All
HEMS is an aviation activity. In the states there are a lot of tails wagging the dog (medical types pretending to be the authority), and the dog is letting it happen, on all levels. That's our primary problem.
Canada simply looks at the 24/7/365 nature of the beast and equips/staffs appropriately. The US simply tries to get the most bang for the buck - which is wrong, but the industry and government won't admit it.
I was a bit shivered to hear one witness from a prominent operator say they decided VFR is the only way and they were spending on TAWS etc. rather than IFR. So, we take the chances that TAWS will keep us out of CFIT than using IFR and being up and away from it all.
The US operators are simply FAR too shy of IFR operations, keep looking only at the number of pure IFR flights they do as a result of equipping to that standard, and forget the VFR flights that get done whilst prepared to go IFR should the weather deteriorate whilst enroute, etc.
Low level helo type IFR infrastructure is very possible, particularly with ADS-B. Probably never see it in my life-time.
WIII