Canadian Insight and How Can Hospital Networks Innovate? (Dr. Lawrence Rosenberg, Danina Kapetanović)

Canada has a universal healthcare system and ranks among the most expensive universal health-care systems among the OECD countries. Canada’s performance for availability and access to resources is generally below that of the average OECD country, while its performance for use of resources and quality and clinical performance is mixed.

Canada is a very large country with 35 million people, divided in 13 political divisions: 10 provinces and 3 territories. The country has a single-payer system, however, each province manages its own system.  

Below are the transcripts (with time stamps) of the two interviews with Dr. Lawrence Rosenberg - President and CEO Integrated Health and Social Services University Network for West-Central Montreal (CIUSSS West-Central Montreal) and Danina Kapetanović, Chief Innovation Officer, the Head of OROT - a Connected Health Innovation Hub inside the network, former Executive Director of Hacking Health Global.

Integrated Health and Social Services University Network for West-Central Montreal (CIUSSS West-Central Montreal) covers 345,000 people, with a staff of over 12,000 and over 600 doctors. In 2020, in the midst of the COVID-19 pandemic, a Connected Health Innovation Hub inside the network was formed to further leverage technologies and innovation for increased healthcare improvement and sustainability.

Jewish General Hospital, CIUSSS, Canada.

“It is important to not just think about the education of professionals who will work on a new digitalized system, but on the education of the population, who's going to have to learn how to live and function and a digitalized healthcare world.” 

Dr. Lawrence Rosenberg

Let's start with the description of the Canadian healthcare. There's a joke, or at least it was, that Canada is like the USA, but with good healthcare. Compared to the USA Canada does have a universal healthcare system. However, if we look at the comparisons among the OECD countries, it ranks as the most expensive universal healthcare system. In terms of availability and access to resources. Canada is generally below that [00:03:00] of the average of the OECD countries. But its, performance for the use of research resources and quality and clinical performance is mixed. From your perspective, how would you describe access to healthcare costs and the general state of healthcare in the country?

Dr. Rosenberg: The Canadian healthcare system is completely unlike the American healthcare system. Our healthcare system here in Canada has absolutely no similarity to what goes on in the United States. It's actually a lot closer to the healthcare system, for example, in North Korea than it would be any other country in the world. And I say that because it's basically a publicly funded healthcare system almost entirely which is not the healthcare [00:04:00] systems throughout much of Europe or the rest of the world where most of the healthcare systems are hybrid systems, a combination of public-private. So Canada is somewhat unique in that respect. Because of that then, because the government is the primary, if not a sole payer of all medical and social services, it imposes on the system very significant constraints with respect to how much money can be spent in the health sector.

And because of that as a consequence access to the system, generally speaking, is based on waitlists for common situations. However, I would add that anybody who's got an urgent situation or an emergency situation could get almost immediate access into the system without having to wait. I think that's the trade-off. I think the quality of Canada generally speaking, is quite high. Where we have our issues or in areas related to elective care and the wait times are required to you see a physician if you have an elective non-urgent situation,

That is quite a common problem in universal systems. What is surprising to me is that while the system in Canada is universal, people actually need to have extra insurance that covers medication costs, right?

Yes and no. Canada is made up of a number of provinces. It isn't just one country. It's really 10 small countries. And healthcare in Canada is a provincial matter. It's not a federal matter. So each [00:06:00] province has its own healthcare system. They're not identical. And each province has its own PharmaCare or drug coverage program.

In Quebec, for example, which is where I am, the provincial government will pay the costs of medication up to a certain amount every year for individuals. So that's a cost that's split between the government and the individual. So you don't need to have private insurance to cover the entire cost of your pharmaceutical costs.

There are 13 political divisions, 10 provinces, and three territories in Canada. How do different parts differ in terms of access to health care, quality of care?

It does vary. I don't think it varies [00:07:00] to any significant degree, but the population in each province is different. The organization of care to a certain extent is different. For example, in Quebec our health care service also includes social services. So it's all under one ministry. Whereas in many other places in Canada, it's split between two and three ministries within a province. So that has a very significant impact on the provision of care.

What would you say is one of the big challenges that the system has? Apart from the waiting times that we already mentioned.

I think there are a number of challenges. One is the public health care system, which is almost entirely public. I don't think it is sustainable much longer because the government can't afford to put all its tax revenue into supporting one ministry. It just isn't viable and feasible going [00:08:00] forward.

The second major challenge which was huge, and it's a global challenge is a lack of professional manpower. Globally at this time, there are probably 18 million jobs in healthcare that are unable to be filled around the world. And we're certainly experiencing that here in Canada as well. It's a problem that cannot be fixed overnight.

And then the third issue is the aging population and it isn't just the aging patient population. It's the aging care provider population as well. And I think how healthcare is provided and organized needs to be completely rethought.

This brings me to the last challenge, which really is the digitalization or the digital transformation of healthcare, which may hold some solutions to some of these problems.

What is the state of digitalization of [00:09:00] healthcare in Canada? There is the hope that with the help of technologies, a lot of challenges will be solved causes decreased prevention improvement, but at the same time, all these things cost and demand investments. They are difficult to implement, you have to take care of adoption. How would you characterize that aspect of healthcare?

I would say at the moment it's very early. There's still a lot of discussion and thinking going on around this in my own institution, we've actually made this a priority over the last two years, even before the pandemic began. We saw that this was going to be the key challenge with respect to healthcare organization and provision of care going forward. And of course, as you indicated, it presents its own challenges. Not least of which is putting in place a robust cybersecurity defense and also very important is not just education of [00:10:00] professionals who will work on a new digitalized system, but the education of the population, who's going to have to learn how to live and function and a digitalized healthcare world.

As the president and CEO of the Integrated Health and Social Services, University Network for West Central Montreal; how are you addressing, the challenges that you mentioned, the fact that you've got an aging workforce, the fact that you might want to employ more healthcare workers that then there are out there on the market?

Dr. Lawrence Rosenberg.

Two things. One is we've always been an organization that's prided ourselves on our excellence and our attractiveness to people who want to work in the healthcare system. So we're a magnet organization with a history of attracting good people and attracting the people we want and the people we need.

So I'm not minimizing the lack of manpower. It's still an issue, but [00:11:00] perhaps it's a little bit less of an issue for us than it would be for other people. And secondly, we began thinking about the digital transformation of healthcare at least two or three years ago. And we've been hiring people with the appropriate expertise. We've been training our own people internally to give them the skillset. They need to function in the new world going forward. And we've been on a fundraising campaign to raise the funds. We need the, not necessarily from government, but privately to affect a transformation in a digital way, how we're organized and how we provide.

You've been in this position as the president and CEO for quite a few years. How would you say, that the whole state in terms of digitalization has changed - you mentioned you've been actively working on this in the last [00:12:00] two years, but it's always interesting to have a comparison of the state before, let's say five years ago and today.

Concretely we've, we're going through a process now of upgrading our it infrastructure, which is fundamental to any digital transformation. So that's almost completed. We've spent the last few years putting in place a very robust cybersecurity defense, which also is a fundamental foundational element to any digital transformation program.

And we're now looking at how we can reorganize care so that we expand our ability to provide virtual care. Eloquent to the community without requiring people to come into our institutions, if they can't or won't. And at the same time, we're engaged in a massive program to develop and implement a next-generation electronic healthcare record that will really improve access to [00:13:00] care, improve cost-effectiveness, and take into account the lack of adequate manpower.

And for the first time as a health network enable us to put in place a continuum of care that allows us to collect data from across the entire continuum.

As I mentioned before, digitalization can be expensive, not just because of the IT systems, but because of all the maintenance, you mentioned that you employ additional experts. You need IT experts, data experts, and in the future, there's going to be an increased need for AI specialists to be in the hospitals. You already started bringing all these people in; how is then the structure of costs in the hospital changing in terms of how you budget, where the money is going to be allocated [00:14:00] to?

As we reimagine how we organize work and provide care there will be things that we no longer have to do the way we used to do them. And we will be doing things differently with more of a digital way of organizing and providing care. Of course, there are some that we call sunk costs at the beginning that will have to be put into purchasing new equipment. But there's also a lot of wasted money at the moment being thrown at old and antiquated IT infrastructure and those costs will go away and we can recoup some of that budget to reinvest in a new digital space.

So individuals doing certain jobs will not have to do those jobs anymore. Like people answering telephones I think that's gonna go away. You don't have to pay chatbots. It's an initial capital investment, but over time that [00:15:00] will save labor costs and there'll be very many others as well.

When you started with the process of digitalization and implementing new systems how did you ensure that these systems were well-accepted among the users and the healthcare professionals? So you don't get the resistance when something new is introduced and it's just another thing that clinicians need to use in their work?

We actually have a very decentralized organizational structure in our institution. It's a very democratically run organization. We believe sincerely in the voice of the customer. And the customer in this case, isn't just the patient, but it's our healthcare professionals as well.

And we involve our professionals and our patients at every level in [00:16:00] decision-making so that no one can say that they're being forced to use something that they didn't have to do in in agreeing to whether to adopt or not to adopt.

That's a very interesting perspective because if we look at healthcare from the entrepreneurial perspective, the usual challenge is that you're designing a product for, let's say a doctor or a nurse, and the payer or the buying decision-maker is not the end-users. That's quite a nice example of how you can make it easier for good innovation to come into the system.

You do that if you have a certain amount of control and that's where the challenge is, we have to be able to balance what we're able to do with what the government will allow us to do. And that's an ongoing discussion. But a priority for us internally certainly is what you would call the user [00:17:00] experience.

One of the challenges that healthcare digitalization has is that healthcare systems or institutions that have been digitalized for a long time are now facing the issue of dealing with legacy systems that are very difficult to either get rid of or renew in a little bit. So how are you ensuring the long-term sustainability of your digital systems?

Since we are at the beginning of this journey we do have a number of legacy systems and this was what I was trying to indicate earlier. The legacy systems are actually costing us more than they're worth in terms of keeping around and providing active platforms.

And so we are rapidly trying to get rid of these legacy systems and hopefully, we will over the next two years as we introduce our next-generation systems. [00:18:00]

And how exactly are you doing that? If it's not a stupid, the reason I'm asking is that one of the strengths of the legacy systems is that the data lock-in, the vendor lock-in? What's your strategy to contain the already existing data that's been captured with the existing systems?

The legacy systems we have are actually quite old, but having said that much of our archive of medical information is in a format that we can easily transfer over to a new system. And we're not going to be held hostage by previous vendors in terms of having our data locked into their system.

It's the way we organize things many years [00:19:00] ago. And I think now we can take advantage of the fact that much of our data was archived in a way that would be, I wouldn't say easily transferable, but certainly transferable into the new generation of software.

What is the state of healthcare infrastructure in this regard in other parts of Canada?

It's different in every province and it's probably different within every institution, within every province. It was just not something that was well-conceived of 20 years ago. And I think now we're all suffering from a lack of creative imagination and investment over the last 20 years.

What about interoperability? What is the state of that around Canada?

That too is an issue. [00:20:00] You would think that interoperability would have been a key principle across the country. Unfortunately, it was never achieved. So in terms of public health data, I think that's easily available and centralize within provinces and within the federal government. But other than that type of data individual healthcare, patient healthcare information stuck within provinces and within institutions.

One of the recently opened up things at your organization was a new command center that enables an overview of hospital activities in the network. How does this command center work? There are 30 member facilities in your network are all the facilities included? What's the main purpose of the command center? How does it help you?

The purpose [00:21:00] of the command center was really to provide real-time access to key pieces of information across our network. And it's still a work in progress when it's fully operational. I think we'll be able to see what our capacity and patient flow is across the entire network. And that will enable us obviously to make better decisions in real-time with respect to bed capacity discharges transfers and staffing.

And I think that's where it will be extremely valuable.

How did COVID [00:22:00] impact your organization in terms of the digital strategy? The solutions that were implemented, the funding? Did the strategy or thinking accelerate?

On the positive side, we had already put in place a digital transformation strategy before the pandemic. So what the pandemic allowed us to do is really accelerate the plans that we had already had on the table. We quite quickly set up a tele-health program across the network. It wasn't perfect. But it was certainly better than nothing since nobody had access to the hospital for many months, unless they had a need for urgent surgery or cancer care.

We were quite successful in setting up telehealth programs for most of our ambulatory clinics where our cancer center for mental health program and we track the experience of patients and these new programs, because [00:23:00] we surveyed everybody continuously to make sure that people were getting from these programs, what they wanted. And in fact, the acceptance rate amongst patients was well over 85%.

When it comes to telehealth and offering it as part of the regular practice, a lot of data gets generated. Is there a specific strategy that you have in terms of how to manage all the new generated data? Maybe do any additional research to try to find some new findings or just to basically plan for the future better.

That is a challenge. There's a lot more data and there's a lot more data coming in real time from places that we didn't normally collect data from. And part of our digital transformation strategy is that IT doesn't involve a data science data, [00:24:00] analytics element, which is only now starting to be put in place.

So that will be built into the entire transformation process. It isn't in place yet. But we are bringing in data science experts. We are expanding our data science infrastructure. And we will be building the appropriate data infrastructure, including AI over the next couple of years in order to accommodate the transformation. This requires a huge investment, not just the money, but in terms of time and energy of individuals.

Sometimes, money can be the easiest problem to solve. Looking at the future: what are some of your strategic thoughts or goals that you would like to achieve with digitalization in the upcoming year?

We're not going to undertake a digital transformation because it's the thing to do. We're doing it to address challenges and fix problems.

And I think the most serious one is the manpower challenge. The second challenge of course, is getting access to real data, not just the hospital, 85% of people will never come into a hospital, but yet they require medical attention and we'll be generating data, for example, from mobile devices, and elsewhere. The challenge really is to begin to put in place a [00:26:00] structure and governance that will allow us to collect this data, verify the data, analyze the data, and react to the data in real-time, in a way that will deliver better care, higher quality care and a better experience, both for the patients and for the professionals.

The data center that you put in place is the beginning of this.

It is, and it will grow. It will become the the brain of the institution that will underlie everything else.

How do you see the [00:27:00] innovation hub that you have inside the institution?

The hub is extremely important because not only does it give us visibility, but it acts as a driver for doing things we might not otherwise been able to do as quickly as we're able to do now.

The hub has also generated a lot of excitement internally. We have a lot of young professional staff who are looking for ways to re-energize their careers. And then the hub certainly has provided them a means to do that. It's also provided a magnet to companies outside of our organization to come in and use us as a living laboratory to test their products or co-developed products with them. And we have many projects now underway.

And the number of projects we've been able to put in place in such a short period of time really surprised me. It's been absolutely astounding. So obviously the need was there. And that will be [00:28:00] another part of our program that will continue to grow.

Can you highlight two or three examples that are put in place and kind of surprised you that you were able to implement them first?

I'll mention one because I think it's quite significant. We developed a partnership between Microsoft Canada Medtronic, and a Quebec engineering firm called the OJ group. Which has enabled us to use the hollow lens in two use case settings that were absolutely spectacular. It allowed us to do a remote cardiac surgery and the other enabled us to provide care remotely to residents in long-term care during the pandemic.

Both of those use cases would have been impossible without the technology and really without the innovation hub, providing a focus for this sort of activity.

Is there any other technology that you would say inspires you most for the future impact on healthcare?

I [00:29:00] think AI is going to drive everything ultimately. I don't think it's there yet, but I think ultimately AI will drive everything.

Danina Kapetanović.

“Even before the pandemic, our leadership was keenly aware that businesses as usual will simply not fly, that our healthcare system is on a collision course with itself.”

Danina Kapetanovič - Chief Innovation Officer, Head of the Innovation Hub (OROT).

Tjasa: OROT brings together clinicians and end users with entrepreneurs and innovators in order to build in launch technologies that improve people's lives. Can you name a few practical examples of what was designed in the hub and is now used in practice so far?

Danina: [00:30:00] So first, let me preface by saying that we're we have been in existence since July last year. Having said that we have we have been very productive and have taken on a number of projects that have resulted in concrete change. Our institution was among the first institutions that were called by the ministry of health and social services to respond to the crisis. We're one of the busiest emergency departments in the province. And we have also in recent renovations opened an entire pavilion that consisted of a number of rooms that were pandemic ready that had were equipped with a negative pressure environment. As a result, we expected that there would be huge pressure on the institution once the pandemic was in full swing, which is exactly what ended up happening. Since we had a pre-existing relationship with the partner who had quite a bit of experience in developing this type of technology for [00:31:00] optimization of workflows, we co-developed care 360, which is a solution that basically sought to use epidemiological modeling predictions one week ahead of time, the number of patients that we will receive in our hospital. And then from there how many of those patients will graduate to intensive care and what would be the use of ventilators?

The second aspect of Care 360 was we're still an environment that does not have a unified electronic health record. And in a situation where you had a large number of patients, all of whom had to be monitored very closely without a single overview that became very risky. We were looking to create an environment where we would continue to provide excellent care, but at the same time minimize the contact between the clinicians and the patients.

So a second aspect was to create a dashboard that gave an overview. [00:32:00] We were able to look at wards where COVID patients were, but also zoom in on single patients. And then based on some pre-agreed parameters that we were monitoring the dashboard was also in position to warn us when certain patients were their parameters were showing signs of deterioration, signaling to the clinicians that they're that they, their, their attention was needed.

From care 360, we have now expanded into a command center that looks to optimize the functioning of the hospital, the intake of patients and then optimize the bad flow too to optimally use our human and physical resources avoid lags and wait times.

If we go back  to the point of inception of OROT; it was established in July last year. Can you talk a little bit about how that looked like in the middle of the pandemic, everybody working from [00:33:00] home, etc.? How is that changing now? With things getting back to normal, we already see that employers are getting more and more and more keen on getting people back to the offices.

Even before the pandemic, our leadership was keenly aware that businesses as usual will simply not fly, that our healthcare system is on a collision course with itself. The demographic change is such that business as usual is not sustainable. We have an increasingly aging population that is living longer, but isn't necessarily healthier. Our healthcare is still largely based on an acute care delivery model. All of which has resulted in significant increases in healthcare spending that outmatches [00:34:00] the GDP growth in Quebec and in Canada. And as you can imagine as our aging population multiplies and with high incidence of chronic diseases and comorbidities we're facing a situation where our healthcare model will simply not be affordable. There was a realization on the part of our leadership that our healthcare model has to change and that it has to be pushed out of the hospital and brought closer to the patient. And that, that was one of them, one of the driving forces behind the healthcare reform that took place in 2016, that brought us, that brought institutions inside networks that have regional coverage in order to ensure that there's continuum of care. But I think there's also a realization that with the technology that exists today we're in position positioned to really push out as much of that care as possible, closer to the [00:35:00] patient and ensure that care is provided wherever the patient is the concept we call care.

So I think healthcare keenly opened itself up and sought to be revolutionized by digital healthcare technology. And yet despite enormous investments, to the tune of 25 billion US dollars only last year in direct investment, no technology has as of yet revolutionized the delivery of healthcare.

Command center at CIUSSS.

Digital transformation is absolutely necessary. That innovation is a keystone of that digital transformation, but that innovation has to be based in a very close collaboration between the users and the innovators. And , that will in fact, help bridge this issue of of, having a whole bunch of technologies out there that haven't been transformative.

We realized also that we live in a universe where technologies and solutions are seeking problems to resolve rather than the [00:36:00] another way around. Clearly, making it known what the issues are and then figuring out how best to solve them and how technology can solve them.

Artificial intelligence is an excellent example. We hear people speaking of artificial intelligence as a game-changer in healthcare. But the focus is on artificial intelligence and not necessarily on what the issue is, and then figuring out how artificial intelligence solved those issues.

There are now a mounting number of studies and evidence that points that technologies such as artificial intelligence can actually be a double-edged sword and dangerous if they are created far away from the setting. If there are data biases, but there are also contextual biases that make it so that something that could be powerful can actually become dangerous.

So with all of this in mind, we've conceptualized a connected health innovation hub that first and foremost focuses on begins the process of [00:37:00] innovation with a clearly identified need as perceived by the clinicians and the users like that is the motivator.

And then from that perspective, we seek partnership with the industry because we believe while we are obviously supportive and proponents of innovation in all its forms, we focus on outside in innovation with the idea of. Accelerating accelerating the development and integration of innovation.

Can you perhaps mention anything more specific about how you identify potential problems that you want to solve or address next? Just from the organizational perspective, what can other healthcare networks or health hospitals that are trying to innovate with an innovation hub, how they should go about that?

Some of this obviously changes contextually, we're a particular kind of [00:38:00] network. Very representative in Canadian terms. We're home to a very diverse, probably the most diverse population in Canada, both in terms of age, in terms of socioeconomic status, in terms of ethnicity.

In this instance, we thought about this long and hard and while innovation initiatives to take hold inside an institution, obviously have to have a strong support of the leadership, which is certainly the case in our in our network, and while the kind of the strategic vision is formed at that level, it is equally important to understand what the perception is on at the grassroots level. So at the level of the patient, and then at the level of the frontline clinician.

The innovation trajectory is built in phases. [00:39:00]

The first phase is clearly identifying the needs and priorities. We've accomplished that by building our governance on both the top-down and bottom-up approach. On the top we have an executive committee that oversees the work of the heart that is constituted. Individuals, presided by our president and CEO, that kind of sets the strategic vision for the network. But then I have established a number of grassroots mechanisms that seek to understand what the need is as perceived by the users, whether they be clinicians or patients.

So I have done so by establishing a network-wide community of practice, that's been somewhat disrupted speed in many communities of practice. And often it can turn into theoretical exercises where you discuss concepts and notions.

We have established a system of collecting needs both push and pull. We have a website that is connected to the network website and the individual institutions website where people can come and fill out a form and submit their ideas.

Whether they are an employee or they are a potential industry partner they can submit our idea. We have also established a mechanism where we can put out a call for ideas and a call for proposals. So proactively go and seek feedback.

And then where projects emerge we have a pre-gating and gating process. Pre-gating establishes the feasibility and whether something, has the potential to form into a [00:41:00] project and what sort of support it would get. And then the gating process formalizes that.

We also established whether something constitutes as the research or as a quality assurance project, or we have this third category, which is co-development. And then based on that, there are paths to be followed. If something is research, then they want to make sure that it's rigorously looked at by our ethics board. The same thing applies to something that's deemed a quality assurance, but just a different instance looks at it.

And then in collaboration with these two instances, we have also established some standards in terms of what are co-creation, co-development activities like what standards they should submit to, once that [00:42:00] process is completed. And we look to establish something that is as optimized and as accelerated as possible.

We then form teams around these projects. Every project has to have a clinical champion, a clinical lead. Every project has an executive sponsor. Currently I fulfill that role. So I make sure that I look at all the projects transversely and I make sure that all the resources that are needed both internally and externally are available and, any blockages removed and then projects typically have project managers.

And then we look to mobilize whatever clinical capacity and nonclinical capacity is needed to make sure that project goes on. We set up a very clear timelines and with the ultimate goal of integrating the innovations. So from that, in that regard, we have also a very close [00:43:00] collaboration with a ministerial body called innovation office that looks to facilitate the collaboration between private sector and the ministry and take applicable innovation system-wide.

At the end of the process, we loop in with that body to make sure that the innovations are considered from a system perspective.

Tjasa: You've been in the innovation space for a long time. Even, before this position, you were heavily involved with Hacking Health. Knowing how the whole idea search process is happening through hackathons and now actually building innovations through an innovation hub. Can you share a little bit of your insight regarding a digital health innovation across Canada, and where do you see are any hot spots or most innovative hubs in the country?

I see innovation, digital health space as a driver as an economic drivers and having a huge role in our economic relaunch. I think it's part of the economy that has continued to be very vibrant. Regardless of the difficult conditions that we have lived through and continue to live through. It is also I would say a silver lining of this pandemic is that it has greatly accelerated and facilitated digital health innovation. For example, in our province, telehealth lagged behind for years and I would say a contributing reason was that there were no provincially approved budget codes [00:45:00] for caregivers delivering care via telemedicine.

This is something that quickly changed at the onset of the pandemic, which opened tons of doors. And so I don't see us going back. I only see us exploiting the space further and and expanding on that space. Montreal and Quebec, obviously I'm biased since I'm from here. This is an incredibly rich ecosystem that's very interested in artificial intelligence and becoming the artificial intelligence hub of the world.  The provincial authorities have recently launched an initiative called innovation zones. They can turn industrial zones that will focus on innovation and AI. We have conceptualized it with a number of institutions both from the private sector, the academic sector, the healthcare sector have joined forces and put forth [00:46:00] an application, which is currently being studied by the Ministry of economic innovation.

Calling for the creation of an innovation zone that would exclusively focus on AI and health. We're also currently revising our strategy, the Ministry of economy innovation is revising its strategy for innovation and research for the next five years.

Toronto is obviously a place that was on the map and continues to be on the map with tremendous resources dedicated to the digital health innovation space. There are great things happening in Alberta. It has taken great strides in creating [00:47:00] structures both human resource-wise and financially in order to foster and spearhead innovation in the digital health space inside the province.

Edmonton has a number of institutions that work exclusively to foster entrepreneurship in this space.

British Columbia as well and Newfoundland, although, a small, tiny Atlantic province is also positioned itself very strongly in the space and looking to spearhead the creation of excellence centers in cybersecurity. I think there's a realization that without a robust cybersecurity system, all of this is very vulnerable and fragile. As a country, I would say, a country that is vast geographically, but small population-wise, I would say we're very strongly positioned to be the leaders in the digital health innovation space.