This research describes the approach taken by Canada Health Infoway to fund and coordinate healthcare IT investments in Canada. It will be helpful to IT funders and planners who wish to deploy interoperable IT across decentralized healthcare systems.

• Infoway has developed a governance and funding model that provides an incentive for projects to be well-managed and sustainable, and to deliver results.
• Infoway uses a "gated funding" model, meaning that payments are linked to predefined milestones of deployment and adoption. For example, for clinical systems, 50% of the funds are paid for implementation and 50% for adoption.
• Whether or not the IT systems funded by Infoway will actually improve the Canadian healthcare system depends on how they are used. Clinical process change will be critical, and this will require strong leadership from the jurisdictional health ministries.

• Government agencies that wish to fund interoperable IT applications and infrastructure across decentralized health systems should consider emulating Infoway's "strategic investor" and gated funding approaches.

The Canada Health Infoway program is spending $1.7 billion (see Note 1), or $50 per citizen, to fund investments in healthcare IT. The program uses an innovative funding model that provides an incentive for projects to be well-managed and sustainable.

During the 1990s, the leaders of Canada's 13 jurisdictions (see Note 2) and the federal government became interested in better ways to fund IT investments intended to improve information sharing in healthcare. With the traditional grant-funding approach, it had been hard to track how the money was being spent, to monitor how well projects were managed and to share expertise across jurisdictions.

The governance structure of Canadian healthcare presented a challenge. Whereas the federal government is responsible for overseeing and partially funding healthcare, the jurisdictions are responsible for delivering healthcare. Although Canadian hospitals are owned by the jurisdictional ministries of health and are coordinated by subjurisdictional structures, such as health regions, in practice, they are self-governing entities that are autonomous in their decision making. It was, therefore, critical that Infoway effectively handle this balance of power between local, jurisdictional and national levels.

At their 2000 annual First Ministers' Meeting, the federal prime minister and the premiers of the jurisdictions allocated money to healthcare IT and set up a not-for-profit, independent corporation called Canada Health Infoway (Infoway) that was responsible for spending this money.

Infoway's mandate is to "accelerate the development and adoption of modern systems of health information and to define and promote standards governing the health "infostructure" to ensure interoperability. ("Infostructure" is a term used to mean "information infrastructure.") Infoway's goal is to have an electronic health record (EHR) covering 50% of Canadians by 2010, with elements of the solution in place across all jurisdictions. The principal elements of the EHR solution include diagnostic imaging systems (using shared repositories), laboratory information systems, drug information systems (that is, a complete medication history with some e-prescribing), client and provider registries, and hospital reports (see http://www2.infoway-inforoute.ca/Documents/Infoway_Business_Plan_2008-2009_Eng.pdf for a detailed description). Note that Canada's use of the term "EHR" differs from the typical usage in the United States and some other countries (see "Global Definitions of EHR, PHR, E-Prescribing and Other Terms for Healthcare Providers").

Infoway is a good example of a profiler-enforcer organization: an organization that endorses standards and develops profiles that use those standards. The elements of the Infoway solution are tied together by the Health Information Access Layer (HIAL), a set of Infoway-mandated specifications for integration, interoperability, privacy, security and other services. In general, each jurisdiction will have its own HIAL; they will follow a similar design and architecture and will use the same standards, although the vendors may be different.

Infoway pursues a Pan-Canadian approach, seeking to:

• Ensure that the EHR elements are built using consistent standards and to consistent levels of quality, thereby facilitating interoperability within and between jurisdictions
• Encourage collaboration, thereby reducing redundancy in system design, vendor negotiations and so on
• Share best practices across jurisdictions in order to reduce costs, save time and minimize custom development

Infoway is owned by the 14 deputy ministers of health (13 jurisdictions and one federal). The decision not to base voting rights on population ensured that the two most populated jurisdictions, Ontario and Quebec, would not stifle the others. However, Infoway's board of directors includes five members, representing the jurisdictions grouped by population (Western Canada, Midwest Canada, Ontario, Quebec and the Atlantic provinces), as well as two members from the federal government and six private-sector executives. A separate operational management committee is responsible for assessing project proposals, monitoring the progress of projects and resolving conflicts. Each of the Infoway programs (for example, diagnostic imaging) has a national director who maintains relationships with relevant industry associations.

Jurisdictions, health regions and hospitals work with Infoway to develop project-funding proposals. Infoway's approach is that of a "strategic investor." This means that:

• Infoway funds up to 75% of the eligible costs of projects; hospitals, health regions and jurisdictions must fund the rest. Cost overruns are the responsibility of the jurisdiction.
• Infoway funds capital costs only. Before agreeing to fund a project, Infoway requires the jurisdictions to demonstrate that they have enough money to fund their share of the capital costs and the operating costs.
• Infoway only funds projects that align with the architecture and standards defined by Infoway.
• Infoway does not mandate products or vendors, but maintains a list of vendors with which it has negotiated preferential pricing and conditions.
• Infoway uses a gated funding model, meaning that payments are linked to predefined milestones of deployment and adoption. For example, for clinical systems, 50% of the funds are paid for implementation and 50% for adoption.
• If a hospital or jurisdiction has existing resources that would benefit the project (for example, administrative staff), Infoway will not normally pay for them.
• An overriding goal is to build on existing applications and infrastructure, avoiding a "rip and replace" approach.
• Infoway pays no more than standard market prices (for example, per terabyte of storage). The philosophy is to "pay for a Chevrolet, not a Cadillac."
• Once the project has kicked off, Infoway only intervenes if the project gets into trouble, and for a short period of time only. Infoway's role is not to do the work; it is to pay once the work gets done.
• However, Infoway offers ongoing quality assurance to projects.
• Infoway oversees its investments using a risk management approach that considers four levels of risk: project, program, jurisdiction and overall corporate.

Infoway's main challenges are:

1. Project control. Infoway cannot do much when projects go wrong. It can withhold money, but this creates the risk that the project will be delayed. In exceptional cases, Infoway has intervened to get projects back on track.
2. Clinical adoption. The biggest danger is that clinicians do not use the systems. Therefore, about 30% of Infoway's funding for a typical project goes to change management, process change and training.
3. Ongoing attention. Infoway needs to continually keep itself in the forefront of attention from ministers. Although it is difficult to develop a compelling story about the need to invest in infrastructure, Infoway must continually articulate the benefits of its projects, and link those benefits to the most pressing healthcare issues of the day. To support this, Infoway funds projects with quick paybacks through its "Innovation and Adoption" and "Patient Access to Quality Care" programs.
4. Proof of impact. Although stakeholders may accept — in theory — the benefits of IT in healthcare, it is difficult to collect hard data that proves these benefits. Infoway has a benefits measurement program and has devised indicators for measuring improvements in access, quality and productivity (see http://www2.infoway-inforoute.ca/Documents/BE%20Techical%20Report%20(EN).pdf ).
5. Managing the jurisdictions. Infoway needs to ensure that jurisdictions commit the necessary funding for the operational costs of the projects, and show engagement. It is no coincidence that the jurisdiction that has made most progress with Infoway-funded projects, Alberta, has had strong leadership and commitment to health IT from the provincial government. Infoway issues regular updates on the progress of jurisdictions in order to inform the public and create peer pressure among the ministers of health.
6. Resourcing. Since the hospitals and jurisdictions do not have enough resources to implement the Infoway projects, implementation is heavily reliant on resources from IT vendors and service providers. Infoway needs to continually demonstrate that its projects provide an attractive market for them. This may become more of a challenge as the money from the U.S. stimulus plan starts to flow to healthcare IT firms.

Infoway has spent or committed $1.6 billion. As of March 2009, Infoway claims the following results:

• Diagnostic Imaging (public facilities only): 79% of the Canadian population is covered, meaning that 79% of citizens live in a jurisdiction with a repository that is collecting images from all public imaging facilities in that jurisdiction.
• Client Registry: 76%.
• Provider Registry: 63%.
• Drug Information Systems: 59%.
• Laboratory Information Systems: 51%.
• Public Health Surveillance: 33%.
• Interoperable EHR: 28%.

Infoway may narrowly miss its goal of having an EHR covering 50% of Canadians by 2010. Assuming progress continues at its current pace, Alberta, Prince Edward Island, the Northwest Territories, Newfoundland and Labrador, and New Brunswick are likely to have all elements of the EHR in place by 2010, while all other jurisdictions (except Yukon) will have parts of their populations covered by an EHR. The total of the people who will be covered by an EHR in all of these jurisdictions represents 47% of Canada's population. Having all elements of the EHR means that a connected clinician can retrieve a health record for a patient in his or her region containing drug data, laboratory data, diagnostic images, some hospital clinical reports and immunization data.

Installing the elements of the EHR and making them available to clinicians is one thing; measuring usage is another. Most of the EHR elements are in the process of installation, so Infoway has not yet had to pay much for usage. Since Infoway typically pays per transaction in each program, it will have to ensure it is counting transactions correctly. For example, if a clinician uses the EHR viewed to look up drug and laboratory data, should that transaction be counted toward the Drug program, the Laboratory program or both?

In January 2009, the federal government announced a grant of an additional $500 million to Infoway as part of a stimulus package. Infoway will use some of the extra money to fund two new programs:

• Electronic Medical Record (EMR) systems are used by only about 17% of physician practices in Canada. Infoway will provide money to jurisdictions for EMR implementations to a defined maximum value and has launched a certification program.
• Consumer Health Program will include patient portals and personal health records (Infoway's original mandate is restricted to systems for clinicians).

Infoway is also exploring how to fund physician order entry and clinical decision support systems in hospitals (see www2.infoway-inforoute.ca/Documents/Vision_2015_Advancing_Canadas_next_generation_of_healthcare[1].pdf for Infoway's self-assessment, vision and priorities for 2015).

Infoway's critical success factors are:

• Infoway has developed a funding model that provides an incentive for projects to be well-managed and sustainable, and to deliver results.
• Infoway's governance structure has facilitated collaboration among the jurisdictions and the federal government.

The following are things that, with the benefit of hindsight, Infoway should have done differently.

• Infoway started with a 50/50 funding model and some expectation that funds would be available when projects were ready. Moving to a 75/25 funding model and a "first come, first served" approach created the sense of urgency that could have been created earlier.
• The HIAL as originally conceived is a very ambitious conceptual architecture, and the jurisdictions are struggling to develop the necessary messaging and middleware. The jurisdictions now need to understand what they really need to implement, as opposed to what would be nice to have. In hindsight, it would have made HIAL implementations easier if Infoway had clearly differentiated what was needed at the beginning versus in the future.
• Getting vendors to upgrade their applications to accept Health Level 7, Version 3 messages via the HIAL is one of the challenges hindering the incorporation of hospital clinical reports into EHRs. Infoway has been developing the standards in parallel with implementing the projects, but vendors have been reluctant to commit to the standards. Infoway is beginning to provide funding to help EMR, hospital and pharmacy vendors with the necessary upgrades.

Other "lessons" relate to issues that were not under the control of Infoway:

• The sponsors of Infoway should have better accounted for its effects. A prime example is radiology. Thanks to the installation of Infoway-funded diagnostic imaging repositories, radiologists are able to read images remotely and perform studies more quickly, yet the payment per study has remained the same. This illustrates that, for the technologies funded by Infoway to deliver real benefits, the jurisdictions must make often difficult changes in areas such as reimbursement.
• Many projects not funded by Infoway would benefit from Infoway's expertise — for example, in project management and quality assurance. There should be a process by which Infoway can make its expertise available to non-Infoway projects.
• EMRs were not originally funded by Infoway. EMRs are critical, because most patient data is generated and used in the outpatient setting. In Canada, each jurisdiction has a medical association; at the time Infoway began, the medical associations had little interest in adopting EMRs. At present, there is a stronger interest, at least in some jurisdictions. Negotiations are under way between medical associations and jurisdictions to determine who will pay for the EMRs. In addition, Infoway is providing funding, as mentioned above.

"Without Profiler-Enforcers, Healthcare IT Standards Cannot Enable Interoperability"

"Critical Success Factors for Electronic Health Record Programs (Business Strategy, Governance and Project Planning)"

"Critical Success Factors for Electronic Health Record Programs (Stakeholder and Vendor Relationship Management)"

This research is part of a set of related research pieces. See Health Information Exchanges Must Meet Specific Needs to Succeed for an overview.