This chapter provides an overview of innovations in the prevention and management of chronic diseases, as well as particular challenges related to innovation in these areas. It examines how many new technologies can contribute to increased self-management of chronic illnesses and reduce risk factors in healthy or at-risk individuals. The chapter concludes with the Committee’s observations and recommendations about supporting and promoting the use of these technologies by Canadians.

A. Chronic Diseases in Canada and the Role Technology Can Play in their Prevention and Management

The Committee heard that increasing numbers of Canadians are living with or at risk of developing chronic illnesses. Two thirds of deaths in Canada are caused by four chronic illnesses: cancer, diabetes, cardiovascular and chronic respiratory diseases.[156] Three out of five Canadians currently live with a chronic disease, and four out of five have at least one risk factor—including physical inactivity, unhealthy diet, smoking and being overweight or obese.[157] The PHAC estimates that the financial burden of chronic diseases in Canada is at least $190 billion annually.[158] Many people living with chronic illness, particularly the elderly, suffer from more than one chronic condition.[159]

Witnesses also discussed the growing problem of risk factors. For example, Dr. Peter Selby of the University of Toronto noted the societal shift that has resulted in a move away from physical labour to driving to exercise at gyms.[160] He also commented on the availability of low-cost high-calorie foods, high rates of nicotine and alcohol use, and high-stress, low-sleep lifestyles, all of which increase predisposition to chronic illness. He noted that high-risk behaviours are “infections within communities.”

Many of the risk factors for chronic disease are modifiable, however.[161] Many witnesses before the Committee argued that technological innovations could be particularly useful in modifying health behaviours to reduce the incidence of or to manage chronic illnesses. They pointed to society’s increased reliance on the Internet, on smartphones, and on social media as an opportunity to create tools for individuals to prevent and manage chronic illness. The Committee heard that in 2010, 80% of Canadian households had Internet access, and  two-thirds of households use the Internet to find health information.[162] Further, 48% of Canadians use smartphones and 70% have downloaded apps; a third of these apps relate to health and fitness.[163] Witnesses suggested that technological innovations can help healthy individuals to manage their risk factors, reducing the incidence of chronic illness.[164] Further, technology can help those living with chronic illnesses to manage their conditions, reducing expensive hospital admittance.[165]

B. Innovative Technologies to Prevent or Manage Chronic Diseases

The Committee heard from Ms. Kim Elmslie of the PHAC about a new initiative to prevent type 2 diabetes.[166] The program, called CANRISK, is a web-based assessment tool to identify individuals at risk of developing diabetes. CANRISK is also available as a mobile app. The aim of CANRISK is to identify people at risk for diabetes and to educate them about modifiable risk factors in order to prevent high-risk individuals from developing type 2 diabetes. Although the tool is widely available to the public on PHAC’s website, CANRISK was rolled out in partnership with pharmacies so that pharmacists can help clients take the test, while educating and counselling clients about their risk factors and about making healthier choices in the process.

The Committee heard from Ms. Heather Sherrard, Vice-President Clinical Services with the University of Ottawa Heart Institute, about the e-health strategy the Heart Institute has implemented for its cardiac patients.[167] The first element of the strategy is telemedicine. Cardiologists in Ottawa are able to consult patients as far away as Nunavut using tools such as an electronic stethoscope that can be used to listen to heart sounds remotely. The second component is a home-monitoring device that connects to patients’ phone jacks, and can relay patients’ vital signs to their care providers. The final element is an automated calling system developed by clinicians that asks patients questions their care providers would ask in a follow-up visit. Patients’ responses are converted to text, which is then reviewed by nurses. If a nurse finds a problematic response, he or she follows up with the patient. Ms. Sherrard noted that the Heart Institute was able to save $340,000 in its first year of running this strategy.

Dr. Robyn Tamblyn of the CIHR described to the Committee several “catalyst grants” that funded projects that used innovative approaches to improve patient quality of life. For example, the CIHR funded a program at Toronto’s Hospital for Sick Children that established a peer-to-peer mentoring system for children with juvenile arthritis, and a McGill-based cardiovascular risk e-health tool. In order for these small grants to be effective, Dr. Tamblyn argued, Canada needs “a high-functioning science and technology innovation system” with an alignment between industry, research and clinical care.

Dr. Richard Birtwhistle, Scientific Director of the Technology Evaluation in the Elderly Network described the Canadian Primary Care Sentinel Surveillance Network, which has been funded by PHAC since 2008.[168] The network includes 420 participant physicians who contribute data on almost half a million patients who have one of eight different chronic diseases, tracking information such as weights and blood pressures. The network facilitates disease monitoring, quality improvement and research, and allows for feedback to physicians on how they are managing their patients’ illness.

The Committee heard from Dr. Saul Quint of INTERxVENT Canada, a business that provides products and services to health care professionals and patients based on behavioural learning theories to facilitate the adoption of healthy lifestyles.[169] INTERxVENT is a platform based on a self-reported health risk assessment supported by laboratory tests and biometric testing. The platform identifies users as low-, medium- or high-risk, and then develops individualized online self-help interventions. These interventions may include support for nutrition, weight management, physical activity, stress management, tobacco cessation, medication management, diabetes and depression, and may include the support of a health coach.

The Committee heard from Dr. Victor Ling, President of the Terry Fox Cancer Research Institute, which is a virtual institute with 55 member organizations, including all the major universities, cancer research centres and cancer hospitals across the country.[170] One of the Institute’s initiatives was to find a means of early detection for lung cancer, which kills more people worldwide than breast, prostate and colon cancers combined. The Institute created a web-based assessment tool that asked about smoking behaviours and other demographic variables that are correlated with the development of lung cancer. The assessment tool was able to detect early-stage lung cancer in 5% of patients before they developed symptoms, which was a three-fold improvement on comparable early assessment models based on medical interventions.

Dr. Ken Milne of the Gateway Rural Health Research Institute described an innovative approach to information dissemination to front-line rural physicians. The Institute developed “Just out of the Gate,” or JOG, through which the Institute gathers up-to-date research, conducts an evidence-based review of the data, then podcasts the new information to rural physicians. It also validated an app, called the REALM, (“rapid estimate of adult literacy in medicine”). The app takes 10 seconds to evaluate a patient’s health literacy, which can improve patient-physician interactions by allowing the physician to adapt the information he or she provides to a level the patient will understand.

Mr. Dale Friesen of Beagle Productions, a business that specializes in the design and development of web applications described “wellness accounts,” which are created as part of an online community and allow users to track their health behaviours.[171] When a company makes this tool available to its employees, employees fill out questionnaires and health risk assessments, and have biometric data uploaded to their account. Employees can then set goals and track fitness, weight loss, nutrition, connect with a coach, and collect health reward points to be used in a health store. Users input and access data through their smartphones. There is easy access to exercise tips and recipes, and users are prompted with reminders if they have not logged in recently. There can be team challenges and leaderboards to encourage team building while adopting healthier lifestyles.

C. Some Advantages and Challenges of Using Technological Innovations to Prevent and Manage Chronic Diseases

Witnesses discussed advantages and challenges of using innovative technologies in preventing and managing chronic illness.

1. Reducing Geographic Barriers

The Committee heard that although estimates vary depending on the definition used, between one in five and nearly one in three Canadians lives in a rural area.[172] Individuals living in rural and remote areas suffer from higher rates of chronic illness than do urban residents, and they have lower life expectancies.[173] The Committee learned about the great potential for technological innovations to contribute to better access to care for rural and remote residents.

The University of Ottawa Heart Institute’s strategy discussed earlier has provided a means for Canadians across the country to access the expertise of the Heart Institute. Patients are given home monitors that they simply ship back to the Heart Institute when their observation period is over.[174] Patients from remote locations can experience social isolation while receiving treatment at the Institute. The Institute’s strategy helps reduce geographical barriers between family members when patients must be treated on-site by connecting families and patients through the same telemonitoring stations used for remote consultations.

As Dr. Robyn Tamblyn of CIHR noted, telehealth can be a very valuable tool for increasing access for individuals living in rural and remote areas, but even small geographical distances can be major barriers to effective care. She argued that even individuals living in major urban areas could receive enhanced care when their health care providers can monitor them at home, and patients with chronic illnesses would not have to make repeated trips to clinics and other care facilities.

2. Financial Barriers to Accessing Health Technologies

Many witnesses discussed Internet-based tools and smartphone apps that are used in the prevention or management of chronic diseases. While these may be readily available technologies for some individuals, there are costs associated with their use, which may, for some patients, render the technologies inaccessible. In some cases, as in the Ottawa Heart Institute’s strategy, the cost savings associated with a particular technology may be so great that the health care provider can absorb the costs associated with any necessary devices meaning no direct cost to patients.[175]

As Dr. Ken Milne of the Gateway Rural Health Research Institute noted, some of the patients least likely to have easy access to smartphone and Internet-based solutions are those with lower socio-economic status who may have limited literacy, or limited health literacy, and who are often the most frequent users of hospital emergency department services. Dr. Robyn Tamblyn of CIHR suggested that in some cases, it may be more cost-effective in the longer term to subsidize technologies at the outset where patients cannot afford to invest themselves than to pay for patients’ care as their health deteriorates. Dr. Peter Selby suggested that a way of addressing the “digital divide” or the discrepancy in access to Internet-based health technologies between individuals of different socio-economic status might be to increase access to these tools in public places such as libraries and health care centres.

3. Physical and Cognitive Barriers to Accessing Health Technologies

The Committee heard about the importance of ensuring that patients are able to use the technological innovations that are designed for them. For example, Ms. Sherrard of the Ottawa Heart Institute explained that some equipment the Institute had provided to monitor cardiac patients is presenting challenges to patients with arthritis who lack the necessary dexterity to use the equipment and find it painful to use. She also noted that in the automated calling platform the Institute uses, it is possible to slow down the questioning for patients with mild dementia to give them more time to answer. Dr. Feng Chang of the Gateway Rural Health Research Institute described challenges with health apps developed for seniors. Specifically, she said the volume on some of the apps is too low for individuals with hearing loss, and the navigation buttons that seemed self-explanatory to the developers are not intuitive for those seniors who are not familiar with common software programs.[176]

4. Scientific Validation for Self-Management Tools

The Committee heard from many witnesses about the wide array of self-management tools available to the public that could either promote healthy choices, thus reducing the risk of chronic illness, or that could help individuals with chronic illnesses monitor their condition. When Ms. Elmslie of PHAC described CANRISK, she noted that a critical aspect of the program is that the tool is scientifically validated. She argued that there should be a great deal more research done on the science underlying e-health apps used to help patients prevent or manage chronic diseases to be sure they do “more good than harm.”

Similarly, the Ottawa Heart Institute tested the automated calling component of its strategy (described earlier) in a randomized controlled trial of 1200 patients, and found that individuals who received a call were statistically more likely to be on best practice medications and less likely to be readmitted after a year.[177]

Dr. Robyn Tamblyn of CIHR noted that it is important for government to be involved in the entire process of development from innovation through to evaluation in order to provide sound guidance on scientifically validated tools. The Honourable Mary Collins, Chair of the Chronic Disease Prevention Alliance of Canada also argued for quality control, and for government identification of scientifically valid information and tools. Dr. Feng Chang noted that this type of initiative has been undertaken in Europe in the form of the European Directory of Health Apps (2012-2013),[178] which identifies recommended apps for patients and for various health care professionals.

5. When to Refrain from Using Technology

Dr. Richard Birtwhistle of the Technology Evaluation in the Elderly Network reminded the Committee that although technological innovations can be very beneficial, in end of life care, the unwanted use of technology can negatively affect quality of life for both patients and their families, and can in fact prolong suffering. Dr. Birtwhistle explained that for seriously ill elderly patients, technological innovations are sometimes used to prolong life for individuals in a very poor state. He stressed the need for communication with health care providers about decision making surrounding the use of life-sustaining technologies.

D. Committee Observations and Recommendations

The Committee’s study of the role of innovative technologies in the prevention and management of chronic diseases revealed that there is an abundance of technologies designed to support and encourage healthy behaviour among individuals whether they are healthy, at-risk, or living with chronic illnesses, but not all these technologies are equally effective. PHAC representatives told the Committee that it sees a role for the federal government in supporting and promoting the use of innovative technologies by identifying and scaling up best practices across Canadian jurisdictions.

Further, witnesses emphasized the importance of health literacy in preventing chronic illness. They suggested that investing in health literacy could result in Canadians making better lifestyle choices and being better equipped to make medical decisions with their health care providers, thus reducing their risk of developing chronic diseases.

Reflecting these findings, the Committee therefore recommends that:

17. The Public Health Agency of Canada and the Canadian Institutes for Health Research consider ways to facilitate the sharing of best practices among industry, researchers and clinicians with respect to technological innovations in chronic disease prevention and management.

18. Health Canada and the Public Health Agency of Canada continue to promote health literacy with a view to empowering patients to take steps to prevent and manage chronic illness.