A Commentary on the World Health Innovation Network’s paper:

Visibility: The New Value Proposition for Health Systems.

(Dr. Anne Snowdon, Odette School of Business, University of Windsor, October 2016)

It was with great anticipation that we read the above noted paper when it was released by Dr. Snowdon, having heard so much about its forecasted impact on Canadian Healthcare.

However, the excitement was short lived upon finding the report to be strangely reminiscent of an earlier paper produced by McKinsey & Company in 2012 titled Strength in unity: The Promise of Global Standards in Healthcare, October 2012. The McKinsey report has been accepted by global healthcare organizations as containing actionable intelligence and strategic direction and many of the recommendations presented are being actively implemented.

Following fairly closely to the same report concepts and presentation path as the McKinsey report, the new paper relies fairly heavily upon older data and reports while seeming to ignore the globally accepted conclusions of its predecessor.  The one thing that Dr. Snowden’s report does accomplish is to drive home the need for change under the mantra that if one repeats something often enough and loud enough people will eventually listen.     

There can be no doubt in anyone’s mind that from a technology adoption perspective, the Canadian Healthcare Supply Chain is both specifically and generally “stuck in the 80’s” when measured against the current landscape in the retail world, despite the industry’s attempts to modernize.

In the late 80’s and early nineties and under the guidance of SNS Inc. of Mississauga, various executives of both hospitals and vendors developed a working group that they called Carenet. The preliminary Carenet mandate was to develop and encourage the use of Electronic Data Interchange for the purchase order to invoice cycle, eliminating paper and reducing costs. The Carenet group worked closely with the Canadian EDI Standards body and Marshal Spence, it’s President at that time, to develop a subset of the X12 EDI document standards which became EDI standards specifically for the Canadian healthcare industry.  The Canadian standards body was originally known as the EDI Council of Canada, subsequently the Electronic Commerce Council of Canada Network (ECCC) and finally evolving into GS1 Canada.  The underlying principle was that if all parties used the same template, community enablement and adoption would be faster and less costly for all parties involved.

These transaction subsets are still in use today, having been updated to take into account the evolution of GS1 Global traceability standards that support the use of GS1 system keys such as the Global Trade Item Number (GTIN) and the Global Location Number (GLN).

As an EDI services provider having taken over the EDI processing that was at one point operated by SNS Inc., Commport links Hospitals, Group Purchasing Organizations (GPOs) and Shared Services Organizations (SSO’s, which contrary to the paper’s reference on page 22, they are not “single sign-ons”) with over 1,000 vendors using these transaction standards.

Commport processes transactions that interface directly with the Enterprise Resource Planning (ERP) systems that almost 100% of Canada’s hospitals and GPO/SSOs have implemented. These ERP systems support the organizational planning needs in terms of inventory and resource planning as well as the creation of purchase orders and the receipt of invoices in electronic format.

Unfortunately, many of the ERP systems in use by Canadian Healthcare Providers have not been updated and as a result in many cases, cannot inherently handle the latest GS1 Standards including the Global Trade Item Number (GTIN) and Global Location Number (GLN). As the manufacturers (Vendors) moved to meet these standards, which many have, the Healthcare Providers technology base has not been able to handle them. Upgrading or replacing ERP systems is an expensive, time consuming task, but one that is slowly happening in many centers.  These improvements are all well underway throughout the Canadian Healthcare System.

However, the reason for the WHIN paper is surely not to encourage the replacement of the ERP systems in hospitals, but one much grander.  On page 52 the WHIN paper states the following:

“Ultimately, our goal in this paper is to reframe the challenge of patient safety into a system infrastructure opportunity that creates clinical environments to support the delivery of the safest care possible. Supply chain transformation is the future for accountable healthcare systems that demonstrate the return on investment in delivering healthcare that is safe and highly effective in performance and quality.”

The stated goal is not only admiral and needed, but seems to be a little late to the game. It joins in the collective desires as presented to Commport by professionals that Commport interacts with regularly, not only in Canada but also on a global basis.

We note that on page 1 second paragraph in the Introduction section of the paper the following statement:   

“The purpose of this paper is to propose a new strategy for addressing the seemingly intractable challenge of patient safety and the growing rates of death and injury associated with adverse events in healthcare systems.”

The prospect of a “new strategy” creates a high level of interest for all involved in Canadian and global Healthcare.  However, “new” suggests innovation and that the strategy has not been put forth before.

In their 2012 report, McKinsey sets forth a strategy for Healthcare that is not only extremely similar to the one eventually put forth in the WHIN paper but one that has in fact, already been recognized and adopted by global Healthcare.  It is seen as the framework upon which Healthcare supply chains, from manufacturer, to provider, to patient are being restructured. The McKinsey report details how adopting the GS1 standards of GTIN, GLN and the use of the Global Data Synchronization Network (GDSN) can improve patient safety significantly, reduce costs and improve efficiency throughout the entire supply chain.  

Since the McKinsey report was released in 2012, this author would need to assert that the stated purpose of the WHIN report to propose a new strategy has failed. Many of the concepts presented are already being implemented and thus there is little to no innovation put forth within the report.  

We evaluated the stated goals of the WHIN paper. What we are looking for are recommended solutions, proposals, and or presentations that move the strategy of Global GS1 standards use to create visibility, traceability and improve patient outcomes from where it has been, to where it becomes a “reframed opportunity”.

Both the McKinsey and WHIN papers suggest that Healthcare can learn from other industries. McKinsey has chosen retailers as its point-to whereas WHIN has chosen the airline industry as its point-to.  However, WHIN’s examples clearly demonstrate a lack of understanding of how these technologies are used within that industry.

As a part of their point-to example, the WHIN paper has chosen to use the ‘boarding pass’ as an example of Track & Trace technology. However, it would appear that the researchers spent little or no time talking to airline industry experts about boarding passes, their use, their underlying technology or the benefits they provide to the industry.

The paper initially introduces the use of a boarding pass as follows:

“In the airline industry, every passenger of every flight carries a boarding pass with a barcode that identifies the passenger and the flight. This ensures that travelers board the correct flight, sit in the correct seat and arrive at their destination safely. When airline staff scan the passenger’s boarding pass, they are immediately informed by visual monitors whether the passenger is boarding the correct flight at the designated gate.” (page 6)

For the most part this definition of use is correct. The boarding pass gives the passenger permission to board the listed flight and to occupy a seat on the aircraft. Passengers receive their “permission” by having paid for the ticket and by having successfully met the local security requirements. The boarding pass is scanned at the gate to confirm the passenger has permission and is imminently about to board and therefore their luggage if any can remain on-board. For security reasons airlines are supposed to ensure that all luggage on board an aircraft belongs to a passenger on the flight.

Confirming the actual seat is up to the passenger or other passenger(s) who find them in the incorrect seat. It is notable that a number of airlines do not assign seats whatsoever in which case there is no way that the boarding pass could provide the insight stated by the WHIN paper.  

Interestingly later in the WHIN report, the power of the boarding pass seems to have grown in such a way that it seems to meet the needs of the author rather than to present an accurate picture of how its technology is used:

“In the airline industry, every passenger is tracked and traced from the time they check in to the time they take their assigned seat on an aircraft and disembark from the airport. Such automated supply chain infrastructure and use of tracking tools are key characteristics that are readily translatable to clinical environments in health systems” (page 19)

Using today’s technology, the airline industry encourages passengers to check in and to print their boarding pass from home.  Certainly as an industry, there is no benefit to tracking a passenger’s movements from their home to the airport.  Everyone who has ever flown knows that once a boarding pass is issued, either at home or at the airport, passengers are free to move throughout the airport with no one or no device tracking them. The boarding pass allows the passenger to access the security screening area and ultimately to board the aircraft. However, between security clearance and the gate, no one knows where the Passenger is until he/she attempts to board the plane.  There is definitely no check beyond a visual inspection by the flight crew that the passenger has left the aircraft. There is absolutely no track and trace evidence that they have left the airport.

The point for raising these examples is two-fold. The first is that in order for the healthcare industry to take the report seriously and undertake the expensive changes prescribed therein, every aspect of the report and every statement made therein must ring true. In this case they do not, and it doesn’t take an expert to know this.

The second point is that the current Healthcare world can look at these two statements and say, “hey we do that now. We use technology to record receipt of that pharmaceutical or device, and we also have our ‘boarding pass’ when we sign the shipment receipt. We also track our patients by the use of ID bracelets. However, the gap is that in healthcare we do not track which patient took the drug or received a device nor do we effectively track who administered it.  The ID bracelet does not track patient movements throughout the entire hospital, just as the airline has no idea where a passenger is once they have received a boarding pass.” 

A much better example from the airline industry is readily available. Delta Airlines recently announced a large traceability investment wherein they have spent $50 million to implement RFID baggage tracking. This is an effort to eliminate the 1% – 2% of the 150 million total bags handled that go astray.  This is the most innovative use of traceability technologies within the airline industry. 

Choosing a bad example may not lessen the value of the paper so long as the recommendations presented hold water.

Thus we look to the “Solutions” presented in the WHIN Paper which we have paraphrased below:

  1. Create a National and International framework to share patient and product related data…..

It is our understanding the Canada Health Infoway is well underway to deliver this solution on a national basis. According to its website, Canada Health Infoway is stated as follows:

A major step toward the development of Canada’s health infostructure occurred with the establishment of Canada Health Infoway Inc. (Infoway) in 2001. Its mandate is to accelerate and coordinate the development and adoption of modern systems of health information and communication technologies (including electronic health record (EHR) initiatives) in Canada and define and promote standards governing shared data to ensure compatibility of health information networks.  (Underline added for clarity only)

So the proposed ‘new’ solution is actually already in existence and is being implemented across Canada. There are a certainly a number of challenges that will need to be addressed as these strategies and solutions are put into place, however the framework and foundation are already well underway.     

  1. Invest in Infrastructure

The costs to retrofit hospitals with the newer technologies is a major hurdle to overcome. Canadian and global healthcare are redeveloping facilities; all are adopting the technologies suggested in both this paper and the McKinsey report.  One only need look to Ontario hospitals like the new Mackenzie Health Centre, in Vaughan, or Humber River Hospital to see how technology is being used to enhance patient safety and improve efficiencies.

So this proposed pre-determined solution also seems to be moving forward as the opportunities arise.

  1. Suggesting a National Product Registry

This appears to be a major pillar in the WHIN proposed solution. However, this pillar raises many issues from both the Provider and the manufacturer/vendor perspective.  Below we quote the section of the WHIN paper that gives rise to these issues:

“A digital registry of health products, accessible to all health system stakeholders who use it, offers access to accurate and up-to-date data on all healthcare products.”

Here again the retail world is at least a decade ahead of Healthcare in addressing the issue of current, accurate and timely product data in a standardized format. With the globalization of manufacturing and commerce and the proliferation of new products, retailers large and small realized that managing this data directly themselves was far too resource intensive. It has caused errors at the Point-of-Sale (POS), impacted scanning technology and slowed down the introduction of new products. These retailers realized that collectively they were spending many tens of billions of dollars in their supply chains to address this issue. 

Nothing inspires a change like recognizing such a huge negative effect on the bottom-line.  Retailers set about developing and introducing a solution to this problem, a solution that has become known as the Global Data Synchronization Network (GDSN).  This network of services providers, called data pools, has been shown to be the system infrastructure opportunity (to paraphrase the WHIN paper) needed to effect supply chain transformation.

The GDSN is a network of 34 securely interconnected and interoperable data pools around the world. These data pools manage over 22 million unique products and product groupings on behalf of 34,000 global manufacturers.  The benefit to the manufacturer is that they only to have enter their product data into one point, their data pool of choice. The GDSN standards and infrastructure will ensure that the authorized recipients are kept updated and accurate, in a constantly cleansed fashion, within hours of a change being posted by the manufacturer.  Although pioneered by the retail sector, through the GS1 Industry Engagement initiative, the GDSN fully supports the needs for the healthcare industry. To date there are over 2 million specific Healthcare products available in the network.    

The GDSN is a truly global, standards based digital registry that has been developed with the input of industry, one that more than meets the need as stated in the WHIN report as per the above quote.  As a part of developing a global solution, any regional and national attributes for every country, including Canada, are handled extremely well. GS1 has a methodology in place to integrate any new or upcoming requirements into the standards, as they come to light.  Duplicating this registry by building national registries of any kind only adds unnecessary costs and could result in product data becoming out of sync with the manufacturers global catalogue held within the GDSN. It definitely means that any manufacturer selling into Canada would have to monitor and interface with 2 registries (or more if country specific registries gain traction), again adding costs to the overall supply chain while offering no benefit to the patient.    

A national product registry could be linked to the Canada Health Infoway mandate to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health solutions across Canada.”

As we reviewed earlier, the Canada Health Infoway mandate is to encourage the use of technology to provide ‘visibility’ into the medical details of all Canadians in order to have the information available where and when it is needed for further Patient Care and review.  The paper fails to detail exactly how a ‘national registry’ would help advance the Infoway mandate nor how it would accelerate the development, adoption and effective use of digital health solutions across Canada”.

The parties active in the GDSN especially the data pool operators, such as Commport, would find the details on how a centralized repository could improve patient safety very helpful since the GDSN is an existing global registry with millions of products whose data is already available to Canada Health Infoway.

“A national registry also makes it possible to implement post-market product surveillance to ensure that only the safest, high performing products are used in healthcare to achieve health and wellness outcomes for patients.”

Again, there are no details on how, but it would appear that the proposed pre-determined solution is more than just a registry. It has the appearance of some kind of product ranking and scorecarding application that would have to rely upon Provider input.  We suggest that this would not gain support from many manufacturers as they must be able to derive a business benefit from any solution introduced.  As a result, a registry with this purpose would most likely fail even if came with ‘no cost’ to the brand owners.

“A national registry eliminates the burden for health professionals or staff of having to key in product information and data manually, thus also reducing the administrative burden downstream when product data is inaccurate.”

At this point the paper is referring to the traditional work needed to enter and maintain the Master Item file (catalogue) in their ERP system(s).  The reality is that the users of the GDSN do not manually handle any data. In 2016, the GDSN will have handled over 100 million product data records being delivered to ERP systems globally. What Canadian Healthcare does not need is a new, duplicate system that will involve costs to build. It must compete with a global standard that has already been proven to work 100 million times per year.  

“A national digital registry offers the added value of supporting cost-effective and accurate e-commerce supply chain processes to ensure that products are available and distributed to clinical settings when and where they are needed.”

We assume that the “cost-effective and accurate e-commerce supply chain processes” are those involved in the ‘Procure-to-Pay’ commercial activity including all the individual logistical steps along the way. The standard for these processes is Electronic Data Interchange (EDI) a topic Commport is extremely familiar with. But how a national product registry would offer any benefit in this process is a mystery. The first step in the Procure-to-Pay process is the creation and release of the purchase order which uses the Item Master file in the ERP system, which we addressed above.

Unfortunate as it may be, it is obvious to anyone operating in the Canadian Healthcare industry that the authors have a very close, cordial relationship with Canada’s GS1 Member Organization (MO), GS1 Canada.  For many years GS1 Canada has worked very hard to protect their existing ECCNet product registry which they inappropriately call “Canada’s Product Registry”. We see in this paper almost verbatim, the statements GS1 Canada uses to market their ECCnet service, which does work in conjunction with the GDSN. Instead, however, ECCNet imposes additional fees for participation as its scope is considered to be outside of the global network.

It is the opinion of this writer that the author(s) have failed to add anything new or reframed the healthcare supply chain in any new way that had not been tried or that were not presented in the McKinsey paper of 2012. The suggested pre-determined solutions presented failed to explain how the solutions would deliver the benefits that are put forth with them.  We believe that for the most part would be duplications of existing solutions already implemented not only in Canadian Healthcare centres, but also globally.

As a supporter and promoter of the global GS1 standards we would always assert that without a doubt, there can be no harm in repeating what has already been said if only to refresh the ideas in everyone’s mind.  However, it is our opinion that this paper would have more weight and credibility if it had made reference to or at least acknowledged the work of McKinsey and their report. It would be even more valuable to Canadian healthcare if the concepts outlined in 2012 by McKinsey were updated and built upon as a part of delivering on a new value proposition for Canadian Health systems.                           

About Commport Communications International, inc. is an e-commerce service provider to a large portion of the Canadian Healthcare marketplace providing electronic supply chain services to both Providers and Vendors in Healthcare across Canada.  Included in these services is the ‘core’ supply chain activity of transactional electronic data exchange (EDI) as well as complete Global Data Synchronization Network (GDSN Product Identification) services. 

With over 30 years of experience in the retail/commercial marketplace assisting retailers and distributors to interact in an electronic way within their supply chains with their many hundreds of thousands of vendors around the world, Commport brings this wealth of knowledge and understanding into the healthcare marketplace from actual experience not theory.   

As one of the oldest certified GDSN data pools in the world, Commport is well versed in and very experienced in the full set of GS1 Global standards which extend well beyond the use of GTIN’s, GLNs, and GSRNs, and works daily with both manufacturers and Healthcare Providers to encourage and assist in adoption of these standards. Part of these services include assisting manufacturers to understand and comply with legislative requirements such as the FDS UDI requirements in the US.

As a “virtual partner” with one of the largest provider of EMR software and services in Canada, Commport also understand the needs for and the benefits of visibility and continuity of information across the complete spectrum of healthcare services at the patient level. 

Working and interacting with over 1,000 healthcare industry entities, both domestic and international, on a daily basis Commport is uniquely situated to comment on the above noted paper from the World Heath Innovation Network (WHIN). 

The commentary that follows herein is based upon our 30 years of retail experience and our daily interaction face-to-face with those involved in the Canadian Healthcare marketplace. 

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Author: Dave Ralph

Dave Ralph is the founder, President and CEO of Commport Communications International, inc. Under Dave’s leadership, Commport has become; a recognized leader in supply chain transactional processing; one of the fastest growing GDSN Certified data pools; and, a major link in the Canadian Healthcare supply chain providing services to hundreds of hospitals, GPOs and SSOs and their vendors across Canada. Dave is also a Member of the Board of Directors for GS1 Data Excellence Inc. (formerly GS1 GDSN Inc.) Since September 2016