Nova Scotia's innovative co-operators, doctors, and credit union officials are quietly rolling out a health care model that combines the power of community with the potential of emerging technologies. Is the health care revolution finally underway?

A constantly ringing phone is all that separates Pearl Flemings from dozens of patients anxious to connect with their family doctor. In her 24 years as a medical office administrator, she finds that most calls are from people who want to schedule an appointment or fill a prescription. Dr. Kent Pottle, one of the office’s doctors, knows routine telephone calls can eat up a lot of valuable time for patients and his staff, but his own investigations have failed to turn up effective solutions. Looking at the way other physicians operate, he says it appears they haven’t found an alternative either. 

According to Susan Helliwell, the managing partner of Connecting People for Health Co-operative (HealthConnex), that’s about to change. “It is mind-boggling to me that you can go online and book a trip to Barcelona, complete with hotels and car rental,” she says, “and yet you can’t book an appointment online with your doctor down the street.” In December patients willing to pay a small fee will be able to book an appointment online or request a prescription renewal via an evolving health portal launched by HealthConnex. 

Other planned services for patients include the ability to hold e-consultations with their doctor, track their health status and goals, set up reminders about appointments and medications, and access high-quality medical information, all from the comfort of home. “It’s what patients have been pushing for since email became mainstream,” says Helliwell. “The problem was that doctors didn’t have a payment model that would work for them. We’re providing that template.”

Dianne Kelderman is president of Atlantic Economics and the CEO of the Nova Scotia Co-operative Council, a major investor in HealthConnex. She saw the growing desire for patient-driven health care emerging several years ago as she talked to more and more doctors and health care users about the alarming rise in health care costs looming on the horizon. “About 45% of government program spending—federal, provincial, and territorial—is already directed to health care,” she says. “If it continues to grow unchecked, other critical areas such as the environment, infrastructure, and social services will struggle. Nova Scotia could be bankrupt by 2020. There has been a lot of talk that we need a new model, but no one we could see was actually doing anything.”

Drawing on the co-op principal that good businesses emerge when people stop depending on government and take action, Kelderman assembled innovative co-operators, doctors, and credit union officials and quietly began pushing a new model that combines the power of community with the potential of emerging technologies. “We have entered the era of ‘impatient patients,’ where it’s illogical that anyone should lose half a day of work just to go across town to a doctor’s office for a two-minute prescription renewal. We have the technology to do better. Let’s use it.”

Early model 

Starting in 2006, HealthConnex envisioned an online tool through which patients could access a wealth of information and interact online with their own doctor or nurse. However, online information has become free and easily available, so the service needed to provide more. That’s when Helliwell and her team stepped up. They concluded that people would only be willing to pay a fee if the service connected the patient with not just any doctor but their own.

Helliwell knew about technology breakthroughs in medical administration because her other company, Praxes Emergency Specialists, had been pioneering them in the commercial and industrial sector for seven years. The Halifax firm, one of the fastest growing in the region, has expertise in emergency telemedicine, providing 24/7 medical support to clients in remote operations such as oil rigs, fishing boats, the Canadian navy—even to climbers on Mount Everest.

Praxes had built a web-based management system to handle all aspects of providing medical advice to remote locations, from medical records and scheduling to managing training and certifications for medical staff. Praxes also provides clients with occupational health services, medical exams, education, and vaccination programs. “Our mantra has always been improving health care while decreasing costs,” says Helliwell. “It’s worked in industry, and now after a year of testing we’re ready to take it into the public sector.”

John Hockin, a senior manager at both HealthConnex and Praxes, says the biggest obstacle to change has always been the salary model. Doctors traditionally don’t get paid unless they see patients in person. It might be more efficient for a doctor to consult with a home-bound patient using Skype or to monitor a patient’s blood-pressure readings by having them emailed in, but doctors haven’t been able to charge for those services, at least in part because they had no mechanism for billing them.

With this in mind, HealthConnex recently acquired Benneworth Advanced Systems, a Halifax-based medical management and billing system already used in roughly 70% of doctors’ offices in Nova Scotia. HealthConnex will be able to link its suite of services directly to the system currently used by doctors. “We’re offering enhancements and efficiencies to existing health care services, not competing with them,” says Hockin. “We’ll simply be enabling a range of services that doctors have always been allowed to charge for but don’t usually bother with because they aren’t usually set up for direct payment.”

Doctors won’t be obliged to participate in HealthConnex programs, but by building on an established connection already in 475 doctors’ offices, Kelderman and Helliwell believe it will be easier to incrementally add new services rather than face the disruption that might come with starting from scratch.

No room for error

Dr. Kent Pottle is intrigued by the concept but isn’t yet convinced about the system’s security and privacy. He says everyone has a story about an email that was lost or sent to the wrong person. When you’re dealing with medical information or test results, for example, he insists there can be no room for error.

With some medical practices already charging a fee for uninsured services such as writing sick notes to employers and prescription renewals, Pottle doesn’t see an electronic fee schedule for third-party billings as objectionable, he just wonders who’s going to set the prices. “We’re an Internet society,” he says. “I can see this happening, but I don’t know if it’ll be tomorrow or 10 years from now.” 

Dr. David Zitner, a professor at Dalhousie Medical School, believes physicians are ready to embrace change and will do so sooner rather than later. “We’re in the tragic situation where doctors don’t have an electronic data trail to tell whether a patient is better or worse than they were a year ago, but Costco can tell what a customer is likely to buy because it tracks the purchases an individual makes,” he says. “That has to change, and doctors know it.”

Many have already taken advantage of technology. When the province introduced a computerized diagnostic radiology system, most radiologists were actively using it within three years. “We have some of the best physicians in the country,” says Kelderman. “By helping them operate more efficiently we help them make more money, and they get to see more of the patients who really need to be seen. Doctors and patients are satisfied, and it’s more cost effective.”

In an effort to answer critics who might suggest a subscription-based service amounts to an attack on universal health care, Helliwell and Kelderman underscore that their offerings conform to the Canada Health Act. “Patients already pay for health care services, from dispensing fees at pharmacies to massage and naturopathy. They just aren’t used to paying for services at their family doctor’s office, but that’s going to change.”

They go on to say that many Canadians think all health care services are free in Canada, arguing that this is a myth. Thirty per cent of the money in the system comes from private sources such as insurance, WCB, and the non-insured portions of health services such as dentistry and vision care. The privately funded health care sector in Canada is worth more than $50 billion, which is greater than the automotive industry, says Kelderman. 

The Nova Scotia Department of Health has little to say about HealthConnex. Spokesman Ryan Van Horne says simply that MSI doesn’t pay doctors for the services the company provides, and that the department will be watching to ensure that HealthConnex services don’t violate the Canada Health Act. He noted that in 2009 the Department of Health established HealthLink 811, which provides the public with free access to clinical advice. “When people have health concerns, they can call and speak to a registered nurse,” says Van Horne. “We encourage people to use this service that is being paid for with their tax dollars.”

Although the payment system isn’t yet in place, early subscribers to the portal are already nominating doctors to become members of HealthConnex. When several patients have nominated the same doctor, the physician is notified. By August 100 people had signed up, and 36 had nominated 25 doctors. With an initial market potential of 300,000 Nova Scotians who already belong to a co-op or a credit union, and 12 million co-op partners nationally, advocates such as Kelderman and Helliwell are confident the future looks bright.