Dr. Joseph Cafazzo is a biomedical engineer, educator, and researcher. He is known for his work on the design of health technologies and how they facilitate patient self-care of complex chronic conditions. He has advised and conducted research for public sector policy makers and private sector medical technology companies on the design and safety of healthcare technology.

Dr. Cafazzo has led the Centre for Global eHealth Innovation since 2007 and founded Healthcare Human Factors in 2004 at the Toronto General Hospital, part of University Health Network (UHN). He is an associate professor at the Institute of Health Policy, Management and Evaluation, and the Institute of Biomaterials and Biomedical Engineering at the University of Toronto. He shared his insights with RDP Associates on the state of digital health in Canada.
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Tell us about Techna Institute and your role in it.
Techna is a research institute within UHN Research.. Techna is also the newest institute, focused on technology, applied research, and near market product development.

I am an investigator within Techna. I’m responsible for two teams; The Centre for Global eHealth Innovation , which was founded in 2002 and Healthcare Human Factors two years later. eHealth Innovation generates intellectual property based on research that we’ve done on patient self-care using digital health tools. All the work we do under the realm of digital health platforms is incubated here under UHN.

How do you think health technologies such as m-health can guide patient self-care for the complex needs of the aging population in Canada? Do you think these technologies should be more heavily invested in?

My position is that patient and informal caregivers (family members and so on) are the largest, untapped resources in the health system. So, at a time when we need increasing health services with our public system strained under an aging population, the continued investment in the health sector is a problem with spending already at 11% of GDP.

Therefore, the change we need in our health system is to tap these untapped resources. In many instances, patients with chronic illness and their family caregivers are passive participants in the health system. They could, and want to, do more. Patients are capable of an extraordinary level of self-care if we give them information and the tools to act. Here, the mobile and digital aspects of health come into play.

If we can shift some of the self-care capabilities toward co-management, the clinic becomes more engaged with the patient, resulting in fewer acute interactions with the system.

In terms of investing more, I’d say for these new technologies to be successful, tech companies, need to know that their tech should ultimately subtract from the system, not add. Meaning, there needs to be a return on investment with clinical outcomes. If you look at other industries, new technology adds efficiency, which includes fewer human resources. But in healthcare, as we adopt new technologies, we tend to add more people along with it; we don’t bring about efficiency that other industries expect.

So, how do you bring about subtraction?
I can give you an example. When home hemodialysis (a technology that is much more complicated than anything related to digital health) was introduced to Ontario nearly 20 years ago, the patient to nursing ratio dropped from 2-1 to 20-1. That’s the kind of efficiencies we need. In the digital health context, we should be reducing the utilization of physicians with the use of self-care and efficient virtual interactions that can take place.

In the application of a new technology like artificial intelligence, unless it reduces the utilization of physicians or other health professionals, it’s not going to have a net benefit for the system. For example, if artificial intelligence (AI) eliminates all normal screenings so that a radiologist only needs to interpret abnormalities, it brings about significant efficiencies by avoiding the radiologist billings for normal cases. This is controversial, and it is a challenge to the establishment. The reality is that there’s not enough money in the health system to speculate on the digital health solutions that are not going to have a return on investment, and that will simply continue to add cost to the health system.

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Considering Canada’s goal in the last 20 years to get e-health off the ground, how do you think the government can invest in Canadian companies to get ahead in the health sector?

One of the challenges with government is that it is sitting on an enormous amount of health data. This data is not utilized to the benefit of Canadians. I think the easiest thing the governments can do right now is to mandate patients to have the right to access to their health information in electronic format. Moreover, we should enable patients to share their health data with transparency of how it will be used and with their explicit consent.

Will eHealth become a vital part of Canada’s future healthcare system?
It is inevitable. It’s just the pace of it is slower than most people expected. In the coming years, the emphasis will be on what can be done for the patient as opposed to just the care providers. We spend 99% of eHealth dollars for the providers; we spend almost nothing on what’s needed by the patients

One would hope there will be a shift in spending to tools for the patient not only for access, but also for specific tools around managing a chronic disease.

Why is Canada’s health-tech industry facing challenges in scaling up?
I think people try to overanalyze this. It’s pretty simple to know that there’s a disparity between Canada and the U.S in this respect. Just in healthcare spending, we’re spending at 11% of GDP and U.S spends at 18% of GDP with a population ten times larger than ours and with a far more mature venture capital. That’s why more is happening in the U.S by orders of magnitude. And quite frankly, there are more opportunities for Canadian companies to break into the U.S before Canada. There’s more money in the US to fund a venture and to scale. In Canada, there’s just not enough money in the system. We’re just north of a market that has got more speculation and risk-taking capital.
Our startups need to venture into developing markets with open eyes and an understanding of those markets. Compared to the US, Canada’s tech hubs are mature, well-educated, and cost relatively lower to fund. An increasing number of companies are realizing that and are moving in, particularly to Toronto, which has a relatively low cost of living and low cost of staffing up. So, we’re leaner than the US in that respect.

Do we have policies in place that help emerging health-tech startups sell to healthcare institutions? Do you see a need to have business grants specific to biotech and health-tech companies?
We do have business grants specific to healthcare and health-tech. They are grants that help a hospital with initial procurement of a technology. For example, Ontario has had OCHIS with the Health Technology Fund (HTF), specific to hospitals that want to work with a company (i.e. startup) to use its technology. HTF helps with the procurement challenges as there’s very little speculative money in our healthcare system to be spent on an unproven technology.
My concern with this is that it may exacerbate the “pilotitis” problem we have in Canada once the HTF funding runs out. And what if the implementation of a technology leads to less staff that is needed or even fewer physicians with fewer billings? Will we be able to make those hard choices? Redistribution of healthcare resources with patients visiting physicians less frequently is a very difficult conversation to have for some.