Andrea Cortinois is a Professor at the University of Toronto, where he teaches International Healthcare and Immigration and Healthcare. He is also part of the Center for Global E-Health Innovation, founded by the Colombian e-health expert Doctor Alejandro Jadad. Cortinois shares his colleague’s interest in what is going in Latin America, a region he is familiar with: he spent six years in Bolivia and worked in many other countries in the region as an expert in international health. On his first visit to Argentina in August 2012, invited by the Panamerican Health Organization to share his experiences working in e-health and equality, present his eSAC project and participate in a debate with local experts on possible ways to implement a national e-health plan, he was interviewed by E-Health Reporter Latin America.
EHealth Reporter Latin America: What can you share from the Canadian experience with regard to the development of e-Health?
Andrea Cortinois: The work we are doing with the University Health Network is very interesting. This is a network of four hospitals, one of which is the largest in Toronto, the General Hospital. At this center there are several work groups: one concentrates on telemedicine, another on analysis of human factors and usability, especially with regard to needs at the hospital level and the one of which I am a member together with Doctor Jadad, called People, Health Equity and Innovation Research.
EHRLA: What does this group do?
AC: We work specifically with vulnerable populations and have three lines of research: firstly, young people, because they are marginalized in many different ways; we don’t take them seriously enough. Secondly, immigrants. Toronto is one of the most multicultural cities in the world. Right now half the population of Toronto are first generation immigrants who weren’t born in Canada. Traditionally the population of Toronto was Anglo-Saxon: now the Anglo-Saxon population is a minority. And in a few years, probably, white people of European origin will be a minority. Historically, the first wave of immigration came from England, then western European countries, then Italy, Portugal, Poland and other nations. Now immigration is mostly Asian, from Vietnam, India, Pakistan, Korea, and China. Immigration from Latin America is also growing. I think about 6% of the population speaks Spanish as its first language.
EHRLA: Is this data for legal immigrants?
AC: Yes, in the great majority.
EHRLA: Does the healthcare system provide for them?
AC: Yes, because Canada has universal healthcare. The Canadian healthcare system is for all residents, although this doesn’t mean that all kinds of treatment are offered; for example: pharmaceuticals and many medical specialties aren’t included in the free provision. There is a package of basic fundamental services that are covered by the public health system and that are not in competition with the private sector. All basic medical services and hospital care are included.
EHRLA: A birth, for example?
AC: A birth would absolutely be covered.
EHRLA: A heart attack?
AC: Of course a heart attack would be covered. But, for example, dental and optical care aren’t included. There are categories that receive help of some kind depending on the pathology and the socio-economic status of the patient but they are not universal. At the same time, what is covered by the public health system cannot be offered privately in Canada. This is to avoid the creation of a dual healthcare system in which those with more resources can have access to better quality medicine than those without resources, which, in general terms, is a very good idea. But Canada also has problems like everywhere else in the world.
EHRLA: Thank you for explaining. Going back to the work of People, Health Equity and Innovation Research, what is the third branch of research?
AC: The third branch is complex chronic diseases, which are one of Dr. Jadad’s main interests, as he is also a specialist in palliative care. One of the solutions we have developed in this field is the Opimec Network, a global network that started in Spain but with our help it is now an Observatory of Innovative Practices in the Care of Complex Chronic Diseases.
EHRLA: Is this an e-health solution?
AC: Yes. It is a platform for the exchange of good practices thanks to international collaboration in the area of complex chronic diseases. And the example I offered in the presentation is that of a book that was published and contains probably the most complete collection of evidence on practices related to complex chronic diseases. The important thing to note about this experience is that it involved a pretty high number of collaborators from different countries in the world who managed to produce this text within a year without ever meeting in person. That’s what’s really amazing! It would have been impossible to achieve this without ICTs.
In this regard, it represents a good example of the type of work we do with the E-health Innovation Group, because we don’t do medical work or offer clinical treatment. We do some work with socially-focused support groups for patients who have problems with cancer or other diseases but our work is not in clinical telemedicine.
EHRLA: Is this what led you to propose a redefinition of the e-health concept?
AC: Yes, exactly. E-health is traditionally seen as the application of ICTs to clinical medicine or any other type of care that involves a healthcare professional and an individual patient. But in reality there’s no reason to limit the term to the use of ICTs in clinical medicine. In contrast, its power rests in the fact that it can include the public health population in its practice, where the objectives are not solely focused on issues surrounding the individual.
EHRLA: Bringing them into the remit of government decision-making, you mean.
AC: Exactly, that’s my personal challenge! What I propose is to explore how issues related to equality and technology are expressed. Equality is a political problem; so how do we calculate costs? The answer is essential. I believe that ICTs can support equality-focused agendas. One example is the eSAC project, which is the project for which I am responsible, together with Giselle Ricur (also present during the conversation). This is a project that has been financed by the International Development Research Center, an organization with public funds from the United States with ties to the government that supports work on e-health in Latin America, Africa and Asia.
EHRLA: What does the eSAC project involve?
AC: The objective of the project, which means public e-health in Latin America and the Caribbean, is to stimulate a debate and attract attention to the issue of the use of technology in public healthcare in order to improve social determinants in healthcare and equality in countries in the region.
The project is aimed at decision makers, researchers, academics and entrepreneurs; we are interested in stimulating the creativity that is often prevalent in the region, but that sometimes doesn’t get the right support or appropriate incentives. We want to take maximum advantage of the creativity of the people who have ideas to support activity that contributes to improving equality. Ideally the project could be considered successful if we eventually realize that there are journalists who write about the subject, maybe university students who decided to explore the issue from an academic point of view, or an innovation competition for researchers to support the best ideas.
EHRLA: How can we expand our vision of e-health as a tool for achieving social equality?
AC: There is an extensive body of scientific literature on equality in healthcare. There is also the Final Report of the World Health Organization Commission on Determinant Social Factors which is focused on determinant factors in social and equality issues. Furthermore there is an enormous body of scientific knowledge on e-health but the two communities don’t communicate much with each other. We need to do that more and more.
EHRLA: Do you think that e-health is expensive? I mean that, although it is often said that the use of technologies helps to lower the cost of healthcare in the long term, the implementation of computer systems is usually an enormous investment that not every institution can afford. Also there is little concrete data that shows that computerization can be a tool for optimizing costs. This is a major weak point, at least in Latin America.
AC: This is not just a problem in Latin America. However, don’t forget that we aren’t talking about just hospitals; we are talking about a public health entity, a community health body. There are many examples of simple solutions being found at a low cost that have an enormous impact on major problems with inequality in the field of healthcare. For example, with geo-referencing information we can do a lot in the field of epidemiological monitoring; it is possible, for example, to design community surveys in areas where there is no stable or known data in marginal neighborhoods, or where the population constantly changes. There are ways to use satellite maps to create a basic structure for geographic subdivisions that allow us to provide surveys with reliable results. Much more can be done: we aren’t saying that the application of ICTs in clinical medicine isn’t important, it’s very important, but there are other things that are important too.
EHRLA: You are inviting doctors to extend their field of activity outside the clinical sphere.
AC: And not just doctors! Everyone responsible for healthcare, users, society in general, experts in public health, social service providers, because they are very closely related with healthcare services too. The best example is with immigrants in Canada. There is a very popular joke that has an immigrant who has just arrived in Canada thinking that he needs to marry a doctor so as to have a doctor in the family. The fact is that they’re coming to a country that fortunately has an enormous network of social services which offer a lot of opportunities that don’t exist elsewhere and they don’t even know where to begin: they don’t speak the language, or even look for certain services because they never had the experience of these services before and so don’t even imagine that they exist. So they are always inadequately served, they don’t take advantage of them because they don’t know where they are, what they are exactly, how they are used, what for, etc. This is an issue in which technology can help a lot.
EHRLA: How this is seen in Canada? Is there a political, state commitment that lasts beyond individual governments?
AC: Policies always clash, someone said that medicine is a form of power. And, as it is related with power, it is necessarily political. At any given moment there are disputes over access to resources, for example in different sectors of society it becomes a political problem about definition, doesn’t it?
EHRLA: But generally, are people happy with the Canadian healthcare system?
AC: Canadians are very protective of their Canadian health system and the law that launched it. Then there are many problems, long waiting times, and the level of treatment continuity isn’t ideal. There are all kinds of problems as there are in every country. Now, what I can say is that even the most conservative governments, such as the present one, which is very conservative, similar to the ideology of Bush or Reagan, know that they can’t modify, at least directly, the healthcare system because they know that they’d lose the next elections. Yes, they can make changes indirectly. There are a thousand ways to sabotage a healthcare system and I’m not saying that they’re sabotaging it but there are enormous interests at play. It’s the most important service sector in the world.
EHRLA: The problem is one kind of healthcare for the rich and another for the rest. Who do you believe is responsible for resolving these differences? In the discussion at the PHO after the presentation, the issues debated centered around the possibility of a national e-health plan, focusing on problems with interoperability, the use of standards, and technical questions. In general terms, there was agreement that these questions need to be resolved before establishing a national e-health plan. Not much was said about your proposal to focus the gaze on key social factors with clear low cost solutions.
AC: Precisely, this happens because modern medicine has become a technical field. Quality and professional relevance are measured almost exclusively in technical terms. The human factor, human interaction, a holistic vision of the patient, have been lost to a great extent. And this isn’t just happening in the medical sphere. We, as a society, as a Western society, have made technology our new religion. Then all discussion of healthcare becomes a medical discourse. And all medical discourse becomes technological discourse. This is why I don’t mind repeating myself a million times. If my repeating certain things a million times makes just one person start to say to themselves: “Well, it’s true that certain things can be done at a low cost and have a large impact, and they’re beyond the hospital walls.” And we’re not discarding the value of telemedicine or hospital IT systems, that’s not what we’re doing. We want to add things but if there are some people who understand the message and start to get interested and see what can be done that would be fantastic, and, little by little, things will change.
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