Earlier today, Paul Lepage [President, TELUS Health] spoke at the Toronto Board of Trade about “Hearing the patient: How people, innovation and technology are transforming healthcare.”

A number of times in the past, I have written about opportunities for improvement that we should be able to implement in Canada’s healthcare system, such as:

• Wringing efficiencies from improved e-Health
• Adopting technology to manage your health
• Ontario’s glacial pace of electronic health

At the Board of Trade, Paul shared some of the things TELUS Health has learned from its work in digital health solutions:

• Surveys show patients want digital health solutions, but there is a gap between patient expectations and the solutions available to them.
• Patient appetites for more digital health solutions are validated by looking at usage patters on today’s solutions.
• Mobility is key

While the past 5 years have seen physician adoption of electronic health records double from 40% to over 80%, he suggests that “if we want to really drive transformation in healthcare, we need to get the different parts of the ecosystem to talk to each other, collaborate, and evolve the way patients and all healthcare providers interact.” TELUS Health has been involved with the Canada Health Infoway to deliver a national electronic prescription solution, trying to tackle the challenges of prescription errors and costs for prescription renewals. And TELUS Health has introduced MedDialog, a secure messaging platform for healthcare providers, enabling them to communicate and conduct digital patient consultations, sharing notes and providing referrals.

How do we drive more innovation in healthcare? He described drivers for TELUS Health that really could apply in any market:

1. Ensuring funding for companies:
• Since 2001 TELUS Ventures has invested in over 50 companies and has close to 25 in its portfolio today
• TELUS Health plans to invest over $750M over the next 5 years
2. Market access
• TELUS Health is creating an ecosystem for smaller companies, leverage its customer base via the TELUS Health Exchange
3. Availability of talent
• TELUS Health has about 2000 people working on health IT
• TELUS Ventures Bench provides companies in the TELUS Ventures portfolio with access to TELUS leaders with varying skillsets to act as advisors
4. Appropriate regulatory frameworks
• Making sure that the healthcare systems encourage the right behaviours to drive innovation
5. Tolerance for failure
• Recognizing healthcare is complex and evolving, like the regulatory and political context in which it operates
• Innovative firms extract the “tuition value from failure”, celebrate it, and move on

In the past year, with friends, colleagues and family members, I have had too many interactions with healthcare providers in clinics, hospitals and doctors offices in Canada, the US and Israel. In his talk, Paul Lepage referred to innovations in health IT being deployed by Clalit Health Services in Israel, a leading group that is now delivering more than 60% of their pediatric consultations on-line. I have seen first hand the excellence in service delivery at Clalit.

Some of the ways we do things make me shake my head and wonder if executives at our hospitals are taking enough time to observe first hand how patients are being treated from the time they enter the campus. As I have said about communications companies, if employees and executives aren’t being treated like the general public, change the way you handle internal accounts immediately. Hospitals, retailers, communications firms alike need to see how your customers are being handled.

Each negative interaction represents an opportunity for innovation in our healthcare system. Each innovation represents an opportunity for improved processes and systems. Each improved process represents an opportunity to deliver better patient outcomes with significantly lower costs.

As Paul said in his concluding remarks, to drive innovation goes beyond technology. It requires changes in people, policies and processes. Implementing those changes may be the biggest challenge in transforming delivery of healthcare in Canada. Indeed, finding the leadership, recruiting and retaining the people to effect those changes, may be the biggest challenge for Canada’s national innovation agenda.

A recent commentary in Cartt.ca by former CRTC Vice-chair Peter Menzies observed that “A more open CRTC is a great leap forward.” The article comments on “the significance of a recent tweak by the CRTC regarding how it runs its hearings” signalled by a simple tweet from the official CRTC account:

It was a small, but notable change in procedure that may be signalling a cultural shift within the regulatory institution.

Last Friday, FCC Chair Ajit Pai tweeted a notable shift south of the border:

I wonder how many regulations Canada still has on the books for services that no longer exist? How many regulations are on the books from a different era before new media and over the top services became serious competitors and have led to significant substitutes for consumers? Indeed, how many regulations have been enacted in recent years for services that face far more competition than ever before?

Whether it is TV distribution or telecom services, despite the availability of unregulated and unlicensed competitive alternatives, one can point to an increased number of regulations that limit the flexibility for legacy service providers to be creative in responding. Many of these regulations have led to increased prices with questionable benefits to consumers. What consumer benefits are being restricted by these limits on the degrees of freedom for marketing departments in Canada’s regulated service providers?

Typically, to change a ruling, the regulatory review process is triggered by an application from a service provider. Canada’s Telecom Act allows for the CRTC to review on its own motion virtually “anything prohibited, required or permitted to be done”.

What was the significance of that “tweak by the CRTC regarding how it runs its hearings”?

The following commentary appears on National News Watch in the National Opinion Centre section.

In their letter of welcome to new CRTC Chair Ian Scott, Ministers Melanie Joly and Navdeep Bains wrote that the government’s objectives are to improve the quality, coverage and price of telecommunications services. This echoed remarks from Minister Bains earlier this year at The Canadian Telecom Summit.

There is a difficult tension in these objectives, seeking increased investment while maintaining, if not improving affordability. The Ministers wrote “All Canadians and Canadian businesses deserve high quality telecommunications services at affordable prices.”

It is a delicate balance. Quality and coverage require significant levels of capital investment, especially in a country like Canada.

How do we define and measure “affordable”? We all want lower prices for everything, but the modifier “high quality” makes low prices more of a challenge. That is why we should be careful not to equate “affordable” with rock bottom prices.

A number of recent speeches and announcements from the government have claimed Canadians pay more for entry-level cell service compared to residents of the US and the UK. There have historically been problems with the way the OECD and CRTC has collected communications pricing information. For example, the CRTC does not include flanker brands (such as Virgin, Koodo or Fido), or examine pre-paid plans, precisely the kinds of services that would be the most attractive choices by lower income consumers. Both OECD and CRTC do not account for the difference in the quality of networks nor for the difference in density of population for these comparisons. Further, the information collected is typically outdated by the time it is published and tough to verify.

A recent report by Wall Communications submitted to the CRTC observed that “an inherent problem in defining affordability is the need to invoke some benchmark for which there is no objective definition.” Canada’s Public Interest Advocacy Centre has suggested communications services are affordable when they make up no more than 4% to 6% of a household’s income.

The Wall report found “The lowest priced Smartphone service that is widely available across Canada constitutes roughly 1% or less of the low income cut-off.” Further, measured as a percentage of low income level, Canadian entry level prices for a voice, text and data plan is similar to Germany, Italy and Australia, and almost half the level of the US, where entry level voice, text and data plans cost 2% of American low income levels. So, while Canadian prices may not be the lowest, entry level plans are affordable when compared to our peers, consistent with a report from The Economist Intelligence Unit ranking Canada number 1 in communications services affordability.

What about coverage and quality?

A February 2017 report from the GSMA found that Canada had the highest spectrum cost measured on a per capita basis, roughly $350 (US) per person, as compared to $200 per person in the US and about $50 per person in the UK. Recent reports have shown that Canada led all G-7 countries in capital spending per subscriber. Measured as a percentage of revenue, Canadian capital spending was top in the G-7 and fourth in the OECD. All of that investment has been paying off, providing high quality network wireless coverage to most Canadians. In announcing the latest spectrum policy consultation, the government acknowledged that Canada’s networks rank second among G7 countries for average wireless connection speeds and 98% of Canadians have access to LTE wireless technology.

Canada is now setting the rules for the next multi-billion dollar auction of spectrum and the country has launched a consultation on what its spectrum policy should look like for the next 5 years. At the same time, the wireless industry is preparing for what has been called a “generational investment” in the latest 5G technology.

Lower prices won’t ensure Canadians have access to affordable options no matter where they live. Regulations, spectrum policy and auction rules have to preserve the delicate balance that enables mobile service affordability, while encouraging investment in high quality networks that are available from coast to coast to coast.

This past weekend, how many people went into hardware stores looking for nails?

Very few.

Of those who came out of the store with nails, most went into the store looking for a way to hold two pieces of wood together. Some of those people chose nails; others chose screws; some decided on glue; some are going to make a dove-tail joint; and then there are those like me who decided that duct tape would be just fine.

I have used this metaphor before, describing the need to apply a systems engineering approach for broadband. It is often a real challenge to define requirements without specifying a solution, allowing flexibility in the choice of technologies to satisfy the requirements.

Frequently, I have said that we need to ensure that we remain technologically agnostic, even though so many associate fibre with advanced broadband. Through the weekend, I tweeted a few mobile speed tests that I conducted, looking at how the TELUS and Freedom Mobile networks performed with a couple of the latest devices optimized for performance on each of the respective networks.

Frankly, I could probably talk for hours about the implications of the 4 pictures attached to the two tweets that you can examine below. I want to focus on the headline speed results from the TELUS network on a Saturday afternoon driving south on Bathurst Street near Eglinton Avenue. The download speed was close to 175Mbps, a speed that would thrill most for achievement on home networks, let alone mobile. Can we finally put to rest the view that advanced broadband needs fibre connections?

The network performance comparisons raise other issues that might merit further discussion, including:

• Will policy makers acknowledge the role of wireless networks in rural and remote network architectures to bridge the digital divide, fulfilling the national gigabit dream?
• Device portability: unlocked devices may allow basic features and some network connectivity on other networks, but not all devices operate the same on all networks. Do Canadians understand what the CRTC’s unlocked phone policy will mean in practical terms? Did the CRTC even hear evidence on these points?
• Operating under load at a sporting event, Freedom Mobile’s network operated at close to the same performance as the TELUS network. What does this mean for spectrum policy, as the government begins to seek public comments on potential spectrum releases over the next five years?
• Do we have the right policies to encourage investment in more towers, as I have written before?

What other questions are raised in your mind by the images in these tweets?

By the way, if you get a chance to test drive an Essential phone, be sure to check out the 360 degree camera (that is actually doing 360×360 recording). It is amazing technology.

“The Government will encourage more private sector competition and investment in services that have become essential in a digital economy.” That is a quote from the letter of welcome sent to CRTC Chair Ian Scott last week by Heritage Minister Melanie Joly and Minister of Innovation, Science and Economic Development Navdeep Bains.

“All Canadians and Canadian businesses deserve high quality telecommunications services at affordable prices.” How do you increase competition to drive “affordable” service prices while simultaneously encouraging investment?

It is a delicate balance. How do we define and measure “affordable”? We all want lower prices for everything, other than our own wages, but when you add the modifier “high quality” to the product definition, it gets more difficult to implement.

What is the right way to increase competition? What is the right level of competition that provides pricing discipline, encourages innovation, and maintains the right incentives for continued investment in infrastructure?

A recent article by Rita Trichur in the Globe and Mail starts by saying

The three-year contract is dead, but monthly bills keep rising. Switching carriers is a nightmare, add-on charges multiply like cockroaches, and being off contract doesn’t guarantee that you’ll find a substantially better deal if you shop around.

Many blame the CRTC. The regulator has tinkered with the rules, but it has largely failed to keep major carriers in check.

Yes. Monthly bills went up precisely because the three year contract is dead, just as the CRTC was warned. The CRTC banning innovative pricing plans like zero rating also has led to less price competition and discouraging product differentiation. In the case of Videotron’s Unlimited Music, the CRTC prohibited a service innovation by a new entrant and denied consumers a chance to save.

On one hand, we want consumers to have more choice, on the other hand certain groups want the only competition to be on the basis of price. If a service provider doesn’t have market power, do we really need to regulate its services and products?

Two sides to every coin.

The issue of spectrum set asides is another one that is more complicated than the average soundbite portrays. On one hand, the new entrants want access to more spectrum in the lower frequency bands, as noted by Christine Dobby in her recent article, which is why they are seeking a set-aside in the 600 MHz auction. On the other hand, Canada’s new entrants in the mobile wireless sector are not start-ups; they are multi-billion dollar vertically integrated communications giants – Shaw and Quebecor.

Quebecor’s Videotron Ltd. now has 16 per cent of wireless subscribers in the province and, after wrapping up expensive investments in building an LTE network, the business now makes a healthy contribution to the telecom division’s free cash flow, which increased by almost $100-million in the first half of this year to $399.5-million.

While Quebecor CEO Pierre Karl Péladeau told The Globe and Mail that Rogers, Bell and TELUS “received swaths of low-band spectrum from the government at no charge when they first set up their cellular networks in the 1980s”, the other side of that issue is that the incumbents have been paying annual license fees for that “free” spectrum. In total, the three companies have paid more than three and a half billion dollars in license fees, with a present value of more than $8.5B in 2017 dollars. This is hardly swaths of spectrum for “no charge”.

Under such considerations, should we still have spectrum set-aside for “new entrants” in the upcoming auction? Is it noteworthy that just last week, Mr. Péladeau criticized a two-tier system for Canadian content obligations, saying it “is blatantly unjust.”

Two sides to every coin.

High quality services at affordable prices creates a difficult tension in implementing communications policy.

What is affordable for some is different than what is considered affordable for others. As I have written before, perhaps our focus should be looking at the issue of affordability by “Looking at who, not just where.”

That would require increased product and service flexibility and the ability for service providers to differentiate themselves. Do we really expect increased competition to emerge from heavy handed government regulation?