literature
  • most studies have relied on comparisons with the United States
  • much is made of raw rates of adoption of EMRs in primary care practice
• In Canada, "primary care physicians are the gatekeepers to the health care system"
• rewarding physicians exclusively for volume of care and providing no incentives for cost management
• Many calls for "collaborative and coordinated care aims to deliver an integrated array of services to Canadians" since 1974
• Implementing EHRs is not only a matter of technology; it requires changes in the way the health system is organized (payment schemes and roles and responsibilities of doctors).
• Evaluating EHRs should focus on their effect on outcomes of the health system.  

√ Canadian National Health Interoperability Standards[edit | edit source]

• Between 2005 and 2015, governments established various types of standards working groups and committees that ultimately had a responsibility to approve interoperability standards... Unfortunately, this didn't come to fruition.
  • 'chicken and the egg' problem, which was that commercially available products didn't support the new standards because there was no evidence of a market demand for them.
  • hubris that every potential data exchange need could be identified, modeled, and standardized on a global scale, and likewise at a national and jurisdictional level.
    • (e.g., https://www.infoway-inforoute.ca/en/component/edocman/resources/technical-documents/391-ehrs-blueprint-v2-full is very over specific)
  • minimal vendor participation
• Integration Engines (IE) and Health Information Exchange (HIE)
• However, it is encouraging to see Canada Health Infoway and provinces like Ontario and Alberta working on patient summaries that source at least some of the data from primary care.

Select Recommendations

• Figure out the adoption model for clinicians
• Favour agility and speed over perfection in architecture and standards.
• Systems integrator mentality.
  • Previously, the prevailing mindset was that jurisdictions could establish a single standard for all end points involved in data exchange.
• Provide Reference Systems and Connectathons for Developers
  • TECHNATION Health is happy to work with any organization that wants to establish connectathons

√ The Role of Interoperability in Health Systems' Digital Transformation[edit | edit source]

Key takeaways listed:

1. Interoperability is a key lever for digitally transforming health systems toward more agile and patient-centered delivery of health services, but the U.S. experience serves as a cautionary tale.
   • Interoperability — secure, appropriate, and ubiquitous data access and electronic exchange of health information.
   • HITECH Act, 2009 — financial incentives for providers to adopt electronic health records
     • EHR usage +80% healthcare professionals and +90% of healthcare organizations use certified EHRs
   • 21st Century Cures Act, 2016 — prevent "information blocking"
   • Information blocking — the refusal by healthcare institutions or providers to share patient health data with other providers
   • Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS)
2. Technical standards, education, and implementation guides are essential necessities for countries' interoperability journeys
   • Global Consortium for eHealth Interoperability = HIMSS, HL7 International and IHE International
   • standards focused education is pivotal
   • Bhutan EHR
     • that participant also acknowledged that Bhutan does not have in-country technical expertise on interoperability and EHR vendors are having to bring specialists from other countries to develop the system. "We are looking at this as an opportunity because then our local capacity will be built for sustaining this e-health system that we are going to implement,"
   • social determinants of health (SDoH)
3. Measuring progress toward digital transformation is a way to pinpoint health organizations' strengths and opportunities for improvement.
   • Digital Health Indicator (used in AUS)
4. Patient data privacy is a top priority but may have unintended consequences.
5. Having an interoperability implementation roadmap and measurement tools does not rule out a bumpy ride, where cultural context and political considerations sometimes stand in the way.

Insights[edit | edit source]

• There is no health care system in Canada, but there are health care systems.

Search terms[edit | edit source]

between 2012 and 2022 for all search terms

• EMR adoption in Canada (I think)
• "open source emr"
• "open source health information technology"
• emr alberta
• health information technology alberta
• Snowball technique

Questions[edit | edit source]

Main[edit | edit source]

• What is the current status of EMR adoption in Canada? How does this adoption compare to other jurisdictions? How interoperable are these EMR systems?
• What are future plans for EMR adoption in Canada?
• What opportunities are there for open-source and emerging technologies with EMR adoption?

Supplemental[edit | edit source]

• √What percent of billing is for cross-provincial border patients?
• √What is the difference between EMRs, EHRs, e-Health, health information technolog, etc.?
• √How can health, software, business, and politics align to provide the best care?
• ~How much has been spent trying to develop EMR technology in Canada?
• ~How much is not having interoperable EMRs costing? (Note that an EMR would save money, not make money, and so this may be the reason)
• xList of largest healthcare networks by population
• xDo medical schools provide any IT training?
• xFrench language support for EMRs
• xWhat is the rate of EMR adoption for different platforms?
• xWhat countries/jurisdictions have national (or subnational emrs).
• xWhat is the TAM for EMR
• xRemote EMR (important for First Nations)
• xHow much has been spent on lobbying EMR in Canada

Open source EMRs[edit | edit source]

• https://www.goodfirms. co/blog/best-free-open-source-Electronic-Medical-Records-software-solutions - has data on country adoption rate and a review comparison of several
• https://worldoscar.org/ heavily used in Canada
• https://openmrs.org/
• Wolfe, B.A., Mamlin, B.W., Biondich, P.G., Fraser, H.S., Jazayeri, D., Allen, C., Miranda, J. and Tierney, W.M., 2006. The OpenMRS system: collaborating toward an open source EMR for developing countries. In AMIA annual symposium proceedings (Vol. 2006, p. 1146). American Medical Informatics Association.
• Mamlin, B.W., Biondich, P.G., Wolfe, B.A., Fraser, H., Jazayeri, D., Allen, C., Miranda, J. and Tierney, W.M., 2006. Cooking up an open source EMR for developing countries: OpenMRS–a recipe for successful collaboration. In AMIA Annual Symposium Proceedings (Vol. 2006, p. 529). American Medical Informatics Association.
• Kiah, M.L.M., Haiqi, A., Zaidan, B.B. and Zaidan, A.A., 2014. Open source EMR software: profiling, insights and hands-on analysis. Computer methods and programs in biomedicine, 117(2), pp.360-382.
• Zaidan, A.A., Zaidan, B.B., Al-Haiqi, A., Kiah, M.L.M., Hussain, M. and Abdulnabi, M., 2015. Evaluation and selection of open-source EMR software packages based on integrated AHP and TOPSIS. Journal of biomedical informatics, 53, pp.390-404.
• Kantor, G.S., Wilson, W.D. and Midgley, A., 2003. Open-source software and the primary care EMR. Journal of the American Medical Informatics Association, 10(6), pp.616-616.
• Asare, E., Wang, L. and Fang, X., 2020. Conformance checking: Workflow of hospitals and workflow of open-source EMRs. IEEE Access, 8, pp.139546-139566.

Ideas[edit | edit source]

• √Timeline diagram of major milestones
• xTable summary of articles
• xTable of state of EMR in each province
• xList of approved EMRS in each province
• √Maybe possible using the Amazon reviewer (?) can we count how much the following topics are mentioned in the literature:
  • lock-in
  • security
  • NHS implementation (NPfIT)
  • US HIS program
  • cost
  • Names of all the open-source softwares
  • The cathedral and the Bazzar
  • limited resource settings
  • Check the names of the software mentioned (maybe use the one's profiled in Open source EMR software: Profiling, insights and hands-on analysis)
  • Articles on

Other[edit | edit source]

√ "In attempting to arrive at the truth, I have applied everywhere for " information but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it or whether the money was not doing mischief rather than good."

• x Vendor market shares in Ontario - https://wwwdev.nonprod.ontariomd.ca/emr-certification/certified-emrs/vendor-market-share
• x https://www.canada.ca/en/health-canada/services/health-care-system/ehealth/canada-health-infostructure/history.html
• x https://www.youtube.com/watch?v=tzq4asJegKY&ab_channel=Fireship
• x Blender is a good example a non-traditional open source project that has achieved much adoption
• x Integration with personal health devices
• x Phoenix pay systems diminishes faith in government development efforts
• √ Newfoundland hack
• x https://en.wikipedia.org/wiki/Code_for_America and https://codefor.ca/
• x https://www.policyready.ca/home
• x How big is the EMR market in Canada (both in hospitals and private clinics)
• √ https://www.canhealth.com/2022/06/30/quebec-to-invest-nearly-1-billion-in-health-it/
• √ Anti-rivalrous good
• x National Grouping System (NGS)
• x https://repolitics.com/features/canadian-federalism-and-public-health-care/
• x Overview of healthcare system - https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html
• √ Government timeline - https://www.canada.ca/en/health-canada/services/health-care-system/ehealth/canada-health-infostructure/chronology.html