Canada E-Health 2000 From Vision to Action

Office of Health and the Information Highway, Health Canada
October 2000

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Table of Contents

• Preface
• Introduction
• Canada E-Health 2000: From Vision to Action
• The Road to E-Health
• The Journey Ahead - A Blueprint and Tactical Plan
• E-Health and the Electronic Health Record
• Telehealth Contribution to E-Health
• Health Information for E-Health
• Conclusion
• List of appendices:
  • Annex A - List of Speakers
  • Annex B - List of Exhibitors
  • Annex C - Bibliography

Preface

Almost 400 of Canada's key health stakeholders gathered in Ottawa on October 22-24, 2000 to discuss progress in developing a national health infostructure and the challenges, priorities, and directions for the future.

The conference began with an opening plenary session dealing with recent key events and federal/provincial/territorial work to identify key directions for investment in health infostructure. Following this, participants broke into conference themed sessions on the Electronic Health Record, Telehealth, and Health Information, to focus more closely on the progress and issues facing their development. The closing plenary provided perspectives on the conference discussions for each theme with a focus on future directions.

More than 65 Canadian and international experts shared with participants their work, thoughts, "lessons learned" and advice on how to achieve success with e-health. An Info Fair highlighting federal, provincial, territorial and health organizations' initiatives in e-health showed that significant progress is being achieved across the country.

This report provides highlights from the two-and-a-half-day conference. More detailed information on the Canada E-Health 2000 conference is available on the website of the Office of Health and the Information Highway (OHIH) located at www.hc-sc.gc.ca/hcs-sss/ehealth-esante/index_e.html. Conference information can be found under "What's Available". This information includes the opening address by David A. Dodge (then Federal Deputy Minister of Health), the complete program, abstracts from the presentations, some actual presentations, speaker biographies, and the conference evaluation report. Additional information on many of the subjects touched upon in this report, such as the Vision 2020 Workshop Series, the Advisory Council on Health Infostructure, and the ongoing federal/provincial/territorial Advisory Committee on Health Infostructure (ACHI) can also be found on the OHIH website.

Important Note

This report synthesizes conference discussions into a narrative that presents an easy-to-read, informative, all-encompassing view of the e-health issues discussed at the conference. The comprehensive information on the specific presentations, available on the OHIH website (www.hc-sc.gc.ca/hcs-sss/ehealth-esante/index_e.html) may be viewed to supplement this report.

Introduction

Information plays a critical role in health and health care. Physicians and other health care professionals rely on accurate and detailed patient information and medical research to correctly diagnose and treat health problems. Patients depend on clear, professional advice about how to manage specific health problems or maintain their overall health. Families rely on information and support networks to help them deal with a loved one's illness. Medical researchers and public health officials rely on comprehensive data on population health as input for their research and surveillance efforts. Health administrators and policy makers require information on how well the health system is working in order to identify opportunities for improvement.

It is now widely recognized that information and communications technologies (ICTs) can facilitate the sharing of information throughout the health care system. In recent years, there has been considerable progress towards the development of a national health infostructure in Canada. Some of the key events have been: the report of the Advisory Council on Health Infostructure; the creation of a federal/provincial/territorial (F/P/T) Advisory Committee on Health Infostructure (ACHI); work by ACHI on a Blueprint and Tactical Plan to guide future development; and significant investments by Health Canada (e.g., the Health Infostructure Support Program, the Canadian Health Infostructure Partnerships Program, the National Health Surveillance Infostructure, the First Nations and Inuit Health Information System, the Canadian Health Network, the Roadmap Initiative, etc.) and by provinces/territories (e.g., alberta we//net, Saskatchewan Health Information System, etc.). Clearly, innovative work by all health jurisdictions is in progress.

Consultation and collaboration have been cornerstones in the strategy to develop a national health infostructure. In 1998, Health Canada and Alberta Health co-hosted the "National Conference on Health Infostructure". As a follow-up to that conference and to take account of activity since then, in October 2000, Health Canada hosted a national conference on e-health.

The conference had two major objectives:

• To raise awareness and share information on activities, priorities, challenges and progress; and
• To stimulate action and collaboration towards a national health infostructure.

Canada E-Health 2000: From Vision to Action

Auspicious timing

Canada E-Health 2000: From Vision to Action was a natural follow-up to recent "Vision 2020" consultations conducted with some key stakeholders (physicians, nurses, health care administrators, and children's health care experts) about how information and communications technologies could best be employed to modernize Canada's health care system.

The timing was auspicious. Canada E-Health 2000 took place on the heels of a breakthrough First Ministers' agreement on health. That agreement includes a federal-provincial-territorial government commitment: to strengthen our health infostructure; to develop an electronic health record system; to enhance telehealth; to work collaboratively to develop common data standards to ensure compatibility of health information networks; and to ensure stringent protection of privacy, confidentiality, and security of personal health information. In support of the agreement, the Government of Canada has committed $500 million to an independent corporation to accelerate the adoption of information technologies in health care. Initially, the focus of the corporation will be on the development of the fundamental building blocks of the electronic health record.

With a shared vision, clear political will, and financial resources to move forward, Canada E-Health 2000 participants were motivated by a strong sense of momentum.

A broad spectrum of participants

Physicians, nurses, representatives of health associations, and health non-governmental organizations (NGOs), federal, provincial, and territorial government officials, health administrators, academics and researchers, privacy advocates, and some private sector representatives attended Canada E-Health 2000. This broad representation provided an excellent forum for an exchange of views among the various stakeholders in the health sector.

Over two-and-a-half days, more than 65 Canadian and international speakers (Annex A) contributed to 25 sessions on the key issues related to e-health and the three conference themes: Electronic Health Record (EHR), Telehealth and Health Information.

Participants discussed their e-health activities, priorities, and progress. They voiced their concerns and shared ideas about their directions and priorities. They met others like themselves who have embraced what technology offers to health and health care.

The conference was opened by Denis Gauthier, Assistant Deputy Minister, Information, Analysis and Connectivity Branch, Health Canada, who discussed how the conference was an opportunity to expand our thinking, knowledge, and ability to put in place the pieces that will eventually become a robust health infoway that will contribute to improving the health of all Canadians. David A. Dodge, then Deputy Minister of Health Canada, described e-health as a major re-engineering of Canada's health care system which was bigger, more complicated, and perhaps more important than any such effort ever undertaken in the past.

Info Fair highlights progress

The Conference featured an Info Fair that offered participants the chance to get a closer look at some of the successes in health sector ICTs (Annex B). They visited OHIH-sponsored booths on the Canada Health Infoway, as well as the upcoming EHR and telehealth initiatives databases. Participants had the opportunity to speak with representatives from various Health Infostructure Support Program (HISP) projects, Statistics Canada, the Canadian Institute for Health Information (CIHI), and a number of regional/provincial health initiatives, including the Western Health Information Collaborative, Saskatchewan Health Information Network, alberta we//net, and the Calgary and Brandon Regional Health Authorities.

The Road to E-Health

Canada has a long history of innovation to overcome the challenges of delivering health care in a geographically dispersed country. For over 40 years, Canadian health care professionals have tested increasingly sophisticated technologies in communities and regions across the country. Their goal has been to expand access to quality services, especially for those Canadians living in rural and remote regions.

Since the early 1990s, Canada's health leaders have been exploring how information and communications technologies can be employed more broadly to modernize Canada's public health care system (Annex C).

In its 1995 final report, The Challenge of the Information Highway, the Information Highway Advisory Council (IHAC) noted that technology can support and enhance our health care system by ensuring that all Canadians have equal and timely access to essential health services.

In 1996, CANARIE issued Towards A Canadian Health Iway, setting out the primary characteristics of a technology-assisted health system for Canada.

In 1997, the National Forum on Health issued a report, Canada Health Action: Building on the Legacy. The report articulated a vision of a national health information system that would support evidence-based decision-making by Canadians and their health care providers.

Also in 1997, the Advisory Council on Health Information was established to develop a Canadian vision for health infostructure and a strategy for achieving that vision. The Council was mandated to establish national priorities, identify challenges and barriers and recommend appropriate solutions.

In February 1999, the Council articulated its vision in Canada Health Infoway: Paths to Better Health. The vision is one of a public empowered to make informed choices about their own health, integrated service delivery, and strengthened privacy protection. It highlights timely, relevant, useful information as the foundation for decision-making, service excellence, accountability, and better understanding of the determinants of health. It seeks to build on provincial and territorial health infostructures.

The vision articulates four strategic goals for a Canada Health Infoway:

1. Empowering the public to make informed decisions;
2. Strengthening and integrating health services;
3. Creating relevant information resources; and
4. Improving the protection of personal health information.

The Journey Ahead - A Blueprint and Tactical Plan

Neil Gardner, Co-chair of the Advisory Committee on Health Infostructure, set the stage for conference discussions by presenting ACHI's work to develop a Canadian Health Infostructure Blueprint and Tactical Plan to move e-health from vision to action. The Blueprint builds upon the people-focused vision articulated by the Advisory Council.

To develop the Blueprint and Tactical Plan, ACHI conducted a current state assessment on programs and projects already in place across Canada. Key technical components were identified. A gap analysis examined what is in place today and what is needed. Broad consultations were undertaken to identify priorities for future action.

The resulting Tactical Plan identified three key strategic directions: health information for the public, integrated provider solutions, and the electronic health record. All three directions are considered as priorities and need to be pursued. However, the EHR is seen as the critical gap requiring immediate attention. Key areas for action include the development of national EHR standards, consistent privacy policies/legislation, and coordinated implementation across all jurisdictions. Successful implementation of the EHR also hinges on the development of practical, integrated provider solutions which support information entry and retrieval by front-line health care professionals. More complete, dynamic health information for the public is also needed. This will, among other things require building on the success of the Canadian Health Network (CHN), linking it to integrated provider solutions and to the provincial/territorial self-care and telecare services already underway.

The Blueprint and Tactical Plan emphasizes the importance of collaboration, risk management and benefit sharing among all stakeholders. Such cooperation is needed to ensure the approach is patient-centred, needs-driven, involves providers and patients as co-architects, and incorporates principles of accessibility, interoperability, privacy, confidentiality, and security.

E-Health and the Electronic Health Record

Better collection, management and use of patient health information

Many conference speakers noted that traditional paper-based approaches to collecting, storing, and using key patient health information are becoming barriers to high quality health care.

Physicians describe the typical primary care interaction as less than ideal. A patient's account of a problem may reflect memory lapses, lack of awareness about what is relevant, or even worry or embarrassment.

Difficulty associated with accessing relevant patient information is a constant source of concern among practitioners and a source of frustration for patients. Paper records may be incomplete and difficult to analyze. Ensuring that patients understand and remember key facts about their diagnosis and treatment can be difficult.

The following list indicates the kinds of information and tools that physicians have indicated they require:

• Integrated patient information;
• Summary information (e.g., problems and medications);
• A mechanism for timely/efficient communication among provider teams;
• A better way to provide patients with information; and
• Convenient access, training and support for computer-based work.

EHR offers benefits, but challenges to implementation exist

An electronic health record system offers a solution for addressing these needs as electronic records are more easily shared among provider teams. New hand-held telecommunication devices can greatly facilitate information collection and retrieval at the point of care. When linked with clinical decision support systems, the EHR can facilitate evidence-based diagnosis and treatment.

However, several speakers noted that the EHR is about more than just digitizing paper records. It represents a significant change in traditional health care approaches and requires significant up-front investment of time, energy, and money. Hence, there remain many challenges ahead in realizing a pan-Canadian EHR.

First, are the range of technical challenges related to developing the hardware, software, and technical supports to operate and maintain the EHR network. Interoperability of the EHR network is critical and will hinge on the development of consistent standards for data collection, storage, and retrieval across all jurisdictions. For the development of a user interface, key content elements such as the patient's problem list, the management strategies (including diagnostic testing, medications, and progress notes), and the consultation letter, will need to be captured. A structured problem list could be the means of helping the provider to navigate easily and intuitively through relevant summary patient information and to drill down to the necessary specific details. Data entry must be designed to help the user keep the data accurate and meaningful. External data sources, such as radiology departments and laboratory services, need to be electronically accessible, through secure, standardized data gateways.

Second are the challenges related to the financial resources required to put the necessary equipment and expertise in place. Investment amounts are high. Risks and benefits must be allocated fairly among health system participants. An integrated and cooperative approach is needed to avoid redundancies or "re-inventing the wheel" in multiple jurisdictions. Providing adequate training and technical support is key to ensuring system reliability, realizing cost savings, and avoiding a prohibitive learning curve.

Third is the challenge related to practitioner adoption of new technologies. Getting the primary care physician, who is often the patients' first contact with the health care system, to "buy in" is critical. But achieving this will take more than mere money and clever software. At present some estimates indicate that only 3-5% of physicians are using electronic patient records. Therefore, if EHR is to become a reality, physicians will need to be motivated to adopt new work practices and tools. They will need to see a strong business case outlining the tangible benefits. They will need assurances about the reliability of the technology, the appropriateness of the user-interface, available training, and technical supports. There can be no violation of the doctor-patient relationship. There can be no breach of privacy or confidentiality - real or perceived.

EHR is already demonstrating its worth

Today, EHR is already proving its usefulness in practice environments across Canada. The Markham Stouffville Hospital, for example, has linked physicians, labs, and the hospital to a single electronic network, permitting fast and efficient electronic documentation of the health care interactions of some 40,000 patients. The Hospital has also implemented computerized administration, featuring point of care electronic documentation and filmless and paperless communications related to diagnostic imaging, radiology, mammography, and nuclear medicine testing.

Other projects such as Calgary's Foothills Medical Centre and the Peter Lougheed Centre are showing the utility of EHR as a support to clinical decision-making. As well, some 50 "chartless" medical practices are cutting their administrative costs by 10-15% by eliminating the workload associated with management of paper files, by increasing the legibility and the organization of chart content as well as by automating data entry.

These and many other projects are showing that EHR benefits are concrete, measurable, and meaningful - more time spent with patients, increased utility of patient files, less superfluous paperwork, better and faster diagnosis and treatment plans, greater opportunities for consultation among providers, and a greater opportunity for patients to be partners in their own health care.

EHR for a better health care system

The EHR is widely cited as a critical key to modernizing health care in Canada. Speakers noted that the EHR will save resources and effort by eliminating sometimes risky or expensive duplicate testing and history taking. Through the use of the Internet, smart cards, and other information technology, patients will be able to access their own EHR and take on the role of "partner" in managing their own health. Finally, EHR stands to make a major contribution to health surveillance, medical research, and the measurement of system effectiveness by providing for the production of aggregate non-identifiable health information.

Telehealth Contribution to E-Health

Canada is on the leading edge of telehealth

Participants talked about how Canada has long employed telehealth to break down geographic barriers in health care. Today, there are dozens of active telehealth programs and pilot projects, as well as several province-wide networks in place. Telehealth is being applied to a wide variety of health services, such as nursing triage, diagnostic services, rehabilitation, consultations, and continuing education for health professionals.

For example, Info-Santé CLSC, a teletriage service throughout the province of Quebec, is currently handling 2.5 million calls per year, increasing citizens' capacity for self-care and contributing to more appropriate use of health services. Other projects, such as the IIU Telehealth Network in Nunavut, the National First Nations and Inuit Telehealth project, and Saskatchewan's Northern Telehealth Network, are increasing the timeliness and accessibility of health services in rural and remote areas. In doing so, they are minimizing the need for travel and lengthy stays away from home, effectively alleviating the burden on patients and their families.

Still other projects, such as Toronto's Hospital for Sick Children Tele-Home Care Project and the West Prince, P.E.I. Telehospice Project, are demonstrating the capacity of telehealth to enhance the effectiveness of on-going monitoring and palliative care. These projects are confirming the benefits of delivering health care in the home where supportive family and friends surround the patient.

Practitioner education a key area for focus

The requirements of the health care profession necessitate that practitioners be continuous learners. However, today's explosions in medical/health knowledge and technology-related change are accelerating the requirements for continuous learning. As well, traditional classroom and apprenticeship learning models have become less practical solutions as practitioners cope with tight schedules and information overload.

The use of computers, telephone lines, the Internet, virtual reality and specialist software offers enormous potential to facilitate learning and "just-in-time" or "on-the-spot" information access. This is particularly true for practitioners in remote areas of the country.

What is needed is access to self-assessment and other tools to enhance practitioners' ability to engage in workplace-based learning.

Policy, regulatory and legal issues must be addressed

Cross-border remuneration issues

Motivated by concerns over health care utilization costs, most rules require that a physician actually see a patient in-person before billing for the services rendered. This approach is changing. A number of provinces including Alberta, Nova Scotia and Saskatchewan, have decided to reimburse physicians for telehealth practice on a broad basis. The outcomes of these "experiments", particularly the impact of telehealth on health care utilization and costs, will have a decisive influence on the future development of telehealth in this country.
Dr. Raymond W. Pong
Laurentian University

Liability questions

When a health care practitioner accepts a call and provides medical advice to a patient, a duty of care is established and the provider is accountable for the advice given. What is less clear is whether that same duty exists when the caller is another practitioner or calling on behalf of someone else. And what are the requirements for follow-up with the patient after hang-up?
Patricia Mclean
Canadian Nurses Protective Society

New Brunswick telehealth service outcomes

• 42% of callers given self-care advice
• 40% referred to walk-in clinics or their family physician
• 13% referred to Emergency
• 5% referred to other care providers
• 95% caller satisfaction levels
  
  Lois Scott
  Clinidata Corporation

Telehealth technology permits the health care provider in one location to provide service to a patient located elsewhere, possibly even in another province, without any direct contact with that patient. This raises questions related to cross-border licensure, reimbursement, and professional liability which will need to be addressed for telehealth to achieve widespread adoption. In some provinces physicians are reimbursed by their provincial health insurance plans for telehealth services. However, in other provinces they are not reimbursed by provincial plans and take part in telehealth activities on a voluntary basis or are paid through some alternative payment mechanism.

The Federation of Medical Licensing Authorities of Canada (FMLAC) has made recommendations to the provincial governing councils related to cross-border licensure of physicians for telemedicine. These recommendations were accepted by some but not all provinces. Thus, each province is on its own and some may require full registration with full requirements and payment of fees.

Evaluating telehealth effectiveness

Health stakeholders agree that telehealth projects must be patient-driven rather than technology-driven. That is, they must meet an identified, legitimate need, employ the simplest, least expensive technology that can do the job, and the tools must be shared among a network of trained and supported users. Telehealth projects must satisfactorily address the following questions:

• Does it adequately support patient-provider professional relationships?
• Is there a sense of security on the part of the patient?
• Does the service provide adequate caregiver support?
• For home care services, can they offer 24-hour support to the patient and family at home?
• What is the best process to involve patients, families, communities, volunteers and other health providers?
• What are the best protocols?
• What is the right care/technology mix?
• For home care services, can they offer 24-hour support to the patient and family at home?
• What is the best process to involve patients, families, communities, volunteers and other health providers?
• What are the best protocols?
• What is the right care/technology mix?

Proven benefits for success

Telehealth will become increasingly commonplace as patients and health professionals recognize the enhanced access, speed and convenience that it offers. Patients will recognize that telehealth services can help them avoid costly travel and precious time away from home. Practitioners will recommend telehealth as a means of allowing their patients to be treated where family and community supports can accelerate recovery. Health care providers will increasingly look to telehealth solutions to support their continuing education needs. Potential funders and decision-makers will watch with interest the results of evaluations on costs, benefits, and effectiveness regarding existing programs and projects.

Health Information for E-Health

Comprehensive, trustworthy, and useful health information is fundamental to informed decision-making by patients and the general public, health care providers, and officials engaged in monitoring and protecting public health.

Patient and general public needs

Relevant, credible, timely, and easy-to-understand health information is key to empowering Canadians to manage their own health. Such information includes the latest health news and research, self-care information, resource directories to support better access to care, self-assessment tools, and links to physicians, teletriage call centres, and health discussion groups.

Patients are pushing their health care providers to use the Internet. Internet searches performed by patients or their families are becoming commonplace additions to the medical office visit.

A number of projects are already providing Canadians with access to trustworthy information on healthier lifestyles, the prevention of disease, self-care, and the performance of the health system. For example, New Brunswick's symptom triage and health information service is providing citizens with 24-hour, toll-free access to nurses supported by decision support software. Veterans Affairs Canada has initiated projects at Royal Canadian Legions to teach veterans how to use the Internet to find information on health care options. The Canadian Cancer Society has created a toll-free information service that provides cancer information to patients, their families, the general public and health care professionals. As well, the Canadian Health Network is demonstrating the benefits of providing a single access window to existing resources of over 500 health NGOs across Canada.

Practitioner needs

Health care practitioners need relevant and reliable data about health care practices, including clinical support tools, data on best practices, clinical practice guidelines, the latest in medical research, and data on broad health trends in the communities they serve. They also require data and tools to support the business and administrative functions surrounding their work.

Practitioner attitudes towards the use of the Internet in the practice environment featured heavily in conference discussions. One of the critical factors that was seen to get physicians and other care providers to use this medium is to have a one-stop single access portal that will provide them with all the information they need.

England's Doctors.net.uk, and Nova Scotia's brand new DoctorsNS.com are revealing benefits for providers. The Canadian Nurses Association has been working on a portal for nurses. Indeed, over the past five years, numerous websites and online services for providers have emerged.

Monitoring and protecting public health

Over the years, disease control programs have relied on a number of reporting systems, such as for communicable diseases, sexually transmitted diseases, tuberculosis, and others. While useful on a program-by-program basis, they have not been standardized or coordinated and are unable to share information when needed.

The fragmented approach to development, coupled with a heavy reliance on paper-based record keeping, has also meant that health surveillance systems have not been able to take full advantage of progress in information technology. Public health information systems have not had the capacity to exchange information electronically with private providers of medical services, such as clinics and laboratories. As a result, public health agencies have often received information slowly and incompletely.

The implications of the traditional approach to disease monitoring are no less troublesome in the chronic, non-communicable disease categories. Chronic diseases exert a significant burden on Canadian society, contributing to premature death, hospitalization and other health care costs, loss of productivity, and restriction in lifestyle activity. Canada lacks a comprehensive system for monitoring these diseases. The current "system" of chronic non-communicable disease surveillance in Canada is a patchwork of activities, each centred on specific diseases or conditions, such as arthritis, asthma, cancer, chronic obstructive pulmonary disease, diabetes, heart disease and stroke, and mental illnesses. Each of the diseases has significant features in common: risk factors and determinants, health services, and outcomes. There are also strong interrelationships between many chronic diseases (e.g., diabetes and heart disease).

E-health offers the potential to enhance capacity to monitor and protect public health through better health surveillance. Participants noted that public fears about emerging diseases and health problems are growing in parallel with their expectations that public health officials should be able to protect Canadians from these threats. Public health officials are also expected to be able to detect emerging health problems and to quickly provide the information needed for a wide range of health concerns such as communicable diseases, consumer product threats to health, and non-communicable diseases such as heart disease and arthritis.

Most agree that a common core platform of data collection and analysis will improve the effectiveness and efficiency of all disease surveillance efforts. Standardized definitions and access to pertinent databases will permit more useful analysis of information on incidence and prevalence of chronic diseases and injuries, risk factors and conditions, health policies, services and programs, and outcomes.

Participants agreed that collaboration among stakeholders in terms of indicator development, data collection, and dissemination of surveillance products will be a critical success indicator.

Conclusion

Information communications technologies, from the alphabet and the printing press to the telephone and Internet, have been changing our lives for some 5,000 years. Even as we have come to recognize that technological tools can dramatically improve our lives, we are increasingly aware of the need to anticipate and manage their consequences. This is particularly true in health where technology and medical knowledge are both advancing rapidly.

Canada E-Health 2000 confirmed that e-health in Canada is more than just a vision. This conference showed that innovative health care professionals are already providing e-health to many Canadians. Participants showed that they are committed to promoting the use of information and communications technologies in the health care sector to maintain and improve the health of Canadians.

Many challenges lie ahead: adopting technology; policy development to address issues such as privacy, confidentiality, security, licensure, reimbursement, liability; managing organizational and cultural change; securing strategic investments; ensuring universal access; and infrastructure development.

Working together in a coordinated and collaborative manner, Health Canada and its partners will ensure we move "From Vision to Action".

Annex A

List of Speakers (in alphabetical order)

Annex B

List of Exhibitors

Health Canada
Canadian Health Network
Electronic Health Record and Telehealth Initiatives Databases
First Nations and Inuit Health Information System
National Health Surveillance Infostructure
Office of Health and the Information Highway

Health Infostructure Support Program
Keeweetinok Lakes Regional Health Authority #15
MOXXI-II Project, Royal Victoria Hospital

Other Federal Department
Statistics Canada

Other Health Organizations
alberta we//net
Brandon Regional Health Authority
Calgary Regional Health Authority
Canadian Institute for Health Information
Saskatchewan Health Information Network
Western Health Information Collaborative

Annex C

Bibliography

Connection, Community, Content: The Challenge of the Information Highway:
The Final Report of Information Highway Advisory Council 1995
http://strategis.ic.gc.ca/SSG/ih01090e.html

Towards A Canadian Health Iway: Vision, Opportunities and Future Steps
The Canadian Network for Research, Industry and Education (CANARIE) 1996
http://www.canarie.ca/funding/health/hreports.html

Canada Health Action: Building on the Legacy
National Forum on Health 1997
http://wwwnfh.hc-sc.gc.ca/publicat/finvol1/1trans.htm

Canada Health Infoway: Paths to Better Health
Advisory Council on Health Infostructure 1999

Conference Evaluation Report
Office of Health and the Information Highway 2000

Canadian Health Infostructure Blueprint and Tactical Plan
Advisory Committee on Health Infostructure 2000