Borders are for Crossing...

Over the past 20 years, The US and Canada have shared an increasing number of patients and an equally growing investment in health information technology, culminating in the parallel creation of Canada Health Infoway and The Office of the National Coordinator for Health Information Technology.

Despite this past decade’s dramatic increase in the health information technology (HIT) industry, borders throughout the world have become less traversable and the sharing of technology more difficult. People are uneasy or even unable to transfer of data across borders because of complicated and often conflicting security measures. Trade regulations are poorly documented and ill-suited to modern technology. Many technologists are afraid to attempt crossing borders because of anti-terrorism measures and ever-changing documentation requirements.

In discussions with vendors and CIOs on both sides of the US-Canadian border, a constant theme is “The Border.” The government policies of the past 8 years have made the border, in the words of one CIO, “sticky and opaque.” Americans are unsure about export regulations being rushed out by the Department of Homeland Security. As many Canadians in technology are of Southeast-Asian descent, they are often afraid to try crossing the US border. Even carrying a laptop in from either country is now seen as a potential risk to the sensitive patient data it might contain.

Organizations involved in cross-border trade are confronted with differences in culture, practices and expectations. Vendors cannot successfully deliver to healthcare providers’ expectations, and organizations have increased management overhead with every cross-border supplier. All of these inefficiencies of culture and commerce drive costs up and productivity down for all parties on all sides of any border.

Very good work is being done by groups like HIMMS and OHITX to facilitate technological sharing issues. But the issues of cultural dissonance, tangled government protocols and the common human factors have been ignored. Now there is an organization to address these human issues of cross-border sharing--The International Health Information Technology Association, IHITA.

IHITA is a trade association of healthcare technology professionals for healthcare technology professionals; developers, providers, administrators and technologists. Members are in government, business, clinical care and academia across the US and Canada.

IHITA is dedicated to;

Business Support: helping the HIT industry successfully deliver products that improve patient care and healthcare delivery systems within and across all borders by offering members and member organizations education, partner/resource introduction and cultural-knowledge services

· Published studies

· Partnership guidance

· Research and development of cultural commerce knowledge resources

Government Relations: improving patient care options and resources by reducing the negative impact of borders on the HIT industry’s ability to deliver by Educating and advocating governments and government personnel for tools and regulations to enable cross-border trade and transfer of HIT products, personnel and data.

· Better documentation of NAFTA visa requirements for transiting personnel

· Treaty enhancement to enable electronic transfers of clinical data across borders

· Clarification of Ex/Im regulations for technology

Philanthropy and Research: building the global HIT knowledge base by developing learning and solutions to pervasive healthcare delivery problems by working concurrently with multiple governments and NGOs in identifying and researching solutions to common, “borderless” problems.

· Studies to deepen insights into strategic trade challenges in the global HIT marketplace

· Joint US-Canadian technology solution for First Nations chronic, at-home care issues

These challenges impact patient care and safety every day. IHITA is looking to clear these hurdles and make The Border simply “invisible.” We’ll keep you posted….

The Seven Myths of Healthcare Technology6. Health IT is just a product

And as a product, it is subject to the same market drivers and business strategies as any other commodity.

This was the point of a rather difficult conversation I had the other day with a very smart, very senior business-management consultant at a major firm. I had asked his thoughts on cross-border IT and the difference in implementation costs between the States and Canada. I brought up the idea of the cultural differences and the market limitations these impose on vendors. I posited that there might be value to both customers and vendors alike in having some sort of "cultural/market versioning support." He did not think so. Smart software developers, according to my friend, only deliver one version of their products for the largest single market or buyer. These "large-target" versions are sold across the board and the additional customization and implementation costs are passed down to the smaller buyers and the smaller markets. The Canadian market is much smaller than the US.

And while the number of people in Canada is one-tenth that in the US, the market for HIT is even smaller. After all, my friend noted, because of National Health, there are only a few buyers--the Provincial and regional health authorities; So, maybe 6 in all of BC? One in Alberta? Who would build a special version for only a few dozen customers when there is the US market with hundreds of facilities?

Now, this friend of mine is very smart, and he has been very generous with his insight and time. But on this I am not sure I can agree. Yes, in business, as in the US, healthcare is a commodity. The Cato Institute just said so in US News and World Reports. In Canada, however, this is not the case. Healthcare here is a community responsibility (and the best thing the government has ever done, according to some surveys. As a community, the Canadian HIT market population (providers) is about 8% the size of that in the US--about the size of California, and no developer is writing off the Gold Rush State. Healthcare providers are also different from consumers of other softwares. They are not shopping for something to give them an "edge" over their competitors. Healthcare providers, including the technologists, are always aware that their work is about someone's life--someone in their community. This very non-business value structure makes them companions, not competitors. As companions, they can work together to pressure US vendors to fulfill requirements of the Canadian market (as is already done for bilingual functionality).

As to there being so few buyers, shouldn't that be a good thing? HIT software is usually licensed by the number of users, not the number of contracts. So shouldn't managing a few large sales be better than making and managing a lot of small ones? Imagine selling to all of California with only 50 sales, instead 1050.

Maybe US software companies just have trouble understanding the Canadian customer. Perhaps Canadians have trouble communicating their values to American vendors successfully. The culture gap is certainly wider than people might think, and it appears in the most unexpected places.

What are your thoughts? Is Canada big enough to get more "ready-to-use" software? Are developers only successful if they follow a Keynesian model? Is healthcare just a commodity? And is HIT just a product like any other?

I grew up in one country and have lived and worked in both the US and Canada. But this is a real puzzle to me--and to many people I speak with every day. So let me know your thoughts. Maybe my friend is right.....